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THE DENTISTS BILL
818
Letters
to
the Editor
VARICOSE ULCERS SIR,—You state in your annotation of April 5 that a few weeks in bed will’heal most varicose ulcers, but that the rest’must be absolute and the leg raised. It is, of course, the impossibility of this in early middle life which leads to the chronic ulcer of late middle life, and I should have thought that the secondary dangers of absolute rest-e.g., fixation of arthritic joints in the neighbourhood of the septic ulcer-might well outweigh its advantages. So far as general practice is concerned I should like to emphasise that most ulcers can now be healed with ambulant treatment if judicious use is made of the different types of supporting bandage and of systemic penicillin and anti-histamine compounds where indicated. This takes longer than rest in bed-perhaps three to nine months-but with patience the ulcer is healed, and the patient is then immediately supplied with an elastic stocking and referred to the surgeons, who in Newcastle are particularly cooperative in wasting no time in dealing with such cases. For the practitioner the essentials to bear in mind are the principles of support, controlling infection and secondary allergic manifestations, and personal attention ; it is important that he should himself apply the bandage, since even minor defects in its application can cause unnecessary discomfort ; if one bandage proves unsuitable he must patiently try another. His personal influence is important at such times in encouraging a patient not to discard treatment
altogether. Thus with modern
appliances and drugs, with a good and with the easy supply service, hospital supporting of elastic stockings under the National Health Service, the treatment of varicose ulcers or their prevention is an excellent example of a field in which the usefulness of the general practitioner has greatly increased in the last decade. This does not affect the cogency of your remarks about prevention, but commonly operation seems the only effective method. Amble, by Morpeth,
R. P. ROBERTSON. Northumberland... Northumberland.
SIR,—Your annotation does not do justice to presentviews. Nearly all authorities have emphasised the absence of varicose veins in most cases of varicose ulcers. When true superficial varicose veins are obvious, the skin in the lower third of the leg is usually remarkably healthy. Superficial varicose veins are a comparatively rare cause of varicose ulceration ; the vast majority of varicose ulcers are due to incompetent valves in the deep veins. These deep veins are rendered valveless, or their valves rendered incompetent, in several ways. Children start life with many more valves than are required to aid venous return against gravity ; but with age there is a progressive diminution in the number of valves. If a, child starts life with a small complement of valves, this progressive disappearance of them will lead to venous congestion. Venosclerosis, or vein hardening (which is as common as arteriosclerosis), allows stretching of the vein wall, rendering the valves incompetent. These two processes of valve atrophy and vein sclerosis are as relentlessly progressive as greying of the hair and age itself ; nothing will delay them. These factors alone probably account for nearly 50% of varicose ulcers. Thrombophlebitis in the deep veins initially blocks the veins ; and reflex arterial and In time these venous spasm may cause a white-leg. blocked channels are re-canalised from the groin to the ankle ; this may take up to twenty years. The re-canalised channels will be completely valveless. The sad fate of 90% of patients with white-legs is a varicose ulcer years later. Injection with sclerosants
day
of varicose veins may by diffusion -through, communi. cating channels destroy the delicate valves in the deep veins. A large proportion of varicose ulcers could be prevented by timely treatment of thrombo-embolic disease, and a clear understanding of the risks associated with sclerosant therapy. It is helpful to remember that approximately 90% of venous blood returns to the heart from the leg by the deep venous channels ; only 10% returns by the superficial saphenous system of veins. If the valves are destroyed or rendered incompetent in the deep channels, then in the standing position severe venous congestion results in the capillaries of the lower leg. This leads to capillary damage, oedema, and eventually ulceration. Incompetent valves in the superficial veins lead to obvious varicose veins and may be ugly. It is
however,
for the venous congestion to cause and ulceration. When occasionally capillary damage this does happen obliteration of these varicose veins will cure the ulcer. The majority of ulcers are due to incompetence of deep valves and then treatment is usually much more difficult. Attempts are made to destroy incompetent deep veins, and thus remove the large static columns of venous blood from the capillaries of the lower leg, by such procedures as section of the superficial femoral and popliteal veins. These opera. tions are not consistently successful in curing " varicose ulcers." Despite all the modern surgical advances, probably the best treatment for varicose ulcers is still initial rest in bed followed by the wearing of an elastic bandage when the patient is ambulant. A. J. PARTRIDGE. Shoreham-by-Sea.
unusual,
’
THE DENTISTS BILL
SIR,—The leading article in your issue of March 29 contains many ingenious arguments but a few misstatements of fact and a number of statements and conclusions which appear to be lacking in justification. In the first place you state that the number of prac. tising dentists is about 10,000. This is certainly a considerable understatement. There are in fact over 15,000 dentists on the Register, and it is by general consent agreed that the number of these in active practice is probably between 12,000 and 12,500, as was the position when the Teviot Committee presented its report in 1946. Moreover, I note that you state in one sentence that the Dental Schools " have no vacant places," and three sentences later that " the dental schools already have difficulty in filling all their vacant places with students able to follow the course of train. ing." Official sources state that there are at the present time 24 applicants for every vacant place in the dental schools. In some schools the- percentage is very much higher, ten or more applications being received for every place that is available. " Again, you state that it is unrealistic to expect that the demand of adults for treatment under the National Health Service will be greatly reduced by the proposed charges." On the contrary, I think there is every evidence that the demand will be considerably reduced. The imposition of charges for dentures has already had the effect of reducing the gross earnings of dentists in the health service by something like one-third, and on this experience alone it may very reasonably be anticipated that a still further serious reduction in demand will result when the new charges come into operation. At the present time many dentists working in the general dental service are much less than fully occupied and would welcome the opportunity of giving to school-children the compre. hensive treatment they alone are legally entitled to give. Finally, to suggest that because many women dentists continue in practice after marriage " it is not unreasonable to expect an equally high proportion of dental nurses to
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.
Letters
to
the Editor
VARICOSE ULCERS SIR,—You state in your annotation of April 5 that a few weeks in bed will’heal most varicose ulcers, but that the rest’must be absolute and the leg raised. It is, of course, the impossibility of this in early middle life which leads to the chronic ulcer of late middle life, and I should have thought that the secondary dangers of absolute rest-e.g., fixation of arthritic joints in the neighbourhood of the septic ulcer-might well outweigh its advantages. So far as general practice is concerned I should like to emphasise that most ulcers can now be healed with ambulant treatment if judicious use is made of the different types of supporting bandage and of systemic penicillin and anti-histamine compounds where indicated. This takes longer than rest in bed-perhaps three to nine months-but with patience the ulcer is healed, and the patient is then immediately supplied with an elastic stocking and referred to the surgeons, who in Newcastle are particularly cooperative in wasting no time in dealing with such cases. For the practitioner the essentials to bear in mind are the principles of support, controlling infection and secondary allergic manifestations, and personal attention ; it is important that he should himself apply the bandage, since even minor defects in its application can cause unnecessary discomfort ; if one bandage proves unsuitable he must patiently try another. His personal influence is important at such times in encouraging a patient not to discard treatment
altogether. Thus with modern
appliances and drugs, with a good and with the easy supply service, hospital supporting of elastic stockings under the National Health Service, the treatment of varicose ulcers or their prevention is an excellent example of a field in which the usefulness of the general practitioner has greatly increased in the last decade. This does not affect the cogency of your remarks about prevention, but commonly operation seems the only effective method. Amble, by Morpeth,
R. P. ROBERTSON. Northumberland... Northumberland.
SIR,—Your annotation does not do justice to presentviews. Nearly all authorities have emphasised the absence of varicose veins in most cases of varicose ulcers. When true superficial varicose veins are obvious, the skin in the lower third of the leg is usually remarkably healthy. Superficial varicose veins are a comparatively rare cause of varicose ulceration ; the vast majority of varicose ulcers are due to incompetent valves in the deep veins. These deep veins are rendered valveless, or their valves rendered incompetent, in several ways. Children start life with many more valves than are required to aid venous return against gravity ; but with age there is a progressive diminution in the number of valves. If a, child starts life with a small complement of valves, this progressive disappearance of them will lead to venous congestion. Venosclerosis, or vein hardening (which is as common as arteriosclerosis), allows stretching of the vein wall, rendering the valves incompetent. These two processes of valve atrophy and vein sclerosis are as relentlessly progressive as greying of the hair and age itself ; nothing will delay them. These factors alone probably account for nearly 50% of varicose ulcers. Thrombophlebitis in the deep veins initially blocks the veins ; and reflex arterial and In time these venous spasm may cause a white-leg. blocked channels are re-canalised from the groin to the ankle ; this may take up to twenty years. The re-canalised channels will be completely valveless. The sad fate of 90% of patients with white-legs is a varicose ulcer years later. Injection with sclerosants
day
of varicose veins may by diffusion -through, communi. cating channels destroy the delicate valves in the deep veins. A large proportion of varicose ulcers could be prevented by timely treatment of thrombo-embolic disease, and a clear understanding of the risks associated with sclerosant therapy. It is helpful to remember that approximately 90% of venous blood returns to the heart from the leg by the deep venous channels ; only 10% returns by the superficial saphenous system of veins. If the valves are destroyed or rendered incompetent in the deep channels, then in the standing position severe venous congestion results in the capillaries of the lower leg. This leads to capillary damage, oedema, and eventually ulceration. Incompetent valves in the superficial veins lead to obvious varicose veins and may be ugly. It is
however,
for the venous congestion to cause and ulceration. When occasionally capillary damage this does happen obliteration of these varicose veins will cure the ulcer. The majority of ulcers are due to incompetence of deep valves and then treatment is usually much more difficult. Attempts are made to destroy incompetent deep veins, and thus remove the large static columns of venous blood from the capillaries of the lower leg, by such procedures as section of the superficial femoral and popliteal veins. These opera. tions are not consistently successful in curing " varicose ulcers." Despite all the modern surgical advances, probably the best treatment for varicose ulcers is still initial rest in bed followed by the wearing of an elastic bandage when the patient is ambulant. A. J. PARTRIDGE. Shoreham-by-Sea.
unusual,
’
THE DENTISTS BILL
SIR,—The leading article in your issue of March 29 contains many ingenious arguments but a few misstatements of fact and a number of statements and conclusions which appear to be lacking in justification. In the first place you state that the number of prac. tising dentists is about 10,000. This is certainly a considerable understatement. There are in fact over 15,000 dentists on the Register, and it is by general consent agreed that the number of these in active practice is probably between 12,000 and 12,500, as was the position when the Teviot Committee presented its report in 1946. Moreover, I note that you state in one sentence that the Dental Schools " have no vacant places," and three sentences later that " the dental schools already have difficulty in filling all their vacant places with students able to follow the course of train. ing." Official sources state that there are at the present time 24 applicants for every vacant place in the dental schools. In some schools the- percentage is very much higher, ten or more applications being received for every place that is available. " Again, you state that it is unrealistic to expect that the demand of adults for treatment under the National Health Service will be greatly reduced by the proposed charges." On the contrary, I think there is every evidence that the demand will be considerably reduced. The imposition of charges for dentures has already had the effect of reducing the gross earnings of dentists in the health service by something like one-third, and on this experience alone it may very reasonably be anticipated that a still further serious reduction in demand will result when the new charges come into operation. At the present time many dentists working in the general dental service are much less than fully occupied and would welcome the opportunity of giving to school-children the compre. hensive treatment they alone are legally entitled to give. Finally, to suggest that because many women dentists continue in practice after marriage " it is not unreasonable to expect an equally high proportion of dental nurses to
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.