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and in BOYD’S series there was only 1 death in over600 operations ; both sides can be done at one time,and age alone is no contra-indication. Paravertebral

sympathetic block with a 10% aqueous solution ofphenol 4 is an effective method of performing a" chemical sympathectomy," though the technique isnot easy. This is a useful procedure for patients whorequire sympathectomy, but in whom there are

contra-indications to operation. Of the various drugswhich have been tried at the Manchester clinic the

only one which has given encouraging results, as

regards both claudication and nutrition of the leg, isvitamin E by mouth. The optimal dosage is 400 mg.daily, and benefit is usually observed withm 6-8weeks. Further work is being done to assess the realvalue of this substance.

Peripheral Neuritis and BronchialCarcinoma

To the many causes of peripheral neuritis anothermust, it seems, be added-bronchial carcinoma.In 1948 DENNY-BROWN 5 described two cases in whichthese two disorders were associated ; in each theneuritis was the presenting feature and the carcinomawas discovered only post mortem. In both thesecases the peripheral neuritis was unusual in that thesensory elements were greatly affected, with relativelylittle motor involvement. Pathological examinationshowed extensive changes in the cells of the posterior-root ganglia with degeneration of the posterior rootsand of sensory fibres in the peripheral nerves. Therewas little apparent change in motor fibres ; but inboth cases there were changes in the muscles, thoughtto be a primary degeneration of muscle-fibres.WyBURx-MASOrT 6 reported the same two cases andadded a third in which the clinical involvementwas motor rather than sensory and pathologicalexamination revealed degenerative changes in theanterior roots and motor fibres of the peripheralnerves.

LENNOx and PRICHARD 7 have now describedtwo further instances of this strange association.In both the neurological symptoms improved for atime, but a severe relapse preceded death. Clinically,motor elements of the peripheral nerves were pre-dominantly affected ; at necropsy in one of thecases there was demyelination, chiefly of motor fibres,in selected peripheral nerves, while in the other therewas no definite pathological change. The posterior-root ganglia were not examined, but severe degenera-tive changes are unlikely to have been present in

these ganglia because the posterior columns of thecord were unaffected. LENNOX and PRICHARD foundrecords of three further cases of bronchial carcinomaassociated with peripheral neuritis ; and in these threealso, the presenting symptoms had been neurological.The important question is whether this association

of peripheral neuritis and bronchial carcinoma ismore than accidental. DENNY-BRowN, impressedby the unusual clinical and pathological featuresof the peripheral-nerve disorder, concluded that thetwo diseases were intimately connected ; but inthe other cases that have been reported this unusual4. Haxton, H. A. Brit. med. J. 1949, i, 1026.5. Denny-Brown, D. J. Neurol. Neurosurg. Psychiat. 1948, 11,

73. 6. Wyburn-Mason, R. Lancet, 1948, i, 203.7. Lennox, B., Prichard, S. Quart, J. Med. 1950, 19, 97.

type of sensory neuropathy has not been found,the nerve involvement being mainly of the motorelement. LENNOX and PRICHARD’S cases were

5 among 299 of bronchial carcinoma ; and that theassociation is not fortuitous is strongly suggested bytheir review of the incidence of peripheral neuritisin cases of carcinoma at other sites and of other typesof chronic chest disease. From the pathological studiesit is evident that the peripheral nerves and spinalroots have not been directly involved by neoplastictissue, and the pathogeny of the peripheral-nervedisorder remains obscure. WYBURN-MASON suggestedthat there was an analogy with hypertrophic pul-monary osteo-arthropathy, and that the disturbanceof neural function was produced " reflexly " from thelungs. DENNY-BROWN pointed out the resemblancebetween the posterior-root ganglion degenerationin his cases and that in the ataxia of swine when theseanimals are fed on a diet deficient in calcium panto-thenate and pyridoxine 8; and he postulated thatthe cause was a metabolic disorder related to thetumour ceils.

This association of diseases indicates the importanceof radiography of the chest in cases of peripheralneuritis of obscure origin ; and it will be interestingto study the course of the neuritis if a case is foundin which the bronchial carcinoma can be removed

completely.

Annotations

DISSATISFIED PRACTITIONERS

LAST week the Conference of Local Medical Committeesmet to discuss the negotiations on general practitioners’remuneration. After emphasising that at no time, eitherbefore or since the appointed day, had agreement beenreached on this subject with the Government, theconference proceeded to express its grave disquiet atthe repeated hold-ups and long delays in the negotiations.The Minister of Health had avoided making any definitereply when asked by the General Medical Services Com-mittee what sum he thought should be in the centralpool to implement the recommendations of the Spensreport. The conference believed that he had all the dataneeded to make this calculation, and it pressed for animmediate statement. It was also disturbed at the

suggestion, implicit in some of the correspondence withthe Ministry, that future negotiations on general-practi-tioner remuneration need not necessarily be conductedthrough Whitley Council machinery.

Because of its dissatisfaction with the present remunera-tion and with the inconclusive negotiations for its

amendment, the conference proceeded to instruct theG.M.S. Committee to make preparations forthwith for thetermination of contracts by general medical practitioners.It did not propose a date on which this collectivetermination of contracts might take place. Such a datewould be fixed at another special conference, to be calledif it became obvious that there was no further prospectof a satisfactory settlement. Unless a settlement isreached first, a conference will be called next Decemberat latest.The Minister has recently proposed to the G.M.S.

Committee that he should, with the cooperation ofthe profession, undertake certain investigations into theactual earnings and expenses of practitioners during theyear ended March 31, 1950. The conference consideredthis suggestion, and concluded that the chances of an8. Wintrobe, M. M., Follis, R. H., Stein, H. J., Mushatt, C.,

Humphreys, S. J. Nutrit. 1942 24, 345.

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equitable settlement of remuneration might be increasedby early and accurate information on practitioners’income from N.H.S. sources, and on practice expenses.Accordingly it was willing to participate.For the rest of its time the conference discussed and

deplored the sinking status of the general practitioner,and urged the G.M.S. Committee to do whatever it couldto buttress and restore this status. Just how it was todo so did not emerge very clearly, for the conferencewas unwilling to admit that the loss of status was asso-ciated with, or could solely be accounted for, by thehurried and harassed form of practice that an increasedload of medical and clerical duties has thrust on manydoctors. It laid more stress on the gulf between thepractitioner and the hospital, and felt that the practi-tioner should be afforded much greater clinical andadministrative contact with his local hospitals and theirmanagement committees. One practical proposal camefrom Buckinghamshire, whose representative had beenencouraged by the initial success of discussions betweenthe Oxford Regional Hospital Board and representativesof all local medical committees in the Oxford region(see p. 65). He put forward the suggestion, which wasaccepted by the conference, that local medical committeesshould themselves form a joint committee over an areacorresponding to that of a regional hospital board, andshould seek through this joint committee to keep in

regular touch with the board.

THE INFECTIOUS TUBERCULOUS

LIKE every other infectious disease, tuberculosispresents two problems-care of the patient, and pro-tection of the rest of us. If it is to be brought undercontrol, neither aspect can be ignored. 1 In our corre-

spondence columns, Dr. Grenville-Mathers and Dr.Trenchard note that the National Health Service Actfocuses attention on treatment, and essentially on thetreatment of those who can profit by it. But even thisis not done well ; the patient waiting for a bed maypass from the hopeful to the hopeless class before hegets so much as the chance of treatment. Moreover, asour correspondents point out, about a quarter of thepulmonary-tuberculosis patients known to the chestclinics who are not in hospital have positive sputum ;and they are actually discharged from sanatoria in thisdangerous state, simply because there is nothing else todo with them. What becomes of them then ? They donot easily find work, and if they are only to be admittedto ordinary employment on condition that they disclosetheir disability to their employers, as the Joint Panelon the Resettlement of the Tuberculous have recom-mended, they will find it hard to get a job at all. Evenas it is they are apt to become derelict ; the healthcommittee of the London County Council note 2 that inLondon alone, there- are at present some 160 of themliving at close quarters with uninfected people in commonlodging houses. The situation is intolerable for them :in their sanatoria no doubt, they were taught that theywere a danger to others, but what can they do about it ’?When society prescribes duties and withholds the meansof fulfilling them, even the most law-abiding transgress,as anyone who tries to park a car in London knows.These patients must be given some measure of shelterand help, not only on their own account but in the

urgent interests of the whole community.The L.C.C. has for some time contemplated building

night sanatoria in which such patients might live undermedical supervision, and from which they could go out.to work, perhaps under sheltered conditions. Beforethe Act came into force arrangements used to be madefor some of them to enter small voluntary, sanatoria.This was not in our view - a satisfactory solution, for

1. Lancet, July 1, 1950, p. 21.2. L.C.C. Agenda Paper no. 2. July 4. See also p. 70.

such sanatoria found great difficulty in getting staff. Weknow of places where girls of 151/2 or 16 were employed,and some of these died of tuberculosis or were crippledby it. Since the Act came into force, the regionalhospital boards, according to the report of the L.C.C.health committee, have been unable to provide accom-modation for irremediably open cases, and take the viewthat these cases are not their responsibility. Meanwhile thehealth committee have been looking for suitable quartersfor hostels or night sanatoria, so far without success ;moreover they feel that the regional hospital boardsshould properly be taking the responsibility, especiallysince a patient needing urgent treatment could betransferred to hospital much more readily if he was in ahostel controlled by the board. The job is so urgent,however, that the health committee feel it matters verylittle who does it as long as it gets done ; and theyintend to send a deputation to ask the Minister of Healthwhere the responsibility lies. They have already madeone important proposal to him-namely, that St. Peter’sHospital, Stepney, should be pulled down and the siteused for a night sanatorium, and for industrial workshopswhich would be run in collaboration with the DisabledPersons Employment Corporation. The Minister wasunable to approve the necessary expenditure for thisproject, but the need is so great that the committeeintend to raise it again with him. Indeed, night sana-toria are needed throughout the country. They couldreceive patients who would otherwise not be dischargedfrom sanatoria until later, and so might greatly relievethe pressure on treatment beds. If the Minister wereable to arrange for the admission of tuberculouspatients to a proportion of general hospital beds(p. 70) this pressure might well be removed altogether,and we should have better prospects of controlling thespread of tuberculosis than we have ever had in ourlives.

THE CHILD AND HIS HEREDITY

As infant deaths go down the proportion due to con-genital abnormalities rises ; according to Dr. FraserRoberts, speaking at the annual conference of theNational Association for Maternity and Child Welfare,these now account for 1 infant death in 6, and are fivetimes commoner as a cause of mortality than they werein 1900. In one way this is good news, because it meanswe are approaching the irreducible minimum-irreducible,that is, by ordinary medical, social, and eugenic measures.On the other hand, it means we are getting no nearerthe prevention of such congenital defects, which areresponsible not only for deaths but also for much unavoid-able disability in infancy and childhood. In 1937, hesaid, among children of school age 37 per 100,000 wereblind, a third of them from congenital defects of vision ;in 1948 the incidence had fallen to 21, but two-thirds ofthe cases were congenital in origin. If the average ageof mothers could be reduced by 5 years, this incidence ofcongenital malformations of all kinds, he stated, wouldbe cut by about half. Meanwhile our growing knowledgeof heredity can often be used to guide-those parents whohave had a congenitally malformed child. In many casesit is possible to predict whether or not other childrenin the family are likely to be affected, and the parentscan sometimes be told the exact chances against theirhaving another defective child. Again, many mal-formations and abnormalities-such as hare-lip or club-foot-can be repaired or treated. In the case of therhesus factor, 1 child in 150 is born with haemolyticdisease, because he has inherited from his father anantigen not present in his mother ; and up till 10 years agohalf these children died. Now that appropriate trans-fusion can be begun at birth, the death-rate has fallento a tenth. It is also becoming possible to predict whichpeople, for genetic reasons, are unduly susceptible to