RAPID hCG-BETA-SUBUNIT RADIOIMMUNOASSAY

779 titres were measured by the standard a-bungarotoxin precipitation method" with human AChR protein from freshly amputated legs and were expressed as nmol bungarotoxin precipitated per litre of serum. All normal controls had a titre of

body

less than 0. 3. Abnormal titres were found in 40% of MG patients with clinically ocular MG (range 0-13-50 nmol/1, mean 3.13) and in 88% of those with generalised MG (0-52.50, 15.41). With 1 exception, all relatives had titres below 0.3, even though 7 were positive for thyroid antibody, 3 for gastric parietal cell antibody, and 1 for smooth muscle antibody. The exception was the father of a 2Y-year-old boy with congenital MG, and his titre was 0- 76 (on several occasions). Our findings indicate that relatives of patients with MG do not have antibody directed against the AChR in their serum, and this contrasts with the electrophysiological evidence for a subclinical disorder of neuromuscular transmission in a proportion of relatives of patients withjuvenile MG. 14 The absence of AChR antibody in relatives who have other autoantibodies present suggests that while these individuals have an abnormality of immune function (resulting in loss of tolerance to a number of different mitogens) it is not a specific defect affecting the AChR antigen. This accords with the concept of a (genetically influenced) fundamental defect in immunoregulatory mechanisms. The presence of AChR antibody in the asymptomatic father of a case of congenital MG may suggest a more direct

Commentary

from Westminster

mode of inheritance for this

particular form of the

Dystrophy Group Research Laboratories, Regional Neurological Centre, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE

G. L. WALKER L. V. B. NICHOLSON F. L. MASTAGLIA*

(dominant) disease. Muscular

* Present address: University Department of Medicine, cal Centre, Nedlands, Western Australia 6009.

RAPID hCG-BETA-SUBUNIT RADIOIMMUNOASSAY

StR,—I found the article by Professor Seppala and colleagues (Jan. 26, p. ’165) on the use of hCG-beta subunit radioimmunoassay in gynaecological emergencies very interesting. Our ’Preg!Stat-Beta’ pregnancy testing kit is based on a method similar to that described by Seppala et al. Urine or serum is mixed with antibody and labelled hCG and incubated for 30 min before

separation of bound and free phases with The cut-off point for confirmation of preg25 mIU/ml for serum or plasma and 150 mIU/ml for

polyethyleneglycol. nancy is urine.

Diagnostic Division, Serono Laboratories (U.K.) Ltd, Welwyn Garden City, Hertfordshire AL7

expenditure plans, rise still

charges The white-paper to

could well be future contraction of the cash available to the N.H.S. in real terms. There are fears at Westminster that the Government’s spending plans for the N.H.S. will-in spite of official intentions to the contrary-result in further hospital closures. The Budget measures are clear enough. The cost of prescriptions to the patient will rise from 70p per item in April to il in December. Dental charges, from April 1, will be levied for the first time on people between 16 and 21 who have left school. There will be a i2 charge for an eyesight test from the same date. Under-16s will be exempt. Income from pay-beds, which is at present channelled into central N.H.S. funds, will become available to the local health authority where the pay-beds are situated. The Social Services Secretary will investigate ways of increasing the proportion of the true cost of treating road-accident victims that goes to the N.H.S. Total spending on the N.H.S. by central Government is to rise by 0-5% next year, and by 1-7% in the followThere are plans, still rather reduce abuses of the N.H.S. by foreign visitors, and to take another look at the cost of treating foreign visitors in general (apart from those covered by reciprocal health-care arrangements). Mr Patrick Jenkin and his colleagues see no reason why British patients too should not make a greater contribution to the cost of their treatment. The rise in prescription charges, he says, will also help doctors to resist the pressure from patients wanting "a pill for every ill". The Government’s

ing two years, in real terms. vague,

to

1AU

MICHAEL S. WALKER

furthermore, allow for all the new further, with the rate of inflation.

on future expenditure, issued at the time as the Budget, says that charges will increase annually in line with costs. The rise in prescription charges is expected to claw back 30 million more on the cost of drugs in 1981-82 than would have been recouped without it. In the same period new dental charges should bring in another ,E9 million, and the new ophthalmic charges another 11 million. Mr Jenkin hopes that by 1983-84, the total of health charges will produce C311 million, or 4.4% of gross expenditure on the N.H.S. Reallocation of resources from richer to poorer regions will continue, Mr Jenkin said, although there was little scope for redistribution this year. Nevertheless the growth of resources in the N.W. Thames region, for instance, will be 0-3% next year, while Trent, North Western, Northern, and East Anglian regions will grow by 0 - 6%. Mr Jenkin declared that the Government stuck to its pledge to maintain spending on the N.H.S.; and expenditure on the N.H.S would continue to grow in real terms over the next few years. But some questions remain unanswered. The expenditure plans for the Health Service are based on the assumption that inflation in the relevant period will average an annual 14%. But Mr Jenkin’s plans for the social services are based on a projected 16.5% inflation rate. It is said that the true inflation rate allowed for on the health side is nearer 15%. But a discrepancy of at least 1.5% remains. Labour’s Shadow Social Services Secretary, Mr Stan Orme, takes the view that this will lead to a severe squeeze on the health services, and indeed to hospital closures. And what will happen if the inflation rate turns out even higher than official expectations ? With his repeated insistence that he has protected the growth of the N.H.S. Mr Jenkin seems to same

Budget Reactions THERE was little cheer in Sir Geoffrey Howe’s Budget last week for either employees or patients of the N.H.S. Apart from the increases in many health charges, there

Queen Elizabeth II Medi-

780 have given a hostage to fortune. The expenditure plans will be fiercely contested by the Opposition as the Finance Bill, which puts them into operation, goes through Parliament. There will be equally determined opposition to the array of new and increased charges. Mr Orme admits that the scale of the increases took him aback. "Since the Conservatives came to power prescriptions will have gone up by 400%. It is outrageous. When you go to see your doctor you will certainly have to pay. The charge is punitive, and it is the working poor who are going to have to carry the burden." Official reiteration that 6 out of 10 prescriptions are covered by exemptions cannot mask the fact that many sick people will be discouraged from going to the doctor by the charges. Mr Orme wondered whether doctors might simply prescribe larger quantities of drugs on each prescription, which was just as undesirable. Mr Jenkin believes that health authorities will be able to live within their budgets as long as there is "responsible wage bargaining on both sides." But with Sir Geoffrey Howe’s Budget expected to increase inflation further, this looks like another hostage to fortune. Rising prices will make trade unions very determined in presenting their pay claims. But health authorities, with their own cash-limits in mind, will be equally keen to resist. The final question concerns the amount of political pressure that D.H.S.S. Ministers can exert on Cabinet decisions. It is said that Mr Jenkin fought hard and successfully in pre-Budget discussions to save the N.H.S. from Sir Geoffrey’s depredations. But no D.H.S.S. Minister can have been happy about Sir Geoffrey’s feeble extra tax of 5p on cigarettes. This is a tax that shows up in the retail price index, and there is thus an obvious public-relations advantage to be gained by not attacking cancer more courageously. One can reasonably expect that Mr Jenkin argued for a stiffer impost-without success.

Energy Conservation in the N.H.S. another ,E30 million a year by economising heating, Sir George Young, D.H.S.S. Under-Secretary, told an energy conservation symposium organised by the Institute of Hospital Engineering. The N.H.S. spent ;E150 million a year on heating, and the figure would double in the next twenty years unless action was taken. "When I talk about saving C30 million a year in fuel costs, it may sound like pie in the sky, but I’m convinced it’s possible," Sir George argued. Even hospitals built at the turn of the century could halve their heating costs. Commonsense, management study, and enthusiasm were the key factors in saving. Electric energy control centres were already used in some hospitals, and more were planned. Once the value of such devices was appreciated they would become widespread. In energy conservation, the N.H.S. should set an example to the nation. The N.H.S. could

save

on

RODNEY DEITCH

Obituary FRANZ JOSEPH INGELFINGER M.D. Harvard

Editor, New England.7ournal of Medicine, 1967-77

Dr Ingelfinger had at least two careers: as a gastroenterologist who made great clinical and investigative contributions to the subject; and later as an Editor who took charge of an already famous journal and enhanced its quality. He died on March 26. born in Dresden in 1910. His father was assistant of professor bacteriology in the University of Gottingen and his mother an American schoolteacher. They left Germany for New England in 1922. He graduated from Yale with a liberal arts degree; and then studied medicine at Harvard. In the’30s gastroenterology was a little frequented specialty and Ingelfinger resolved to make it his own. He worked in Philadelphia with Miller and Abbott, designers of the intestinal tube, and he became keenly involved in the study of intestinal motility and absorption. In 1940 he was appointed chief of gastroenterolosv at the Evans Memorial Hospital in Boston. By his use of intraluminal manometry and his work on hepatic blood flow and post-gastrectomy megaloblastic anaemia he made fundamental progress in the understanding of gastrointestinal function and disease. He established a great reputation as a teacher and many of his students have achieved positions of distinction from the basis he provided by his tireless enthusiasm and exacting standards. In 1961 he took on a new role as chief of Boston University Medical Services at Boston City Hospital; and six years later he made another change when he followed Dr Joseph Garland in the Editor’s chair at the New EnglandJournal of Medicine. For the next ten years he added much to the journal’s already vast reputation-and circulation. He seldom drew back from controversy and the publication of anti-establishment views, though he always insisted that contributions must pass the scrutiny of expert reviewers. He was particularly active in stimulating debate on issues of medical ethics and in presenting the social aspects of medicine. The clarity and logic of the journal’s contents were kept rigorously under his daily eye. He believed in open editing and he explained in signed editorials what he was doing and how he saw the developing role and the difficulties of his journal. His views, like those of his predecessor, were closely studied by medical editors elsewhere, though some may have flinched at his tell-it-all methods. He disapproved heartily of laxity in writing and incoherence of argument and he would devote many hours to the elimination of these faults in any article. He opposed with great force anything approaching dual or prior publication: if the contents of a paper submitted for publication had had or were to receive advance publicity in a medical newspaper or a lay publication the author’s chances of a place in the New England Journal were diminished almost to vanishing point. He often expressed concern about the unjustifiably high expectations which the medical profession had induced in its patients; and he always strove, with conspicuous success, to provide a journal that was of benefit to both doctors and patients. His many honours included the Friedenwald medal of the American Gastroenterological Association, the American College of Physicians’ Distinguished Teacher Award, the Flexner Award of the Association of American Medical Colleges, and He

was