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SUBSTITUTES FOR WINDOW GLASS.
THM USM AND MISUSE OF DENTAL SKIAGItAM’Ì.
Correspondence. "Audi alteram partom."
THE USE AND MISUSE
891
and the average dentist has very little knowledge of general pathology, so that only by their close coöperation can the patient derive the maximum benefit. I am. Sir, yours faithfully, J. H. BADCOCK. F3,rloy-street, W., Oct. 12th, ] [);J7.
OF DENTAL
SKIAGRAMS. To the Editor of’l’HE LANCET. SIR,—Permit me to draw your attention to a practice which appears to be growing and is, I venture to think, prejudicial to all concerned. It is this. A doctor, thinking that the condition of his patient’s teeth may have a bearing on his illness, sends him to On the strength a radiographer of his own choosing. of his own or the radiographer’s interpretation of the resulting radiograph, often not too clear, he makes a diagnosis, possibly prescribes treatment, and either requires the patient’s own dentist to carry it out or very frequently sends him to someone else of his own selection. Surely this is wrong. Dental radiograms are a very valuable aid to diagnosis, but only an aid, and no substitute for clinical examination. They are often invaluable in revealing unsuspected trouble, more often still in affording ocular and convincing proof of what the dentist already knows or suspects ; but, on the other hand, there may be serious sepsis without there being any signs of it in the radiogram; their negative evidence cannot be relied upon. Moreover, to be of value they must be really good, and to produce good dental films requires considerable practice. With certain brilliant exceptions the dentist who takes his own usually attains to a higher level of perfection than the general radiographer. Far too many reports are made upon skiagrams so imperfect that no safe deductions can be drawn from them. Having obtained good films they must be correctly interpreted, often no easy matter, and here again the dentist is more likely to be successful than the medical man or the radiologist in whose report the doctor usually puts implicit faith. As examples of the gross errors easily made I may mention a case where a patient was recently told by his doctor that an upper wisdom tooth was diseased and must come out, the " tooth " in question being the coronoid process of the mandible ; and the frequent condemnation of lower premolars as the subject of apical sepsis, by reason of the proximity of the inferior dental foramen to .their roots. It is obviously unwise to depend upon the shadow for diagnosis and entirely ignore the substance. No dentist would rely solely upon radiograms apart from clinical examination and the clinical history. Were he limited to one or the other he would certainly choose a careful It is not uncommon for a clinical examination. patient to come to a dentist with films taken at the request of his doctor and instructions that certain teeth are septic and to be removed, while others much worse have passed unnoticed. It is not only unprofessional and discourteous to ignore the patient’s own dentist, but shortsighted ; because, if a careful man, he will have a recorded history of the mouth which may prove of the utmost value. The reasons why he is so often ignored by the doctor when a diagnosis is to be made would appear to be that the doctor mistrusts dentists in general (or, possibly with good reason, that one in particular) while he overrates skiagrams as a source of accurate and complete information, and fails to realise that their interpretation is a matter where the knowledge and experience of the dentist and his clinical findings are of the utmost value, with the assistance of the radiologist in case of difficulty. Surely the correct course is to refer the patient in the first instance to his own dentist, if he has one, for a report, with skiagrams, of the condition of the mouth. If, for any reason, this report should not inspire confidence, a second opinion should be sought. In this way the patient’s best interests would be served and no one would have cause to complain. The facts are that the average doctor has very little knowledge of teeth,
PARAPLEGIA IN HODGKIN’S DISEASE. To the Editor of THE LANCET. SIR,-In connexion with the three articles in THE LANCET of Oct. 15th (pp. 806-810), perhaps I may be permitted to draw attention to a case of Hodgkin’s Disease with Paraplegia, by Dr. J. Carslaw and Dr. J. S. Young, in the current number of the Glasgow Medical Journal (1927, cviii., 193). In their case there was a diffuse growth of fibrocellular tissue, comprising a small proportion of large cells with irregular, hyperchromatic nuclei, in the extradural space of the dorsal region. As far as I know no involvement of the extradural space has yet been noted in cases of Hodgkin’s disease in which during life there has been herpes zoster, but perhaps this is because in such cases the vertebral canal has not been examined at postmortem examinations. Personally, I used to think that the occurrence of herpes zoster in cases of Hodgkin’s disease was due to arsenical treatment, but it may well be that in some cases it has been a result of involvement of the posterior roots (with their ganglia) of spinal nerves in the lymphogranulomatous process. I note that these authors speak of Incidentally " Hodgkin’s sarcoma " after J. Ewing. Surely, the term " Hodgkin sarcoma " would be better, as Hodgkin certainly did not distinguish a Hodgkin sarcoma from a Hodgkin granuloma, though now both may well be named after him (in his honour). I am, Sir, yours faithfully, F. PARKES WEBER. London, W. 1, Oct. 15th, 1927. "rrL..-
SUBSTITUTES FOR WINDOW GLASS. To the Editor of THE LANCET. have read with great interest the comment SiB,—I in THE LANCET of August 6th, p. 316, on the report of the Council on Physical Therapy of the American Medical Association on various materials advertised as pervious to ultra-violet rays. Your cooperation and support as evidenced by the publicity given this report and previous reports of the Council in your valued journal is deeply appreciated. Such cooperation and support of the Council in its great task will materially hasten the day when physical therapy will be on as sound a basis as pharmacotherapy is
to-day. In view of the undoubtedly good influence of such publicity it is unfortunate that in the comment on the report on window glass substitutes the writer should apparently not thoroughly understand the purposes of some of the experimental work that was done by the Council. In the last paragraph of your
article it is stated that in view of the well-established fact that it is the shortest ultra-violet rays of sunlight that make heliotherapy valuable in the prophylaxis and cure of rickets, it seems hardly necessary to have tested the value of these glass substitutes biologically. The object of the biologic test performed on the materials under consideration has been apparently
understood imperfectly. The object of the biologic test was threefold : (1) to determine whether sufficient ultra-violet energy is present in winter sunshine in urban centres to warrant the use of materials of this sort for glazing windows ; (2) to determine the relative value of the materials tested as transmitters of the antirachitic rays of the sun ; and (3) to determine the antirachitic effect of winter sunlight filtered through these materials as compared with that of ultra-violet light from an artificial source. I am,
Sir,
yours
faithfully,
H. J.
Chicago, Oct. 6th.
HOLMQUEST,
Secretary, Council
on
Physical Therapy.
OBITUARY.
892
THE POSITION OF MEMBERS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND To the Editor of THE LANCET.
Obituary. MAJ.-GBN. SIR WILLIAM 0 IU;’IJ’I’ MACPIIEBSON, K.C.M.G., C.B., r.ATH A.M.S. WE regret to announce the death of Sir William " Macpherson, the editor-in-chief of the official Medical and a familiar to medical of the War," History person lie died on Saturday men as a great soldier-doctor. last at his house in Evelyn Oardcns, Kensington, at the age of 69. Macpherson was the son of the Rev. W. Macpherson, of Kilmuir Easter, Ross-shirc, where he was born in 1858. He was educated at Fettes College, being one of the original band with whom that school was opened in 1870. He proceeded to the University of Edinburgh, where he graduated in the first instance in high
SiR,—The Council of the Royal College of Surgeons of England has just published the result of the poll of the Fellows of the College on the question of the admission of Members to some representation on the Council. The voting paper was sent to 1850 Fellows ; 846 voted No, 234 voted Yes ; 770 Fellows did not vote. Unfortunately, and unfairly, I contend, the Council issued with the voting paper a definitely biased and ex parte statement of the Members’ case. It is remarkable that 770 Fellows did not vote. Also it should be noted that there are about 600 Fellows in the metropolitan area. I am, Sir, yours faithfully, REDMOND ROCHE. Eccleston-square, S.W., Oct. 16tb,
1927.
y
classical1
honours, HOSPITALS AND MOTOR-CAR ACCIDENTS. To the Editor
of
being university
THE LANCET.
scholar
I trespass upon your columns to ask the secretaries of hospitals throughout the country who can provide statistics as to the number of motorcar accident cases treated (with, if obtainable, the average length of stay) to send them to me, if possible, by the end of the present month. I am endeavouring to obtain statistical proof of the circumstances which have been alluded to so frequently in your columns of late.-I am, Sir, yours faithfully, H. W. BURLEIGH, Secretary and General Superintendent.
later he to turned
medicine, and in 1882 gradua t e d M.B., C.M. Edin. After taking out
post-graduate courses at the Universities of Leipzig and
Hospital for Epilepsy and Paralysis. Maida Vale. W., -
---
’
-.
Oct.17th, 1927.
Tiibingen,
MISLEADING QUALIFICATIONS. To the Editor
of THE LANCET.
SIR,-By an old-standing convention (adopted by makers of dictionaries and works of reference) Fellowship of the Royal College of Surgeons of England is denoted by the letters F.R.C.S., and Fellowship of the Royal College of Physicians of London by the letters F.R.C.P. Fellowship of other colleges, according to the same custom or convention, should be indicated by the addition of letters distinctive of the college to which the Fellow belongs. Those who do not conform to this convention are therefore liable to be judged ignorant if not, indeed, anxious to appear other than what they are. But there is no existent convention by virtue of which any one who appends M.D. to his name is to be supposed doctor of medicine of any particular university. M.D. means doctor of medicine ; F.R.C.S. means Fellow of the Royal College of Surgeons of I am, Sir, yours faithfully, England. F.R.C.P. Oct. 14th, 1927.
I
* * * More authority is needed for the closing " ipse dixit."-ED. L. PAYMENT
TO
HOSPITALS
FOR
MOTOR ACCIDENTS.-
Motor accidents are causing a serious increase of the waiting list at the Norfolk and Norwich Hospital, besides heavy expenditure. Motor insurance companies, it is stated, have resisted liability for payment of the hospital costs of such accidents on the ground that hospitals are voluntary institutions, and are therefore unable to sustain a claim. A report shows that in the first week of September there were 35 cases of injury in motor accidents in the hospital, and that their length of stay was considerably above the average. At a meeting of the hospital authorities on Oct. 8th it was pointed out that a private practitioner to whose surgery a motoring victim was taken could send his bill to the insurance company, and that the hospital could put itself in the same position as a private practitioner by sending all its motor cases to the new paying ward which would be opened early in the new year.
in
Greek, but
SIR,-May
he entered the Royal Army Niedical Corps crewith dentials of an
unusu-
ally high so order, that his success was
d 1 - SIR WILLIAM MACPHERSON. predicted and opportunities for special service came readily to his hand. In 1892 he was in medical charge of Sir Euan Smith’s mission to Fez, and he filled the same position in Sir Arthur Nicolson’s mission to Morocco City. In such capacities he made a mark for himself alike as a doctor and as a man of the world, and previous to the outbreak of the European War his career formed a series of special duties in South Africa, Panama, and Cuba, while in 1904, having received the C.M.G., he was appointed senior medical officer to the North China Command. This post he was permitted to select for himself in response to a flattering suggestion that he should go where he could be most useful. He chose the China appointment because it would bring him near the scene of the impending struggle between Russia and Japan, with the result that he was attached during the RussoJapanese War to the Japanese Army in the field, saw a great variety of service, while his personal work was recognised by two Japanese decorations. The experience gained in these several ways on all sides of medical organisa.tion was used by him immediately afterwards in Geneva, where he was one of the British plenipotentiaries at a conference for the revision of the Geneva Convention, and in 1906, and for the next four years, he was attached to the general staff A.M.S. In 1910 he was appointed P.M.O. at Malta, and after holding this position for one year he was transferred for three years to the 1
m in e
ately
Correspondence. "Audi alteram partom."
THE USE AND MISUSE
891
and the average dentist has very little knowledge of general pathology, so that only by their close coöperation can the patient derive the maximum benefit. I am. Sir, yours faithfully, J. H. BADCOCK. F3,rloy-street, W., Oct. 12th, ] [);J7.
OF DENTAL
SKIAGRAMS. To the Editor of’l’HE LANCET. SIR,—Permit me to draw your attention to a practice which appears to be growing and is, I venture to think, prejudicial to all concerned. It is this. A doctor, thinking that the condition of his patient’s teeth may have a bearing on his illness, sends him to On the strength a radiographer of his own choosing. of his own or the radiographer’s interpretation of the resulting radiograph, often not too clear, he makes a diagnosis, possibly prescribes treatment, and either requires the patient’s own dentist to carry it out or very frequently sends him to someone else of his own selection. Surely this is wrong. Dental radiograms are a very valuable aid to diagnosis, but only an aid, and no substitute for clinical examination. They are often invaluable in revealing unsuspected trouble, more often still in affording ocular and convincing proof of what the dentist already knows or suspects ; but, on the other hand, there may be serious sepsis without there being any signs of it in the radiogram; their negative evidence cannot be relied upon. Moreover, to be of value they must be really good, and to produce good dental films requires considerable practice. With certain brilliant exceptions the dentist who takes his own usually attains to a higher level of perfection than the general radiographer. Far too many reports are made upon skiagrams so imperfect that no safe deductions can be drawn from them. Having obtained good films they must be correctly interpreted, often no easy matter, and here again the dentist is more likely to be successful than the medical man or the radiologist in whose report the doctor usually puts implicit faith. As examples of the gross errors easily made I may mention a case where a patient was recently told by his doctor that an upper wisdom tooth was diseased and must come out, the " tooth " in question being the coronoid process of the mandible ; and the frequent condemnation of lower premolars as the subject of apical sepsis, by reason of the proximity of the inferior dental foramen to .their roots. It is obviously unwise to depend upon the shadow for diagnosis and entirely ignore the substance. No dentist would rely solely upon radiograms apart from clinical examination and the clinical history. Were he limited to one or the other he would certainly choose a careful It is not uncommon for a clinical examination. patient to come to a dentist with films taken at the request of his doctor and instructions that certain teeth are septic and to be removed, while others much worse have passed unnoticed. It is not only unprofessional and discourteous to ignore the patient’s own dentist, but shortsighted ; because, if a careful man, he will have a recorded history of the mouth which may prove of the utmost value. The reasons why he is so often ignored by the doctor when a diagnosis is to be made would appear to be that the doctor mistrusts dentists in general (or, possibly with good reason, that one in particular) while he overrates skiagrams as a source of accurate and complete information, and fails to realise that their interpretation is a matter where the knowledge and experience of the dentist and his clinical findings are of the utmost value, with the assistance of the radiologist in case of difficulty. Surely the correct course is to refer the patient in the first instance to his own dentist, if he has one, for a report, with skiagrams, of the condition of the mouth. If, for any reason, this report should not inspire confidence, a second opinion should be sought. In this way the patient’s best interests would be served and no one would have cause to complain. The facts are that the average doctor has very little knowledge of teeth,
PARAPLEGIA IN HODGKIN’S DISEASE. To the Editor of THE LANCET. SIR,-In connexion with the three articles in THE LANCET of Oct. 15th (pp. 806-810), perhaps I may be permitted to draw attention to a case of Hodgkin’s Disease with Paraplegia, by Dr. J. Carslaw and Dr. J. S. Young, in the current number of the Glasgow Medical Journal (1927, cviii., 193). In their case there was a diffuse growth of fibrocellular tissue, comprising a small proportion of large cells with irregular, hyperchromatic nuclei, in the extradural space of the dorsal region. As far as I know no involvement of the extradural space has yet been noted in cases of Hodgkin’s disease in which during life there has been herpes zoster, but perhaps this is because in such cases the vertebral canal has not been examined at postmortem examinations. Personally, I used to think that the occurrence of herpes zoster in cases of Hodgkin’s disease was due to arsenical treatment, but it may well be that in some cases it has been a result of involvement of the posterior roots (with their ganglia) of spinal nerves in the lymphogranulomatous process. I note that these authors speak of Incidentally " Hodgkin’s sarcoma " after J. Ewing. Surely, the term " Hodgkin sarcoma " would be better, as Hodgkin certainly did not distinguish a Hodgkin sarcoma from a Hodgkin granuloma, though now both may well be named after him (in his honour). I am, Sir, yours faithfully, F. PARKES WEBER. London, W. 1, Oct. 15th, 1927. "rrL..-
SUBSTITUTES FOR WINDOW GLASS. To the Editor of THE LANCET. have read with great interest the comment SiB,—I in THE LANCET of August 6th, p. 316, on the report of the Council on Physical Therapy of the American Medical Association on various materials advertised as pervious to ultra-violet rays. Your cooperation and support as evidenced by the publicity given this report and previous reports of the Council in your valued journal is deeply appreciated. Such cooperation and support of the Council in its great task will materially hasten the day when physical therapy will be on as sound a basis as pharmacotherapy is
to-day. In view of the undoubtedly good influence of such publicity it is unfortunate that in the comment on the report on window glass substitutes the writer should apparently not thoroughly understand the purposes of some of the experimental work that was done by the Council. In the last paragraph of your
article it is stated that in view of the well-established fact that it is the shortest ultra-violet rays of sunlight that make heliotherapy valuable in the prophylaxis and cure of rickets, it seems hardly necessary to have tested the value of these glass substitutes biologically. The object of the biologic test performed on the materials under consideration has been apparently
understood imperfectly. The object of the biologic test was threefold : (1) to determine whether sufficient ultra-violet energy is present in winter sunshine in urban centres to warrant the use of materials of this sort for glazing windows ; (2) to determine the relative value of the materials tested as transmitters of the antirachitic rays of the sun ; and (3) to determine the antirachitic effect of winter sunlight filtered through these materials as compared with that of ultra-violet light from an artificial source. I am,
Sir,
yours
faithfully,
H. J.
Chicago, Oct. 6th.
HOLMQUEST,
Secretary, Council
on
Physical Therapy.
OBITUARY.
892
THE POSITION OF MEMBERS OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND To the Editor of THE LANCET.
Obituary. MAJ.-GBN. SIR WILLIAM 0 IU;’IJ’I’ MACPIIEBSON, K.C.M.G., C.B., r.ATH A.M.S. WE regret to announce the death of Sir William " Macpherson, the editor-in-chief of the official Medical and a familiar to medical of the War," History person lie died on Saturday men as a great soldier-doctor. last at his house in Evelyn Oardcns, Kensington, at the age of 69. Macpherson was the son of the Rev. W. Macpherson, of Kilmuir Easter, Ross-shirc, where he was born in 1858. He was educated at Fettes College, being one of the original band with whom that school was opened in 1870. He proceeded to the University of Edinburgh, where he graduated in the first instance in high
SiR,—The Council of the Royal College of Surgeons of England has just published the result of the poll of the Fellows of the College on the question of the admission of Members to some representation on the Council. The voting paper was sent to 1850 Fellows ; 846 voted No, 234 voted Yes ; 770 Fellows did not vote. Unfortunately, and unfairly, I contend, the Council issued with the voting paper a definitely biased and ex parte statement of the Members’ case. It is remarkable that 770 Fellows did not vote. Also it should be noted that there are about 600 Fellows in the metropolitan area. I am, Sir, yours faithfully, REDMOND ROCHE. Eccleston-square, S.W., Oct. 16tb,
1927.
y
classical1
honours, HOSPITALS AND MOTOR-CAR ACCIDENTS. To the Editor
of
being university
THE LANCET.
scholar
I trespass upon your columns to ask the secretaries of hospitals throughout the country who can provide statistics as to the number of motorcar accident cases treated (with, if obtainable, the average length of stay) to send them to me, if possible, by the end of the present month. I am endeavouring to obtain statistical proof of the circumstances which have been alluded to so frequently in your columns of late.-I am, Sir, yours faithfully, H. W. BURLEIGH, Secretary and General Superintendent.
later he to turned
medicine, and in 1882 gradua t e d M.B., C.M. Edin. After taking out
post-graduate courses at the Universities of Leipzig and
Hospital for Epilepsy and Paralysis. Maida Vale. W., -
---
’
-.
Oct.17th, 1927.
Tiibingen,
MISLEADING QUALIFICATIONS. To the Editor
of THE LANCET.
SIR,-By an old-standing convention (adopted by makers of dictionaries and works of reference) Fellowship of the Royal College of Surgeons of England is denoted by the letters F.R.C.S., and Fellowship of the Royal College of Physicians of London by the letters F.R.C.P. Fellowship of other colleges, according to the same custom or convention, should be indicated by the addition of letters distinctive of the college to which the Fellow belongs. Those who do not conform to this convention are therefore liable to be judged ignorant if not, indeed, anxious to appear other than what they are. But there is no existent convention by virtue of which any one who appends M.D. to his name is to be supposed doctor of medicine of any particular university. M.D. means doctor of medicine ; F.R.C.S. means Fellow of the Royal College of Surgeons of I am, Sir, yours faithfully, England. F.R.C.P. Oct. 14th, 1927.
I
* * * More authority is needed for the closing " ipse dixit."-ED. L. PAYMENT
TO
HOSPITALS
FOR
MOTOR ACCIDENTS.-
Motor accidents are causing a serious increase of the waiting list at the Norfolk and Norwich Hospital, besides heavy expenditure. Motor insurance companies, it is stated, have resisted liability for payment of the hospital costs of such accidents on the ground that hospitals are voluntary institutions, and are therefore unable to sustain a claim. A report shows that in the first week of September there were 35 cases of injury in motor accidents in the hospital, and that their length of stay was considerably above the average. At a meeting of the hospital authorities on Oct. 8th it was pointed out that a private practitioner to whose surgery a motoring victim was taken could send his bill to the insurance company, and that the hospital could put itself in the same position as a private practitioner by sending all its motor cases to the new paying ward which would be opened early in the new year.
in
Greek, but
SIR,-May
he entered the Royal Army Niedical Corps crewith dentials of an
unusu-
ally high so order, that his success was
d 1 - SIR WILLIAM MACPHERSON. predicted and opportunities for special service came readily to his hand. In 1892 he was in medical charge of Sir Euan Smith’s mission to Fez, and he filled the same position in Sir Arthur Nicolson’s mission to Morocco City. In such capacities he made a mark for himself alike as a doctor and as a man of the world, and previous to the outbreak of the European War his career formed a series of special duties in South Africa, Panama, and Cuba, while in 1904, having received the C.M.G., he was appointed senior medical officer to the North China Command. This post he was permitted to select for himself in response to a flattering suggestion that he should go where he could be most useful. He chose the China appointment because it would bring him near the scene of the impending struggle between Russia and Japan, with the result that he was attached during the RussoJapanese War to the Japanese Army in the field, saw a great variety of service, while his personal work was recognised by two Japanese decorations. The experience gained in these several ways on all sides of medical organisa.tion was used by him immediately afterwards in Geneva, where he was one of the British plenipotentiaries at a conference for the revision of the Geneva Convention, and in 1906, and for the next four years, he was attached to the general staff A.M.S. In 1910 he was appointed P.M.O. at Malta, and after holding this position for one year he was transferred for three years to the 1
m in e
ately