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THE CAPITATION FEE
134
end of the fever, when the pulse-rate fell to 60 a minute or less. WALKER and DoDS were unable to study the blood-picture adequately, but leucopenia affecting the granular leucocytes only is a typical finding for the first four or five days, and this is followed, it is said, by a leucocytosis up to 15,000 or 20,000 per c.mm. about the tenth day of the disease. Treatment is purely palliative, but sedatives relieve the symptoms to some extent. The mortality is negligible. The importance of this malady (apart from its unpleasantness to the sufferer) lies in its tendency to arise epidemically, for outbreaks may make it difficult to keep a non-immune force active in the field during the epidemic season. Prophylaxis is difficult on account of the very small size, the breeding habits and the voracity of the sandfly vector. The breeding grounds of the insects are rubble, dug-outs, cracks in walls and embankments, and sun cracks in the ground. The larvae penetrate to a depth of a foot or more in loose, slightly moist soil, and the insect hibernates in the larval stage, emerging in the spring. The female alone bites, usually after dark, and its powers of flight are limited. The erection of parapets, the excavation of tent and hutment floors, and similar earthworks necessary in the field of
CAPITATION
flies.
astinum, pernicious anaemia and
Annotations THE
may facilitate the breeding of the Where cracks can be levelled or filled in, especially with tar, the insects can be discouraged from breeding. Blackout conditions increase the liability to be bitten, because men prefer to sit outside, on or near the ground, where the flies await them, rather than in dark tents or huts. The ordinary mesh mosquito net is useless against these tiny aerial invaders and suitable nets of muslin, or of particularly fine mesh, although efficient in excluding them from a sleeper, feel close and stuffy in a hot climate. Their use should, however, be insisted on whenever practicable. The use of a pyrethrum insecticidal spray inside huts and tents daily, before sweeping the floors, will reduce the sandflies, mosquitoes and house flies in such places, and an electric fan where available will provide currents of air sufficient to carry the sandflies away. If huts and similar dwellings can be built on piles well off the ground they will be comparatively immune from invasion by sandflies. No drug, serum or vaccine therapy is available for immunisation against the disease, and the best precautionary measure against undue morbidity in endemic areas is to employ on active operations troops " salted " by previous infection.
military activity
so on they found that the colour and relieved his dyspimproved patient’s nœa. In only one case-their first-was any complication encountered; here an old man became temporarily unconscious during the. administration, with extensor plantar reflexes, but he soon recovered and was none the The only disadvantage appeared to be that worse. the method required the whole-time attention of the administrator, and as it is now generally agreed that oxygen should be given continuously this is a serious drawback. The method has since been little used, though it was revived a year ago by Singh and Shah,2 who found that amounts up to 10 c.cm. a minute could be safely injected from a cylinder, or double this amount if chemically pure oxygen was used, representing some 10% of the patient’s requirement. They gave up to 350 c.cm. to six patients with pneumonia and satisfied themselves that there was clinical improvement. They mention that oxygen embolism, unless carried to extremes, is not dangerous. There is, then, no doubt that intraOn venous oxygen is practicable and reasonably safe. the other hand, its use in peace-time would be -confined to the patient whose functional lung is much reduced extensive pneumonia, and such cases are rare. ’ In the treatment of shock without cyanosis it is doubtful whether the method would have any place. Here the blood is fully oxygenated in the lungs, and the tissues are only short of oxygen because their blood-supply is deficient. The inhalation of pure oxygen relieves this shortage slightly by forcing an extra 2-3 c.cm. of oxygen into solution in every 100 c.cm. of plasma. To do this by the intravenous route would mean giving the exact amount necessary to oxygenate the haemoglobin plus a very little more to saturate the plasma. In other words, the patient would have to be given a little more oxygen than he was consuming, a procedure which would certainly produce embolism. Giving a little less would be safer, but this would only relieve the lungs of their task of oxygenating the haemoglobin, which they had previously been doing efficiently and without difficulty. When the patient is cyanosed the position is different, for unsaturated haemoglobin is avid of’,oxygen, and there seems a possible use for the method in cyanosed patients with severe injuries of the lungs or chest wall. It is in
this
FEE
WHEN introducing on July 15 the second reading of the bill with a long name the Secretary of State for Scotland said that the question of the doctor’s capitation fee was still under consideration. Actually, as Dr. Anderson told the Insurance Acts Committee on July 10, the Minister of Health had already agreed to increase
capitation fee from 9s. to 9s. 9d. and there is to be further advance on this offer. At the beginning of 1942 provision will be made for finding 20s. a year as a - fixed charge for each insured person : 14s. 6d. of this will be paid into the medical pool, out of which it is .estimated administration will draw 10d., drugs 3s. 7d., mileage 41 4d ., the remainder with luck being very nearly if not quite 9s. 9d. Of the additional 9d. the larger part (5d.) is intended to cover the increased expenses of practice. The 3d. is added, apparently, to compensate the doctor for the transfer of the new higher-income group (JE250-jE420) from his private to his insured practice. Dr. Anderson calculated that an extra 3d. ,all round will bring in something like lls. 6d. per head of these new entrants. The doctor can thus pretend that he is getting a guinea for each of them, and if he lives in a Utopia where there are 40 previously insured persons .to each new entrant he may even be right. Admittedly the 9d. increment to the capitation fee has been arrived -at without reference to enhanced cost of living and the Minister has given an undertaking that the basic fee will be reassessed immediately after the war. the no
INTRAVENOUS OXYGEN
A CORRESPONDENT asks why more use is not made of :intravenous oxygen in the treatment of shock, and points ,out that the method has been proved practicable. During the last war Tunnicliffe and Stebbingl worked out such a method with a view to applying it to the treatment of acute cyanosis caused by mustard gas and other respiratory -irritants. Using simple apparatus they experienced no difficulty in introducing oxygen into a vein at the rate ,of 600-1200 c.cm. an hour, and in cases of chronic cyanosis arising from malignant disease of the medi1. Tunnicliffe, F. W. and Stebbing, G. F. Lancet, 1916, 2, 321.
by
2.
Singh,
I. and
Shah, M. J. Ibid, 1940, 1,
922.
end of the fever, when the pulse-rate fell to 60 a minute or less. WALKER and DoDS were unable to study the blood-picture adequately, but leucopenia affecting the granular leucocytes only is a typical finding for the first four or five days, and this is followed, it is said, by a leucocytosis up to 15,000 or 20,000 per c.mm. about the tenth day of the disease. Treatment is purely palliative, but sedatives relieve the symptoms to some extent. The mortality is negligible. The importance of this malady (apart from its unpleasantness to the sufferer) lies in its tendency to arise epidemically, for outbreaks may make it difficult to keep a non-immune force active in the field during the epidemic season. Prophylaxis is difficult on account of the very small size, the breeding habits and the voracity of the sandfly vector. The breeding grounds of the insects are rubble, dug-outs, cracks in walls and embankments, and sun cracks in the ground. The larvae penetrate to a depth of a foot or more in loose, slightly moist soil, and the insect hibernates in the larval stage, emerging in the spring. The female alone bites, usually after dark, and its powers of flight are limited. The erection of parapets, the excavation of tent and hutment floors, and similar earthworks necessary in the field of
CAPITATION
flies.
astinum, pernicious anaemia and
Annotations THE
may facilitate the breeding of the Where cracks can be levelled or filled in, especially with tar, the insects can be discouraged from breeding. Blackout conditions increase the liability to be bitten, because men prefer to sit outside, on or near the ground, where the flies await them, rather than in dark tents or huts. The ordinary mesh mosquito net is useless against these tiny aerial invaders and suitable nets of muslin, or of particularly fine mesh, although efficient in excluding them from a sleeper, feel close and stuffy in a hot climate. Their use should, however, be insisted on whenever practicable. The use of a pyrethrum insecticidal spray inside huts and tents daily, before sweeping the floors, will reduce the sandflies, mosquitoes and house flies in such places, and an electric fan where available will provide currents of air sufficient to carry the sandflies away. If huts and similar dwellings can be built on piles well off the ground they will be comparatively immune from invasion by sandflies. No drug, serum or vaccine therapy is available for immunisation against the disease, and the best precautionary measure against undue morbidity in endemic areas is to employ on active operations troops " salted " by previous infection.
military activity
so on they found that the colour and relieved his dyspimproved patient’s nœa. In only one case-their first-was any complication encountered; here an old man became temporarily unconscious during the. administration, with extensor plantar reflexes, but he soon recovered and was none the The only disadvantage appeared to be that worse. the method required the whole-time attention of the administrator, and as it is now generally agreed that oxygen should be given continuously this is a serious drawback. The method has since been little used, though it was revived a year ago by Singh and Shah,2 who found that amounts up to 10 c.cm. a minute could be safely injected from a cylinder, or double this amount if chemically pure oxygen was used, representing some 10% of the patient’s requirement. They gave up to 350 c.cm. to six patients with pneumonia and satisfied themselves that there was clinical improvement. They mention that oxygen embolism, unless carried to extremes, is not dangerous. There is, then, no doubt that intraOn venous oxygen is practicable and reasonably safe. the other hand, its use in peace-time would be -confined to the patient whose functional lung is much reduced extensive pneumonia, and such cases are rare. ’ In the treatment of shock without cyanosis it is doubtful whether the method would have any place. Here the blood is fully oxygenated in the lungs, and the tissues are only short of oxygen because their blood-supply is deficient. The inhalation of pure oxygen relieves this shortage slightly by forcing an extra 2-3 c.cm. of oxygen into solution in every 100 c.cm. of plasma. To do this by the intravenous route would mean giving the exact amount necessary to oxygenate the haemoglobin plus a very little more to saturate the plasma. In other words, the patient would have to be given a little more oxygen than he was consuming, a procedure which would certainly produce embolism. Giving a little less would be safer, but this would only relieve the lungs of their task of oxygenating the haemoglobin, which they had previously been doing efficiently and without difficulty. When the patient is cyanosed the position is different, for unsaturated haemoglobin is avid of’,oxygen, and there seems a possible use for the method in cyanosed patients with severe injuries of the lungs or chest wall. It is in
this
FEE
WHEN introducing on July 15 the second reading of the bill with a long name the Secretary of State for Scotland said that the question of the doctor’s capitation fee was still under consideration. Actually, as Dr. Anderson told the Insurance Acts Committee on July 10, the Minister of Health had already agreed to increase
capitation fee from 9s. to 9s. 9d. and there is to be further advance on this offer. At the beginning of 1942 provision will be made for finding 20s. a year as a - fixed charge for each insured person : 14s. 6d. of this will be paid into the medical pool, out of which it is .estimated administration will draw 10d., drugs 3s. 7d., mileage 41 4d ., the remainder with luck being very nearly if not quite 9s. 9d. Of the additional 9d. the larger part (5d.) is intended to cover the increased expenses of practice. The 3d. is added, apparently, to compensate the doctor for the transfer of the new higher-income group (JE250-jE420) from his private to his insured practice. Dr. Anderson calculated that an extra 3d. ,all round will bring in something like lls. 6d. per head of these new entrants. The doctor can thus pretend that he is getting a guinea for each of them, and if he lives in a Utopia where there are 40 previously insured persons .to each new entrant he may even be right. Admittedly the 9d. increment to the capitation fee has been arrived -at without reference to enhanced cost of living and the Minister has given an undertaking that the basic fee will be reassessed immediately after the war. the no
INTRAVENOUS OXYGEN
A CORRESPONDENT asks why more use is not made of :intravenous oxygen in the treatment of shock, and points ,out that the method has been proved practicable. During the last war Tunnicliffe and Stebbingl worked out such a method with a view to applying it to the treatment of acute cyanosis caused by mustard gas and other respiratory -irritants. Using simple apparatus they experienced no difficulty in introducing oxygen into a vein at the rate ,of 600-1200 c.cm. an hour, and in cases of chronic cyanosis arising from malignant disease of the medi1. Tunnicliffe, F. W. and Stebbing, G. F. Lancet, 1916, 2, 321.
by
2.
Singh,
I. and
Shah, M. J. Ibid, 1940, 1,
922.