51
until the
priorities
political expediency is removed from development the trap will fill up with suffering infants and needy
mothers.
only way to change the political will is for politicians to be brought in to see, not diplomats and development bureaucrats, but the sick, hungry, and destitute. It will be man’s compassion, not The
statistics and reports, that will make the shift. International Community for the Relief of Starvation and Suffering, PO Box 15619,
J. BARNES
Mbagathi, Kenya
MICHAEL K. MEEGAN
SIR,-Dr King’s paper and the accompanying editorial are unscientific and morally repugnant. King creates a simplistic "straw man", stating "that the necessary and sufficient condition for reducing birth-rate is to reduce the child death rate", and proceeds to argue that this alone will not reduce births. From there he concludes, "Reduced childhood mortality must no longer be promoted... such desustaining measures as oral rehydration should not be introduced on a public health scale, since they increase the man-years of human misery, ultimately from starvation." "However", he proceeds "the individual doctor must rehydrate his patient." Here he betrays his underlying logic: those who can afford doctors are chosen to survive, the less fortunate are left to die. Similarly, he admits that the threat to global ecology is exacerbated by consumption patterns of the developed world, but prescribes for those 10% of the world who consume 50% or more of its resources and provide the major threats to global environment (ozone depletion, warming, deforestation,
mass
pollution) only
"the deliberate quest of poverty" in order to achieve "further increase in living standards". The babies of the south are singled out to be sacrificed for sustainability of the status quo of the north. Demographic transition has occurred, with a decline in both mortality and fertility: the sequence and pace of decline may vary, but both decline. Modem demographic analysis invariably identifies mortality decline as a precondition to fertility decline,l the only uncertainty being the timing. With survival rates of children already at 850-880 per 1000 live births, a halving of death rates among the under-5’s would increase survival by only 7-8% and population growth rates by a mere 0’18-02%. Comparing this small demographic effect of improved survival with the dramatic reduction in suffering attendant upon a 50% decline in infant and child deaths, it is not hard to see why, historically, such mortality declines are associated with 25% or more reduction in fertility rates and a steep fall in population growth.2 The World Fertility Survey and other large demographic surveys have amply documented the already unmet desire by a substantial portion of women to limit their fertility.3 With family planning services as a part of a comprehensive "child survival package" birth rates can be predicted to fall even further. King’s proposition, linking further efforts at child mortality reduction to achieved decline in fertility, condemns vast populations to continued rampant growth, caught in the midst of his "demographic trap". To return to a level of pretransitional equilibrium, crude death rates would have to rise to two or three times present levels yielding a life expectancy of 30 or 35 years-an unthinkable regression of the human condition. There is no reasonable or ethical alternative other than to push ahead with the obvious and provide the necessary inputs for both survival of children and reduced fertility together. Tagore’s "meagre coverlet", with which King prefaces his article, is yet big enough to go around, if only big brother would stop hogging so much more than his fair share. B-9 West End, New Delhi 110 021, India 1. Chesnais 2. 3.
JON ELIOT ROHDE
J-C. La transition demographique étapes, formes, implications économiques. Pans: Presses Universitaires de France, 1986. Coale AJ, Watkins SC. The decline of fertility m Europe. Princeton, NJ: Princeton University Press, 1986. UN Population Fund. The state of world population 1990 New York UN Population Fund, 1990.
1
SiR,—Dr King’s article revisits issues much discussed two to three decades ago. His logical development of the need to give priority to the ecological foundations of health is a timely reminder but these concerns do not justify the conclusion that health measures such as oral rehydration "should not be introduced on a public health scale". For the past thirty years we have tended to take "either/or" positions rather than recognising that both disease control and family planning are essential and that practical realism is congruent with ethical compulsions. As one of the original proponents of the child survival hypothesis,’ I can affirm that none of us claimed that reduction in child mortality is a necessary and sufficient condition for reducing fertility. We have always considered it only one important factor in shifting patterns of multifactorial causality. Evidence from Bangladesh, cited in the editorial that accompanies King’s article, shows that reduction in child mortality is not even a necessary precondition for some reduction in fertility. This does not mean, however, that a stable population balance will result in Bangladesh or elsewhere if high child mortality persists. Parents in countries with an average of seven children presumably have different motivations from the more common situation where families average four to five children. The child survival hypothesis is increasingly accepted by developing countries as a rational basis for policy. Reducing mortality and providing contraceptives are two variables that can be changed by action programmes, while general socioeconomic development, including female literacy, tends to take longer. King is correct in saying that when children die in high parity situations their partial "replacement" is due mainly to shortening of lactational amenorrhoea. One factor influencing parents to have extra children may be "insurance motivation", related to subconscious expectations that some children might die. This is supported by evidence of temporal associations between mortality and fertility decline. Proof probably requires long-term prospective field research rather than correlations, which do not show the direction of causal associations. We tried to sort out these issues in the Narangwal studies in the PunjabZ but the research was terminated by the Bangladesh war just as definitive findings were beginning to emerge. We did demonstrate the much greater cost-effectiveness and acceptability of integrated services when impact on both health and fertility were included in the analysis. Most developing countries have reintegrated maternal and child health services because of the duplication and non-sustainable cost of separate vertical programmes. King rightly objects to vertical disease control programmes but a decision to separate fertility from mortality control leads inevitably to vertical family planning programmes, even when the arguments used are broadly ecological. One of the main lessons from the past is that foreign support for vertical programmes, including family planning, may achieve short-term impact but will have poor sustainability. Institute for International Programs, School of Hygiene and Public Health, Johns Hopkins University Baltimore, Maryland 21202, USA
CARL E. TAYLOR
1.
Taylor CE, Hall MF Health, population and economic development Science 1965;
2.
Taylor CE,
157: 651-57. et al. Child and maternal health services in rural India: the Narangwal experiment, vol II. Integrated family planning and health care (World Bank Research Publication). Baltimore: Johns Hopkms University Press, 1983.
Extracorporeal membrane oxygenation SIR,—In response to our editorial’ Dr Greenough and Dr Emery (Sept 29, p 760) suggest that there is no established need for ECMO in the UK and that the treatment is both expensive and carries a high risk of morbidity. We think that mature infants potentially amenable to treatment with ECMO in the UK are dying. We agree that it is difficult to be sure from retrospective analysis how many infants will benefit from this treatment. Audit of neonatal units alone will underestimate demand since several suitable infants with severe persistent fetal circulation are referred to cardiothoracic units
52
in the belief that they have cyanotic heart disease. Whether suitable children genuinely do better with ECMO or whether difficulties in transfer and speed of deterioration make the use of ECMO impossible, can all be answered by a controlled trial. In setting up such a trial, great care must be taken in defining entry criteria, "conventional therapy", and "successful outcome"; these points lie at the heart of the ECMO controversy world wide.z It is our impression that in the UK, ECMO is little more expensive than conventional intensive care. Even in the United States, ECMO is felt to be cost effective. This too needs formal prospective evaluation. We do not wish to see the piecemeal introduction of ECMO. A trial with close attention to entry criteria and to morbidity and mortality is the correct way to establish whether ECMO has a place. Department of Child Health, Leicester Royal Infirmary
D.
J. FIELD
Regional Cardiothoracic Unit, Groby Road Hospital,
R. K. FIRMIN
Leicester LE3 9QE, UK 1. Sosnowski
AW, Bonser SJ, Field DJ, Graham TR, Firmin RK. Extra corporeal membrane oxygenation. Br Med J 1990; 301: 303-04. 2. Lantos JD, Frader J. Extra corporeal membrane oxygenation and the ethics of clinical research m pediatrics. N Engl JMed 1990; 323: 409-13.
US military medical school SIR,—Iam surprised to see The Lancet stoop to such a low level of journalism as Mr Greenberg’s piece (Nov 24, p 1306) on the Uniformed Services University of the Health Sciences (USUHS). One does not need to know the facts to discern the tone of bias and ridicule ("superfluous", "extravagant", "costly relic", "pampered lord", "reprieves from oblivion"). However, those familiar with the facts know that USUHS provides more than 10% of US military physician acquisitions each year. These doctors, besides an excellent medical education, receive extensive military experience which sets them apart from their civilian-trained counterparts. This training is not accomplished at a cost "4-5 times more expensive than civilian medical education". USUHS operates more economically than civilian medical schools (comparisons can be made from data in the Aug 15, 1990, issue of JAMA). Those who are willing to investigate the facts and evaluate the quality of the institution and its graduates will see that USUHS does not need a newspaper columnist as its saviour. The appeal to Ann Landers was to address the publicity issue mentioned in the opening sentence of Greenberg’s article. 700 Fordham St,
Rockville, Maryland 20850, USA
Altered
JOHN W. GARDNER
grounds for abortion?
SIR,-The Human Fertilisation and Embryology Act 1990 amends the Abortion Act 1967 by substituting the following grounds for termination of pregnancy:
"(a) that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk greater than if the pregnancy were terminated, of injury to the physical and mental health of the pregnant woman or any existing children of her family; or (b) that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;
or
(c) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were
terminated; or
(d) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped." Termination of pregnancy under (a) which is similar to the 1967 Act, can take place up to 24 weeks only, but sections (b), (c), and (d) apply without regard to gestational age.
It had hitherto always been lawful for a doctor to bring a to an end if the woman’s life or health were threatened, the commonest reason for this being fulminant toxaemia, an example quoted several times in the Parliamentary debate. Previously it was the case that if the infant was capable of being bom alive, then, after affording priority to the woman’s own health, every effort to perserve the life and wellbeing of the infant was required. However, very-low-birthweight infants delivered under adverse conditions are at "considerable risk of long-term morbidity". Such babies will be close to or at the limit of viability and at such risk of disability that there could be grounds for destructive delivery under pregnancy
(d). It appears therefore that in the UK
a
doctor
now
needs the
explicit consent of the woman to save her baby during delivery if there is a risk of serious handicap. If she withholds it or cannot give it then the Human Fertilisation and Embryology Act permits the doctor to destroy the child-indeed if the doctor does not, it is conceivable that the parent(s) could bring an action for negligence, using the doctors refusal to apply the criterion in (d). Furthermore (d) bears an interpretation which would apply to any of the common complications of pregnancy which can result in cerebral palsy. The consequences for obstetric management could be very grave involving the destruction of many thousands of at-risk infants. Will it be necessary to take those destructive instruments from the age of obstructed labour from the museum shelves? This Act makes it more expedient to kill than to strive to save where the wellbeing of the child is in doubt. Worcester Royal Infirmary, Worcester WR1 3AS, UK
A. P. COLE J. G. DUDDINGTON
Tolerance and the fetal
graft
(p 538) suggests the expression of a form of the major-histocompatibility-complex non-immunogenic (MHC) class I molecule at the fetomaternal interface as the main reason for maternal tolerance towards the fetal graft. However, in a response to this editorial Dr Innes and colleagues (Nov 3, p 1133) suggest that these molecules are indeed immunogenic. If this is so, why do maternally derived T lymphocytes migrating into the decidua (which is in direct contact with cytotrophoblast) not respond to these MHC molecules? We have demonstrated the lack of expression of the two variants of the T-cell antigen receptor (TCR) by mature intradecidual T lymphocytes during early normal pregnancy.l Our data clearly show that CD3T lymphocytes in first trimester decidua do not express immunohistochemically detectable amounts of &agr;/&bgr; or r/8 TCR molecules. It therefore seems probable that most intradecidual T lymphocytes will not be activated by the antigen and thus will be functionally anergic towards paternally derived fetal antigens. In addition we found that T lymphocytes isolated from the decidua can be induced to express normal amounts of the &agr;/&b(3gr; TCR heterodimer by in-vitro stimulation with phytohaemagglutinin-P and exogenous interleukin-2, which suggests that TCR expression can be restored in this T lymphocyte subset. This supports the notion that the absence of detectable TCR molecules on intradecidual T lymphocytes in situ results from specific down-regulation or modulation rather than from intrinsic deficiency of TCR expression. These findings provide an additional structural basis to explain local matemal tolerance towards the semiallogeneic fetus. SIR,—Your Sept
1 editorial
Departments of Obstetrics and Gynaecology and Pathology, University of Tubingen, 7400 Tubingen, Germany
KLAUS MARZUSCH JOHANNES DIETL HANS-PETER HORNY PETER RUCK EDWIN KAISERLING
Department of Pathology, University of Kiel
HENRIK GRIESSER
Department of Immunology, University of Heidelberg
DIETER KABELITZ
J, Homy H-P, Ruck P, et al. Intradecidual T lymphocytes lack immunohistochemically detectable T-cell receptors. Am J Reprod Immunol (in press)
1. Dietl
until the
priorities
political expediency is removed from development the trap will fill up with suffering infants and needy
mothers.
only way to change the political will is for politicians to be brought in to see, not diplomats and development bureaucrats, but the sick, hungry, and destitute. It will be man’s compassion, not The
statistics and reports, that will make the shift. International Community for the Relief of Starvation and Suffering, PO Box 15619,
J. BARNES
Mbagathi, Kenya
MICHAEL K. MEEGAN
SIR,-Dr King’s paper and the accompanying editorial are unscientific and morally repugnant. King creates a simplistic "straw man", stating "that the necessary and sufficient condition for reducing birth-rate is to reduce the child death rate", and proceeds to argue that this alone will not reduce births. From there he concludes, "Reduced childhood mortality must no longer be promoted... such desustaining measures as oral rehydration should not be introduced on a public health scale, since they increase the man-years of human misery, ultimately from starvation." "However", he proceeds "the individual doctor must rehydrate his patient." Here he betrays his underlying logic: those who can afford doctors are chosen to survive, the less fortunate are left to die. Similarly, he admits that the threat to global ecology is exacerbated by consumption patterns of the developed world, but prescribes for those 10% of the world who consume 50% or more of its resources and provide the major threats to global environment (ozone depletion, warming, deforestation,
mass
pollution) only
"the deliberate quest of poverty" in order to achieve "further increase in living standards". The babies of the south are singled out to be sacrificed for sustainability of the status quo of the north. Demographic transition has occurred, with a decline in both mortality and fertility: the sequence and pace of decline may vary, but both decline. Modem demographic analysis invariably identifies mortality decline as a precondition to fertility decline,l the only uncertainty being the timing. With survival rates of children already at 850-880 per 1000 live births, a halving of death rates among the under-5’s would increase survival by only 7-8% and population growth rates by a mere 0’18-02%. Comparing this small demographic effect of improved survival with the dramatic reduction in suffering attendant upon a 50% decline in infant and child deaths, it is not hard to see why, historically, such mortality declines are associated with 25% or more reduction in fertility rates and a steep fall in population growth.2 The World Fertility Survey and other large demographic surveys have amply documented the already unmet desire by a substantial portion of women to limit their fertility.3 With family planning services as a part of a comprehensive "child survival package" birth rates can be predicted to fall even further. King’s proposition, linking further efforts at child mortality reduction to achieved decline in fertility, condemns vast populations to continued rampant growth, caught in the midst of his "demographic trap". To return to a level of pretransitional equilibrium, crude death rates would have to rise to two or three times present levels yielding a life expectancy of 30 or 35 years-an unthinkable regression of the human condition. There is no reasonable or ethical alternative other than to push ahead with the obvious and provide the necessary inputs for both survival of children and reduced fertility together. Tagore’s "meagre coverlet", with which King prefaces his article, is yet big enough to go around, if only big brother would stop hogging so much more than his fair share. B-9 West End, New Delhi 110 021, India 1. Chesnais 2. 3.
JON ELIOT ROHDE
J-C. La transition demographique étapes, formes, implications économiques. Pans: Presses Universitaires de France, 1986. Coale AJ, Watkins SC. The decline of fertility m Europe. Princeton, NJ: Princeton University Press, 1986. UN Population Fund. The state of world population 1990 New York UN Population Fund, 1990.
1
SiR,—Dr King’s article revisits issues much discussed two to three decades ago. His logical development of the need to give priority to the ecological foundations of health is a timely reminder but these concerns do not justify the conclusion that health measures such as oral rehydration "should not be introduced on a public health scale". For the past thirty years we have tended to take "either/or" positions rather than recognising that both disease control and family planning are essential and that practical realism is congruent with ethical compulsions. As one of the original proponents of the child survival hypothesis,’ I can affirm that none of us claimed that reduction in child mortality is a necessary and sufficient condition for reducing fertility. We have always considered it only one important factor in shifting patterns of multifactorial causality. Evidence from Bangladesh, cited in the editorial that accompanies King’s article, shows that reduction in child mortality is not even a necessary precondition for some reduction in fertility. This does not mean, however, that a stable population balance will result in Bangladesh or elsewhere if high child mortality persists. Parents in countries with an average of seven children presumably have different motivations from the more common situation where families average four to five children. The child survival hypothesis is increasingly accepted by developing countries as a rational basis for policy. Reducing mortality and providing contraceptives are two variables that can be changed by action programmes, while general socioeconomic development, including female literacy, tends to take longer. King is correct in saying that when children die in high parity situations their partial "replacement" is due mainly to shortening of lactational amenorrhoea. One factor influencing parents to have extra children may be "insurance motivation", related to subconscious expectations that some children might die. This is supported by evidence of temporal associations between mortality and fertility decline. Proof probably requires long-term prospective field research rather than correlations, which do not show the direction of causal associations. We tried to sort out these issues in the Narangwal studies in the PunjabZ but the research was terminated by the Bangladesh war just as definitive findings were beginning to emerge. We did demonstrate the much greater cost-effectiveness and acceptability of integrated services when impact on both health and fertility were included in the analysis. Most developing countries have reintegrated maternal and child health services because of the duplication and non-sustainable cost of separate vertical programmes. King rightly objects to vertical disease control programmes but a decision to separate fertility from mortality control leads inevitably to vertical family planning programmes, even when the arguments used are broadly ecological. One of the main lessons from the past is that foreign support for vertical programmes, including family planning, may achieve short-term impact but will have poor sustainability. Institute for International Programs, School of Hygiene and Public Health, Johns Hopkins University Baltimore, Maryland 21202, USA
CARL E. TAYLOR
1.
Taylor CE, Hall MF Health, population and economic development Science 1965;
2.
Taylor CE,
157: 651-57. et al. Child and maternal health services in rural India: the Narangwal experiment, vol II. Integrated family planning and health care (World Bank Research Publication). Baltimore: Johns Hopkms University Press, 1983.
Extracorporeal membrane oxygenation SIR,—In response to our editorial’ Dr Greenough and Dr Emery (Sept 29, p 760) suggest that there is no established need for ECMO in the UK and that the treatment is both expensive and carries a high risk of morbidity. We think that mature infants potentially amenable to treatment with ECMO in the UK are dying. We agree that it is difficult to be sure from retrospective analysis how many infants will benefit from this treatment. Audit of neonatal units alone will underestimate demand since several suitable infants with severe persistent fetal circulation are referred to cardiothoracic units
52
in the belief that they have cyanotic heart disease. Whether suitable children genuinely do better with ECMO or whether difficulties in transfer and speed of deterioration make the use of ECMO impossible, can all be answered by a controlled trial. In setting up such a trial, great care must be taken in defining entry criteria, "conventional therapy", and "successful outcome"; these points lie at the heart of the ECMO controversy world wide.z It is our impression that in the UK, ECMO is little more expensive than conventional intensive care. Even in the United States, ECMO is felt to be cost effective. This too needs formal prospective evaluation. We do not wish to see the piecemeal introduction of ECMO. A trial with close attention to entry criteria and to morbidity and mortality is the correct way to establish whether ECMO has a place. Department of Child Health, Leicester Royal Infirmary
D.
J. FIELD
Regional Cardiothoracic Unit, Groby Road Hospital,
R. K. FIRMIN
Leicester LE3 9QE, UK 1. Sosnowski
AW, Bonser SJ, Field DJ, Graham TR, Firmin RK. Extra corporeal membrane oxygenation. Br Med J 1990; 301: 303-04. 2. Lantos JD, Frader J. Extra corporeal membrane oxygenation and the ethics of clinical research m pediatrics. N Engl JMed 1990; 323: 409-13.
US military medical school SIR,—Iam surprised to see The Lancet stoop to such a low level of journalism as Mr Greenberg’s piece (Nov 24, p 1306) on the Uniformed Services University of the Health Sciences (USUHS). One does not need to know the facts to discern the tone of bias and ridicule ("superfluous", "extravagant", "costly relic", "pampered lord", "reprieves from oblivion"). However, those familiar with the facts know that USUHS provides more than 10% of US military physician acquisitions each year. These doctors, besides an excellent medical education, receive extensive military experience which sets them apart from their civilian-trained counterparts. This training is not accomplished at a cost "4-5 times more expensive than civilian medical education". USUHS operates more economically than civilian medical schools (comparisons can be made from data in the Aug 15, 1990, issue of JAMA). Those who are willing to investigate the facts and evaluate the quality of the institution and its graduates will see that USUHS does not need a newspaper columnist as its saviour. The appeal to Ann Landers was to address the publicity issue mentioned in the opening sentence of Greenberg’s article. 700 Fordham St,
Rockville, Maryland 20850, USA
Altered
JOHN W. GARDNER
grounds for abortion?
SIR,-The Human Fertilisation and Embryology Act 1990 amends the Abortion Act 1967 by substituting the following grounds for termination of pregnancy:
"(a) that the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk greater than if the pregnancy were terminated, of injury to the physical and mental health of the pregnant woman or any existing children of her family; or (b) that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman;
or
(c) that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were
terminated; or
(d) that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped." Termination of pregnancy under (a) which is similar to the 1967 Act, can take place up to 24 weeks only, but sections (b), (c), and (d) apply without regard to gestational age.
It had hitherto always been lawful for a doctor to bring a to an end if the woman’s life or health were threatened, the commonest reason for this being fulminant toxaemia, an example quoted several times in the Parliamentary debate. Previously it was the case that if the infant was capable of being bom alive, then, after affording priority to the woman’s own health, every effort to perserve the life and wellbeing of the infant was required. However, very-low-birthweight infants delivered under adverse conditions are at "considerable risk of long-term morbidity". Such babies will be close to or at the limit of viability and at such risk of disability that there could be grounds for destructive delivery under pregnancy
(d). It appears therefore that in the UK
a
doctor
now
needs the
explicit consent of the woman to save her baby during delivery if there is a risk of serious handicap. If she withholds it or cannot give it then the Human Fertilisation and Embryology Act permits the doctor to destroy the child-indeed if the doctor does not, it is conceivable that the parent(s) could bring an action for negligence, using the doctors refusal to apply the criterion in (d). Furthermore (d) bears an interpretation which would apply to any of the common complications of pregnancy which can result in cerebral palsy. The consequences for obstetric management could be very grave involving the destruction of many thousands of at-risk infants. Will it be necessary to take those destructive instruments from the age of obstructed labour from the museum shelves? This Act makes it more expedient to kill than to strive to save where the wellbeing of the child is in doubt. Worcester Royal Infirmary, Worcester WR1 3AS, UK
A. P. COLE J. G. DUDDINGTON
Tolerance and the fetal
graft
(p 538) suggests the expression of a form of the major-histocompatibility-complex non-immunogenic (MHC) class I molecule at the fetomaternal interface as the main reason for maternal tolerance towards the fetal graft. However, in a response to this editorial Dr Innes and colleagues (Nov 3, p 1133) suggest that these molecules are indeed immunogenic. If this is so, why do maternally derived T lymphocytes migrating into the decidua (which is in direct contact with cytotrophoblast) not respond to these MHC molecules? We have demonstrated the lack of expression of the two variants of the T-cell antigen receptor (TCR) by mature intradecidual T lymphocytes during early normal pregnancy.l Our data clearly show that CD3T lymphocytes in first trimester decidua do not express immunohistochemically detectable amounts of &agr;/&bgr; or r/8 TCR molecules. It therefore seems probable that most intradecidual T lymphocytes will not be activated by the antigen and thus will be functionally anergic towards paternally derived fetal antigens. In addition we found that T lymphocytes isolated from the decidua can be induced to express normal amounts of the &agr;/&b(3gr; TCR heterodimer by in-vitro stimulation with phytohaemagglutinin-P and exogenous interleukin-2, which suggests that TCR expression can be restored in this T lymphocyte subset. This supports the notion that the absence of detectable TCR molecules on intradecidual T lymphocytes in situ results from specific down-regulation or modulation rather than from intrinsic deficiency of TCR expression. These findings provide an additional structural basis to explain local matemal tolerance towards the semiallogeneic fetus. SIR,—Your Sept
1 editorial
Departments of Obstetrics and Gynaecology and Pathology, University of Tubingen, 7400 Tubingen, Germany
KLAUS MARZUSCH JOHANNES DIETL HANS-PETER HORNY PETER RUCK EDWIN KAISERLING
Department of Pathology, University of Kiel
HENRIK GRIESSER
Department of Immunology, University of Heidelberg
DIETER KABELITZ
J, Homy H-P, Ruck P, et al. Intradecidual T lymphocytes lack immunohistochemically detectable T-cell receptors. Am J Reprod Immunol (in press)
1. Dietl
