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ARTIFICIAL LIMBS
35 TWO QUALITIES OF SERVICE ?
SlR,—-You are to be congratulated on your annotation Surely the real difference in the future between a private and a State patient will be that the former will have an appointment to see his doctor at a time convenient. to both, whereas the latter will attend at the doctor’s regular consulting hours and take his turn last week.
itT-h At,hpl’’’
Worthing.
’
HAROLD LEESON.
It may be said that general practitioners would not have enough experience to prevent them overlooking disease or, making mistakes through misinterpretation. I have even heard a case quoted, as an argument against such facilities in health centres, in which a healthy kidney was removed because the practitioner had mistaken a staghorn calculus on one side for a normal pyelogram. Without adequate safeguards suchmisinterpretations could possibly take place, but with visiting radiologists and pathologists to check X-ray and laboratory findings they should be rare. A final word must be said on the differences of opinion about the scope and structure of " health centres " ’differences fostered by this rather vague name for them which could be abandoned with advantage. Some think of the centre as similar to the Peckham Health Centre, which concentrates on frequent overhauls of the healthy population. Others think of it as an outpost of ’ a in hitherto unserved country, and run by specialists and consultants as a kind of branch outpatient department. Much can be said in favour of both these ideas ; but the first cannot be widely applied for many years, while the purpose of the second would be better served by having more hospitals with outpatient
ARTIFICIAL LIMBS and letters in the press have articles SiR,-Recent referred to the artificial limbs to be provided in the new " " service as standard " or " utility limbs. As one of the firms of artificial-limb makers appointed to supply these " limbs we have no knowledge whatsoever of a" standard " The to limb. limbless to us be fitted sent or utility " with artificial legs each constitutes an individual case, and there is no such thing in our experience as standardisation. The appliances for children and adults born with congenital deformities are also individual in design for each case. Because of the size of our organisation we can employ specialist fitters for each site of amputation (incidentally we haveno knowledge of a departments. standard amputation" but only of a good or bad What is required, whatever its name, is a centre stump for fitting) and we are probably the only firm in the where practitioners can work under good conditions world doing this. with administrative staffto look after records and notes, To allay other fears which have been expressed we and where they have direct access to those pathological should like to make it clear that we have for years past carried out repairs to artificial legs of all makes, and we and radiological services without which they literally cannot nowadays make a diagnosis. are in a position to continue to do so. H. M. GRANT. A. W. SHAW J. E. Hanger & Co. Ltd. Barry Accident and Surgical Hospital. Roehampton. Managing Director.
hospital
.
HEALTH CENTRES SIR,-One aspect of the proposed and now, alas, postponed introduction of health centres has not, I feel, been sufficiently stressed. This concerns the relation-
between general practitioners and consultants. I believe that the extra facilities, such as radiological departments and laboratories, made possible by establishing health centres, would bring about a more normal and healthy relationship. Fifty years ago, before the technical side of medicine became so advanced, a practitioner would seek the advice as consultant of a man whose clinical acumen was respected or who had had special experience in a particular type of disorder. The consultant would approach the case with the same implements for examination as the practitioner-i.e., his eyes, ears, sense of touch, and so forth. Nowadays, however, the practitioner starts at a technical disadvantage, since he is not in a position to use many of the methods of investigation in which he has been trained, and which would be useful to him. Hence the hospital specialist or consultant is now in some respects valued more because he has resources for these methods than because of his clinical acumen or experience. His work is greatly increased because many cases are sent not so much for advice as for that extra investigation. The diagnosis of pernicious anaemia, though it can be made very nearly by a laboratory technician, can seldom be made with any certainty by
ship
the general practitioner.
A properly organised system of health centres with direct access for the practitioner to laboratories and radiography facilities would improve the efficiency of the medical services in several ways : 1. It would reduce the amount of
work at
outpatient
hospitals. 2. It would allow the general practitioner to use the methods of examination and investigation by which he has been trained to diagnose disease, and so greatly increase the quality and interest of his work. 3. It would counteract the tendency in the occasional less conscientious practitioner to become merely the tenant of an office for dispatching patients to hospital. 4. It would put the consultant and the general practitioner back into a proper relationship with one another, in that, on the whole, they would approach a case on the same terms. The consultant would not need to be called in for help in diagnosis solely because the practitioner was unable to do the investigation, but only because he was not certain of his interpretation of the findings.
ATTACK ON RHEUMATISM
SIR,—In his letter of June 19 Dr. Stone is attacking the word " rheumatism," not the group of diseases. This word has the advantages of antiquity and of being customarily accepted. Any substitute must prove its worth. The Shorter Oxford English Dictionary defines rheumatism as " a disease of which inflammation and pain of the joints are prominent features." The Encyclopœdia Britannica states that rheumatism is a "general term for various forms of disease subdivided as follows : acute, subacute, chronic, muscular, and arthritic." It is clear that " rheumatism " refers to a group of diseases joints, and affecting a section of" the body-the muscles, " therefore is the allied structures. Rheumatology special aspect of medical science that cares for this group of diseases. The definition, admittedly .loose, is anatomical. The neurologist deals with diseases of the central nervous system-an anatomical division-but no-one complains because tabes and disseminated sclerosis are not clinical varieties of the same disease. The causation of many of the rheumatic diseases is unknown, but that is no reason to object to the term. If it were, then other branches of medicine would be in need of similar treatment. Altering the name of this group of diseases will not bring divine inspiration and solve our problems. The example quoted by Dr. Stone is comparable to such a phrase as : "This man has palpitations ; are they neurotic ? " Misuse of words by others is no reason for No-one suggests that neurologists changing them. should be styled " nervous physicians," or that there should be such terms as " geriatric physician " or " venereal surgeon." I can see no reason why the term " orthopaedic physician " should be introduced, if only because I should not like to see, broken bones in the rheumatic clinic. DAVID P. NICHOLSON. London, S.W.l. 1.
Lancet, 1947, i, 32.
’
St. Thomas’s Hospital have once more published their list of old students. This first post-war edition also contains the school’s roll of honour and the names of those who have died since 1938. The kindly pre-war custom of free distribution has had to be reluctantly abandoned, but copies may be had from the beadle of the medical school for 2s. 6d.
SlR,—-You are to be congratulated on your annotation Surely the real difference in the future between a private and a State patient will be that the former will have an appointment to see his doctor at a time convenient. to both, whereas the latter will attend at the doctor’s regular consulting hours and take his turn last week.
itT-h At,hpl’’’
Worthing.
’
HAROLD LEESON.
It may be said that general practitioners would not have enough experience to prevent them overlooking disease or, making mistakes through misinterpretation. I have even heard a case quoted, as an argument against such facilities in health centres, in which a healthy kidney was removed because the practitioner had mistaken a staghorn calculus on one side for a normal pyelogram. Without adequate safeguards suchmisinterpretations could possibly take place, but with visiting radiologists and pathologists to check X-ray and laboratory findings they should be rare. A final word must be said on the differences of opinion about the scope and structure of " health centres " ’differences fostered by this rather vague name for them which could be abandoned with advantage. Some think of the centre as similar to the Peckham Health Centre, which concentrates on frequent overhauls of the healthy population. Others think of it as an outpost of ’ a in hitherto unserved country, and run by specialists and consultants as a kind of branch outpatient department. Much can be said in favour of both these ideas ; but the first cannot be widely applied for many years, while the purpose of the second would be better served by having more hospitals with outpatient
ARTIFICIAL LIMBS and letters in the press have articles SiR,-Recent referred to the artificial limbs to be provided in the new " " service as standard " or " utility limbs. As one of the firms of artificial-limb makers appointed to supply these " limbs we have no knowledge whatsoever of a" standard " The to limb. limbless to us be fitted sent or utility " with artificial legs each constitutes an individual case, and there is no such thing in our experience as standardisation. The appliances for children and adults born with congenital deformities are also individual in design for each case. Because of the size of our organisation we can employ specialist fitters for each site of amputation (incidentally we haveno knowledge of a departments. standard amputation" but only of a good or bad What is required, whatever its name, is a centre stump for fitting) and we are probably the only firm in the where practitioners can work under good conditions world doing this. with administrative staffto look after records and notes, To allay other fears which have been expressed we and where they have direct access to those pathological should like to make it clear that we have for years past carried out repairs to artificial legs of all makes, and we and radiological services without which they literally cannot nowadays make a diagnosis. are in a position to continue to do so. H. M. GRANT. A. W. SHAW J. E. Hanger & Co. Ltd. Barry Accident and Surgical Hospital. Roehampton. Managing Director.
hospital
.
HEALTH CENTRES SIR,-One aspect of the proposed and now, alas, postponed introduction of health centres has not, I feel, been sufficiently stressed. This concerns the relation-
between general practitioners and consultants. I believe that the extra facilities, such as radiological departments and laboratories, made possible by establishing health centres, would bring about a more normal and healthy relationship. Fifty years ago, before the technical side of medicine became so advanced, a practitioner would seek the advice as consultant of a man whose clinical acumen was respected or who had had special experience in a particular type of disorder. The consultant would approach the case with the same implements for examination as the practitioner-i.e., his eyes, ears, sense of touch, and so forth. Nowadays, however, the practitioner starts at a technical disadvantage, since he is not in a position to use many of the methods of investigation in which he has been trained, and which would be useful to him. Hence the hospital specialist or consultant is now in some respects valued more because he has resources for these methods than because of his clinical acumen or experience. His work is greatly increased because many cases are sent not so much for advice as for that extra investigation. The diagnosis of pernicious anaemia, though it can be made very nearly by a laboratory technician, can seldom be made with any certainty by
ship
the general practitioner.
A properly organised system of health centres with direct access for the practitioner to laboratories and radiography facilities would improve the efficiency of the medical services in several ways : 1. It would reduce the amount of
work at
outpatient
hospitals. 2. It would allow the general practitioner to use the methods of examination and investigation by which he has been trained to diagnose disease, and so greatly increase the quality and interest of his work. 3. It would counteract the tendency in the occasional less conscientious practitioner to become merely the tenant of an office for dispatching patients to hospital. 4. It would put the consultant and the general practitioner back into a proper relationship with one another, in that, on the whole, they would approach a case on the same terms. The consultant would not need to be called in for help in diagnosis solely because the practitioner was unable to do the investigation, but only because he was not certain of his interpretation of the findings.
ATTACK ON RHEUMATISM
SIR,—In his letter of June 19 Dr. Stone is attacking the word " rheumatism," not the group of diseases. This word has the advantages of antiquity and of being customarily accepted. Any substitute must prove its worth. The Shorter Oxford English Dictionary defines rheumatism as " a disease of which inflammation and pain of the joints are prominent features." The Encyclopœdia Britannica states that rheumatism is a "general term for various forms of disease subdivided as follows : acute, subacute, chronic, muscular, and arthritic." It is clear that " rheumatism " refers to a group of diseases joints, and affecting a section of" the body-the muscles, " therefore is the allied structures. Rheumatology special aspect of medical science that cares for this group of diseases. The definition, admittedly .loose, is anatomical. The neurologist deals with diseases of the central nervous system-an anatomical division-but no-one complains because tabes and disseminated sclerosis are not clinical varieties of the same disease. The causation of many of the rheumatic diseases is unknown, but that is no reason to object to the term. If it were, then other branches of medicine would be in need of similar treatment. Altering the name of this group of diseases will not bring divine inspiration and solve our problems. The example quoted by Dr. Stone is comparable to such a phrase as : "This man has palpitations ; are they neurotic ? " Misuse of words by others is no reason for No-one suggests that neurologists changing them. should be styled " nervous physicians," or that there should be such terms as " geriatric physician " or " venereal surgeon." I can see no reason why the term " orthopaedic physician " should be introduced, if only because I should not like to see, broken bones in the rheumatic clinic. DAVID P. NICHOLSON. London, S.W.l. 1.
Lancet, 1947, i, 32.
’
St. Thomas’s Hospital have once more published their list of old students. This first post-war edition also contains the school’s roll of honour and the names of those who have died since 1938. The kindly pre-war custom of free distribution has had to be reluctantly abandoned, but copies may be had from the beadle of the medical school for 2s. 6d.