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SKELETAL FLUOROSIS
1291
If bone mineralisation has to be stimulated, it should be advantageous to increase the affinity for calcium, and an ample supply of magnesium and proteins might be very helpful in this connection. The Netherlands Institute of Nutrition, L. M. DALDERUP Wageningen, C. B. M. DALDERUP. Amsterdam. RUPTURE OF THE POSTERIOR URETHRA
SIR,-It is significant that among Mr. Wilkinson’s 12 examples of this injury (May 27), the least good results of treatment were in an 11-year-old boy. The small size of the urethra in boys may make the traction method of treatment with a Foley catheter difficult, if not impossible, to apply. Apparently the smallest Foley catheter obtainable is
12 French gauge. Faced recently with the problem of treating a complete rupture of the posterior urethra with wide separation, first in a boy of 9 and, a few months later, in a boy of 11, we resorted to an indwelling plastic catheter. Owing to the possibility of an infected impassable stricture if treatment failed we decided to keep the catheter in for 2-3 months until the patient had fully recovered from other injuries and was able to walk. The results were satisfactory. Both boys were free from urinary infection a few days after removal of the catheter and have remained free since. Both have normal intravenous pyelograms. The younger boy has full control of micturition; the older boy, who had the more severe pelvic fracture, still has some stress incontinence. We consider it wise to pass a urethral dilator every few months, and so far, 20 months and 12 months respectively after injury, the urethra of each boy has taken a full-size instrument first time without difficulty. There is no evidence of stricture. It appears safe to leave a plastic catheter indwelling for a no.
several weeks; and
traction, though theoretically indicated together, may
to bring the ruptured ends of the urethra not be essential. Moreover, retaining the
catheter for a dislocation of the the time may prevent upper end long of the urethra which sometimes happens if the splinting is removed too early. Hillingdon Hospital, Uxbridge, Middlesex.
C. G. SCORER.
SKELETAL FLUOROSIS
SiR,-May I briefly reply to Mr. James (May 20) ? It is difficult to understand what he means by the lower end of the category " mild nuorosis ". Dr. Dean’s clear definition1 (which has been universally adopted) of this grade based on his examination of children is as follows: " The white opaque
areas
in the enamel of the teeth involve
at
least half of the tooth surface. The surface of molars, bicuspids and attrition show thin white layers worn off and the bluish shades of underlying normal enamel. Light brown stains are sometimes apparent generally on the superior incisors ". An appearance showing less damage would surely be placed in Dean’s category of " very mild fluorosis ". The paper by Ast et al.,2 to which Mr. James refers, has been
cuspids subject
to
seriously criticised by Sutton.3 But Mr. James, while quoting their figures that 6 out of 438 children in Newburgh had " mild nuorosis ", does not mention that a further 26 had " " very mild " and 46 had " questionable fluorosis. The brown stain that is " so faint as to be almost indistinct " in a child with " very mild " mottling may be quite prominent when he becomes an adult.4 No matter what the final proportion of cases of " mild " or " very mild " fluorosis will be when properly conducted investigations have been carried out to eliminate examiner bias, examiner variability, &c., the facts
remain: (1) these are the dental signs of chronic endemic fluorosis 1; (2) fluorine is an insidious poison, harmful and cumulative in its effect 5; and (3) the dose per person per day from water intake is scientifically uncontrollable. Those who support fluoridation of public water might meet their scientific critics on the question of toxicity and safety if they would turn their attention to the use of fluoride-free compounds which recent work6 indicates are effective in inhibiting dental caries in children and adults. Institute of Pathology, The Royal Infirmary, R. A. HOLMAN. Cardiff.
THE NATURE OF VAGINAL DISCHARGE SiR,-In his article of May 20, Dr. Boycott describes the results of his examination of 595 vaginal swabs taken
from women who had complained of vaginal discharge. In a high proportion, 62%, he found that the vaginal secretion was normal. This is not surprising, and offers a very good illustration of the inadequacy of taking only vaginal swabs when investigating this complaint. It is impossible to assess the comparative incidence of the many types of genital discharge in women, but undoubtedly cervicitis is one of the most common causes. When the discharge is cervical in origin, the vagina and the vaginal fluid may be normal. This also applies if the discharge is from the urethra, bartholinian ducts, or rectum. In these cases a cotton-wool swab inserted into the vagina may collect normal vaginal fluid only, and in fact this frequently happens. Only a properly detailed examination of the various sites of genital infection, with appropriate specimens taken from each, will lead to an ’
diagnosis. This clinic is recognised for the treatment of venereal disease, but this does not, of course, mean that all the patients seen here are suffering from gonorrhoea or syphilis. We see many women who are complaining only of vaginal discharge and who have been referred here for investigation, or have attended of their own accord. It is only very occasionally that we find no evidence of any abnormality in a patient who complains of vaginal discharge. Reliance on a vaginal swab alone appears to be very widespread, and has serious consequences. Firstly, very many women with a most distressing symptom are deprived of adequate treatment. Secondly, serious infections are missedparticularly gonorrhoea, which can rarely be diagnosed in a woman unless specimens taken directly from the cervical canal accurate
and urethra
are
examined.
The incidence of gonorrhoea has recently increased; there is little doubt that our lack of control over this condition is in some measure due to the fact that the diagnosis is so frequently missed in women. Whitechapel Clinic, London Hospital, London, E.1.
EVA GALLAGHER.
SHORTAGE OF RADIOGRAPHERS
SiR,-On behalf of the Society of Radiographers I to comment briefly on some points raised by Professor Johnstone in his letter (April 29). The insistence on a pass in mathematics at ordinary level in the G.c.E. before registration as a student radiographer was a decision reached by the council of the society after full should like
consultation between its education committee and representatives of the Faculty of Radiologists and the Hospital Physicists’ Association. Experience would suggest that a student who does not possess this basic qualification is sometimes so deficient even in simple arithmetic that she does not know the meaning of 25% ". Surely everyone would agree that this failing hinders the production of good radiographs or the safe handling of ionising radiations. As a result of local experience, a number of training schools, when selecting candidates for admission, now require a pass "
-
1. Dean, H. T. in Fluoridation (by F. B. Exner). New York, 1960. 2. Ast, D. B., Smith, D. J., Wachs, B., Cantwell, K. T. J. Amer. dent. Ass.
1956, 52, 314.
3. Sutton, P. R. N.
Fluoridation: Errors and Omissions in Experimental
Trials; p. 52. Melbourne,
1959.
4. Exner, F. B. Fluoridation. New York, 1960.
5. Gross, L. New York Times, April 1, 1957. 6. Ritchie, D. B. Nature, Lond. 1961, 190, 456.
If bone mineralisation has to be stimulated, it should be advantageous to increase the affinity for calcium, and an ample supply of magnesium and proteins might be very helpful in this connection. The Netherlands Institute of Nutrition, L. M. DALDERUP Wageningen, C. B. M. DALDERUP. Amsterdam. RUPTURE OF THE POSTERIOR URETHRA
SIR,-It is significant that among Mr. Wilkinson’s 12 examples of this injury (May 27), the least good results of treatment were in an 11-year-old boy. The small size of the urethra in boys may make the traction method of treatment with a Foley catheter difficult, if not impossible, to apply. Apparently the smallest Foley catheter obtainable is
12 French gauge. Faced recently with the problem of treating a complete rupture of the posterior urethra with wide separation, first in a boy of 9 and, a few months later, in a boy of 11, we resorted to an indwelling plastic catheter. Owing to the possibility of an infected impassable stricture if treatment failed we decided to keep the catheter in for 2-3 months until the patient had fully recovered from other injuries and was able to walk. The results were satisfactory. Both boys were free from urinary infection a few days after removal of the catheter and have remained free since. Both have normal intravenous pyelograms. The younger boy has full control of micturition; the older boy, who had the more severe pelvic fracture, still has some stress incontinence. We consider it wise to pass a urethral dilator every few months, and so far, 20 months and 12 months respectively after injury, the urethra of each boy has taken a full-size instrument first time without difficulty. There is no evidence of stricture. It appears safe to leave a plastic catheter indwelling for a no.
several weeks; and
traction, though theoretically indicated together, may
to bring the ruptured ends of the urethra not be essential. Moreover, retaining the
catheter for a dislocation of the the time may prevent upper end long of the urethra which sometimes happens if the splinting is removed too early. Hillingdon Hospital, Uxbridge, Middlesex.
C. G. SCORER.
SKELETAL FLUOROSIS
SiR,-May I briefly reply to Mr. James (May 20) ? It is difficult to understand what he means by the lower end of the category " mild nuorosis ". Dr. Dean’s clear definition1 (which has been universally adopted) of this grade based on his examination of children is as follows: " The white opaque
areas
in the enamel of the teeth involve
at
least half of the tooth surface. The surface of molars, bicuspids and attrition show thin white layers worn off and the bluish shades of underlying normal enamel. Light brown stains are sometimes apparent generally on the superior incisors ". An appearance showing less damage would surely be placed in Dean’s category of " very mild fluorosis ". The paper by Ast et al.,2 to which Mr. James refers, has been
cuspids subject
to
seriously criticised by Sutton.3 But Mr. James, while quoting their figures that 6 out of 438 children in Newburgh had " mild nuorosis ", does not mention that a further 26 had " " very mild " and 46 had " questionable fluorosis. The brown stain that is " so faint as to be almost indistinct " in a child with " very mild " mottling may be quite prominent when he becomes an adult.4 No matter what the final proportion of cases of " mild " or " very mild " fluorosis will be when properly conducted investigations have been carried out to eliminate examiner bias, examiner variability, &c., the facts
remain: (1) these are the dental signs of chronic endemic fluorosis 1; (2) fluorine is an insidious poison, harmful and cumulative in its effect 5; and (3) the dose per person per day from water intake is scientifically uncontrollable. Those who support fluoridation of public water might meet their scientific critics on the question of toxicity and safety if they would turn their attention to the use of fluoride-free compounds which recent work6 indicates are effective in inhibiting dental caries in children and adults. Institute of Pathology, The Royal Infirmary, R. A. HOLMAN. Cardiff.
THE NATURE OF VAGINAL DISCHARGE SiR,-In his article of May 20, Dr. Boycott describes the results of his examination of 595 vaginal swabs taken
from women who had complained of vaginal discharge. In a high proportion, 62%, he found that the vaginal secretion was normal. This is not surprising, and offers a very good illustration of the inadequacy of taking only vaginal swabs when investigating this complaint. It is impossible to assess the comparative incidence of the many types of genital discharge in women, but undoubtedly cervicitis is one of the most common causes. When the discharge is cervical in origin, the vagina and the vaginal fluid may be normal. This also applies if the discharge is from the urethra, bartholinian ducts, or rectum. In these cases a cotton-wool swab inserted into the vagina may collect normal vaginal fluid only, and in fact this frequently happens. Only a properly detailed examination of the various sites of genital infection, with appropriate specimens taken from each, will lead to an ’
diagnosis. This clinic is recognised for the treatment of venereal disease, but this does not, of course, mean that all the patients seen here are suffering from gonorrhoea or syphilis. We see many women who are complaining only of vaginal discharge and who have been referred here for investigation, or have attended of their own accord. It is only very occasionally that we find no evidence of any abnormality in a patient who complains of vaginal discharge. Reliance on a vaginal swab alone appears to be very widespread, and has serious consequences. Firstly, very many women with a most distressing symptom are deprived of adequate treatment. Secondly, serious infections are missedparticularly gonorrhoea, which can rarely be diagnosed in a woman unless specimens taken directly from the cervical canal accurate
and urethra
are
examined.
The incidence of gonorrhoea has recently increased; there is little doubt that our lack of control over this condition is in some measure due to the fact that the diagnosis is so frequently missed in women. Whitechapel Clinic, London Hospital, London, E.1.
EVA GALLAGHER.
SHORTAGE OF RADIOGRAPHERS
SiR,-On behalf of the Society of Radiographers I to comment briefly on some points raised by Professor Johnstone in his letter (April 29). The insistence on a pass in mathematics at ordinary level in the G.c.E. before registration as a student radiographer was a decision reached by the council of the society after full should like
consultation between its education committee and representatives of the Faculty of Radiologists and the Hospital Physicists’ Association. Experience would suggest that a student who does not possess this basic qualification is sometimes so deficient even in simple arithmetic that she does not know the meaning of 25% ". Surely everyone would agree that this failing hinders the production of good radiographs or the safe handling of ionising radiations. As a result of local experience, a number of training schools, when selecting candidates for admission, now require a pass "
-
1. Dean, H. T. in Fluoridation (by F. B. Exner). New York, 1960. 2. Ast, D. B., Smith, D. J., Wachs, B., Cantwell, K. T. J. Amer. dent. Ass.
1956, 52, 314.
3. Sutton, P. R. N.
Fluoridation: Errors and Omissions in Experimental
Trials; p. 52. Melbourne,
1959.
4. Exner, F. B. Fluoridation. New York, 1960.
5. Gross, L. New York Times, April 1, 1957. 6. Ritchie, D. B. Nature, Lond. 1961, 190, 456.