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Also it should be borne in mind that, particularly in the larger series, a decrease in infection rate will be due in part to the fact that the problem is being investigated (the "Hawthorn effect"), resulting inevitably in greater awareness and therefore greater care among all grades of staff involved. In our work with shunting devices for hydrocephalus we have found that "late" infections are invariably missed "early" infections.' This was confirmed only because the patients were seen frequently after operation and serum antibody titres and C-reactive protein levels were estimated routinely, even when they were clinically fit. Obviously true late infections may occur after total hip replacement and there is good evidence to support the view that such a diagnosis may be quite valid. " However, we would suggest that frequent follow-up coupled with routine serological testing would clarify whether these are true late infections or missed early infections. R BAYSTON R B ZACHARY

donors concerning their detailed medical and family histories, with particular reference to malignancies and infections. We have not investigated the "responder" status of the relatives. The accompanying table shows that in 267 relatives in the "non-responder" group there were 17 cases of malignancy (13 confirmed from either case notes or death certificates or both), while eight cases of malignancy (six confirmed) were found in the 297 relatives in the "responder" group. No evid_nce of an increase in infections was found. For th2 findings to have any significance we would need at least 100 men in each group investigated similarly and hence a combined survey involving other transfusion centres is required. We would be willing to supply specific details of our questionnaire and data to those interested.

WVe are indebted to Sir Cyril Clarke and Professor R D Weir for their help and interest in this survey and to the Highland Health Board for a research grant. IAIN A COOK SALLY SHEPHERD

University Departmcnts of Paediatrics and Paediatric

Surgery

North of Scotland Blood Transfusion Service, Raigmore Hospital, Inverness

Children;s Hospital, Sheffield

Bayston, R, and Lari, J, Developmental Aledicinie anid (Child Neurology, 1974, suppl 32, p 16. Charnley, J, and Eftekhar, N, British Joutrnial (f Slurgery, 1969, 56, 641. Collis, D K, and Steinhaus, K, _7ouirnal of Bone and Joint Suirgery, 1976, 58A, 446. Ring, P A, 7ournal of Bonte anid 7oin?t Surgery, 1974, 56B, 44. '*'urner, R S, Jouirnal of Bonie, and1i J7oint Suirgery, 1974, 56A, 430. Bayston, R, Developmental Medicine anid Child Neurology, 1975, suppl 35, p 104. Burton, D) S, and Schurman, D J, j7ournal of B3oc anid 7oint Suirgery, 1975, 57A, 1004. Creuss, R L, Bickel, W S, and von Kessler, K L C, Clinical Orthopaedi'cs and Related Research, 1975, 106, 99. D'Ambrosia, R D, Hiromu, S, and Heater, R D, J7ournial of Bonie anid Joinit Sutrgery, 1976, 58A, 450. Downes, E M, Jouirnial of' Bone anid J7oint Suirgery, 1977, 59B, 42. Hall, A J, Journal of Bone anid J7oint Suirgery, 1974,

Archer, G T, et al, Recite FraiiSaise de 7'ransfutsion, 1969, 12, 341. Cook, I A, Britishl lo-rnal of Haetniatology, 1971, 20, 369. Gunson, H H, Stratton, F, and Phillips, P K, British jlour-nial oJ Hacematology, 1976, 3, 317.

Urinary incontinence in children

the paucity of treatment offered-namely, bladder expression, incontinence pads and appliances, catheters, and diversion. True, "urethral dilatation or other minor urological surgery" is mentioned in passing. The overactive bladder causing incontinence may be treated successfully with anticholinergic drugs. Hydrodistension has also been used. Of course, bladder irritability may be due to infection, and this must first be excluded. Dr Meadow refers to the problem of dribbling around the catheter. This may result from bladder hyperactivity and may respond to anticholinergic drugs. Catheters blocked by debris or kinking may also cause bypassing. Intermittent drainage of urine is usually to be preferred, particularly in the older patient, since freedom from a bag makes the problem less obvious and also reduces the risk of ulceration of the bladder by the tip of the catheter, another cause of bladder irritability leading to bypassing. The smallest size catheter and the smallest volume in the balloon consistent with adequate drainage and security should be used. Large catheters and balloons are more likely to provoke bypassing. Intermittent catheterisation once or even twice daily in the female together with expression and training probably offers the easiest non-operative procedure when incontinence results from an atonic bladder. The mother can be trained to do this initially, and later the girl herself may be capable and willing to perform this simple procedure. Dr Meadow mentions bladder training. This is important, and bowel training should also be considered, especially in the "neurolopathic" group. The defecation reflex is often poor and a lower bowel loaded with faeces may interfere with bladder emptying, presumably by pressure on the bladder neck. Physiotherapy and electrical stimulation should also be considered, including the use of patientoperated miniaturised stimulators. A great deal of work has been done in recent years to improve the diagnosis and subsequent treatment of the various types of urinary incontinence. The extent of this continuing work can best be seen in the Proceedings of the International Continence Society, which are published regularly in Urologia Internationialis.

SIR,-Dr Roy Meadow has provided a great deal of useful information in his paper (27 August, p 567) and the BMJ is to be congratulated on continuing to highlight the problem of urinary incontinence, now apparently in the main stream after many years in 144. 56B, the backwaters of medical interest. Whereas your leading article on stress incontinence (2 July, p 3) has been criticised by some correspondents on the grounds that it advoMalignancy in relatives of cates over-investigation, I think Dr Meadow "non-responders" to Rh antigen rather underemphasises investigation. Reading between the lines, it seems likely that he SIR,-It is well recognised now that about 20 on average, of Rh-negative male blood investigates the incontinent child's urinary transfusion volunteers cannot be immunised tract by excretion urography, micturition Urodvnamic Service, of Urology, to the Rh antigen despite repeated or varying cystography, cystometry, and endoscopy when Department Southern General Hospital, doses of Rh-positive blood or both.'t These simple measures fail. However, the lack of Glasgow

emphasis on investigation leading to accurate diagnosis of the bladder and urethral problem may mislead readers into thinking that there Effect of wholemeal and white bread is no real point in investigating the incontinent on iron absorption child. This impression may be reinforced by

"non-responders" are possibly immunologically incompetent to some extent despite their good health. In order to obtain further information on this point, we interviewed 25 such "non-responder" and 21 "responder"

Malignancies in relatives of notn-responder and responder dotnors Non-responder donors (n Relatives

Children

F {M A_ F

Total No .

..

.. .. Brothers Sisters . .. . Fathers . .. . Mothers . .. . .. .. Paternal aunts .. .. Paternal uncles .. .. Maternal aunts .. Maternal uncles ..

Total

25)

Deceased

30 32 34 27 24 25 21 29 23

4 4

22

1

267

13

*C = confirmed, Uc = unconfirmed. tHodgkin's disease.

=

Malignancies C*

Total No

it 1 3

1 2 4

Responder donors (n 21) Malignancies Deceased Uc*

C*

Uc*

+ (17)

ERIC S GLEN

58

31 18 40 32 21 21 28 28 44 31

1 4

294

6

1

1 1 -

(8)

2

94

SIR,-The contribution by Drs R J Dobbs and I MacLean Baird (25 June, p 1641) has provided short-term evidence which, combined with that reported by other workers, indicates that consumption of bran or brown bread, because of the phytic acid contribution, can reduce the absorption of iron, calcium, and zinc. To carry conviction, however, it is necessary to demonstrate that, in a Western dietary context, habitually high consumers of phytic acid are unequivocally stigmatised in mineral status compared with low consumers. The evidence incriminating phytic acid, based on relatively brief studies on humans and animals, is often at variance with epidemiological evidence, the principal exception being the experience in Iran.' In South Africa Blacks in rural areas are accustomed to a relatively high intake of phytic acid. Yet our

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BRITISH MEDICAL JOURNAL

studies on groups on very high intakes compared with those on lower intakes have revealed no differences in mean haematological values, whether in children or adults. Observations on contrasting groups have revealed no differences in mean serum calcium levels, nor in the mean cortical thickness or other dimensions of the second metacarpal. Indeed, we have found satisfactory calcification even in groups of mothers who hav e had numerous pregnancies and long lactations.' Nor in the groups mentioned have we found differences in the growth rate of children. In our appreciation, Third World experience does not support the view that phytic acid is significantly prejudicial to mineral metabolism or to health. In Iran the reported ill effects due to a very high phytic acid intake, associated apparently with a high calcium intake, are extremely interesting.' Nevertheless, definitive studies on the occurrence of rickets in Iran (of the calibre of the studies that have been made on Asian children in Britain) do not appear to have been published, nor have studies on bone density, etc, such as we have undertaken on African Blacks. As an illustration of the extravagant claims made regarding phvtic acid it has been reported that researchers at the Danish Food Institute are maintaining that "the ingestion of bran may also lead to cancer, arteriosclerosis, or phlebolithiasis.`"8 Soon after the last war, in a discussion on the nutritive value of bread, Fredericia' stated, "In Denmark we eat, and have done for thousands of years, brown rye bread, 100 wholemeal. If what has been said about brown bread is true, we should get rickets, and yet we have very little rickets in To which of these views are Denmark. we to attach credence ? It must be understood that even clear-cut evidence from experimental studies on animals and man may disagree profoundly with what is found epidemiologically. For example, the 2ariogenic effect of sucrose is very readilv demonstrable in experimental studies; yet epidemiologically differences in caries scores in high compared with low consumers of sucrose consistently are disappointingly small. A R P WALKER B F WALKER .\Mdical Research Council Human Biochcmistrv Research Unit, South African Institute for Medical Research, Johannesburg, South Africa

Reinhold, J G, Lancet, 1976, 2, 1132. Walker, A R P, Richardson, B D, and Walker, B F, Clinical Science, 1972, 42, 189. ot'orld If8ncironmzenit Report, 1977, 25 April, p 8. Frcdericia, L S, Proccedintgs of rhe .WNtrition .S'ociety, 1976, 4, 28.

The community physician: will he survive?

SIR,-Under the above heading Drs W H Parry and J E Lunn (27 August, p 589) report the reduction in responsibility and job satisfaction perceived by the majority of 52 former medical officers of health of county or county borough councils employed in community medicine posts in 1976 compared with their pre-NHS reorganisation experience in 1972. They further show that a group of 52 carefully matched doctors who were not working in the public health field in 1972 did not feel that they had suffered a similar decline in responsibility and job satisfaction over the same period.

To argue, as the title suggests, that on the basis of these findings the existence of community physicians is threatened is to go much further than the data warrant. In the first place, according to the establishment and inpost figures presented in the article the 52 erstwhile medical officers of health make up only 8"t) of the community physicians in established posts in 1976 and the views they express may therefore be unrepresentative of the majority of community physicians, many of whom entered the specialty by quite different routes. Secondly, while it is unlikely that doctors in this group would encourage aspirants to careers in community medicine, it is probable that the slow rate of recruitment to the specialty is also the result of other factors such as the unavailability of UNIT payments in the training grades in this specialty. Moreover, it is assumed that all the posts currently established in community medicine will endure. A rather more obvious deduction from the data presented would be that the previous training and experience of some public health doctors did not fit them too well for the interdisciplinary approach to the planning and administration of the reorganised Health Service and that the short-term training measures taken in an attempt to equip them for their new roles have failed to maintain their professional satisfaction. A more appropriate title to the report might have been "Paradise Lost for the MOH." BRIAN WILLIAMS TI rent Regional Health Authority, Sheffield

Antibiotics for presumed viral respiratory infections SIR,-In the results of their trial of antibiotics for presumed Xviral respiratory infections '27 August, p 552) Dr Brent Taylor and his colleagues report that placebo treatment allowed an earlier return to normal activity; but as over 10", of the placebo-treated children were withdrawn with complications compared with only 15 ,, of the antibiotictreated children it might reasonably be assumed that those remaining wNere not properly comparable. Despite this bias they report a significant difference in favour of the antibiotics (P