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540 Annotations A CENTRALISED AMBULANCE SERVICE THE coming of a National Health Service must profoundly affect the existing ambulance associations, and the Hospitals and Welfare Services Union has issued a memo on the ambulance service it thinks ought to be provided. There is much cogency in its views, In the past several unhappy incidents have arisen from the rule that ambulances should not operate outside the area of the authority which provides them. People injured close to the boundary between two areas have sometimes found that no-one knew precisely where the boundary line was drawn and neither authority was willing to help until this point was settled. To avoid such happenings the union suggests that all ambulance services should be free and centrally adjninistered ; the. Minister of Health should appoint a chief director of ambulance services and he should operate these services through deputy directors appointed by the new regional authorities. This, however, is not the only point which interests the Hospitals and Welfare Services Union. It is anxious that those engaged in the ambulance service should be properly trained whole-time workers. Three years of continuous street work is suggested, plus classes and lectures, before a man is qualified to take charge of an ambulance, and the union would like to see a state register of ambulance workers, similar to the nurses’ register. There is not always anyone to accom- pany the driver of an ambulance, and even if there is some friend riding inside with the patient it may be found in emergency that this friend has no training and cannot even assist the driver to any useful extent. Occasionally drivers have even had to conduct maternity cases in the ambulance to the best of their ability, and the union therefore suggests that " drivers and male attendants should receive a certain amount of education with regard to midwifery." The advantages which have accrued from the unification of our fire services under national control are cited in support of the claim that our ambulance services should be similarly dealt with ; and the union is undoubtedly wise in making its voice heard as early as possible. STILBŒSTROL AND LACTATION THE possibilities and limitations of diethylstilbcestrol are still imperfectly defined, though it is eight years since Dodds and his colleagues introduced this syn- thetic cestrogen to clinical medicine. Its uses in the puerperium have been clarified by two recent American papers. Walsh and Stromme divided 190 recently delivered patients in whom breast-feeding was un- desirable or contra-indicated into three groups. To one no treatment except analgesics was given to check lactation ; in another they applied all the old routine measures such as binders, ice-bags, restriction of fluid intake and saline catharsis ; the third received stilb- oestrol only, an initial dose of 10 mg. being followed by two subsequent doses of 5 mg. at ’24-hour intervals. The pain associated with the onset of lactation- was just as severe in those receiving routine treatment as in those who received no treatment at all, but stilbcestrol much reduced both the incidence and the intensity of the pain. Lactation itself was also profoundly affected by the drug. Thus in the group which received no treatment 88% of the women lactated and this function was estab- lished about the fifth day. In the stilbcestrol group only 43% lactated, and the secretion was much dimin- ished in amount and did not reach its maximum until the eighth day. Redness of the breasts was noted in 14% of the patients who received no treatment, in 8% of group 2, and in 4% of the stilbcestrol group. Where 1. Walsh, J. W. and Stromme, W. B. Amer. J. Obstet. Gynec. 1944, 47, 655. lactation has already been established the drug will rapidly inhibit the flow, but it is not so efficacious in controlling breast pain once the glands have been allowed to secrete. Evidence of its usefulness in established mastitis is as yet inconclusive. There are of course some disadvantages of synthetic oestrogen therapy: nausea and vomiting are fairly common, angioneurotic symptoms have been recorded and there have been a few cases of exfoliative dermatitis. Some women who are treated with stilbcestrol in the puerperium have an abnormally heavy loss when the menstrual flow first returns. Moreover, the patient,in whom lactation has been inhibited by a synthetic oestrogen may seem satisfactory on the tenth day of the puerperium but may report some days later with the breasts engorged again. Bloom 2 has tried combining diethylstilboestrol with another synthetic oestrogen, dimethyletherstilb- cestrol, which acts less rapidly but for a longer period. It is claimed that when thetwo drugs are used together to control lactation re-engorgement of the breasts is rare. TWO RAT-BITE FEVERS HAT-BiTE fever has been known for many years, out its aetiology has only been clarified quite recently. Until Brown and Nunemaker 3 thoroughly reviewed the condi. tion in 1942, the Spirillum minus was generally recognised as the causal organism : but they showed that infection by Streptobacillus moniliformis, which had. been isolated, under the name streptothrix as long ago as 1914 by Schottmuller 4 and in 1916 by Blake,5 and was shown by Parker and Hudson 6 in 1926 to be responsible- for the milk-borne epidemic called Haverhill - fever, was at least as frequent as, and possibly more common than, spirillar infection. This had not been recognised before because the streptobacillus requires somewhat ’special cultural methods for its isolation and is consequently missed if ordinary blood-culture technique is alone relied on. Up to the present there has been no authentic case of rat-bite fever due to a double infection with both organisms, and the conclusion must be that there are two rat-bite fevers. The spirillar disease usually responds dramatically to a comparatively few injections of one of the organic arsenicals, but therapy of the streptobacillary form has been much less satisfactory. Arsenic is usually of no value, sulphonamides have no effect, and gold, in the form of sodium aurothiomalate seemed to be the most promising therapy ; it certainly benefited the arthritic symptoms which were a striking symptom of two of Brown and Nunemaker’s cases, and was of great value prophylactically in controlling experi- mental infections with the strentobacillus in mice. Heilman and Herrell have recently investigated the value of penicillin in experimental spirillar and strepto- bacillary infections in mice, with successful results in both. In infections with Spirillum minus the blood of all- treated mice contained no spirilla after a day’s.. treatment, while - 24 out of 25 controls still contained spirilla after 37 days. The results in the streptobacillary infection were even more remarkable-42 out of 43 controls died, while the 43 treated mice all survived; treatment for 7 days produced complete recovery, but while treatment for only 5t days saved the lives of all the mice, half of the survivors had arthritic complications. In his letter in this issue, Dr. Kane reports that he has put penicillin to clinical test, with successful results. A boy of 15 with rat-bite fever, in which the strepto- bacillus was demonstrated in blood-cultures as the pathogen, was treated with penicillin after he had had nine relapses. Fever ceased in 12 hours and there was 2. Bloom, O. H. Ibid, 1944, 47, 692. 3. Brown, T. McP. and Nunemaker, J. C. Bull. Johns Hopk. Hosp. 1942, 70, 201. 4. Schottmüller, H. Derm. Wschr. 1914, 58 (suppl.) 77. 5. Blake, F. G. J. exp. Med. 1916, 23, 39. 6. Parker, F. jun. and Hudson, N. P. Amer J. Path. 1926, 2, 357. 7. Heilman, F. R. and Herrell, W. E. Proc. Mayo Clin. 1944, 19, 257.
