634
Journal of the Royal Society of Medicine Volume 84 October 1991
frame and held to hard tooth tissue by a specially designed clamp in the operating area. This will not only retract and isolate adjacent soft tissues such as gingivae, the floor of the mouth, lips, cheeks, and the circumoral tissues from risk of damage and ingress into the operator's vision, but also eliminate blood, saliva,, tissue- and crevicular fluids, and exhaled products from respiratory and alimentary tracts from being incorWrated in the aerosol equation. Sadly, most dentists in the UK choose to totally ignore this useful technique which all were taught (albeit probably badly!) as undergraduates in their clinical years3. Even in high. risk situations where the patient is also hazarded by the potential ingress of small instruments into the oro-pharynx and respiratory tree during endodontics for example, 93% of dentists do not utilize the protection offered by rubber dam. The acknowledgment ofthe provisions and requirements of both the Health and Safety at Work Act (1984) and the Control of Substances Hazardous to Health Regulations (1989) may well highlight the avenue whereby this situation could be changed. The potential for infection - however minor - to support staff in the dental field is very reaL K F MARSHALL
Maurice Wohl GIDP Centre King's College School of Medicine & Dentistry, London SE5 9RW
References 1 Evans D, Samaranyake LP, Reid J. The efficacy of rubber dam isolation in reducing atmospheric bacterial contamination. J Dent Child 1989;56:442-4 2 Cochran MA, Miller CH, Sheldrake MA. The efficacy of the rubber dam a" a barrier to the spread of microorganisms during dental treatment. J Am Dent Assoc 1989;119:141-4 3 Marshall K, Page J. The use of rubber dam in the UK - a survey. Br Dent J 1990;16:286-91
Sherlock Holmes Readers ofthe Royal Society's Journal evidently eWoy an interest in Sherlock Holmes'-3. The popularity of international Sherlockian or Holmsean clubs bespeaks an ongoing affinity for the Sacred Canons. Traditionally such societies carry a high representation of academics and professionals, even physicians,. on their rolls. The attraction must be more than superficial. I suggest that the obsession is not with his character or plots but with his methods. Unfortunately, medical commentators have failed to achieve a full understanding of Holmes. Oderwald and Sebus2 are correct in rejecting the Peschels' reduction of Holmes' methods to a jigsaw puzzle analogy. Theirs is a just concern that retrospective analyses of medical case histories are an inadequate inquiry into Holmes' methods. Their choice of William of Baskerville, Umberto Eco's monk-sleuth in The Name of the Rose is closer to the full truth4. Like clinical decision makers, William too was forced to act with data that were often incomplete, frequently misleading and sometimes incorrect but Umberto Eco has given us another treatise to ponder. In an instructive but fortunately disjointed collection of papers published in book form5, Eco and his collaborators enunciate the principles of ratiocination (Edgar Allan Poe's
term) or abduction (Eco's preferred appellation). Abduction's principles are these: 'never assume anything, the nature of the object under scrutiny must dictate the nature of the inquiry, it is necessary to keep sight of the matter as a whole, one must prove that crucial "apparent impossibilities" are possible (if, indeed, they are so)'6. Reserchers enamoured with computer algorithms to support an artificial intelligence to handle medicine's uncertainties in decision making may be misspending valuable research monies. The analogues are all in Sherlock's methods. W R AYERS Georgetown University Georgetown University School of Medicine Washington, DC
References '1 Peschel RE, Peschel E.' What physicians have in common with Sherlock Holmes: discussion paper. J R Soc Med 1989;82:33-6 2 Oderwald AK, Sebus JH. The physician and Sherlock Holmes. J R Soc Med 1991;84:151-2 3 Watts MT. The mysterious case of the doctor with no patients. J R Soc Med 1991;84:166-6 4 Eco U. The Name of the Rose. London: Picador, 1984 5 Eco U, Sebock TA, eds. The Sign of Three. Bloomington: Indiana University Press, '1983 6 Harrowitz N. The body ofthe Detective Model: Charles S. Pierce and Edgar Allan Poe. In: Eco U, Sebock TA, eds. The Sign of Three. Bloomington: Indiana University PNess, 1983:179
Pathology: is it weli taught? May 1 congratulate you on the report of the symposium on the importgnc of pathology to the understanding of disease processes and therefore to clinical teaching (June 1991 JRSM, p 33. It emphasized in a practical way the influence which laboratory investigation has on every aspect of clinical practice and the need for this influence to be stressed in undergraduate and postgraduate teaching. The onus for this, appeared to be laid mainly on the shoulders of the clinicians. There was, however, a significant omission - the other side of the coin. In these days of early specialization in hospital medicine, the young recruit to laboratorynmedicine has -usually the minimum exposure to clinical. practice. Although I am now a very senior memb.er of the profession, my own experience illustrates an example of this situation. I started in a general pathology department and sub8equently lbcame a senior lecturer in the subject. Later I was appoint4d Director of the laboratory at the Royal Maternity Hospital, Glasgow, in succession to Harold Sheehan, and very soon thereafter to the position of pathologist to the Royal Samaritan Hospital for Women, the largest gynaecological unit in the UK in its time. I very quickly realized the depths of my ignorance in both obstetrics and gynaecology, but was very fortunate in that with the encouragement of my clinical colleagues, I took part in ward rounds and the clinical examination of patients. I gained a great deal of clinical experience without the responsibility for treatment. The latter was no bad thing for both the patient and myself. It allowed me to have an objective approach to the clinical discipline, to recognize the problems and most important of all, to formulate questions which required investigation and answers.
Journal of the Royal Society of Medicine Volume 84 October 1991
635
I know that already the pathologist's lack of intimate clinical knowledge is being remedied by CPCs etc, but I would emphasize the need to find ways and means whereby this cross-fertilization process canb6improved. A D T GOVAN University Department of Obstetrics & Gynaecology Royal Infirmary, Glasgow G31 2ER
The Coma report: sugars and dental caries The letter by Walker and Walker on sugas and dental caries (May 1991 JRSM, p 320) made interesting reading. No one would disagree that the aetiology of dental caries is multifactorial, as is its decline in developed countries. However the key role of sugar in the development of dental caries must be emphasized. The Vipeholm Study' gave unequivocal evidence that sugar between meals results in an increase -in caries. Further evidence is reported by those who have examined the results of a change to a 'westernized' diet by communities such as t-he Eskimos2 or the inhabitants of Tristan da Cunha3. These and similar communities witnesse an increase in caries levels, accompanying their change in eating habits. In the Western world socially-deprived groups have seen less of a decline in caries levels compared to their more advantaged peers. Blinkhorn found caries and sweet-eating higher in deprived children4. Longitudinal studies relating caries experience to the level of consumption of sugar, are important as they relate diet to the number of new carious lesions initiated over the same time period. Rugg-Gunn et al. reported a positive correlation5 between confectionery, table sugar and soft drinks being particularly
implicated6. The Turku Study substituted sucrose in the diet, which resulted in a 66% reduction in aes7. In answer to the points made by Walker and Walker: (i) sugar is heavily incrimi-nated as the major cause of dental caries; (ii) even if one were to accept the claim of a 20-25% reduction following sugar reduction, this is significant both in terms of reduced suffering and cost; (iii) there is no reason that a reduction in sugar intake, particularly between meals need necessitate an increase in fat intake. C DEERY
Department of Dental Health, University of Dundee, Dundee DD1 4HN
References 1 Gustaffson BE, Quensel CE, Lanke LS, et al. The Vipeholm dental caries study. The effect of different levels of carbohydrate intake on caries activity in 436 individuals observed for five years. Acta Odont Scand 1954;11:232-64 2 Curzon MEJ, Curzon JA. Dental caries prevalence in the Baffin Island eskimo. Pediatr Dent 1979;1:169-72 3 Fisher FJ. A field study of dental caries, periodontal disease and enamel defects in Tristan da Cunha. Br Dent J 1968;125:447-53 4 Blinkhorn AS. The caries experience and dietary habits of Edinburgh nursery school children. Br Dent J 1982;152:227-30 5 Rugg-Gunn AJ, Hackett AF, Appleton DR, Jenkins GN, Eastoe JE. Relationship between dietary habits and caries increment assessed over two years in 405 English adolescent schoolchildren. Arch Oral Biol 1984;29:983-92 6 Rugg-Gunn AJ, Hackett AF, Appleton DR, Moynihan PJ. The dietary intake of added and natural sugars in 405 English adolescents. Hum Nutr Appl Nutr 1986;40a: 115-24 7 Scheinin A. Influence of the diagnostic level on caries incidence in two controlled clinical trials. Caries Res 1979;13:91(abstr. 20)
EXEMPT FUND JERSfEY INVESTMENT PLAN £12 BILLION FUND * Backed by a major financial institution it can provide you with tax-free benefits payable in sterling from Jersey to any part of the world. * A secure sterling investment and Norwich Union guarantees your Capital can never fall nm value. * An offshore tax-haven with guaranteed profit, with -no risk and the investor retains control. * The fund has achieved an average growth of between 16-20% since 1975. A Plan for the longer term- investor (3-10 years) not looking for immediate income. This investment opportunity is available to all non-residents of the United Kingdom, Isle of Man and Channel Islands. For further details please contact Home & Overseas Ltd or return the coupon below to: Home & Overseas Ltd 10/12 Swan Place, Dublin 4, Ireland Tel: 353-1-607355 Fax: 35314-607348 Dl Please send full details: Name ...
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Address
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monthily
(min. £5000) (mmn. £600) (min. £50)
0
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Journal of the Royal Society of Medicine Volume 84 October 1991
frame and held to hard tooth tissue by a specially designed clamp in the operating area. This will not only retract and isolate adjacent soft tissues such as gingivae, the floor of the mouth, lips, cheeks, and the circumoral tissues from risk of damage and ingress into the operator's vision, but also eliminate blood, saliva,, tissue- and crevicular fluids, and exhaled products from respiratory and alimentary tracts from being incorWrated in the aerosol equation. Sadly, most dentists in the UK choose to totally ignore this useful technique which all were taught (albeit probably badly!) as undergraduates in their clinical years3. Even in high. risk situations where the patient is also hazarded by the potential ingress of small instruments into the oro-pharynx and respiratory tree during endodontics for example, 93% of dentists do not utilize the protection offered by rubber dam. The acknowledgment ofthe provisions and requirements of both the Health and Safety at Work Act (1984) and the Control of Substances Hazardous to Health Regulations (1989) may well highlight the avenue whereby this situation could be changed. The potential for infection - however minor - to support staff in the dental field is very reaL K F MARSHALL
Maurice Wohl GIDP Centre King's College School of Medicine & Dentistry, London SE5 9RW
References 1 Evans D, Samaranyake LP, Reid J. The efficacy of rubber dam isolation in reducing atmospheric bacterial contamination. J Dent Child 1989;56:442-4 2 Cochran MA, Miller CH, Sheldrake MA. The efficacy of the rubber dam a" a barrier to the spread of microorganisms during dental treatment. J Am Dent Assoc 1989;119:141-4 3 Marshall K, Page J. The use of rubber dam in the UK - a survey. Br Dent J 1990;16:286-91
Sherlock Holmes Readers ofthe Royal Society's Journal evidently eWoy an interest in Sherlock Holmes'-3. The popularity of international Sherlockian or Holmsean clubs bespeaks an ongoing affinity for the Sacred Canons. Traditionally such societies carry a high representation of academics and professionals, even physicians,. on their rolls. The attraction must be more than superficial. I suggest that the obsession is not with his character or plots but with his methods. Unfortunately, medical commentators have failed to achieve a full understanding of Holmes. Oderwald and Sebus2 are correct in rejecting the Peschels' reduction of Holmes' methods to a jigsaw puzzle analogy. Theirs is a just concern that retrospective analyses of medical case histories are an inadequate inquiry into Holmes' methods. Their choice of William of Baskerville, Umberto Eco's monk-sleuth in The Name of the Rose is closer to the full truth4. Like clinical decision makers, William too was forced to act with data that were often incomplete, frequently misleading and sometimes incorrect but Umberto Eco has given us another treatise to ponder. In an instructive but fortunately disjointed collection of papers published in book form5, Eco and his collaborators enunciate the principles of ratiocination (Edgar Allan Poe's
term) or abduction (Eco's preferred appellation). Abduction's principles are these: 'never assume anything, the nature of the object under scrutiny must dictate the nature of the inquiry, it is necessary to keep sight of the matter as a whole, one must prove that crucial "apparent impossibilities" are possible (if, indeed, they are so)'6. Reserchers enamoured with computer algorithms to support an artificial intelligence to handle medicine's uncertainties in decision making may be misspending valuable research monies. The analogues are all in Sherlock's methods. W R AYERS Georgetown University Georgetown University School of Medicine Washington, DC
References '1 Peschel RE, Peschel E.' What physicians have in common with Sherlock Holmes: discussion paper. J R Soc Med 1989;82:33-6 2 Oderwald AK, Sebus JH. The physician and Sherlock Holmes. J R Soc Med 1991;84:151-2 3 Watts MT. The mysterious case of the doctor with no patients. J R Soc Med 1991;84:166-6 4 Eco U. The Name of the Rose. London: Picador, 1984 5 Eco U, Sebock TA, eds. The Sign of Three. Bloomington: Indiana University Press, '1983 6 Harrowitz N. The body ofthe Detective Model: Charles S. Pierce and Edgar Allan Poe. In: Eco U, Sebock TA, eds. The Sign of Three. Bloomington: Indiana University PNess, 1983:179
Pathology: is it weli taught? May 1 congratulate you on the report of the symposium on the importgnc of pathology to the understanding of disease processes and therefore to clinical teaching (June 1991 JRSM, p 33. It emphasized in a practical way the influence which laboratory investigation has on every aspect of clinical practice and the need for this influence to be stressed in undergraduate and postgraduate teaching. The onus for this, appeared to be laid mainly on the shoulders of the clinicians. There was, however, a significant omission - the other side of the coin. In these days of early specialization in hospital medicine, the young recruit to laboratorynmedicine has -usually the minimum exposure to clinical. practice. Although I am now a very senior memb.er of the profession, my own experience illustrates an example of this situation. I started in a general pathology department and sub8equently lbcame a senior lecturer in the subject. Later I was appoint4d Director of the laboratory at the Royal Maternity Hospital, Glasgow, in succession to Harold Sheehan, and very soon thereafter to the position of pathologist to the Royal Samaritan Hospital for Women, the largest gynaecological unit in the UK in its time. I very quickly realized the depths of my ignorance in both obstetrics and gynaecology, but was very fortunate in that with the encouragement of my clinical colleagues, I took part in ward rounds and the clinical examination of patients. I gained a great deal of clinical experience without the responsibility for treatment. The latter was no bad thing for both the patient and myself. It allowed me to have an objective approach to the clinical discipline, to recognize the problems and most important of all, to formulate questions which required investigation and answers.
Journal of the Royal Society of Medicine Volume 84 October 1991
635
I know that already the pathologist's lack of intimate clinical knowledge is being remedied by CPCs etc, but I would emphasize the need to find ways and means whereby this cross-fertilization process canb6improved. A D T GOVAN University Department of Obstetrics & Gynaecology Royal Infirmary, Glasgow G31 2ER
The Coma report: sugars and dental caries The letter by Walker and Walker on sugas and dental caries (May 1991 JRSM, p 320) made interesting reading. No one would disagree that the aetiology of dental caries is multifactorial, as is its decline in developed countries. However the key role of sugar in the development of dental caries must be emphasized. The Vipeholm Study' gave unequivocal evidence that sugar between meals results in an increase -in caries. Further evidence is reported by those who have examined the results of a change to a 'westernized' diet by communities such as t-he Eskimos2 or the inhabitants of Tristan da Cunha3. These and similar communities witnesse an increase in caries levels, accompanying their change in eating habits. In the Western world socially-deprived groups have seen less of a decline in caries levels compared to their more advantaged peers. Blinkhorn found caries and sweet-eating higher in deprived children4. Longitudinal studies relating caries experience to the level of consumption of sugar, are important as they relate diet to the number of new carious lesions initiated over the same time period. Rugg-Gunn et al. reported a positive correlation5 between confectionery, table sugar and soft drinks being particularly
implicated6. The Turku Study substituted sucrose in the diet, which resulted in a 66% reduction in aes7. In answer to the points made by Walker and Walker: (i) sugar is heavily incrimi-nated as the major cause of dental caries; (ii) even if one were to accept the claim of a 20-25% reduction following sugar reduction, this is significant both in terms of reduced suffering and cost; (iii) there is no reason that a reduction in sugar intake, particularly between meals need necessitate an increase in fat intake. C DEERY
Department of Dental Health, University of Dundee, Dundee DD1 4HN
References 1 Gustaffson BE, Quensel CE, Lanke LS, et al. The Vipeholm dental caries study. The effect of different levels of carbohydrate intake on caries activity in 436 individuals observed for five years. Acta Odont Scand 1954;11:232-64 2 Curzon MEJ, Curzon JA. Dental caries prevalence in the Baffin Island eskimo. Pediatr Dent 1979;1:169-72 3 Fisher FJ. A field study of dental caries, periodontal disease and enamel defects in Tristan da Cunha. Br Dent J 1968;125:447-53 4 Blinkhorn AS. The caries experience and dietary habits of Edinburgh nursery school children. Br Dent J 1982;152:227-30 5 Rugg-Gunn AJ, Hackett AF, Appleton DR, Jenkins GN, Eastoe JE. Relationship between dietary habits and caries increment assessed over two years in 405 English adolescent schoolchildren. Arch Oral Biol 1984;29:983-92 6 Rugg-Gunn AJ, Hackett AF, Appleton DR, Moynihan PJ. The dietary intake of added and natural sugars in 405 English adolescents. Hum Nutr Appl Nutr 1986;40a: 115-24 7 Scheinin A. Influence of the diagnostic level on caries incidence in two controlled clinical trials. Caries Res 1979;13:91(abstr. 20)
EXEMPT FUND JERSfEY INVESTMENT PLAN £12 BILLION FUND * Backed by a major financial institution it can provide you with tax-free benefits payable in sterling from Jersey to any part of the world. * A secure sterling investment and Norwich Union guarantees your Capital can never fall nm value. * An offshore tax-haven with guaranteed profit, with -no risk and the investor retains control. * The fund has achieved an average growth of between 16-20% since 1975. A Plan for the longer term- investor (3-10 years) not looking for immediate income. This investment opportunity is available to all non-residents of the United Kingdom, Isle of Man and Channel Islands. For further details please contact Home & Overseas Ltd or return the coupon below to: Home & Overseas Ltd 10/12 Swan Place, Dublin 4, Ireland Tel: 353-1-607355 Fax: 35314-607348 Dl Please send full details: Name ...
...........................
......
Address
Date of Birth Amount to invest single yearly
monthily
(min. £5000) (mmn. £600) (min. £50)
0
....
