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Journal of the Royal Society of Medicine Volume 85 September 1992

and vomiting, ultrasound has clearly demonstrated appendicitis. We have thus firmly arrived at a correct diagnosis in patients with an Alvarado score of no more than 4 or 5 and have not erred after recommending five such patients for surgery. Needless to say our surgical colleagues are most appreciative of the diagnostic help provided, and morbidity is minimized by facilitating early surgery. One patient had experienced pain for a month and one for 5 days. A child had a confusing history of recent abdominal trauma. It seems ultrasound is useful as long as the reliability of positive detection is stressed and negative results treated with reserve. The Alvarado score system may prove of inestimable value especially to the less experienced clinician in deciding on the appropriate line of treatment. Undoubtedly trials should now concentrate on the integration of ultrasound into the overall assessment provided by the Alvarado system. It would seem that scores of less than six should be referred for immediate US. This group will undoubtedly include those females in which pelvic disease may cause difficulties in diagnosis and young children in whom clinical evaluation is difficult6. M TOBIAS

E SAMUEL

Brenthurst Clinic

PO Box 370

Johannesburg 2000 South Africa

References 1 Sherwood T. Ultrasonography in patients with suspected acute appendicitis. Br J Radiol 1991;64:183 2 Rosenquist CJ. AJR 1988;150: 1189-90 3 Skaane P, Amland PF, Nordshus T,-Solheim K. Ultrasonography in patients with suspecd acute appendicitis: a prospective study. Br J Radiol 1990;63:87&7-793 4 Jeffrey RB, Laing FC, Townsend RR. Radiology

1988;167:327-9 5 Abu-Yousef MM, Bleicher JJ, Maher JW, tJrdaneta LD, Franken EA, Metcalf AM. AJR i987;149:53-8 6 Rasmussen 0, Hoffman J. Asseesmeit of the reliability of the symptoms and signs of a_JtRiependicitis. JR Coil Surg Edinb 1991;36:372-7

Folklore of warts We read with interest Dr Burns' review ofthe folklore of warts, and the various remedies which have found popularity in history (January 1992 JRS-M, p 37). Dr Burns concludes with the suggestion that where magic or ritual have failed, doctors might like to consider referring patients to the local warts clinic. Current treatment of warts usually entails excision, or the application of caustics or cytotoxics. To our knowledge the long term success or benefit- of these regimens has not been well demonstrated. Perlhs, in some cases, an alternative s trategy might be to leave them alone to go away of their-own accord. There is at least one historical precedent for such therapeutic nihilism; the views of the grsat empiric Theophrastus Bombast von Hohenheim (1493-M1-l) known as Paracelsus, who rote: Then now also know that if it should happen that warts or similar growths arise from another cause, that this is not harmful but useful. But these are often suppressed by alleged physicians, using caustics and cutting, and afterwards there arise complaints and lesions described which would not have

happened if these alleged physicians had not employed their unfounded arts1. A M RENTON H BIRLEY

Academic Department of Public Health St Mary's Hospital Medical School,

Norfolk Place,

London W2 1PG

Reference 1 Paracelsus. Das Zweite Buch der Grossen Wundarznei. Der ander tractat. Das Xll capitel. Quoted in Coulter BL. Divided legacy; a history ofthe schism in medical thought, vol 1. Washington DC: Wehawken Book Co, 1977:480

He/She etc. I refer to the letter from Harold Ellis (April 1992 JRSM, p 24). The problem can be resolved 'at a stroke' by the term 's/he' that I, and I am sure others, have been using for many years. Kingswear, Devon R ELLERBY

It is evident that JRSM, like many other journals, is in need of a brace of non-sexist pronouns (April 1992 JRSM, p 246). I offer for your use the suggestions I also supplied to the South African Medical Journal (S Afr Med J.1990;77:552): Nominative (he, she, it): hsht. The initial h- is silent in the vernacular, but retained in polite speech. Genitive (hers, his, its): erst. This gives primacy to the female genitive. Dative/accusative (him, her, it): mert. The male stands at the forefront of the accusative. For rendition of polite compliments to the fair sex a dative alternative i$ available: hrmt. D LIDSEY

Department of Surgery, University of Arizona Tucson, AZ 85724, USA

Patient denial in breast cancer I read with interest the paper by Phelan et al. about the late presentation of some patients with cancer of the breast (April 1992 JRSM, p 206). I well remember a patient of mine who greatly delayed attendance for treatment. She consulted me, her general practitioner, about a lump in the breast. I explained to her carefully that she should seek a specialist's advice, as it was likely to be cancer. She refused to take this advice, wishing to seek non:medical care from a 'therapist', and had only approached me to obtain a certificate for absence from work-While she was being treated. I refused to cooperate with her, and made a hospital appointment; she-did not keep this. She told me that she would sooner die of cancer without a disfiguring operation, than die of cancer after it. In view of my refusal to aOjt her wishes she requested the Executive Council torembve her name from my list. -Wt t would you have done? 233 Boroughbridge Road G'S PLPi York Y02 6AY

medical encounters I Tr I found- Dr Qureshi's editorial (February 1992 JRSM, p 65) on problems that can arise in medical encounters of the transcultural kind very helpful. I