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THE GENERAL PRACTITIONER
867
CORRESPONDENCE two days after her brother. All the patients were members of the same family with the exception of one man who was a cousin. In no case was the disease fatal.
THE GENERAL PRACTITIONER
To the Editor
of THE
LANCET
An examination of the house mentioned in (4) shows some features of interest. The building was situated by itself and was enclosed by an orchard of orange and lemon trees which gave shade to the house and protected it against wind. It had a low thatched overhanging roof. The windows were very small and were unprotected by mosquitonetting. The interior of the house was dark even There were 11 occupants who were at midday. subject to frequent attacks of subtertian malaria. Such a building would be an ideal resting place for mosquitoes which could readily gain entrance through the unprotected windows at night, but owing to the absence of light and draught, would show no inclination to leave during the day. This should be compared with the typical house of an ordinary Indian village in this district which, though unprovided with mosquito-netting, possessed a high corrugated iron roof with a wide interval between roof and walls and usually fairly large windows which, if opened during the day, would allow entrance to light and air. There were only a few small trees in the
current issue of THE LANCET, with very great pleasure, Dr. E. K. le Fleming’s inaugural address at St. George’s Hospital and I am glad that he has brought up the subject of the general practitioner. This subject is one about which, in my own small way, I have been agitating for years. At the present time students become qualified and are launched into the world without any knowledge whatever of the very essentials of conducting a general practice successfully, and when I say successfully I mean both as regards the patients I do not think Dr. as well as regards themselves. le Fleming’s suggestion goes far enough. I should like to see the old days of apprenticeship revived, though in a modified form. I do not think four years, such as I served, necessary but I do think that before a man is allowed to practice he should be compelled to serve at least one year’s apprenticeship with a general practitioner. The result would be incalculable benefit to the public and to the man himself. I would go further and apply the same compulsion to all intending consultants. They would then have a far better understanding of, and a greater sympathy for, the many difficulties with which a general practitioner has to contend. I am, Sir, yours faithfully, lBI.B. E. F. PRATT, M.B. Clarges-street, W., Oct. 10th, 1932.
Sm,-I have read in the
vicinity.
,
These observations strongly favour the importance of chronic subtertian malaria, which is the prevalent form encountered in this district, in the aetiology of blackwater fever, and the view that Icertain houses predispose to the disease by reason of Ithe shelter which they offer to the infected anopheles am, Sir, yours faithfully, A. D. CHARTERS, M.B. 1LB. Camb., D.T.M. &
mosquito.-I HOUSE INFECTION IN BLACKWATER FEVER
To the Editor
of THE
Sevenoaks, Oct. 4th, 1932.
LANCET
H.
Eng.
’
a leading article on blackwater fever in of MARMITE IN PERNICIOUS ANÆMIA issue your Sept. 17th (p. 636) it is pointed out that Dr. Ross is in agreement with previous observers in To the Editor of THE LANCET finding no justification for the suspicion that certain houses predispose to infection. While on the staff 1 SiR,-In your last issue (p. 782) Dr. A. Goodall of the C.M.S. Hospital, Ngora, Uganda, I had anrecords hisexperience of giving marmite in large opportunity of studying the disease amongst Indians, I doses to 19 cases of pernicious anaemia. Similar and would like to draw attention to the following findings of my own, as yet unpublished, may be of interest. A year ago I noted in your columns (1931, examples which are evidence to the contrary. (1) On Oct. 30th, 1930, a man, aged 40, developed an ii., 63) the occurrence of a reticulocyte response attack of blackwater fever after being given plasmoquine during the administration of bemax, and since that and quinine for malaria. His wife had died from the disease time I have endeavoured to determine the potency in the same house four days previously. in vitamin B for blood rich various substances be A came to examined on man, aged 24, (2) April 22nd, 1931, because he was in anxiety lest he might develop regeneration in anaemias. I have found that in blackwater fever, his brother having died from this disease Addison’s anaemia marmite in doses of 4 oz. daily in his house 13 days before. On examination he was found a satisfactory reticulocyte response, to have a palpable liver, a spleen whose lower limit was usually produces three fingers-breadth below the costal margin and a tem- with a rise of red cells and haemoglobin, although in perature of 101-2° F. His urine had a specific gravity of some instances the remission has seemed less rapid 1020, was acid in reaction, and contained no albumin or than with large doses of liver extract. Since these bile. I considered that he was in the pre-blackwater state though it should be acknowledged that certain authorities, results are obtained in cases of true Addisonian including Drs. Ross and Yorke, Murgatroyd, and Owen,l pernicious anaemia with achylia, in which the intrinsic do not recognise such a condition. factor of Castle is presumably absent, it would seem (3) A man, aged 24, gave a history of seven attacks of possible that yeast contains some substance effective blackwater fever, five of which occurred during the year 1930. His daughter, a girl aged 6, who had been living for blood regeneration in this disease, apart from that in the same house, also complained of three attacks all of which Strauss and Castle1 believe to be the extrinsic which occurred during the year 1930. factor. (4) This is an interesting example of a house in which As Dr. Goodall infers in his closing remarks, it seven attacks of blackwater fever had occurred, two of them being recurrences three years and four years respectively would be unwise to let any form of extract take the after previous bouts of the disease. Four of the cases of whole liver where subacute combined occurred during the spa,ce of 11 months, between July 6th, place 1930, and May 15th, 1931, one of the patients developing degeneration of the cord is present. the disease one day after his brother. Of the other three I am, Sir, yours faithfully, cases one was that of a girl who developed the disease C. C. UNGLEY. Newcastle-on-Tyne, Oct. 10th, 193;?.
SiR,-In
i
,
of
I
1 Yorke, W., Murgatroyd, F., and Owen, D. U.: Trans. Roy. Soc. Trop. Med. and Hyg., 1930, xxiii., 353.
1 THE
LANCET, July 16th
p. 111.
CORRESPONDENCE two days after her brother. All the patients were members of the same family with the exception of one man who was a cousin. In no case was the disease fatal.
THE GENERAL PRACTITIONER
To the Editor
of THE
LANCET
An examination of the house mentioned in (4) shows some features of interest. The building was situated by itself and was enclosed by an orchard of orange and lemon trees which gave shade to the house and protected it against wind. It had a low thatched overhanging roof. The windows were very small and were unprotected by mosquitonetting. The interior of the house was dark even There were 11 occupants who were at midday. subject to frequent attacks of subtertian malaria. Such a building would be an ideal resting place for mosquitoes which could readily gain entrance through the unprotected windows at night, but owing to the absence of light and draught, would show no inclination to leave during the day. This should be compared with the typical house of an ordinary Indian village in this district which, though unprovided with mosquito-netting, possessed a high corrugated iron roof with a wide interval between roof and walls and usually fairly large windows which, if opened during the day, would allow entrance to light and air. There were only a few small trees in the
current issue of THE LANCET, with very great pleasure, Dr. E. K. le Fleming’s inaugural address at St. George’s Hospital and I am glad that he has brought up the subject of the general practitioner. This subject is one about which, in my own small way, I have been agitating for years. At the present time students become qualified and are launched into the world without any knowledge whatever of the very essentials of conducting a general practice successfully, and when I say successfully I mean both as regards the patients I do not think Dr. as well as regards themselves. le Fleming’s suggestion goes far enough. I should like to see the old days of apprenticeship revived, though in a modified form. I do not think four years, such as I served, necessary but I do think that before a man is allowed to practice he should be compelled to serve at least one year’s apprenticeship with a general practitioner. The result would be incalculable benefit to the public and to the man himself. I would go further and apply the same compulsion to all intending consultants. They would then have a far better understanding of, and a greater sympathy for, the many difficulties with which a general practitioner has to contend. I am, Sir, yours faithfully, lBI.B. E. F. PRATT, M.B. Clarges-street, W., Oct. 10th, 1932.
Sm,-I have read in the
vicinity.
,
These observations strongly favour the importance of chronic subtertian malaria, which is the prevalent form encountered in this district, in the aetiology of blackwater fever, and the view that Icertain houses predispose to the disease by reason of Ithe shelter which they offer to the infected anopheles am, Sir, yours faithfully, A. D. CHARTERS, M.B. 1LB. Camb., D.T.M. &
mosquito.-I HOUSE INFECTION IN BLACKWATER FEVER
To the Editor
of THE
Sevenoaks, Oct. 4th, 1932.
LANCET
H.
Eng.
’
a leading article on blackwater fever in of MARMITE IN PERNICIOUS ANÆMIA issue your Sept. 17th (p. 636) it is pointed out that Dr. Ross is in agreement with previous observers in To the Editor of THE LANCET finding no justification for the suspicion that certain houses predispose to infection. While on the staff 1 SiR,-In your last issue (p. 782) Dr. A. Goodall of the C.M.S. Hospital, Ngora, Uganda, I had anrecords hisexperience of giving marmite in large opportunity of studying the disease amongst Indians, I doses to 19 cases of pernicious anaemia. Similar and would like to draw attention to the following findings of my own, as yet unpublished, may be of interest. A year ago I noted in your columns (1931, examples which are evidence to the contrary. (1) On Oct. 30th, 1930, a man, aged 40, developed an ii., 63) the occurrence of a reticulocyte response attack of blackwater fever after being given plasmoquine during the administration of bemax, and since that and quinine for malaria. His wife had died from the disease time I have endeavoured to determine the potency in the same house four days previously. in vitamin B for blood rich various substances be A came to examined on man, aged 24, (2) April 22nd, 1931, because he was in anxiety lest he might develop regeneration in anaemias. I have found that in blackwater fever, his brother having died from this disease Addison’s anaemia marmite in doses of 4 oz. daily in his house 13 days before. On examination he was found a satisfactory reticulocyte response, to have a palpable liver, a spleen whose lower limit was usually produces three fingers-breadth below the costal margin and a tem- with a rise of red cells and haemoglobin, although in perature of 101-2° F. His urine had a specific gravity of some instances the remission has seemed less rapid 1020, was acid in reaction, and contained no albumin or than with large doses of liver extract. Since these bile. I considered that he was in the pre-blackwater state though it should be acknowledged that certain authorities, results are obtained in cases of true Addisonian including Drs. Ross and Yorke, Murgatroyd, and Owen,l pernicious anaemia with achylia, in which the intrinsic do not recognise such a condition. factor of Castle is presumably absent, it would seem (3) A man, aged 24, gave a history of seven attacks of possible that yeast contains some substance effective blackwater fever, five of which occurred during the year 1930. His daughter, a girl aged 6, who had been living for blood regeneration in this disease, apart from that in the same house, also complained of three attacks all of which Strauss and Castle1 believe to be the extrinsic which occurred during the year 1930. factor. (4) This is an interesting example of a house in which As Dr. Goodall infers in his closing remarks, it seven attacks of blackwater fever had occurred, two of them being recurrences three years and four years respectively would be unwise to let any form of extract take the after previous bouts of the disease. Four of the cases of whole liver where subacute combined occurred during the spa,ce of 11 months, between July 6th, place 1930, and May 15th, 1931, one of the patients developing degeneration of the cord is present. the disease one day after his brother. Of the other three I am, Sir, yours faithfully, cases one was that of a girl who developed the disease C. C. UNGLEY. Newcastle-on-Tyne, Oct. 10th, 193;?.
SiR,-In
i
,
of
I
1 Yorke, W., Murgatroyd, F., and Owen, D. U.: Trans. Roy. Soc. Trop. Med. and Hyg., 1930, xxiii., 353.
1 THE
LANCET, July 16th
p. 111.