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THE ECONOMIC VALUE OF THE DOCTOR
964
Histologically many caruncles consist of masses of granulation tissue. Such a lesion, though obviously not neoplastic, cannot be described as prolapsed mucosa. "
We believe therefore that the clinical term ’’ caruncle is no more misleading than the term " polyp," which is used to describe a variety of pathological lesions. The important fact emphasised by Mr. Campbell Begg is that the condition of true erosion, although by no means rare, is not a common lesion. Department of Obstetrics C. W. TAYLOR and Gynæcology, H. C. MCLAREN. University of Birmingham. COMBINED ABDOMINO-VAGINAL HYSTERECTOMY
J. ELLSWORTH LAING.
TUBERCULIN SENSITIVITY IN HOSPITAL CHILDREN
SiR,-Dr. Lunn’s article of Feb. 17 is a most valuable contribution to an important problem. Only large-scale investigations of this kind will provide a scientific basis for tuberculosis control programmes, with or without In view of the importance of this investigation, B.c.G. however, I wish to submit that the percentages reported in table i and 11 are erroneous. The calculation of the percentage of positive reactors (1071) was based on the total admissions (7555) and reported as 14.7%. This would only be true if all results not available " were negative. However, as " results not available " will probably show the same incidence of positive and negative reactors, the total of " results not available " (1309) should be deducted from the total admissions (7555 - 1309 6246) ; and the positives (1071) should be related to the corrected figure of admissions (6246). This will give 17-1% positive instead of 14.7%. The same correction will have to apply to the other percentages listed in tables i and 11. "
=
Almirante, Panama.
** * We
GUSTAV ENGLER.
have shown this letter to Dr. Lunn, who follows :
as "
or
3’4% using
suggested by Dr. Engler). It appropriate to use the total number
the correction
seemed, therefore,
more
of admissions rather than the total number of Mantoux tests done as the basis for the calculation of percentage sensitivity rates." "
THE ECONOMIC VALUE OF THE DOCTOR
SiB,—The letter from Dr. Hughes (April 14), in which regret to note that he seems to belittle the value of prevention " in a health service, confirms what has been apparent for many a day-namely, that the word health " by itself fails to convey to the hearer all that it connotes. For clarity and simplicity, and to avoid misunderstanding, two words seem to be needed when we discuss health matters, because health, as the word is used today, has two main and distinct aspects-a maintenance of health or prevention-of-disease side ; and a healing side. Hygiene " is sometimes used for the first of these aspects ; but it is an unsatisfactory word, and the Army medical authorities, in their search for a better word, have recently substituted the term " Army health" for hygiene. This is an improvement, certainly, but does not quite meet the difficulty so far as civil affairs are I
"
"
SIR,-Mr. Howkins, in his article last week on the above operation, mentions that some surgeons believe it worth leaving some portion of the vagina. This has obviously to be considered in operating on the younger age-groups. Further, the slow healing of the cavity left by removal of the vagina, with its inevitable infection and continuous discharge requiring constant attention for up to six months, must be distressing to the patient. Might not this unpleasant (though temporary) complication be avoided by combining the radical surgical removal described by Mr. Howkins, with all its advantages, with the relatively simple reconstruction of the vagina popularised by Sir Archibald Mclndoe ? This would add little, if any. time to the operation, since the vaginal dissection is completed before the abdominal closure starts, and the reconstruction is a short procedure. It is quite possible to cut the Thiersch graft from the thigh, without removing the patient’s legs from the Lloyd Davies supports. The skin is then inserted into the cavity either on a preformed acrylic mould or on a gutta-percha mould, which is easily made at the time of operation. If haemostasis has been obtained, and the walls of the cavity are reasonably smooth, healing should be sound in 10-14 days. If the grafting were not completely successful, then there would be delayed healing, which would not be comparable to that of a granulating cavity. It should be noted that a Thiersch graft has a high resistance to infection. In selected cases the addition of the reconstruction is, I am sure, a refinement worth considering. Odstock Hospital, Salisbury.
as was mentioned in the paper, 890 (83%) of these under three months. The incidence-rate of positive reactors from birth to one year is very low (2’3% in table n,
and indeed, were
replies
The point made by Dr. Engler is important, and was not overlooked. Of the children for whom results of Mantoux tests were not available 1074 (82%) were under one year of age,
"
concerned. The average individual comes into the world healthy, and what the various public-health and Army-health and other " preventative " workers are trying to do is to keep him healthy. It is the" maintenance of health" they are mostly concerned with ; this seems a better term than " prevention of disease." Disease to the average healthy person is something that is unlikely, he hopes, to happen to him. The maintenance of health, on the other hand, is a personal matter ; it is something of which every healthy individual understands the value, and in which he is interested. If therefore we want to have good cooperation from the public, let us talk in future not so much of the prevention of disease, but rather of the maintenance of health. The National Health Service is, I feel, mis-named. It should surely be called the " National Back-toHealth Service " ! Is that not what it principally is?1 The doctor whom Dr. Hughes has in mind is not primarily concerned with maintaining health, for he is seldom consulted by the healthy individual; his job is, in the main, to treat the sick person, and help him to regain that healthy level from which lie has fallen. To differentiate between these two aspects, two new words are needed. Any suggestions ? Public Health Adviser’s Office, W. STRELLEY MARTIN. Bad Salzuflen, Germany.
TRANSPARENT FILM ENVELOPES FOR A SYRINGE SERVICE
SiR,-I read with great’ interest the article by Dr. McCartney (March 3). Before the article appeared we had been testing these envelopes with a view to using them in the syringe service of this hospital, to overcome the shortage of glass tubes. We found that after sterilisation the syringes were sometimes non-sterile, and we were at a loss to ’understand this. On minutely examining the envelopes we found that small cracks had appeared which were not readily discernible to the naked eye. It was thus felt that this was not an ideal way of packing syringes for sterilisation since handling in the wards and depart. ments might render them non-sterile, even though the envelope appeared intact. These minute cracks seem to be due to slight brittleness of the envelope after sterilisation, despite the fact that the envelopes were not touched for a few hours after being sterilised. Ancoats Hospital, Manchester.
EVELYN P. BUTTON Chief Pharmacist.
Histologically many caruncles consist of masses of granulation tissue. Such a lesion, though obviously not neoplastic, cannot be described as prolapsed mucosa. "
We believe therefore that the clinical term ’’ caruncle is no more misleading than the term " polyp," which is used to describe a variety of pathological lesions. The important fact emphasised by Mr. Campbell Begg is that the condition of true erosion, although by no means rare, is not a common lesion. Department of Obstetrics C. W. TAYLOR and Gynæcology, H. C. MCLAREN. University of Birmingham. COMBINED ABDOMINO-VAGINAL HYSTERECTOMY
J. ELLSWORTH LAING.
TUBERCULIN SENSITIVITY IN HOSPITAL CHILDREN
SiR,-Dr. Lunn’s article of Feb. 17 is a most valuable contribution to an important problem. Only large-scale investigations of this kind will provide a scientific basis for tuberculosis control programmes, with or without In view of the importance of this investigation, B.c.G. however, I wish to submit that the percentages reported in table i and 11 are erroneous. The calculation of the percentage of positive reactors (1071) was based on the total admissions (7555) and reported as 14.7%. This would only be true if all results not available " were negative. However, as " results not available " will probably show the same incidence of positive and negative reactors, the total of " results not available " (1309) should be deducted from the total admissions (7555 - 1309 6246) ; and the positives (1071) should be related to the corrected figure of admissions (6246). This will give 17-1% positive instead of 14.7%. The same correction will have to apply to the other percentages listed in tables i and 11. "
=
Almirante, Panama.
** * We
GUSTAV ENGLER.
have shown this letter to Dr. Lunn, who follows :
as "
or
3’4% using
suggested by Dr. Engler). It appropriate to use the total number
the correction
seemed, therefore,
more
of admissions rather than the total number of Mantoux tests done as the basis for the calculation of percentage sensitivity rates." "
THE ECONOMIC VALUE OF THE DOCTOR
SiB,—The letter from Dr. Hughes (April 14), in which regret to note that he seems to belittle the value of prevention " in a health service, confirms what has been apparent for many a day-namely, that the word health " by itself fails to convey to the hearer all that it connotes. For clarity and simplicity, and to avoid misunderstanding, two words seem to be needed when we discuss health matters, because health, as the word is used today, has two main and distinct aspects-a maintenance of health or prevention-of-disease side ; and a healing side. Hygiene " is sometimes used for the first of these aspects ; but it is an unsatisfactory word, and the Army medical authorities, in their search for a better word, have recently substituted the term " Army health" for hygiene. This is an improvement, certainly, but does not quite meet the difficulty so far as civil affairs are I
"
"
SIR,-Mr. Howkins, in his article last week on the above operation, mentions that some surgeons believe it worth leaving some portion of the vagina. This has obviously to be considered in operating on the younger age-groups. Further, the slow healing of the cavity left by removal of the vagina, with its inevitable infection and continuous discharge requiring constant attention for up to six months, must be distressing to the patient. Might not this unpleasant (though temporary) complication be avoided by combining the radical surgical removal described by Mr. Howkins, with all its advantages, with the relatively simple reconstruction of the vagina popularised by Sir Archibald Mclndoe ? This would add little, if any. time to the operation, since the vaginal dissection is completed before the abdominal closure starts, and the reconstruction is a short procedure. It is quite possible to cut the Thiersch graft from the thigh, without removing the patient’s legs from the Lloyd Davies supports. The skin is then inserted into the cavity either on a preformed acrylic mould or on a gutta-percha mould, which is easily made at the time of operation. If haemostasis has been obtained, and the walls of the cavity are reasonably smooth, healing should be sound in 10-14 days. If the grafting were not completely successful, then there would be delayed healing, which would not be comparable to that of a granulating cavity. It should be noted that a Thiersch graft has a high resistance to infection. In selected cases the addition of the reconstruction is, I am sure, a refinement worth considering. Odstock Hospital, Salisbury.
as was mentioned in the paper, 890 (83%) of these under three months. The incidence-rate of positive reactors from birth to one year is very low (2’3% in table n,
and indeed, were
replies
The point made by Dr. Engler is important, and was not overlooked. Of the children for whom results of Mantoux tests were not available 1074 (82%) were under one year of age,
"
concerned. The average individual comes into the world healthy, and what the various public-health and Army-health and other " preventative " workers are trying to do is to keep him healthy. It is the" maintenance of health" they are mostly concerned with ; this seems a better term than " prevention of disease." Disease to the average healthy person is something that is unlikely, he hopes, to happen to him. The maintenance of health, on the other hand, is a personal matter ; it is something of which every healthy individual understands the value, and in which he is interested. If therefore we want to have good cooperation from the public, let us talk in future not so much of the prevention of disease, but rather of the maintenance of health. The National Health Service is, I feel, mis-named. It should surely be called the " National Back-toHealth Service " ! Is that not what it principally is?1 The doctor whom Dr. Hughes has in mind is not primarily concerned with maintaining health, for he is seldom consulted by the healthy individual; his job is, in the main, to treat the sick person, and help him to regain that healthy level from which lie has fallen. To differentiate between these two aspects, two new words are needed. Any suggestions ? Public Health Adviser’s Office, W. STRELLEY MARTIN. Bad Salzuflen, Germany.
TRANSPARENT FILM ENVELOPES FOR A SYRINGE SERVICE
SiR,-I read with great’ interest the article by Dr. McCartney (March 3). Before the article appeared we had been testing these envelopes with a view to using them in the syringe service of this hospital, to overcome the shortage of glass tubes. We found that after sterilisation the syringes were sometimes non-sterile, and we were at a loss to ’understand this. On minutely examining the envelopes we found that small cracks had appeared which were not readily discernible to the naked eye. It was thus felt that this was not an ideal way of packing syringes for sterilisation since handling in the wards and depart. ments might render them non-sterile, even though the envelope appeared intact. These minute cracks seem to be due to slight brittleness of the envelope after sterilisation, despite the fact that the envelopes were not touched for a few hours after being sterilised. Ancoats Hospital, Manchester.
EVELYN P. BUTTON Chief Pharmacist.