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SOME years ago, attention was focused on the almost total failure of the primary physician to detect promptly tumors of the larynx.1 This glaring defect was attributed to an inability to cope with the technical demands of the angled laryngeal mirror that, for more than 100 years, had been the only available tool for looking over the top of the tongue down to the glottic bed. As a solution, the article recommended replacing the mirror with the relatively new laryngeal telescopes and then proceeded to elaborate their virtues for the primary physician. They were so simple that they required little training; they afforded a clear view of the larynx in a high percentage of cases; and the examination required only a minute.Now the time has come to look back and see who's gaining on whom. With an effective instrument available, are these tumors being discovered earlier? Has there

In Reply.—I am grateful for the stimulating letters from Drs Deeb, Toohill, and Flaum. In answer to Dr Deeb, I do believe that expecting to resolve the issue via a return to rotating internships in our medical training is wistful thinking. In our reported survey, we found that the physicians trained in the old rotational system were as ill-equipped and as unwilling to undertake laryngoscopy as their younger counterparts. The problem is not how much exposure the student gets, but, rather, to what he is exposed. The mirror cannot work for us. The telescope at least is within our capability.Dr Toohill's comment is well taken because it certainly has to take time and many examinations of the larynx to become familiar with its vagaries and variances. Just as putting a stethoscope in the ears of a novice does not qualify him as a cardiologist, so the telescope does

You, the ear, nose, and throat (ENT) specialists, and we, the internists, have a joint problem to probe. We have long turned our backs on the unconscionable lag between the onset of symptoms and the start of therapy for tumors of the larynx, and it is time we faced up to it. It is a responsibility that we share, and we need to work together to correct it.The contributing deficiency of the primary physician is that woefully few of us have been able to accomplish the simple process of adequately examining the larynx—either as part of a routine examination or even in response to the patient with hoarseness or pain deep in the throat. In our ignorance, we temporize over the early symptoms, while the lesions are permitted to grow unchecked for months.Actually, the problem has its beginnings in the programming of our medical schools. In the course

Several aspects of nesting behavior (nest-height preference, nest and nest-site attachment, and numbers and types of nests constructed) of Peromyscus floridanus, P. gossypinus, P. polionotus, and Ochrotomys nuttalli were studied in the laboratory. Nest-height selection of each species under experimental conditions generally agreed with field knowledge of its nest location and position along a terrestrial-arboreal gradient. However, some of the laboratory results were at variance with expectations based on knowledge of the species in the wild. These differences may be an effect of the artificial conditions of the experiment or they may indicate that natural nesting behavior of certain of the species studied is more variable than presently supposed. Peromyscus polionotus and O. nuttalli showed stronger attachment to a particular nest and built fewer incomplete nests than P. floridanus and P. gossypinus. These differences may be related to a higher energetic cost of nest and/or nest-site construction and greater security of the nests of P. polionotus and O. nuttalli as compared with those of P. floridanus and P. gossypinus. It is concluded from laboratory and field data on nesting behavior of these species that interspecific competition for nest sites is minimal in areas of sympatry.

THE LARYNGOPHARYNGEAL area is usually overlooked in most physical examinations, and symptoms arising from it are generally appraised at arm's length. Patients with persistent pain or prolonged hoarseness are shuttled off to the otolaryngologist. In the usual run, however, the neck is palpated and the mouth looked into, but without further inspection, treatment becomes a guessing game, played with a prayer for a cure of a nameless disease.The current emphasis on the importance of early detection for successful management of malignant diseases is of particular significance in the laryngopharyngeal area. Tumors in this region hold promise of a high rate of cure if found and treated early. Conversely, the prognosis in the neglected growths is one of the worst.1 Also, some early lesions, particularly the supraglottic cancers, may grow silently in situ for long periods before producing symptoms. There is an urgency, therefore, to include an inspection of

TO THE EDITOR:— Words of caution in regard to the hazards of radiation for both malignant and nonmalignant disease have often been spoken. Radiation for ulcer, as outlined in our report, must, of necessity, be administered by a radiotherapist, who should be well versed in the possible sequelae of his method.As for the documented experience in this form of treatment, we refer to the article of Drs. Kirsner and Palmer on treatment of peptic ulcer (Amer J Med29:793-803 [Nov.] 1960) in which they report on a total of 1,755 patients treated by gastric radiation since 1937. In our bibliography, we referred to the article by Drs. Levin, Clayman, Palmer, and Kirsner, which is a similar report on a portion of the same group noted above.In my own experience (Dr. Berman) there has been a total of 310 cases of duodenal ulcer treated by radiation since January,