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ORAL POLIOMYELITIS VACCINE
719
Letters
to
the Editor
CHRISTMAS GIFTS FUND SIR,-Ishould be grateful if you would allow me space to make the customary annual appeal to enable the Royal Medical Benevolent Fund to send a special Christmas gift to each of its regular beneficiaries. Last year to our delight but not surprise, there was a very generous response which brought gladness to the hearts of many. In making this appeal for Christmas, 1962, we hope, nay we believe, that the members of our profession will respond as generously, or even more generously, than last year. Would donors kindly send their contributions, marked "Christmas Gifts" to the Royal Medical Benevolent Fund, 37, St. George’s Road, Wimbledon, London, S.W.19. ZACHARY COPE President, Royal Medical Benevolent Fund. AN UNUSUAL VILLAGE AND ITS PROBLEMS
SIR,-Readers of the article on an Oxfordshire village (Sept. 22, p. 603) may be interested in further details about the unfortunate girl who was described in it, and her family background. The mother, who was booked with the family doctor, was delivered at home in 1947 by the district nurse midwife. When the child was 8 the health visitor referred her through the health department to the eye specialist and from then on she was under the care of the hospital consultants. Meanwhile, the family, all of whom are mentally backward, moved from one house and district to another, so that continuity of supervision was not easy. In 1959 the health visitor reported that the child was clean and well cared for. In January, 1960, the mother refused special education for her. At this time the living conditions were dirty and untidy but there was no evidence of neglect. In June, 1960, the family were evicted from the hut in the village. Two months later they were traced to an isolated cottage in a nearby village, and it was found that serious mental deterioration had occurred both in the child and, more especially, in the mother. The mental welfare officer was called in and in his report he refers to the very bad living conditions; cups were without handles and coats were being used instead of blankets. The mother refused to see her doctor, so arrangements were made for a domiciliary psychiatric consultation, following which the patient was admitted informally to a mental hospital and arrangements were made for the children to be taken into care. Examination of the mother’s blood gave a positive Wassermann, so the doctor to the children’s home was asked if he would refer the two children to hospital for investigation, with the result that one child was found to have congenital syphilis. The sequel to this unhappy story gives reason for hope for the future. The mother was discharged from hospital after initial treatment, and the health department decided to try and bring the family together again. With the help of the district council, a house-isolated it is true-was found. The next problem was to furnish the house. Fortunately, the health department was able to obtain furniture and beds and so enable the family to live together again. The mother is visited regularly by the mental welfare officer, who transports her to and from hospital. The affected child remains in a children’s home (but returns home at weekends); she is due to leave school soon, and sheltered employment is being considered for her. With regard to the general medical background to the village it should perhaps be mentioned that about 1500 of the population consist of American servicemen and their families, who have available to them the excellent clinical, medical, and shopping facilities at the base. Consideration
has been
to setting up a pharmacy, but a village of about 2500 does not attract a pharmacist. population Despite the facilities available to the Americans at the base it is interesting to see how much they appreciate the services of the local health visitor. When I accompanied her on her rounds some time ago, I could not help remarking how many American women, some of them coloured, turned to her for advice on welfare problems regarding their children. It was noteworthy, too, that the thriving infant-welfare clinics, in the village, which are attended by the local doctor, attract about 90% of the mothers, and are welcomed by the American families. Perhaps this is associated in part with the fact that the health visitor’s case load has been reduced in order to enable her to attend to the particular problems of a community where a number of families, by force of circumstances, do not remain for long. Her services are soon to be supplemented by mothercraft, relaxation, and health-education classes by a health visitor appointed especially for healtheducation purposes. There is good liaison with the medical staff of the base and the special treatment department of the United Oxford Hospitals regarding cases of venereal disease, and from time to time meetings are held to see if improvements in contact tracing can be worked out. The article by Dr. Smallpeice and Miss Martin-Hurst states that there has been no trace of the social pattern of resident squire, parson, and doctor in the village, but in fact the present vicar has been living in this village for nearly two years, having taken up his appointment in December, 1960. The doctors who already hold surgeries in the village are trying to obtain land for a surgery with a dispensing practice. The Church authorities have planned a combined church and community centre. Only the former will be consecrated; the latter is being adapted for use as a surgery and welfare centre. It is hoped that building will start in a few weeks. The local social services have also raised funds for a community centre to be sited near the parish recreation ground. The transport position has improved recently with new bus services, but attendance at the Oxford hospitals, twenty miles away, is never easy by public transport and there is a big demand on the ambulance service.
given
The problems of a village like this call for increased efforts in coordination by everyone in the health services. Those working in the field need to be notified in advance of patients discharged from hospital so that home conditions can be made fit for their return; this is essential with feckless families. Home-helps are not easy to obtain, but the difficulties are not insuperable. In talking to people in the village I was struck by the number who commented on the improvements which had taken place over the past ten years. This gives encouragement for the future and makes one realise that there is much good in a village where local people have been making considerable efforts to improve the social and living conditions. M. J. PLEYDELL Health Department, Oxford.
County
Medical Officer.
ORAL POLIOMYELITIS VACCINE SIR,-Several medical representatives from Britain have just returned from the European Poliomyelitis Symposium in Prague, where we were concerned with studying the latest reports from all parts of the world regarding the
prevention of poliomyelitis. The reports received will be fully considered in relation to the current programme being used in this country, and I for one have full confidence in the Ministry’s advisers on this matter. to read your editorial of the subject, for it seems to me that you are prejudging the issues involved. I would point out that you adopted the same procedure in 1961, for your
I am, Sept. 29
however, disturbed
on
720
editorial of Sept. 9 was also written shor’tly before our European conference. This can hardly be considered a very statesmanlike approach to a difficult problem. Could you not have waited until you had heard the further facts which were reported in Prague this week ? Department of Neurology, Radcliffe Infirmary, Oxford.
W. RITCHIE RUSSELL Chairman of the U.K. Committee for Poliomyelitis.
*
DETERMINISM, RESPONSIBILITY, AND ILLNESS SIR,-I want to thank Dr. Merskey and Mr. Clarke (Sept. 1) for dealing with my questions and stating their
assumptions and preconceptions more fully. It is difficult to be wholly " scientific and objective, and without special pleading "; since the type of scientific method advocated as being of primary importance in the study of human behaviour is itself a form of special pleading. Such bias must always be taken into account, so as not to detract from the value of such scientific findings by a tendency to exclude or minimise other methods of study and findings in this complex field. Discipline and restraint are necessary for the more difficult task of attempting to resolve and reconcile these differences in the quest for more adequate theory, rather than the less exacting procedure of setting up one method and approach as superior and more important than others. The dualistic theory put forward by the authors creates the problem of who or what decides which universe of discourse is appropriate to a given situation. It seems unsatisfactory to leave them as apparently unrelated alternatives. Although the authors finally come down on the side of determinism, is it not really the more difficult question of how much of determinism and free will there is in any given human behaviour ? St. George’s Hospital, Stafford.
H. M. FLANAGAN.
TRAINING OF NURSES
SIR,-The nurses are being urged by the Industrial Court to put their salary structure in order by March 31, 1963. I think it would be equally worth putting the professional strata right at the same time, and I would suggest the following: All hospitals which are medical teaching schools should become the State-enrolled-nurse training schools of the United Kingdom. I suggest this because the great work in surgery, medicine, and specialisation is done in these hospitals, and therefore they are the best training centres for the bedside It would also give the doctors the opportunity of nurse. planning and supervising the clinical teaching of the pupil, and of growing up with the nurses they always say they wantnot the academic, but the practical. All men and women who want to become State-registered nurses would take their training in hospitals geared, not to teaching the future doctors, but to teaching and training the future team-leaders in nursing. These schools of nursing would be the regional-board hospitals, approved by the General Nursing Council, throughout the country. The results would be: (a) Removing a lot of chips from the shoulders of the nurses who have trained in non-medical teaching hospitals, but who believe they are as good nurses but have less kudos. (b) Producing a State-registered nurse with a feeling of equality with all other State-registered nurses trained after March 31, 1963. (c) Producing a State-enrolled nurse who would not have an inferiority complex, and if it is social/matrimonial status the candidate is seeking, State-enrolled nursing will become fashionable. Richmond,
Surrey.
E WALSH E. A A. WALSH. WALSH.
PREMATURITY, TETRACYCLINE, AND OXYTETRACYCLINE IN TOOTH DEVELOPMENT
SIR,-We have reported1 the finding of pigmentation, with or without enamel hypoplasia, in deciduous teeth of children who were given tetracycline in the neonatal period, and the apparent rarity of these complications after oxytetracycline therapy. Prof. M. A. Rushton (May 5), Mr. Stewart (May 5), and Dr. Miller (May 19) suggested that prematurity alone, or the disease for which the drug was given, rather than tetracycline, may have been responsible for the enamel hypoplasia. To elucidate this problem we investigated 46 prematurely born children to determine the incidence of tooth deformity. In a separate survey 21 children who had been given oxytetracycline in the neonatal period were also investigated to assess the effects of this drug on dentition. We examined the records of all babies born at the King Edward Memorial Hospital for Women in Perth in the twelve months from January, 1960, to January, 1961. 46 children whose birthweight was less than 2-5 kg. (this being taken as the criterion of " prematurity ") were traced. The teeth were examined and the gestation period, birthweight, any significant illness, and details of the administration of antibiotics were noted. Enamel hypoplasia was diagnosed when there was naked-eye deformity of the teeth. This was usually manifested in the canines and molars as abnormally sharp cusps and obvious deficiency of the enamel. The average birthweight in this group was 2-06 kg., and the average gestation period was 35-1 weeks. 32 children had normal teeth. 6 of these had illnesses: conjunctivitis (3), respiratory distress (2), and cyanotic attacks (1). None had been given tetracycline. 14 children had abnormal teeth. Of this group, 1 had kemicterus and had received oxytetracycline. He had enamel hypoplasia and slight yellow pigmentation. The other 13 had all been given tetracycline in doses ranging from 120 to 750 mg. 9 had enamel hypoplasia and pigmentation, and 4 had pigmentation alone. The drug was given for respiratory distress in 4 cases, for conjunctivitis in 2, for cyanotic attacks in 2, for pustules in 2, for pneumonia in 1, and prophylactically in 2, 21 children who had been given oxytetracycline in the neonatal period were traced. Most of them had been given the drug in the first week of life. In each instance we recorded the birthweight, gestational age, the dose of oxytetracycline, the duration of treatment, and the reason for giving the drug. This group includes the 8 cases previously
reported.1 Oxytetracycline was given for respiratory distress in 4 cases, for conjunctivitis in 4, for pyrexia in 3, for pustules in 1, for infected umbilicus in 1, for cellulitis in 1, and prophylactically in 7. The average birthweight was 2’82 kg.; the average gestational period was 38 weeks. The average total dose of oxytetracycline was 620 mg. (an average total dose of 210 mg. per kg. with an average daily dose of 38 mg. per kg.). 2 children had abnormal teeth. 1 was a mentally defective child, previously described, who had superficial yellow pigmentation of the teeth which did not fluoresce in ultraviolet light. There was. no associated enamel hypoplasia. The 2nd child had kernicterus due to rhesus incompatibility. 700 mg. of oxytetracycline had been given in the neonatal period. The teeth showed moderate enamel hypoplasia with slight yellow pigmentation. Other than varying degrees of caries, the remaining children had normal teeth. 2 children whose birthweights were 2-2 kg. and 1’6 kg. received 630 and 750 mg. per kg., yet neither had abnormal teeth. Kernicterus is often followed by severe enamel hypoplasia. Forrester and Miller2 examined 13 children who had had kernicterus, and found that all had tooth deformity. They also described enamel hypoplasia in some premature babies, and noted that most of these children 1. 2.
Wallman, I. S., Hilton, H. B. Lancet, 1962, i, 827. Forrester, R. M., Miller, J. Arch. Dis. Childh. 1955, 30, 224.
Letters
to
the Editor
CHRISTMAS GIFTS FUND SIR,-Ishould be grateful if you would allow me space to make the customary annual appeal to enable the Royal Medical Benevolent Fund to send a special Christmas gift to each of its regular beneficiaries. Last year to our delight but not surprise, there was a very generous response which brought gladness to the hearts of many. In making this appeal for Christmas, 1962, we hope, nay we believe, that the members of our profession will respond as generously, or even more generously, than last year. Would donors kindly send their contributions, marked "Christmas Gifts" to the Royal Medical Benevolent Fund, 37, St. George’s Road, Wimbledon, London, S.W.19. ZACHARY COPE President, Royal Medical Benevolent Fund. AN UNUSUAL VILLAGE AND ITS PROBLEMS
SIR,-Readers of the article on an Oxfordshire village (Sept. 22, p. 603) may be interested in further details about the unfortunate girl who was described in it, and her family background. The mother, who was booked with the family doctor, was delivered at home in 1947 by the district nurse midwife. When the child was 8 the health visitor referred her through the health department to the eye specialist and from then on she was under the care of the hospital consultants. Meanwhile, the family, all of whom are mentally backward, moved from one house and district to another, so that continuity of supervision was not easy. In 1959 the health visitor reported that the child was clean and well cared for. In January, 1960, the mother refused special education for her. At this time the living conditions were dirty and untidy but there was no evidence of neglect. In June, 1960, the family were evicted from the hut in the village. Two months later they were traced to an isolated cottage in a nearby village, and it was found that serious mental deterioration had occurred both in the child and, more especially, in the mother. The mental welfare officer was called in and in his report he refers to the very bad living conditions; cups were without handles and coats were being used instead of blankets. The mother refused to see her doctor, so arrangements were made for a domiciliary psychiatric consultation, following which the patient was admitted informally to a mental hospital and arrangements were made for the children to be taken into care. Examination of the mother’s blood gave a positive Wassermann, so the doctor to the children’s home was asked if he would refer the two children to hospital for investigation, with the result that one child was found to have congenital syphilis. The sequel to this unhappy story gives reason for hope for the future. The mother was discharged from hospital after initial treatment, and the health department decided to try and bring the family together again. With the help of the district council, a house-isolated it is true-was found. The next problem was to furnish the house. Fortunately, the health department was able to obtain furniture and beds and so enable the family to live together again. The mother is visited regularly by the mental welfare officer, who transports her to and from hospital. The affected child remains in a children’s home (but returns home at weekends); she is due to leave school soon, and sheltered employment is being considered for her. With regard to the general medical background to the village it should perhaps be mentioned that about 1500 of the population consist of American servicemen and their families, who have available to them the excellent clinical, medical, and shopping facilities at the base. Consideration
has been
to setting up a pharmacy, but a village of about 2500 does not attract a pharmacist. population Despite the facilities available to the Americans at the base it is interesting to see how much they appreciate the services of the local health visitor. When I accompanied her on her rounds some time ago, I could not help remarking how many American women, some of them coloured, turned to her for advice on welfare problems regarding their children. It was noteworthy, too, that the thriving infant-welfare clinics, in the village, which are attended by the local doctor, attract about 90% of the mothers, and are welcomed by the American families. Perhaps this is associated in part with the fact that the health visitor’s case load has been reduced in order to enable her to attend to the particular problems of a community where a number of families, by force of circumstances, do not remain for long. Her services are soon to be supplemented by mothercraft, relaxation, and health-education classes by a health visitor appointed especially for healtheducation purposes. There is good liaison with the medical staff of the base and the special treatment department of the United Oxford Hospitals regarding cases of venereal disease, and from time to time meetings are held to see if improvements in contact tracing can be worked out. The article by Dr. Smallpeice and Miss Martin-Hurst states that there has been no trace of the social pattern of resident squire, parson, and doctor in the village, but in fact the present vicar has been living in this village for nearly two years, having taken up his appointment in December, 1960. The doctors who already hold surgeries in the village are trying to obtain land for a surgery with a dispensing practice. The Church authorities have planned a combined church and community centre. Only the former will be consecrated; the latter is being adapted for use as a surgery and welfare centre. It is hoped that building will start in a few weeks. The local social services have also raised funds for a community centre to be sited near the parish recreation ground. The transport position has improved recently with new bus services, but attendance at the Oxford hospitals, twenty miles away, is never easy by public transport and there is a big demand on the ambulance service.
given
The problems of a village like this call for increased efforts in coordination by everyone in the health services. Those working in the field need to be notified in advance of patients discharged from hospital so that home conditions can be made fit for their return; this is essential with feckless families. Home-helps are not easy to obtain, but the difficulties are not insuperable. In talking to people in the village I was struck by the number who commented on the improvements which had taken place over the past ten years. This gives encouragement for the future and makes one realise that there is much good in a village where local people have been making considerable efforts to improve the social and living conditions. M. J. PLEYDELL Health Department, Oxford.
County
Medical Officer.
ORAL POLIOMYELITIS VACCINE SIR,-Several medical representatives from Britain have just returned from the European Poliomyelitis Symposium in Prague, where we were concerned with studying the latest reports from all parts of the world regarding the
prevention of poliomyelitis. The reports received will be fully considered in relation to the current programme being used in this country, and I for one have full confidence in the Ministry’s advisers on this matter. to read your editorial of the subject, for it seems to me that you are prejudging the issues involved. I would point out that you adopted the same procedure in 1961, for your
I am, Sept. 29
however, disturbed
on
720
editorial of Sept. 9 was also written shor’tly before our European conference. This can hardly be considered a very statesmanlike approach to a difficult problem. Could you not have waited until you had heard the further facts which were reported in Prague this week ? Department of Neurology, Radcliffe Infirmary, Oxford.
W. RITCHIE RUSSELL Chairman of the U.K. Committee for Poliomyelitis.
*
DETERMINISM, RESPONSIBILITY, AND ILLNESS SIR,-I want to thank Dr. Merskey and Mr. Clarke (Sept. 1) for dealing with my questions and stating their
assumptions and preconceptions more fully. It is difficult to be wholly " scientific and objective, and without special pleading "; since the type of scientific method advocated as being of primary importance in the study of human behaviour is itself a form of special pleading. Such bias must always be taken into account, so as not to detract from the value of such scientific findings by a tendency to exclude or minimise other methods of study and findings in this complex field. Discipline and restraint are necessary for the more difficult task of attempting to resolve and reconcile these differences in the quest for more adequate theory, rather than the less exacting procedure of setting up one method and approach as superior and more important than others. The dualistic theory put forward by the authors creates the problem of who or what decides which universe of discourse is appropriate to a given situation. It seems unsatisfactory to leave them as apparently unrelated alternatives. Although the authors finally come down on the side of determinism, is it not really the more difficult question of how much of determinism and free will there is in any given human behaviour ? St. George’s Hospital, Stafford.
H. M. FLANAGAN.
TRAINING OF NURSES
SIR,-The nurses are being urged by the Industrial Court to put their salary structure in order by March 31, 1963. I think it would be equally worth putting the professional strata right at the same time, and I would suggest the following: All hospitals which are medical teaching schools should become the State-enrolled-nurse training schools of the United Kingdom. I suggest this because the great work in surgery, medicine, and specialisation is done in these hospitals, and therefore they are the best training centres for the bedside It would also give the doctors the opportunity of nurse. planning and supervising the clinical teaching of the pupil, and of growing up with the nurses they always say they wantnot the academic, but the practical. All men and women who want to become State-registered nurses would take their training in hospitals geared, not to teaching the future doctors, but to teaching and training the future team-leaders in nursing. These schools of nursing would be the regional-board hospitals, approved by the General Nursing Council, throughout the country. The results would be: (a) Removing a lot of chips from the shoulders of the nurses who have trained in non-medical teaching hospitals, but who believe they are as good nurses but have less kudos. (b) Producing a State-registered nurse with a feeling of equality with all other State-registered nurses trained after March 31, 1963. (c) Producing a State-enrolled nurse who would not have an inferiority complex, and if it is social/matrimonial status the candidate is seeking, State-enrolled nursing will become fashionable. Richmond,
Surrey.
E WALSH E. A A. WALSH. WALSH.
PREMATURITY, TETRACYCLINE, AND OXYTETRACYCLINE IN TOOTH DEVELOPMENT
SIR,-We have reported1 the finding of pigmentation, with or without enamel hypoplasia, in deciduous teeth of children who were given tetracycline in the neonatal period, and the apparent rarity of these complications after oxytetracycline therapy. Prof. M. A. Rushton (May 5), Mr. Stewart (May 5), and Dr. Miller (May 19) suggested that prematurity alone, or the disease for which the drug was given, rather than tetracycline, may have been responsible for the enamel hypoplasia. To elucidate this problem we investigated 46 prematurely born children to determine the incidence of tooth deformity. In a separate survey 21 children who had been given oxytetracycline in the neonatal period were also investigated to assess the effects of this drug on dentition. We examined the records of all babies born at the King Edward Memorial Hospital for Women in Perth in the twelve months from January, 1960, to January, 1961. 46 children whose birthweight was less than 2-5 kg. (this being taken as the criterion of " prematurity ") were traced. The teeth were examined and the gestation period, birthweight, any significant illness, and details of the administration of antibiotics were noted. Enamel hypoplasia was diagnosed when there was naked-eye deformity of the teeth. This was usually manifested in the canines and molars as abnormally sharp cusps and obvious deficiency of the enamel. The average birthweight in this group was 2-06 kg., and the average gestation period was 35-1 weeks. 32 children had normal teeth. 6 of these had illnesses: conjunctivitis (3), respiratory distress (2), and cyanotic attacks (1). None had been given tetracycline. 14 children had abnormal teeth. Of this group, 1 had kemicterus and had received oxytetracycline. He had enamel hypoplasia and slight yellow pigmentation. The other 13 had all been given tetracycline in doses ranging from 120 to 750 mg. 9 had enamel hypoplasia and pigmentation, and 4 had pigmentation alone. The drug was given for respiratory distress in 4 cases, for conjunctivitis in 2, for cyanotic attacks in 2, for pustules in 2, for pneumonia in 1, and prophylactically in 2, 21 children who had been given oxytetracycline in the neonatal period were traced. Most of them had been given the drug in the first week of life. In each instance we recorded the birthweight, gestational age, the dose of oxytetracycline, the duration of treatment, and the reason for giving the drug. This group includes the 8 cases previously
reported.1 Oxytetracycline was given for respiratory distress in 4 cases, for conjunctivitis in 4, for pyrexia in 3, for pustules in 1, for infected umbilicus in 1, for cellulitis in 1, and prophylactically in 7. The average birthweight was 2’82 kg.; the average gestational period was 38 weeks. The average total dose of oxytetracycline was 620 mg. (an average total dose of 210 mg. per kg. with an average daily dose of 38 mg. per kg.). 2 children had abnormal teeth. 1 was a mentally defective child, previously described, who had superficial yellow pigmentation of the teeth which did not fluoresce in ultraviolet light. There was. no associated enamel hypoplasia. The 2nd child had kernicterus due to rhesus incompatibility. 700 mg. of oxytetracycline had been given in the neonatal period. The teeth showed moderate enamel hypoplasia with slight yellow pigmentation. Other than varying degrees of caries, the remaining children had normal teeth. 2 children whose birthweights were 2-2 kg. and 1’6 kg. received 630 and 750 mg. per kg., yet neither had abnormal teeth. Kernicterus is often followed by severe enamel hypoplasia. Forrester and Miller2 examined 13 children who had had kernicterus, and found that all had tooth deformity. They also described enamel hypoplasia in some premature babies, and noted that most of these children 1. 2.
Wallman, I. S., Hilton, H. B. Lancet, 1962, i, 827. Forrester, R. M., Miller, J. Arch. Dis. Childh. 1955, 30, 224.