1183 that the scaphoid going through this variation of normal ossification may perhaps be more vulnerable at a certain stage and therefore more susceptible to the influences of minor traumata; hence the symptoms.
suggests
THE CAPITATION FEE
THE Panel Conference having last year declared that 9s. is too small a capitation fee for insured persons, and the Minister having said he thinks it may well be too much, arrangements have now been made for arbitration. The arbitrators, constituted as a court of inquiry, are Lord Amulree (chairman), Mr. Thomas Howorth, and Mr. D. H. Robertson, with Mr. E. H. Phillips of the Ministry of Health as secretary. Their task is to advise what, if any, alteration should be made next January in the capitation fee, " having regard to any changes which may have taken place since 1924 in the cost of living, the working expenses of practice, the number and nature of the services rendered by insurance practitioners to their insured patients, and other relevant factors." The inquiry is to proceed on the assumption that employed persons under 16 years of age will by that time be entitled to medical benefit ; and the arbitrators’ findings should help to resolve the conflict of opinion that has arisen from the Minister’s belief that a substantially lower fee should be paid for children than for adults.
MENINGOCOCCAL MENINGITIS TREATED WITH SULPHANILAMIDE
SULPHANILAMIDE, as p-aminobenzenesulphonamide conveniently called, has been proved lethal to meningococci,l and accounts on its use in cerebrospinal fever are eagerly awaited. A small series of cases now reported from Baltimore is encouraging so far as its goes. Schwentker, Gelman, and Long2 have treated 10 patients with meningitis and 1 with meningococcal septicaemia—the series being to is
all intents and purposes consecutive-and are able to record recovery in all but 1 of them. They used a physiological solution of sodium chloride containing 0-8 per cent. of sulphanilamide, and they gave it by intraspinal and subcutaneous injection. They began by withdrawing cerebro-spinal fluid and replacing it with the sulphanilamide solution, the amount injected varying from 10 to 30 c.cm. and usually being 5 to 10 c.cm. less than the amount of fluid withdrawn. A larger quantity of the solution was then given subcutaneously ; they injected about 100 c.cm. for each 40 lb. (18 kg.) of body-weight. Both intraspinal and subcutaneous injections were repeated every twelve hours for the first two days, and once daily thereafter until definite improvement was evident. Sometimes the cell count of the cerebro-spinal fluid fell rapidly and progressively ; sometimes it remained high for a few days and descended precipitately. In no case could organisms be found in the C.S.F. more than three days after treatment started. No untoward effects were noted : the subcutaneous injections gave no more reaction than would be expected with normal saline, and there were none of the signs of systemic reaction sometimes reported after sulphanilamide, such as rashes, methaemoglobinsemia, or sulphaemoglobinaemia.3 Schwentker and his colleagues are rightly cautious in their con1 Buttle, G. A. H., Gray, W. H., and Stephenson, D. (1936) Lancet, 1, 1286 ; Proom, H. Ibid, Jan. 2nd, 1937, p. 16. 2
Schwentker, F. F., Gelman, S., and Long, P. H., J. Amer. med. Ass. April 24th, 1937, p. 1407. 3 See paper by Paton and Eaton on p. 1159 of our present issue.
clusions, but in their 11cases they found the therapeutic response " quite comparable to that which usually follows treatment with specific antiserum," and they point out that sulphanilamide has the substantial advantage over serum that it does not cause irritation like a foreign protein. RISKS OF ENDOTRACHEAL ANÆSTHESIA AND OF EXPLOSIONS
A CONTROVERSY has been going on in the last two numbers of the British Journal of Ánaesthesia over the possible dangers of nasal endotracheal
methods. Dr. Massey Dawkins in January asserted that bacteria lie within the external nares whence they are normally removed by ciliary action. The nasal catheter, he thinks, may carry these organisms directly to the trachea where they may not be effectively dealt with. He quotes two fatal cases of broncho -pneumonia following endotracheal ansesthesia, which he believes illustrate and support his contention, and he also produces statistical evidence. His opinion is that " administration of an endotracheal anaesthetic for every case is becoming too common," though he does not deny that the method is " certain, easily controllable and admirably suited to the needs of the surgeon and of the ansesthetist." The cudgels in defence of nasal endotracheal methods were taken up in the April number and wielded with vigour. Dr. Ivan Magill, who was the originator of this method and has employed it since 1919, has not yet met an instance of pulmonary complication that could justly be attributed to it. He holds that any bacteria present in the nose are probably already present in the trachea too. He agrees with Dr. Dawkins that " indiscriminate use of the endotracheal method by all and sundry, whether indicated or not, is to be deprecated." Mr. W. A. Mill suggests that the best way to avoid lung complications is to avoid operating until some time has elapsed after any acute infection of the upper respiratory tract. Cocainisation of the nares, the use of a small tube, an ansesthesia deep enough for insertion of the tube without spasm of the cords, and lubrication of the tube are features of the technique which other writers to the journal regard as
important.
Another paper in the April number, by Mr. J. H. Coste, F.I.C., deals with the cognate question of fire and explosion in operating theatres. It is a valuable contribution because other investigators have usually given primary consideration to the source of the spark or flame which starts an explosion. Mr. Coste, examining the chemical aspect, has experimented on the explosibility and inflammability of a number of the commonly employed inhalation anaesthetics. He gives numerous details and as regards ether draws the important practical conclusion that explosion due to dangerous concentrations of ether in the air of an operating theatre ... are most unlikely if the possible source of ignition is a foot or more above the floor level...." CEREBRO-SPINAL RHINORRHŒA
CEREBRO-SPINAL rhinorrhoea if rare is a serious condition since it carries with it the danger of meningitis. Diagnosis is easy if the possibility is not forgotten : profuse flow, or free dripping of a clear fluid which does not stiffen on the handkerchief is a characteristic sign, confirmed when chemical examination of the fluid shows absence of albumin and The cases fall mucin and the presence of glucose. into three groups : (1) those due to injury, (2) those