676

which could not be tolerated except as part of the sacrificeof war, and many nurses are still in billets which are apoor substitute for a nurses’ home or residence. This

brings home the fact that the Hetherington Committee’sdesire for canteen facilities may require bricks andmortar to complete the picture. But there are brightspots ; Professor Nixon tells us in a letter on anotherpage that despite vicious air bombardment some of theBristol hospitals have not suffered severely from thedomestic shortage. One of the most important reasonsfor this is the status and consideration given to domesticsin these hospitals. A peace-time tradition of strongloyalty, both to city and hospital, has not been upsetby the upheaval of war. Long and faithful service istangibly recognised. Quarters and food are good,reasonable off-duty time, leave and allowances are

provided, and the domestic staff wear an honourablebadge or uniform. Here are most of the essentials of acontented service, and to these is added the most

important condition of ,all-wisdom and understandingat the head.

’

CALCIUM SULPHADIAZINEOCCASIONS often arise when it is desirable to introduce

a sulphonamide parenterally either because rapidity ofaction is required or because the patient is vomiting orcomatose. In such cases it is the accepted practice toinject the sodium salt intravenously or intramuscularly.The intramuscular route is the easier one to use, but ittends to cause necrosis of the muscle at the site ofinjection on account of the alkalinity of the sodium salts.Sodium sulphapyridine and sodium sulphathiazole areparticularly alkaline, and even sodium sulphadiazine,which is less alkaline, causes tissue irritation and tender-ness if a concentration of 3-5% is used for subcutaneousinjection. In attempts to circumvent this difficulty,trial has been made by Nelson and Spink 1 of the lessalkaline calcium salts. Calcium sulphadiazine issoluble about 5.1 % at 250 C. and the pH of the solutionis 8-5 (neutrality, 7’4). It was given to 24 patients asa 4% solution, an initial dose of 4 g. being injectedsubcutaneously, followed by two doses each of 3 g. at12-hour intervals. The blood-concentration curves of

sulphadiazine resulting from these injections were

closely similar to those produced by injection of sodiumsulphadiazine, the concentrations of total drug rangingfrom 7 to 15 mg. per 100 c.cm., and the therapeuticaction was what would be expected from these levels.Locally, no ill effects were observed. It should howeverbe noted that the evidence for the absence of local

damage depends only upon clinical observation; histo-

logical examination of the site of injection may revealappreciable tissue damage produced by substances whichhave apparently caused no pain or swelling. But whencalcium sulphathiazole (pH of 5% solution, 8.8) wasemployed, as a 4% solution injected subcutaneously,it caused redness, induration and pain at the site ofinjection in 3 out of 5 patients ; accordingly calciumsulphathiazole is not recommended for subcutaneousinjection. If these results are confirmed, the use ofcalcium sulphadiazine may offer a (slight) advantage forparenteral administration.

FAMILIAL AURICULAR FIBRILLATION IT is wise to suspect thyrotoxicosis in the patient with

auricular fibrillation and no cardiac lesion, but even aftercareful investigation there is a residuum of such caseswhere the cause remains a mystery. Among 376 casesof auricular fibrillation analysed by White and Jones 2there were 30 " apparently free from heart disease."In a few cases in this small group arrhythmia seems to befamilial : Wolff 3 records auricular fibrillation in two setsof brothers, in none of whom could an organic cause befound. In one of these families he found the condition

1. Nelson, C. T. and Spink, W. W. Amer. J. med. Sci. 1943, 206, 315.2. White, P. D. and Jones, T. D. Amer. Heart J. 1928, 3, 302.3. Wolff, L. New. Engl. J. Med. 1943, 229, 396.

in 3 brothers. The heart of the eldest was said to havebeen irregular at birth, and- from the age of 7 years hehad had a grossly irregular pulse. When first seen byWolff in 1927, at the age of 25, the presence of auricularfibrillation was confirmed by the electrocardiogram, andthe ventricular rate was 80 per minute. Normal rhythmwas achieved by quinidine following digitalisation, butafter several relapses, in which normal rhythm was alwaysrestored by the same method, the man refused furthertreatment, and when last seen in the early part of this year- 16 years after the initial diagnosis-auricularfibrillationwas still present and he was leading a normal, active life.In the other two brothers, aged 31 and 24, the heart wassaid to have been irregular since childhood and at the timeof examination the ventricular rate was relatively slow-70 and 80 per min. In both, normal rhythm wasrestored by digitalis and quinidine. In the other family2 brothers, aged 35 and 25, had paroxysmal auricularfibrillation, the arrhythmia having been present for 10and 2 years ; both were leading active lives, one beinga "

physical director." In the elder brother a paroxysmpersisting for 6 months precipitated congestive heart.failure, and though subsequently he " was able to carryon well," when last seen, 11 years after the original diag.nosis, the transverse diameter of the heart had increasedfrom 14-1 cm. to 14-8 cm. In the first family, one

of the brothers had had nose bleeding as a child andthe other two growing pains ; but if the arrhythmiahad been due to a rheumatic infection there wouldalmost certainly have been some evidence of a valvularlesion. Moreover, all three brothers led such activelives that there could scarcely have been much wrong withtheir myocardium. Wolff suggests that the arrhythmiamay have been due to excessive vagal action, quotingas a possible sign of such preponderant vagal tonethe slow ventricular rate and the fact that on the returnof normal rhythm there was definite sinus arrhythmia.The irregularity said to have been present at birth inthe eldest brother is more likely to have been due tosinus arrhythmia than to congenital auricular fibrilla-tion. These cases provide striking evidence of how

benign auricular fibrillation can be, even when main-tained over long periods. ,

USE OF ZINC TO DELAY ABSORPTIONTHE demonstration that the addition of zinc salts

would prolong the hypoglycsemic action of insulin inlaboratory animals was rapidly utilised in clinicalpractice. Experiments showed that the action was dueto a slowing of absorption from the injection site; andsubsequent research showed that this principle could alsobe used to prolong the action of pituitary gonadotrophin,the antidiuretic principle of the posterior pituitary,histamine, adrenaline, and morphine. Thus the retarda-tion is not confined to a single type of chemical substance,and it is difficult to see why the success that attended theuse of zinc insulin preparations did not’foster clinicalresearch in similar applications of zinc. At least oneclinical report has, however, appeared in which Foldes 1shows that it is possible to prolong the action of adrenaline,thiamine, and posterior pituitary antidiuretic factor byadding zinc to them. In the case of the posterior pituitaryextract 0.4 i.u. alone or with the addition of 0-1%zinc was injected into two normal people,and threepatients with diabetes insipidus. The addition of zincgreatly prolonged the antidiuretic action in all cases, sothat the diuresis following the ingestion of 1000 ml: of tapwater, which started after 12 4 hours when the extractwas injected alone, only started 4-8 hours after the

ingestion when zinc was added to the extract. - In thediabetes insipidus patients daily injections of 10 i.u. ofpostpituitary extract with added zinc reduced the waterintake and urine output by 30-50%, and the treatmentwas well tolerated for at least eight months. Similar

1. Foldes, F. F. J. clin. Invest. 1943, 22, 499.