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THE INDIAN MEDICAL SERVICE.
574 8. That the presence of adenoids has more to do with the presence of carious teeth than have mouth-breathing and palate shape, and that this is probably due to the increased tendency to oral sepsis in adenoid children. 9. That irregularity of the upper incisors is less a result of adenoids than of palate shape. 10. That the percentage of ear complications in adenoid children is about 10-8, and that adenoids are probably by far the most important factor in the a-tiology of ear affections in childhood.
Correspondence. "Audi alteram partem."
THE
INDIAN
MEDICAL SERVICE. of THE LANCET.
To the Editor
SiB,—I was delighted this morning to read the leading article in THE LANCET on the Indian Medical Service. It was most refreshing after the orgy of pessimistic representations that have appeared in other papers. The article is, I believe, an accurate statement of the present position of the I.M.S., and taken with what appeared in the Students’ Number last week should be very helpful to young medical men wishing to know the exact state of things. I was very glad also to read your eulogy of Lord Sydenham’s speech. The fundamental point is that the I.M.S. is not to be abrogated. I am inclined to think that once the home schools’ embargo is raised there will be a rapidly increasing number of candi-
There is no need to compare my conclusions with those of Dr. Newsholme, but I cannot agree with his estimate that 5 per cent. only of the school-children would be suffering from symptoms calling for operation, presuming, of course, that the children referred to are the 600 out of 18,000. I am much more in agreement with my friend Dr. Dan McKenzie, that the percentage requiring operation is 30. There is one thing that must be said in conclusion, for it has come repeatedly before me in my work as an officer of the L.C.C., and my experience has been endorsed by other otologists to whom I have spoken on the subject. It is that a large percentage of adenoid operations are inefficiently performed. Not a month passes without my being told by mothers that a child’s deafness has been made.worse by, or dated from, an adenoid operation. It is not the special hospitals that this complaint involves, but the large general hospitals and general practitioners in poor neighbourhoods. Even when the operation has been efficiently performed it would appear that in many instances the child is expected to recover hearing by itself, and no trouble is taken to follow cases up and to ensure that proper aural after-treatment is obtained. Finally, the more I see of the treatment of adenoids and tonsils, the more I am convinced that the operation should be regarded as one of the highest " importance and not as one so trivial that anyone can perform it. I am, Sir, yours faithfully, MACI.EOD YEARSLEY, MACLEOD Y]EAR.SLEY, F.R.C.S., Consulting Aural Surgeon to the London
dates for the I.M.S. There will be few home candidates for the 50 per cent. appointments of the civil the Lee or rather provincial medical services ; Commission recommended that the shortage of these 50 per cent. was to be made up by additional transfers (apart from the War Reserve of 122) from the R.A.M.C. (India). If this is given effect to in the I.M.S., we shall go near to a restoration of the status quo ante. Nous verrons! ! I am, Sir, yours faithfully, P. HEHIR. Westward Ho ! Devon, Sept. 4th, 1925. ** * If the recommendations of the Lee Commission are applied in their entirety to the Indian Medical Service it follows, as we set out in the Students’ Number of THE LANCET, that no attempt will be made to perpetuate that Service as at present constituted. Happily, the Government of India and the Secretary of State for India are in agreement that the Indian Medical Service must be maintained. Lord Birkenhead has still to communicate his final decisions, but there is nothing in the existing situation to belie optimism.-ED. L. .
"
County Council, &c. Wimpole-strect, W., Sept. 4th, 1925.
RADIATION FOR CARCINOMA: MR. BONNEY’S CHALLENGE.
ADENOIDS AMONG SCHOOL-CHILDREN. To the Editor of THE LANCET. SiB,—In reference to the annotation upon this subject in your issue of August 22nd (p. 391), it may be of interest to your readers to be reminded of an investigation into the occurrence of adenoids in three of the London County Council elementary schools, the results of which I published 15 years ago.l The investigation dealt with 2315 children and was made during the winter of 1907-08. Without going into details, which can be seen in the reference given, the conclusions to be drawn were as follows :1. That on the average about 37 per cent. of the children in elementary schools have adenoids, and between 72 and 76 per cent. have enlarged tonsils as well. 2. That on the average 31-2 per cent. of adenoid cases are mouth-breathers, complete or partial, and that hypertrophy of the faucial tonsils may give rise to mouth-breathing in the absence of adenoids. 3. That sex appears to have no influence upon the incidence of adenoids. 4. That adenoids are most common about the age of 8 and are next most frequent at about 12. 5. That true aprosexia is often confused with apparent dullness due to defective hearing, and that true aprosexia occurs only in about 4-7 per cent. of adenoid cases, is more frequent in girls, and, when present, is associated with a marked degree of adenoids. 6. The so-called adenoid facies is uncommon, save in association with a marked degree of adenoids. 7. That the association of an abnormally high palate with adenoids is rather due to peculiarities of cranial formation than to extra-uterine influences of nasal stenosis, and that, if there is any relation between a high narrow palate and adenoids, it is possible that the palate shape is rather the cause of the adenoids than vice versa. 1 British Journal of Children’s Diseases, February and March, 1910.
,
To the Fdztor of THE LANCET. SIR,-Iperceive from your report of the proceedings of the Section of Gynaecology at the B.M.A. annual meeting that Mr. Victor Bonney has been at it again. The mere mention of the word " radiation " appears to make him see red. Speaking of cases of carcinoma. of the uterus with carcinomatous glands, Mr. Bonney said (THE LANCET, Sept. 5th, p. 498) :" He did not use radium beforehand as a routine, though he had operated on a good many cases in which it had been so used with the idea of making the growth removable. Those who said it could do this did not know the limits of operability. It did nothing of the sort, but on the contrary made the operation much more formidable on account of the intense fibrosis set up, which so welded the surrounding tissues to the growth that all planes of cleavage were lost."
If Mr.
goes on at this rate (and he does his later remarks will show) his name will become a bogy with which to frighten young radiologists at their mother’s knee ! I am not specially concerned to take up the cudgels for radium as a preoperative treatment, as I think it is less easily controlled than X rays, and may, unless very skilfully handled, cause actual tissue necrosis, with resultant extensive scarring. But Mr. Bonney does not confine his hostility to radium. He goes forth with bell, book, and candle, reciting a, kind of Athanasian Creed which includes radium, X rays, and their advocates in one comprehensive damnation. Now, if there is one thing firmly established in radiotherapy, it is that X rays in suitable doses have the power to cause the absorption of pathological fibrous tissue. Keloid melts away under their influence, and the tense bands of a Dupuytren’s become softened. The X ray, it is true, go on,
Bonney
as
contraction
Correspondence. "Audi alteram partem."
THE
INDIAN
MEDICAL SERVICE. of THE LANCET.
To the Editor
SiB,—I was delighted this morning to read the leading article in THE LANCET on the Indian Medical Service. It was most refreshing after the orgy of pessimistic representations that have appeared in other papers. The article is, I believe, an accurate statement of the present position of the I.M.S., and taken with what appeared in the Students’ Number last week should be very helpful to young medical men wishing to know the exact state of things. I was very glad also to read your eulogy of Lord Sydenham’s speech. The fundamental point is that the I.M.S. is not to be abrogated. I am inclined to think that once the home schools’ embargo is raised there will be a rapidly increasing number of candi-
There is no need to compare my conclusions with those of Dr. Newsholme, but I cannot agree with his estimate that 5 per cent. only of the school-children would be suffering from symptoms calling for operation, presuming, of course, that the children referred to are the 600 out of 18,000. I am much more in agreement with my friend Dr. Dan McKenzie, that the percentage requiring operation is 30. There is one thing that must be said in conclusion, for it has come repeatedly before me in my work as an officer of the L.C.C., and my experience has been endorsed by other otologists to whom I have spoken on the subject. It is that a large percentage of adenoid operations are inefficiently performed. Not a month passes without my being told by mothers that a child’s deafness has been made.worse by, or dated from, an adenoid operation. It is not the special hospitals that this complaint involves, but the large general hospitals and general practitioners in poor neighbourhoods. Even when the operation has been efficiently performed it would appear that in many instances the child is expected to recover hearing by itself, and no trouble is taken to follow cases up and to ensure that proper aural after-treatment is obtained. Finally, the more I see of the treatment of adenoids and tonsils, the more I am convinced that the operation should be regarded as one of the highest " importance and not as one so trivial that anyone can perform it. I am, Sir, yours faithfully, MACI.EOD YEARSLEY, MACLEOD Y]EAR.SLEY, F.R.C.S., Consulting Aural Surgeon to the London
dates for the I.M.S. There will be few home candidates for the 50 per cent. appointments of the civil the Lee or rather provincial medical services ; Commission recommended that the shortage of these 50 per cent. was to be made up by additional transfers (apart from the War Reserve of 122) from the R.A.M.C. (India). If this is given effect to in the I.M.S., we shall go near to a restoration of the status quo ante. Nous verrons! ! I am, Sir, yours faithfully, P. HEHIR. Westward Ho ! Devon, Sept. 4th, 1925. ** * If the recommendations of the Lee Commission are applied in their entirety to the Indian Medical Service it follows, as we set out in the Students’ Number of THE LANCET, that no attempt will be made to perpetuate that Service as at present constituted. Happily, the Government of India and the Secretary of State for India are in agreement that the Indian Medical Service must be maintained. Lord Birkenhead has still to communicate his final decisions, but there is nothing in the existing situation to belie optimism.-ED. L. .
"
County Council, &c. Wimpole-strect, W., Sept. 4th, 1925.
RADIATION FOR CARCINOMA: MR. BONNEY’S CHALLENGE.
ADENOIDS AMONG SCHOOL-CHILDREN. To the Editor of THE LANCET. SiB,—In reference to the annotation upon this subject in your issue of August 22nd (p. 391), it may be of interest to your readers to be reminded of an investigation into the occurrence of adenoids in three of the London County Council elementary schools, the results of which I published 15 years ago.l The investigation dealt with 2315 children and was made during the winter of 1907-08. Without going into details, which can be seen in the reference given, the conclusions to be drawn were as follows :1. That on the average about 37 per cent. of the children in elementary schools have adenoids, and between 72 and 76 per cent. have enlarged tonsils as well. 2. That on the average 31-2 per cent. of adenoid cases are mouth-breathers, complete or partial, and that hypertrophy of the faucial tonsils may give rise to mouth-breathing in the absence of adenoids. 3. That sex appears to have no influence upon the incidence of adenoids. 4. That adenoids are most common about the age of 8 and are next most frequent at about 12. 5. That true aprosexia is often confused with apparent dullness due to defective hearing, and that true aprosexia occurs only in about 4-7 per cent. of adenoid cases, is more frequent in girls, and, when present, is associated with a marked degree of adenoids. 6. The so-called adenoid facies is uncommon, save in association with a marked degree of adenoids. 7. That the association of an abnormally high palate with adenoids is rather due to peculiarities of cranial formation than to extra-uterine influences of nasal stenosis, and that, if there is any relation between a high narrow palate and adenoids, it is possible that the palate shape is rather the cause of the adenoids than vice versa. 1 British Journal of Children’s Diseases, February and March, 1910.
,
To the Fdztor of THE LANCET. SIR,-Iperceive from your report of the proceedings of the Section of Gynaecology at the B.M.A. annual meeting that Mr. Victor Bonney has been at it again. The mere mention of the word " radiation " appears to make him see red. Speaking of cases of carcinoma. of the uterus with carcinomatous glands, Mr. Bonney said (THE LANCET, Sept. 5th, p. 498) :" He did not use radium beforehand as a routine, though he had operated on a good many cases in which it had been so used with the idea of making the growth removable. Those who said it could do this did not know the limits of operability. It did nothing of the sort, but on the contrary made the operation much more formidable on account of the intense fibrosis set up, which so welded the surrounding tissues to the growth that all planes of cleavage were lost."
If Mr.
goes on at this rate (and he does his later remarks will show) his name will become a bogy with which to frighten young radiologists at their mother’s knee ! I am not specially concerned to take up the cudgels for radium as a preoperative treatment, as I think it is less easily controlled than X rays, and may, unless very skilfully handled, cause actual tissue necrosis, with resultant extensive scarring. But Mr. Bonney does not confine his hostility to radium. He goes forth with bell, book, and candle, reciting a, kind of Athanasian Creed which includes radium, X rays, and their advocates in one comprehensive damnation. Now, if there is one thing firmly established in radiotherapy, it is that X rays in suitable doses have the power to cause the absorption of pathological fibrous tissue. Keloid melts away under their influence, and the tense bands of a Dupuytren’s become softened. The X ray, it is true, go on,
Bonney
as
contraction