OPPORTUNITIES IN GENERAL PRACTICE

819

work in the same Way is at variance with all experience.’ Many women doctors continue in practice-after marriage, but the proportion of nurses who do likewise is very much smaller. "

continue their

I observe that- you make no mention at all of the aspects of the proposal contained in the Bill. It amounts, in brief, to a suggestion that on the one hand one can, at a cost ofjEx, give two years’ training to ancillary workers who will then be able to carry out two dental operations on children or one dental operation on adults and who may give service for ten years or something more. On the other hand for an expenditure oH2x a dental surgeon can be trained for five years and will then be able to give comprehensive service for a normal practising lifeof forty years. Bearing in mind the inevitable lapse of time before any considerable numbers of these dental ancillaries are available for the school dental service, it is, I suggest, uneconomic and unrealistic to force the creation of such a class, whose usefulness has not yet been demonstrated in the conditions of this country, to meet a crisis which may very well be a matter of long-past history before they are available.

economic

British British Dental Dental Association. Association, 13, Hill Street, London, W.1.

H. H T. T RROPER-HALL H T. ROPER-HALL President.

THE CHARGES under the above

SiR,ŁAs reported

heading in your issue of April 5, Dr. Edith Summerskill and Mr. Bevan seem to supply an answer which should appeal to all sections of the community. Mr. Bevan suggests that it would be logical to put drugs out of the National Health Service scheme. Dr. Summerskill states that in residential areas the cost of prescriptions is more than three times what it is in industrial areas ; which means that if drugs were outside the scheme the loss to the better-off would be three times as great as the loss to the industrial community. Doctors would like to prescribe less and have more To omit time for the examination of their patients. drugs from the scheme would represent a great saving in cost to the N.H.S. ;and to offset hardships it should not be difficult to devise a method of subsidy against the high cost of those drugs deemed from time to time to be of the greatest value in treatment. The prescribing of many proprietary remedies of doubtful usefulness would be discouraged. STANLEY ALCOCK. Reading. EARLY DUMPING SYNDROME AFTER

SiR,ŁWe have read with great interest the article by Mr. Goligher and Dr. Riley (March 29). If their conclusions are correct, the term dumping syndrome is an exact description of the mechanics of the condition, "

back where we started-in the illustrious of Sir Arthur Hurst. company Unfortunately their whole investigation appears to have been based on the false premise that the behaviour of a barium meal " is comparable to that of ingested food. The sensation of fullness after meals experienced by nearly all gastrectomised patients usually disappears in time ; and we have always assumed that the sensation, and its subsequent disappearance, were due to the small size of the stomach, and its gradual anatomical and physiological adaptation to the increased load which it is called upon to bear. It never occurred to us to doubt that barium cream would be retained in the stomach for a shorter period than a hearty lunch ; but in an effort to produce some radiological support for this assumption, we have investigated a patient on whom one of us performed a subtotal antecolic Polya-Hofmeister gastrectomy two and a half years ago. and

we are

"

’

We are well aware that one barium swallow does not make a statistical summer, but we have often observed distinct sphincteric action at the stoma after both Billroth i and Polya-type gastrectomies, and are of the opinion that any barium studies purporting to indicate the rate of emptying of the gastric remnant should be carried out after the ingestion of barium-impregnated food. V. J. DOWNIE HILLIARD.. CEDRIC HILLIARD. Barnet General Hospital.

’

SPLENECTOMY

SIR,-In his paper (March 29), Mr. Maingot lists no.

as

9 in the group of conditions where

splenectomy is Primary tumours-e.g., lymphosarcoma."

indicated " He does not discuss this further, and one is left with the impression that lymphosarcoma is a primary neoplasm of the spleen. Most workers regard this condition as a generalised disease closely related to lymphatic leukaemia. Indeed Willis1 suggests that lymphosarcoma and lymphatic leukaemia should not be differentiated as the presence or absence of a preponderance of lymphocytes in the peripheral blood is quite fortuitous. This close relationship would be demonstrated more often if routine bone-marrow examination was done in all cases

diagnosed as lymphosarcoma. Perhaps Mr. Maingot considers that splenectomy is indicated if the disease apparently involves only the spleen when first diagnosed. If this is so, the results of this method of treatment would be most interesting. Rarely lymphosarcoma is associated with a haemolytic anaemia, and in such cases splenectomy may be of benefit. It is difficult, however, to see how splenectomy will influence the course of the disease in the majority of cases.

0. D. BERESFORD. O.

Cardiff.

OPPORTUNITIES IN GENERAL PRACTICE 5 includes an account of the debate in the House of Lords on the administration of the National Health Service. During this debate Lord Moran made some remarks about which I feel

SiR,,-Your issue of April

deeply.

GASTRECTOMY

"

This patient, a memberof the hospital staff, agreed to adulterate his lunch, consisting of sausages, mashed potatoes, and cabbage, with 2 oz., of barium sulphate. At the end of 20 minutes none of this meal had left the stomach. At 65 minutes a very little had passed through into the jejunum ; and at the end of 2 hours about half the meal was distributed throughout the small intestine, whilst the remainder was still in the stomach.

to me unforgiveable that people in high should state that there has been an " insidious decline in the status of the general practitioner." There are, I believe, large numbers of extremely competent men in general practice, whose skill and knowledge entitles them to rank, in their own field, equally with the specialists. Regrettably, some are less able; and it may be this that has given rise to the impression of a decline in the status of the general practitioner. But then there are bad as well as good consultants. General practice is an intensely interesting and rewarding branch of medicine in its own right, and, although much serious illness has to be referred to the hospital; an increasing number of conditions can be adequately nursed and treated at home. To the farsighted it will be apparent that if the present trend of medical progress continues the hospitals will be used less and less. It may appear to the consultant that the general practitioner should be somehow given access to hospitals. But I, as a general practitioner, do not think this to be essential or even desirable. There is plenty of scope in the general practice of medicine, which ranges through

It

seems

places

1.

Willis, R.

A.

Pathology

of Tumours.

1948.

820 the whole field from obstetrics and the care of the newborn to the care of the aged. All that is required is a wide interest. It is also in my view quite wrong to assume that the general practitioner cannot keep up to date unless he is attached to a hospital. There is no reason to suppose that only the specialist can be modern.. One further qualification of paramount importance in general practice is an abiding love of people, without which all is as naught. MAXWELL KENT. KENT. Castle Bromwich. .

BOVINE TUBERCULOSIS PREVENTS HUMAN

TUBERCULOSIS ?

SIR,-Mr. Pitcher, in his letter last week, insists that the increase in admissions to hospital (Overdale) is evidence of an increase of tuberculosis in Jersey, in spite of the falling mortality-rate. Prior to 1925 there were no admissions to Overdale of tuberculosis patients ; so if Mr. Pitcher’s argument is valid there was no tuberculosis in Jersey in the year 1924, although according to the records there were 65 deaths from all forms of tuberculosis in that year. ,

In 1925, 8 beds were provided for tuberculosis at Overdale ; from 1934 the number of beds provided began to increase, and we now have 49 beds solely for such cases. The figures given by Mr. Pitcher show our increasing care of the tuberculous and not an increase in tuberculosis. Before 1925 the great majority of patients were treated on a domiciliary basis only. Surely Mr. Pitcher does not expect anybody to accept the odd idea of a rapidly increasing incidence with

-

rapidly decreasing mortality.

"

Sporadic cases of bovine tuberculosis in cattle have always occurred, and still do occur, in the Jersey herd. They are very rare, and there is no evidence that their number has either increased or decreased during the period discussed in Mr. Pitcher’s letter. R. N. MCKINSTRY South Hill, Jersey, Channel Islands.

Medical Officer of Health, States of Jersey.

A VISIT TO PONT ST. ESPRIT

sudden outbreak of madness in August, Esprit in the Rhone Valley was traced to a ’certain consignment of bread. About 200 people were taken ill, of whom 4 died and 15 became temporarily insane. Victims were reported to have run through the streets crying that they were " on fire," -and it was generally concluded that this was an epidemic of St. Anthony’s Fire—i.e., ergotism caused by the infection of rye bread with ergot. It was alleged that 66 spurred rye" had been mixed with the flour used in the bread. But, as your annotation of Sept. 8 pointed out, the symptoms of this collective mania were not the classical ones of ergot poisoning, nor was ergot found on analysis of the bread. In January I visited Pont St. Esprit and talked with Dr. Jean Vieu, many of whose patients were poisoned. He told me that they did not complain of feeling " on fire" ; reports of this symptoin seem to be without foundation. He gave me details of the psychological and mental disturbances which developed a week after the acute irritant poisoning, and which affected some 30% of patients. He described an initial " euphoria which then transformed itself into a nervous depression with anxiety and delusions of persecution."

SiR,—The

cause

of

sider that the cause was Indianhemp (marihuana). This is the only known drug which could have produced these symptoms, with the possible exception of amphet. amine, which can be excluded in the circumstances. Allentuck and Bowmanstudiod the effects of marihuana given by mouth, and concluded that " the main features of the poisoning are the restlessness and mental excite. ment of a delirious nature with intermittent periods of euphoria and an overhanging state of anxiety and dread." Their description is strikingly similar to that of Dr. Vieu. They also mention frequentvisual halluci. The account nations and occasional claustrophobia. given by Theophile Gautier in Le Club des Hachichiens contains vivid and fantastic pictures very like those seen by some of the people of Pont St. Esprit. Deaths from Indian hemp are rare but they have been reported. The severity of the outbreak suggests large doses ; and the drug was taken in an unusual way -after being baked in bread for some hours. It is by no means unlikely that a strongly irritant compound was formed which caused the acute symptoms of general The vomiting and diarrhoea probably intoxication. eliminated the poison in most cases. In the less fortunate the delay in the appearance of mental symptoms may be explained by the impaired absorption of the remainder of the drug from the damaged intestine. By what ghastly mistake hemp may have been mixed with the bread, one can only guess. But hemp can grow as a weed in the climate of central France; and recently a citizen was found growing the plant in innocence of its true nature. It is possible that the spurred rye " was mixed with flowering hemp growing on the same ground. DONALD MCI. JOHNSON. Md. JOHNSON. Sutton, Surrey.

a

1951, at Pont St.

One man was seized with claustrophobia and broke his when he jumped from an upstairs window. I later read of an old woman who kept seeing an immense silver-shod black horse as big as a mountain, and of a girl of 14 who told her mother she was flying over enormous singing flowers which clutched at her dress as she passed.

leg

I do not think these people were poisoned by ergot. The symptoms are totally unlike those of any scientifically recorded cases of epidemics of ergot poisoning. I con-

ANÆSTHESIA FOR TUBERCULOUS PATIENTS

SiR,-Dr. Mushin’s letter of March

22 cannot be months Some simply. ago, thinking on the same lines, the anaesthetists of this area commenced a long-term study of the effects of inhalational anaesthesia for tuberculous patients ;Iam, however, quite sure that there are too many variable factors for any definite conclusions to be possible. What factors, associated with inhalational anaesthesia, are liable to have a detrimental effect on a lung with active or quiescent tuberculosis1

answered

1. There is the general metabolic disturbance ; but an important factor here is the pathology which has made the operation necessary. Pregnancy and gastric ulcer are two examples ;ill effects resulting directly or indirectly from these conditions must not be attributed to anaesthetic techniques. 2. During anaesthesia there may be morbidity from : (a) the drugs used (e.g., ether) ;; (b) spread of sputum following coughing or vomiting, or failure to aspirate sputum; and (c) breakdown of cavities from straining, coughing, &c., during a difficult induction. 3. Postoperative vomiting and coughing might again cause spread of disease. These factors are, I believe, the salient ones ; the only really doubtful one is ether, which can easily be dispensed with. We only need, then, an anaesthetist who can be ’

relied upon to give smooth induction and maintenance, and who will promptly deal with sputum should occasion arise ;; the postoperative stage is then unlikely to be troublesome. Even if thereafter the patient does not do well, the case against inhalational anaesthesia has by no means been proved. The prognosis at all stages of tuber. culosis is most uncertain, and the technique of the anaesthetist may become the scapegoat. I would like to emphasise-as have others-that it is not the drugs that matter, but the anaesthetist. I would suggest that an earnest if inexperienced registrar"is a most unsuitable anaesthetist for this type of case. "

1. The Marihuana Problem in the City of New York. New York, 1944.