76
fact, the ability is ultimately lost. It is debatable whether advancing this disuse with atropine or bifocals addresses the problem. A good medical principle is that a growing organism, unless in a completely abnormal environment, should be encouraged, helped, or educated to behave normally. Until accommodation is proved harmful to myopic children’s eyesight, abolishing the use of accommodation seems little better than preventing a child with cerebral palsy from walking or a child with dyslexia from trying to read. Reduction of the anteroposterior enlargement by means of contact lenses attacks only the anterior end of the axis, and in high myopes it is the posterior part of the globe which is out of proportion. One might suppose that, to be effective, these lenses would have to have a
splinting effect than was conducive to the health of a growing tissue. Even amongst young adults myopia is not arrested by contact lenses. One further fact which has come to light is the relation of myopia to social class. This finding, arising from work by the National Childrens Bureau,s accounts for the reported difference in growth-rates between myopes and other children.6 This work also uncovered an excess of females over males in the high-myopia bracket. Douglas, Ross, and Simpsonpreviously reported that parents of short-sighted children were likely to be middle-class. We are therefore left with a process, known to have a strong genetic basis, whose likely duration or rate cannot be estimated at inception or at any time during the growing years. For this reason any study of myopia and its therapy in children requires the most rigorously matched controls and would be best carried out in one social class, so as to eliminate one known variable among many. With such controls lacking, we are thrown back on clinical impressions. We must beware of committing children to a complicated therapeutic regimen without explaining the uncertainty of outcome to their parents. The lesson of the sight-saving schools, which altered the whole lives of many children to no good purpose, must not be forgotten. more severe
FLUORIDES AND HEALTH NOW A GENERATION ago the people of Grand Rapids, Michigan, raised the fluoride concentration of their water-supply to 1 mg/1 (1 part per million). Ten years later similar experiments began in the United Kingdom, and by the late 1960s results from all over the world were in accord: when the fluoride content of the public water-supply is raised to 1 mg/1 (or is naturally at that concentration or higher) the population, especially the
children, have healthier teeth. Even the staunchest advocates of fluoridation as a national public-health policy would be happier with a higher therapeutic ratio (i.e., ratio of harmful to beneficial doses), and happier still if they knew how this element prevents caries; nevertheless, many years’ experience in populations drinking naturally or artificially fluoridated water has 5. Peckham, C., Adams, B. Chid Care Hlth Devel. 1975, 1, 93 Gardiner, P. A. Lancet, 1954, i, 476. Douglas, J., Ross, J., Simpson, H. Jl R. statist. Soc. 1967, 130,
6. 7.
yielded no evidence of harm. In the U.K., some of the most convincing evidence of good has come from the long Anglesey follow-up and from Kilmarnock, where fluoridation was abandoned to the detriment of the children’s teeth.,Yet, thanks largely to the antifluoridation movement, only 1 person in 10 in England and Wales now drinks fluoridated water. An excellent review’ from the Royal College of Physicians comprehensively demolishes all the science-based objections of the antifluoride caucus. If this report is widely readand one hopes that it will be read particularly carefully by those in local government-the antifluoridators may have to shift to the other leg of their argument, the matter of individual liberty and the right to opt out. Even here, the College has an answer: its committee sees no great distinction between copper sulphate, chlorine, aluminium, and calcium (which are regularly added to water) and fluoride; indeed, it is "concerned with the propriety of withholding a procedure if this is safe and of benefit". The call for fluoridation is uncluttered by doubts or by saving clauses about the need for further study or a public inquiry: "The College recommends fluoridation of water supplies in the United Kingdom where the fluoride level is appreciably below 1 mg per litre." The Royal College is trying to do for tooth decay what it has formerly attempted for lung cancer, bronchitis, and heart-disease. The chances of success ought to be greater: no ingrained habit has to be overcome (unless the nation is addicted to prejudice). The response to this latest call for fluoridation will tell us much about the outlook for other projects in preventive medicine.
INCURABLE PATIENTS A SHORT Bill introduced in the House of Lords by Lady Wootton aims, firstly, at helping the patient with incurable pain. Any such patient, even if he refuses other treatment, is to be entitled to receive drugs for full relief from pain and physical distress, and to be rendered unconscious if needs be. (This accords with current practice.) The incurable patient who intentionally causes his own death is to be deemed to have died by misadventure-a provision with legal implications. No-one shall be obliged to interfere with action taken by an incurable patient to relieve his suffering in a manner likely to cause his own death, and any such interference contrary to the known wishes of the patient is to be unlawful. Secondly, a patient who by reason of brain damage or degeneration has become permanently incapable of giving directions is to be regarded as refusing to receive lifesustaining treatment if previously he has formally stated that he does not wish to receive such treatment. This measure would require some difficult medical judgments. Under it the "incurable patient" is defined as one judged by his attendant physician to be suffering without any reasonable prospect of cure from a distressing physical illness or disability that he finds intolerable. Deciding what is intolerable to any one patient will not be easy; nor for that matter will incurability, with the irreversible action or inaction that may follow its accept1.
479.
Fluoride, Teeth and Health:
a report of the Royal London:Pitman Medical. 1976. Pp. 85. £2.50.
College
of
Physicians..
77
determined. And the patient who, while well, has declared that he should be left untreated when incurably stricken may find himself, stricken but still conscious, wishing after all to live as long as medical science will permit but unable to make this known. Lady Wootton’s Bill may escape the religious and medical objections raised by euthanasia. It has the virtue of seeking to ensure that incurable illness shall be as pain-free as possible and that those who do not want their lives prolonged shall have this wish respected. But, as worded at present, it places an undue burden on a single doctor; and it does not fully protect those who may change their minds about life-sustaining treatment. ance,
always
be
readily
ORAL IMMUNISATION AND ANTIBODIES IN MILK IT has been suggested that feeding infants with human milk reduces risk of gastrointestinal infections.’1 R. M. Goldblum and colleagues2 have investigated the mechanism by which secretion of antibodies against enterobacteria in milk can be stimulated. Women volunteers ingested the harmless bacterium Escherichia coli 083 during the last month of their pregnancy. The number of cells in colostrum forming antibodies of different classes against E. coli 083 antigens was measured by the haemolysis-in-gel technique. (This is a more reliable indication of local IgA-antibody synthesis than measurement of antibodies in colostrum, since such antibodies could be deiived from serum). As early as three days after the ingestion of bacteria, cells producing secretory IgA antibodies against the 0 antigens of E. coli 083 were found. By contrast, no increase in colostral cells producing 083 antibodies of the IgM or IgA class
was observed. It seems unlikely that bacterial antigens enter the blood from the gastrointestinal tract and elicit an anti-
since no systemic imGoldblum et al. favour could be detected. response the hypothesis that sensitised lymphocytes pass from the gastrointestinal tract to the mammary gland, and there synthesise secretory IgA antibodies. Since the mother is exposed to the micro-organisms which the newborn baby is likely to encounter, the passive immunity provided by this mechanism may help to protect the gastrointestinal tract of the infant. Other observations consistent with this mechanism are the appearance of secretory IgA antibodies in the milk of rabbits fed with dinitrophenylated (D.N.P.) bovine gamma-globulin and with D.N.P. type m pneumococcal vaccine,3 and the occurrence of IgA antibodies against Salmonella typhimurium in the milk of three women infected with this bacterium during pregnancy.* Because only antibodies were measured in these investigations, the possible transfer of antibody from the serum could not be excluded. It is not known whether helper cells or IgA-antibody-forming cells pass from the gastro-
body response in mammary tissue, mune
1. Mata, L. J., Urrutia, S. A. Ann. N.Y. Acad. Sci. 1971, 176, 93. 2. Goldblum, R. M., Ahlstedt, S., Carlsson, B., Hanson, L. A., Jodal, U., LidinJanson, G., Sohl-Åkerlurd, A. Nature, 1975, 257, 797. 3. Montgomery, P. C., Cohn, J., Lally, E. T. in The Immunoglobulin A System (edited by J. Mestecky and A. R. Lawton); p. 453. New York, 1973. 4. Allardyce, R. A., Shearman, D. J. C., McClelland, D. B. L., Marwick, K., Simpson, A. J., Laidlaw, R. B. Br. med. J. 1974, iii, 307.
intestinal tract to the mammary gland, although the results with D.N.P. type III pneumococcal vaccine favour the second possibility. These investigations provide a link between stimulation in the mother’s gut and secretion of IgA antibodies in milk. The efficiency of these antibodies in protection of the newborn against infection remains to be clearly established.
HANDICAPPED SCHOOL LEAVERS HANDICAPPED people need sequential care. Yet doctors based in hospitals tend to see their illnesses as episodic: instead of taking a personal grip on follow-up they often leave the patient to organise return visits. In general, the preschool and school-age person gets adequate continued care; but not so the school leaver and the young adult. When these people pass from the care of paediatric hospital and paediatric community health services, often there is no organisation waiting to take over. Handicapped school leavers and young adults need follow-up services comparable to those they had before they left school. Is there anything that the people who knew them as children-paediatricians, teachers, social workers, voluntary agencies-could be doing? Paediatricians who decide to step in may well find allies. The social services department may already be at work on behalf of mentally handicapped school leavers-they have a statutory duty to provide for all handicapped people. The education authority may be catering for those up to age 20; there may be an interested specialist in medical rehabilitation; and local voluntary agencies for the visually handicapped, the deaf, and spastics are a possible source of help. Two or three people may need to apply persuasion (and other techniques of democratic revolution) for what may seem to them a long time. So the activists will go to see the area community specialist; the child health services (including the area or district centres for assessment and care) and the senior community paediatricians; the specialist in medical rehabilitation; district consultants in physical medicine, orthopaedics, urology (for spina-bifida people), neurology, audiology, ophthalmology, mental deficiency, and dentistry; the education officer; voluntary agencies; and community health councils. Having discovered exactly what services exist they will be well-placed to identify the gaps. Is there adequate provision for periodic reassessment of all the handicapped ? If not, who would take on the medical, educational, and social parts of the periodic reviews? Are there suitable premises at the hospital or elsewhere? Do the medical, educational, and social services exist to meet the needs discovered at the periodic reviews? Who is responsible for providing these services? These questions answered, a start can be made. It is wise to begin in a small way. The sessions may be in a church hall, in a hospital outpatient room, or at a school. Grateful patients, parents, and consultants (glad you have prevented deterioration) will give support. General practitioners may be willing to help and to be trained to do so. In the longer term it may be necessary to persuade health, education, and social services to redeploy some of their money--on the argument that costs will be recouped by rehabilitation and prevention of unnecessary deterioration.
fact, the ability is ultimately lost. It is debatable whether advancing this disuse with atropine or bifocals addresses the problem. A good medical principle is that a growing organism, unless in a completely abnormal environment, should be encouraged, helped, or educated to behave normally. Until accommodation is proved harmful to myopic children’s eyesight, abolishing the use of accommodation seems little better than preventing a child with cerebral palsy from walking or a child with dyslexia from trying to read. Reduction of the anteroposterior enlargement by means of contact lenses attacks only the anterior end of the axis, and in high myopes it is the posterior part of the globe which is out of proportion. One might suppose that, to be effective, these lenses would have to have a
splinting effect than was conducive to the health of a growing tissue. Even amongst young adults myopia is not arrested by contact lenses. One further fact which has come to light is the relation of myopia to social class. This finding, arising from work by the National Childrens Bureau,s accounts for the reported difference in growth-rates between myopes and other children.6 This work also uncovered an excess of females over males in the high-myopia bracket. Douglas, Ross, and Simpsonpreviously reported that parents of short-sighted children were likely to be middle-class. We are therefore left with a process, known to have a strong genetic basis, whose likely duration or rate cannot be estimated at inception or at any time during the growing years. For this reason any study of myopia and its therapy in children requires the most rigorously matched controls and would be best carried out in one social class, so as to eliminate one known variable among many. With such controls lacking, we are thrown back on clinical impressions. We must beware of committing children to a complicated therapeutic regimen without explaining the uncertainty of outcome to their parents. The lesson of the sight-saving schools, which altered the whole lives of many children to no good purpose, must not be forgotten. more severe
FLUORIDES AND HEALTH NOW A GENERATION ago the people of Grand Rapids, Michigan, raised the fluoride concentration of their water-supply to 1 mg/1 (1 part per million). Ten years later similar experiments began in the United Kingdom, and by the late 1960s results from all over the world were in accord: when the fluoride content of the public water-supply is raised to 1 mg/1 (or is naturally at that concentration or higher) the population, especially the
children, have healthier teeth. Even the staunchest advocates of fluoridation as a national public-health policy would be happier with a higher therapeutic ratio (i.e., ratio of harmful to beneficial doses), and happier still if they knew how this element prevents caries; nevertheless, many years’ experience in populations drinking naturally or artificially fluoridated water has 5. Peckham, C., Adams, B. Chid Care Hlth Devel. 1975, 1, 93 Gardiner, P. A. Lancet, 1954, i, 476. Douglas, J., Ross, J., Simpson, H. Jl R. statist. Soc. 1967, 130,
6. 7.
yielded no evidence of harm. In the U.K., some of the most convincing evidence of good has come from the long Anglesey follow-up and from Kilmarnock, where fluoridation was abandoned to the detriment of the children’s teeth.,Yet, thanks largely to the antifluoridation movement, only 1 person in 10 in England and Wales now drinks fluoridated water. An excellent review’ from the Royal College of Physicians comprehensively demolishes all the science-based objections of the antifluoride caucus. If this report is widely readand one hopes that it will be read particularly carefully by those in local government-the antifluoridators may have to shift to the other leg of their argument, the matter of individual liberty and the right to opt out. Even here, the College has an answer: its committee sees no great distinction between copper sulphate, chlorine, aluminium, and calcium (which are regularly added to water) and fluoride; indeed, it is "concerned with the propriety of withholding a procedure if this is safe and of benefit". The call for fluoridation is uncluttered by doubts or by saving clauses about the need for further study or a public inquiry: "The College recommends fluoridation of water supplies in the United Kingdom where the fluoride level is appreciably below 1 mg per litre." The Royal College is trying to do for tooth decay what it has formerly attempted for lung cancer, bronchitis, and heart-disease. The chances of success ought to be greater: no ingrained habit has to be overcome (unless the nation is addicted to prejudice). The response to this latest call for fluoridation will tell us much about the outlook for other projects in preventive medicine.
INCURABLE PATIENTS A SHORT Bill introduced in the House of Lords by Lady Wootton aims, firstly, at helping the patient with incurable pain. Any such patient, even if he refuses other treatment, is to be entitled to receive drugs for full relief from pain and physical distress, and to be rendered unconscious if needs be. (This accords with current practice.) The incurable patient who intentionally causes his own death is to be deemed to have died by misadventure-a provision with legal implications. No-one shall be obliged to interfere with action taken by an incurable patient to relieve his suffering in a manner likely to cause his own death, and any such interference contrary to the known wishes of the patient is to be unlawful. Secondly, a patient who by reason of brain damage or degeneration has become permanently incapable of giving directions is to be regarded as refusing to receive lifesustaining treatment if previously he has formally stated that he does not wish to receive such treatment. This measure would require some difficult medical judgments. Under it the "incurable patient" is defined as one judged by his attendant physician to be suffering without any reasonable prospect of cure from a distressing physical illness or disability that he finds intolerable. Deciding what is intolerable to any one patient will not be easy; nor for that matter will incurability, with the irreversible action or inaction that may follow its accept1.
479.
Fluoride, Teeth and Health:
a report of the Royal London:Pitman Medical. 1976. Pp. 85. £2.50.
College
of
Physicians..
77
determined. And the patient who, while well, has declared that he should be left untreated when incurably stricken may find himself, stricken but still conscious, wishing after all to live as long as medical science will permit but unable to make this known. Lady Wootton’s Bill may escape the religious and medical objections raised by euthanasia. It has the virtue of seeking to ensure that incurable illness shall be as pain-free as possible and that those who do not want their lives prolonged shall have this wish respected. But, as worded at present, it places an undue burden on a single doctor; and it does not fully protect those who may change their minds about life-sustaining treatment. ance,
always
be
readily
ORAL IMMUNISATION AND ANTIBODIES IN MILK IT has been suggested that feeding infants with human milk reduces risk of gastrointestinal infections.’1 R. M. Goldblum and colleagues2 have investigated the mechanism by which secretion of antibodies against enterobacteria in milk can be stimulated. Women volunteers ingested the harmless bacterium Escherichia coli 083 during the last month of their pregnancy. The number of cells in colostrum forming antibodies of different classes against E. coli 083 antigens was measured by the haemolysis-in-gel technique. (This is a more reliable indication of local IgA-antibody synthesis than measurement of antibodies in colostrum, since such antibodies could be deiived from serum). As early as three days after the ingestion of bacteria, cells producing secretory IgA antibodies against the 0 antigens of E. coli 083 were found. By contrast, no increase in colostral cells producing 083 antibodies of the IgM or IgA class
was observed. It seems unlikely that bacterial antigens enter the blood from the gastrointestinal tract and elicit an anti-
since no systemic imGoldblum et al. favour could be detected. response the hypothesis that sensitised lymphocytes pass from the gastrointestinal tract to the mammary gland, and there synthesise secretory IgA antibodies. Since the mother is exposed to the micro-organisms which the newborn baby is likely to encounter, the passive immunity provided by this mechanism may help to protect the gastrointestinal tract of the infant. Other observations consistent with this mechanism are the appearance of secretory IgA antibodies in the milk of rabbits fed with dinitrophenylated (D.N.P.) bovine gamma-globulin and with D.N.P. type m pneumococcal vaccine,3 and the occurrence of IgA antibodies against Salmonella typhimurium in the milk of three women infected with this bacterium during pregnancy.* Because only antibodies were measured in these investigations, the possible transfer of antibody from the serum could not be excluded. It is not known whether helper cells or IgA-antibody-forming cells pass from the gastro-
body response in mammary tissue, mune
1. Mata, L. J., Urrutia, S. A. Ann. N.Y. Acad. Sci. 1971, 176, 93. 2. Goldblum, R. M., Ahlstedt, S., Carlsson, B., Hanson, L. A., Jodal, U., LidinJanson, G., Sohl-Åkerlurd, A. Nature, 1975, 257, 797. 3. Montgomery, P. C., Cohn, J., Lally, E. T. in The Immunoglobulin A System (edited by J. Mestecky and A. R. Lawton); p. 453. New York, 1973. 4. Allardyce, R. A., Shearman, D. J. C., McClelland, D. B. L., Marwick, K., Simpson, A. J., Laidlaw, R. B. Br. med. J. 1974, iii, 307.
intestinal tract to the mammary gland, although the results with D.N.P. type III pneumococcal vaccine favour the second possibility. These investigations provide a link between stimulation in the mother’s gut and secretion of IgA antibodies in milk. The efficiency of these antibodies in protection of the newborn against infection remains to be clearly established.
HANDICAPPED SCHOOL LEAVERS HANDICAPPED people need sequential care. Yet doctors based in hospitals tend to see their illnesses as episodic: instead of taking a personal grip on follow-up they often leave the patient to organise return visits. In general, the preschool and school-age person gets adequate continued care; but not so the school leaver and the young adult. When these people pass from the care of paediatric hospital and paediatric community health services, often there is no organisation waiting to take over. Handicapped school leavers and young adults need follow-up services comparable to those they had before they left school. Is there anything that the people who knew them as children-paediatricians, teachers, social workers, voluntary agencies-could be doing? Paediatricians who decide to step in may well find allies. The social services department may already be at work on behalf of mentally handicapped school leavers-they have a statutory duty to provide for all handicapped people. The education authority may be catering for those up to age 20; there may be an interested specialist in medical rehabilitation; and local voluntary agencies for the visually handicapped, the deaf, and spastics are a possible source of help. Two or three people may need to apply persuasion (and other techniques of democratic revolution) for what may seem to them a long time. So the activists will go to see the area community specialist; the child health services (including the area or district centres for assessment and care) and the senior community paediatricians; the specialist in medical rehabilitation; district consultants in physical medicine, orthopaedics, urology (for spina-bifida people), neurology, audiology, ophthalmology, mental deficiency, and dentistry; the education officer; voluntary agencies; and community health councils. Having discovered exactly what services exist they will be well-placed to identify the gaps. Is there adequate provision for periodic reassessment of all the handicapped ? If not, who would take on the medical, educational, and social parts of the periodic reviews? Are there suitable premises at the hospital or elsewhere? Do the medical, educational, and social services exist to meet the needs discovered at the periodic reviews? Who is responsible for providing these services? These questions answered, a start can be made. It is wise to begin in a small way. The sessions may be in a church hall, in a hospital outpatient room, or at a school. Grateful patients, parents, and consultants (glad you have prevented deterioration) will give support. General practitioners may be willing to help and to be trained to do so. In the longer term it may be necessary to persuade health, education, and social services to redeploy some of their money--on the argument that costs will be recouped by rehabilitation and prevention of unnecessary deterioration.
