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Annotations

THE CAPITATION FEE

LAST week the Ministry of Health announced that-" An agreement has now been reached between the

Minister of Health and the Insurance Acts Committee ofthe British Medical Association on the application of theSpens report to the current capitation fee under the existingNational Health Insurance scheme. Mr. Bevan has prO!!posed that the present capitation fee of 12s. 6d. should beincreased to 15s. 6d., with effect from Jan. 1, 1946. and thatthere should, in addition, be an increase in the specialpayments made to rural practitioners." -

This announcement will be received with general satis-faction. It resolves a controversy which only a few weeksago seemed about to disrupt relations with the Ministryand precipitate widespread resignations of doctors fromthe panel service.The principal cause of disagreement was the Minister’s

unwillingness to discuss the proper level of the N.H.I.capitation fee without at the same time discussing themode and amount of remuneration appropriate forthe new National Health Service. The Insurance ActsCommittee, having neither the power nor the wish tonegotiate on - anything other than National HealthInsurance matters, maintained that they should beallowed to settle the single issue of the current fee withouthaving to enter into the much more controversial fieldof future remuneration. Their will eventually prevailed,and a settlement has been reached. The figure agreed,although not as high as some doctors may have hopedin view of the high betterment figure quoted by Dr. Dainin his Exeter speech, is very appreciably higher thanMr. Bevan’s interim payment of 12s. 6d., and is even inexcess of the I.A.C.’s own suggestion of a 15s. fee madeless than a year ago. Before answering the Minister, theI.A.C. submitted his offer to meetings of local medicaland panel committees throughout the country, and inthese meetings acceptance was strongly favoured. In

accepting the offer the committee have, however, statedthat they do so

" without prejudice to the assessment ofremuneration in any future service." It is of course nowgenerally agreed that new factors arising in the new ser-vice, such as the inclusion of children and the extensionof the service to all people in all income groups, will makeit necessary for the doctor to have higher remunerationfor each patient than under National Health Insurance.This necessity is well recognised by the Minister himself ;it is, in fact, stressed in the official statement from theMinistry, which continues :

" In making this offer the Minister has made it clearthat remuneration under the new National Health Servicewill be a matter for negotiation with the medical profession.Some of the factors on which the 15s. 6d. -is based will, inhis view, have a bearing on the negotiations for the remunera-tion in the new service which, it is agreed, will be on ahigher level than the remuneration now settled for healthinsurance."

Altogether, this is a very satisfactory position to havereached, and one reflecting credit on the negotiators onboth sides.

CARE OF SPASTICS

THE British Council for the Welfare of Spasticswasestab-lished on Dec. 12 at a meeting held in the London School ofHygiene and Tropical Medicine.l Prof. J. M. Mackintosh,who took the chair, could give no exact estimate of thenumbers of cases of spasticity due to cerebral palsy inGreat Britain, though he noted that 234 spastic childrenare known to the school medical officer in Glasgowalone. The meeting was attended by representativesof 7 Government departments, 12 medical associations,

1. See Lancet, 1946, ii, 624, 889.

9 ancillary medical services, 26 educational and welfarebodies, 2 organisations of medical officers, and 2 schoolsfor spastics-evidence of a wide national interest in thecare of children and grown people affected in this way.The Ministries of Education, Labour and NationalService, Health, and Pensions, and the Scottish Depart-ments of Health and Education, all assured the councilof their support in a task which at this stage is wellsuited to the voluntary approach. The council willact as an advisory and consultative body, coordinatingthe work of all agencies for the care, education, andtraining of patients with cerebral palsy. It will alsofoster interest in this condition, help to provide schools,clinics, and equipment for the care and education of thoseaffected, will train staff in educational methods and intreatment, and will encourage research.. One school forspastic children has already been founded at Croydon,and another is being established in Birmingham. The

Birmingham school has been given by Mr. Paul S.

Cadbury, and is to be named Carlson House afterDr. Earl R. Carlson, the American pioneer in work forspastics.The council appointed Lord Horder as medical vice-

president, Professor Mackintosh as chairman, Mr.Cadbury as vice-chairman, Mr. H. P. Weston as secretary,and Mr. Isaac Wolfson as treasurer. The executivecommittee was composed of Mrs. Lionel Hitchens,Mr. R. A. S. Lloyd, Dr. Hamilton Hogben, and Mr. S: K.Quale, who has taken an active part in the founding ofthe council. The headquarters of the council will be at34, Eccleston Square, London, S.W.I.

VOLUNTEERS FOR COLDS

THE virus of the common cold has not yet beencultured, and the only susceptible laboratory animal,the chimpanzee, is hard to obtain, expensive, and difficultto handle. Hence the only practicable way of establishingthe presence of the virus is by human inoculation, andour knowledge of the cold virus today is as limited aswas our knowledge of the influenza virus up to 1933,when the ferret was found to be susceptible. -

Last summer the Medical Research Council and theMinistry of Health set up a common-cold research unit.1Since July volunteers have been received at the HarvardHospital, Salisbury, which was built during the war forAmerican volunteers, was later occupied by the UnitedStates Army, and has since been presented to the

Ministry of Health. The volunteer must be aged between18 and 40, must be free from respiratory infection, andshould have a normal susceptibility to the cold. Onarrival he is thoroughly examined and his chest is

radiographed. He remains for ten days, during the firstfour of which he is observed for the cold he may havecontracted before arrival. Fluid is then instilled intohis nose, half the volunteers receiving infected fluidand the other half acting as controls to check the efficiencyof the isolation measures and the accuracy of observationsby doctor and volunteer. So far no control has developeda cold. The need for isolation calls for gentle discipline ;but the volunteers, who live in pairs, are free to make useof the opportunities for games and to walk where theywill, provided they do not approach other people.The principal source of volunteers so far has been

university students, in whose estimation the less-than-even chance of a mild cold is a trifling price for ten days’peaceful retirement in a comfortable flat, with all foundand three shillings a day pocket-money. In term-time,however, the number of students does not suffice to

keep the investigation going. Although the BritishRed Cross has stimulated recruitment, and a few indus-trial undertakings have encouraged their employees tovolunteer, still more are needed to bring the total to the

1. See Lancet, 1946, i, 822.

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required 600 à year. Last week a press conference was

held to announce the formation of a national panel ofvolunteers. ’

It was emphasised that rapid progress is not to be

expected ; the work must be measured in years ratherthan months, the first aim being to find a susceptibleanimal or to develop a.laboratory technique. It is atleast encouraging, however, that the problem of the coldis at last being energetically tackled on both sides of theAtlantie,.2

SEX HORMONES IN PERIPHERAL VASOSPASM

IN his classical description of the syndrome named afterhim Raynaud observed that " the complete disappearanceof local syncope has always been noted by this ladyas the first index of a commencing pregnancy." 1 Nearly70 years later, in 1929, Snapper 2 noticed that a femalepatient’s acrocyanosis improved when she received

cestrogenic hormone for ovarian dysfunction ; and similarclinical observations have since been repeatedly made.In 1935 McGrath injected ergotamine tartrate intoalbino rats, some of which were also given an oestrogen.Gangrene of the tail developed in all male rats and inevery female which had not received the hormone;but among 40 females protected with the hormone

gangrene resulted in only 2. It has also been shownthat castrated male rats treated with the hormone havethe same immunity as females.4 4 The physiologicalexplanation seems to be that oestrogens cause localliberation of acetylcholine. b

Recently Burckhardt,6 recording the time taken forartificially lowered skin-temperature to return to normal,has confirmed the vasodilator effect of cestrogenswhen administered by injection or in the form of linguetsby mouth. Their action persisted for several weeks afterthe implantation of crystals. Male sex hormone had asimilar, but less pronounced, effect, which is difficultto explain, seeing that more men than women getRaynaud’s disease. A series of 345 patients treated forvasomotor disturbances with the female hormone havebeen followed up by McGrath and Herrmann,7 whohave no doubt of its efficacy, though White and Smith-wick 8 deny that cestrogens will prevent vasospasm in theearly stages of Raynaud’s disease. It is well to rememberthat spontaneous improvement is common, and thoughthis is usually temporary it may be sustained. Further-more, sex hormones are not lightly to be prescribed forwomen between puberty and the climacteric ; it isseldom justifiable to interfere with the menstrual cycleto avoid a harmless frostbite.

SULPHYDRYL COMPOUNDS IN MERCURYPOISONING

IT has long been known that -SH compounds willreduce or abolish the toxicity of mercury salts. In 1908,for instance, Chick 1 reported that ammonium sulphidenot only stopped the disinfectant action of mercuricchloride on bacteria, but apparently reversed toxic

compounds formed between the metal and the substanceof the bacterial cell. Again Rapkine 2 in 1931 found thatcysteine or thioglycollic acid could protect sea-urchineggs against the toxic action of mercuric chloride on celldivision, and Fildes 3 in 1940 noted that the antibacterial2. Ibid, 1946, ii, 355.1. Raynaud, A. G. M. De l’asphyxie locale et de la gangrene

symétrique des extrémités, Paris, 1862.2. Cited by Hitzenberger, K. Wien. klin. Wschr. 1937, 50, 465.3. McGrath, E. J. Arch. intern. Med. 1935, 65, 942.4. Suzman, M. M., Freed, C. C., Prag, J. J. S. Afr. J. med. Sci.

1938, 3, 29.5. Reynolds, S. R. M. Science, 1938, 87, 537.6. Burckhardt, W. Schweiz. med. Wschr. 1946, 76, 1147.7. McGrath, E. J., Herrmann, L. G. Ann. Surg. 1944, 120, 607.8. White, J. C., Smithwick, R. Autonomic Nervous System,

2nd ed., London, 1942.

1. Chick, H. J. Hyg., Camb. 1908, 8, 92.2. Rapkine, L. Ann. Physiol. Physicochim. biol. 1931, 7, 382.3. Fildes, P. Brit. J. exp. Path. 1940, 21, 67.

growth effect could be reversed by sulphydryl compounds.These observations were an indication that mercuric saltscombine with some -SH constituent in the cells.

Research on B.A.L.4 (2, 3-dimercaptopropanol) hasdemonstrated its effectiveness against poisoning by someother metals, such as cadmium and mercury, in additionto arsenic, and Gilman et awl. have used it successfullyin mercuric-chloride poisoning in dogs. In BaltimoreProf. W. T. Longcope and his associates have foundB.A.L. a remarkably effective antidote in patients withmercuric-chloride poisoning. (Oddly enough, this is- afairly common drug for suicides to choose.) It has beensuggested that the complex formed by B.A.L. with mercurysalts has the composition :

A recent study by Long and Farah 6 at Harvard isinstructive. The organic mercurial diuretic, mersalyl(’ Salyrgan ’), is toxic to the heart-lung preparation ofthe dog, 150 mg. producing a severe heart-failure. Thiscan be immediately relieved by as little as 10 mg. ofB.A.L.; it is interesting that a larger amount (100 mg.)of glutathione had a similar effect. In the intact cat or

dog, the cardiac changes produced by a lethal dose ofthe mercurial-such as sudden drop in blood-pressureand electrocardiographic changes-were counteractedimmediately by the -SH compounds, B.A.L. again provingmore effective. It seems advisable therefore to have a-SH compound ready where there is any possibility ofmercurial poisoning.

EMERGENCY BEDS

IN quite a small room in Old Jewry three recent WRENSsit taking and making telephone calls. They face a wallcovered with the names of hospitals and coloured tallieshung on hooks. The King’s Fund emergency bedservice began work on June 21, 1938, in an experi-mental and hopeful mood. Hospitals had agreed to

play in this new game of snap, where beds must bematched with patients ; so every day a report of vacantbeds was obtained from all hospitals of substantial size.Tallies showing not only the number but the types ofbeds available were then hung on the wall so that thegirls at the telephones could see at a glance where agynaecological bed, say, could be found for a postpartumhsemorrhage in Putney, or where a native of St. Pancrascould take his perforated gastric ulcer. An early fearwas that calls would be too few to justify the experiment.On the first day there were only seven calls, and bedswere easily found ; but they were the first of a total nowexceeding over 40,000, and bed-finding is sometimes noteasy at all. Apart from looking for beds the serviceundertakes to answer urgent inquiries from doctors,finding what -they want, from iron lungs to mother’smilk. The first request for mother’s milk, made beforethe days of milk banks, stumped the girl on duty, butshe answered hardily : " Yes, doctor, I’ll ring you backin five minutes " ; and then with brilliant aplomb rangup the General Nursing Council. There was silence fora moment at the other end; then the voice said firmly :" Try the London Hospital." Within very little overfive minutes the doctor had been put in touch with themilk-supply.When hospitals were evacuated, at the Munich crisis,

the emergency bed service, on its own responsibility,collected a daily report of the bed state of all hospitals4. Peters, R. A., Storton, L. A., Thompson, R. H. S. Nature, Lond.

1945, 156, 616. Waters, Ll., Stock, P. C. Science, 1946, 102,601. Young, L. Ibid, 1946, 103, 439.

5. Gilman, A., Allen, R. P., Phillips, F. S., St. John, E. J. clin.Invest. 1946, 25, 549.

6. Long, W. K., Farah, A. Science, 1946, 104, 220.