20 REMUNERATION

and there are now official injections of desoxycortoneacetate, chorionic (and serum) gonadotrophin, ethi-sterone, hexo3strol, oestradiol dipropionate, oestradiolmonobenzoate, progesterone, and testosterone pro-pionate. Separate injections are now official forvasopressin and oxytocin. Vitamin K as menaphtoneand vitamin Bl as aneurine hydrochloride are, as

expected, now available as injections. Notablemiscellaneous injections include those of diodone andof iodoxyl which are intended for pyelography.Soluble salts of sulphathiazole and of sulphadiazineare official preparations for parenteral administration.Ethanolamine oleate is used as a sclerosing agentfor varicose veins. Vinyl ether has earned approvalpresumably because experience has shown that in

expert hands it is a valuable general ansesthetic.A growing literature shows how difficult it is to combineefficiency with safety in cocaine substitutes. Butylaminobenzoate and butacaine sulphate (known bythe trade names ’ Butesin ’ and ’ Butyn ’) andcinchocaine hydrochloride join amethocaine andorthocaine. Among drugs used as basal anaestheticsare the sodium salts of hexobarbitone and thiopentone,which have long been in common; use as ’ Evipan ’and ’ Pentothal.’ Picrotoxin, which is firmly estab-lished as the drug of choice in barbiturate poisoning,is now official ; and phenytoin represents the newerdrugs for the treatment of epilepsy. Thiouracil and

methylthiouracil are included, and so are papaverineand pethidine, which share an antispasmodic actionbut differ in other important respects. The originalflavine antiseptics did not fulfil expectations, sometending to delay the healing of wounds, but the bestof these compounds, proflavine, becomes official asthe hemisulphate. Suppositories of old familiar drugs(cocaine, hamamelis, &c.) have returned to the

pharmacopoeia. The list of vaccines is growing, butthe only recent ones that interest the practitionerin Britain are those for the treatment or preventionof acne, whooping-cough, staphylococcal infections,and tuberculosis. The use of tubercle bacilli as an

antigen brings the B.P. into line with its continentalequivalents.Much wholesome pleasure can be derived from

deleting the names of drugs from a pharmacopoeia.Thus there will be general satisfaction on finding thatupwards of 100 articles and preparations included inprevious editions find no place in the B.P. 1948; ;but this is not to say that the Commissioners’ reasonsfor lightening the load will always be appreciated.For example, ammonium carbonate is banished, butammonium bicarbonate (possessing all the virtues ofthe carbonate, such as they are) takes its place.Several aromatic waters are excluded, but one

(aq. menth. pip.) is replaced by a concentrated water.Few will lament the passing of hoary remedies whosetitle-deeds to.therapeutic potency are lost in antiquity ;such are copaiba, buchu, asafoetida, and sandalwoodoil-drugs which were once esteemed as urinaryantiseptics. Not a few drugs formerly official havebeen discarded because more active preparations arenow preferred ; dry extract of liver, powder of vitaminBl, anti-dysenteric and anti-pneumococcal serum,Easton’s syrup, injection of iron, carbromal, and

injections of mercury and calomel are all examples ofthis type. To exclude hexamine on the same grounds

seems odd, for even if the sulphonamides have oustedhexamine it is undoubtedly a potent drug in largedoses. Other preparations can be sacrificed morereadily because they have objectionable side-effects ;such are methylsulphonal (though sulphonal remains),cantharadin (including liquor epispasticus), jalap,chrysarobin ointment, and sulphapyridine. Eightinfusions and the majority of 17 tinctures are deletedfor reasons best known to the pharmacist or on groundsof redundancy.Many doctors will be surprised and perturbed to

find some of their most cherished remedies thrownon the scrap heap. The confections of senna and of

sulphur, lobelia, linseed, black wash, and the solutionof glyceryl trinitrate no longer claim monographs ;but it is comforting to know that many drugs whichdo not pass muster for the B.P. are listed in the

13.P.C. ; and who shall say that none of these will

regain its former status in some future edition

Annotations

REMUNERATION

LAYMEN reading successive reports from the Spenscommittees have been known to question the need toimprove the financial position of doctors and dentistsin relation to other people. They remark that suchimprovement was not part of the original programmefor a public medical service. Doctors, on the other hand,can fairly reply that it was no part of the originalprogramme to lower the standard of living of professionalmen and women who are doing good and necessarywork. The Minister’s message on p. 24 suggests thathe accepts this principle, and we hope he will be ableto give early attention in particular to the situation ofthe country doctor with a relatively small potentialnumber of patients-a situation which has been wellpresented in our correspondence columns and was dis-cussed by the representative body of the British MedicalAssociation last week. As was pointed out at the

representative meeting, one of the difficulties of paymentby capitation fee is that any doctor trying to give reallygood attention to a small number of patients-andperhaps prevented geographically from augmenting thatnumber-is at a serious monetary disadvantage, and aspeaker suggested that the deserving general practitionerin such circumstances should be entitled to some additionalemolument for merit, on the lines of the " distinctionawards" which the Spens Committee has proposed forspecialists.

This suggestion is the more interesting coming at atime when the Spens proposal is itself under nra. Its

opponents say that all sorts of personal difficulties willarise if any primarily professional body has to decide onunequal payment of doctors holding similar appointments.Certainly the awkwardness of choice will be increasedby the fact that the three awards of 500, 1500, andjE2500 differ so widely, and the committee’s task mightbe less formidable if these awards took the form of

promotion to one of three ascending scales in which lengthof service would again operate. Complaints might alsobe reduced if the regular increments granted to allspecialists did not cease quite so abruptly and so earlyin their career. Such minor modifications, however, donothing to meet the main objection that a small centralcommittee cannot possibly know much about all thecandidates, and that the chances of personal acquaintancemight therefore affect its decisions. In answer to this,the suggestion has been put forward that the awardsshould be made in the regions, by regional appointments

21

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.