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PROJECT 70
1327 FLUORIDATION AND THE COUNCILLORS SIR,-In her letter (May 14) the honorary secretary of the National Pure Water Association refers to " the general practice ... to limit the permitted amount of food additives or pesticides to 1 % of the maximum no-effects level as ascertained by animal experiments ". I hope she will not adhere too strongly to this formula; it may embarrass us all. There is a particular well-characterised substance which, when administered by mouth to rabbits in daily doses of 300-333 ml. per kg. body-weight, causes listlessness, ataxia, diuresis, stupor, convulsions, and death within two to three weeks. This clearly is beyond the no-effect level. Even so, if we apply to it the 1 % factor as suggested by your correspondent, the permitted level so deduced should be substantially less than 3-0-3-3 ml. per kg. daily, or, in practical terms, somewhat over 200 ml. daily for a man. That substance
is-pure
water.
National Poisons Information Service, Guy’s Hospital, London S.E.1.
ROY GOULDING.
FLUORIDES AND THE LOCOMOTOR SYSTEM SiR,—The knowledge of the possible relations of fluoride ingestion to various rheumatic disorders has been extensively described in your leading article (May 28). A more direct cause and effect relation to bone changes has been reported, and is a European condition as distinct from the pronounced osteosclerosis with bony exostoses that you describe as of Eastern origin. The condition described as " periostitis deformans " by Professor Soriano of Barcelona is no doubt the same as the " ankylosing hyperostosis " first referred to by Jacques Forestier in 1964. Soriano states categorically that the vehicle causing the hyperfluoridosis is the common wine of the district, to which great amounts of sodium fluoride are added for preservation. The article makes no mention of any associated malnutrition, but the author leaves little doubt as to the fluoride intake being directly related to the osteophytic outgrowths in this condition. Charterhouse Rheumatism Clinic, 54—60 Weymouth Street, London W.1.
HARRY COKE.
THE DISPLACEMENT SYNDROME SIR,-Dr. Goodall’s intercepted letter (May 14) should help many to beware of unnecessary displacement. I used to be a believer in unlimited powers of adaptation. Now, after
PROJECT 70
SiR,—Thank you for your notice last week of Project 70; we should like to point out that this plan aims at solving the problem of financing better accommodation for the aged, rather than the quite distinct one of staffing, which has to be solved in any event. It should, however, be easier to attract good staff for the small, modern units provided by our scheme than for the huge, antiquated communities resulting from the isolation of mental hospitals. In a symposium held this year at Severalls Hospital, Dr. Stephen Horsley expressed the opinion that the main cause of staff shortage is the atmosphere of hopelessness. Letters received by AEGIS (Aid for the Elderly in Government Institutions) from staff who have left this branch of nursing endorse his opinion. May we ask in what way the proposed new towns would be " artincial " communities ? Is it seriously suggested that the inclusion of a proportion of the elderly in new towns is more artificial than their segregation in mental hospitals ? Your note speaks of old people being " moved around " as if they were to be shunted about like goods trucks in a marshalling yard. Those affected would, however, change hospital sites but once. Surely much depends on the way that they are prepared for such moves, the spirit in which the journey is undertaken, and the reception given on arrival. We do not of course profess to offer a total panacea for a complex problem. We have, however, made a serious attempt at resolving a part of the Government’s hospital rebuilding difficulties. Might we not have hoped for a more cordial welcome in an issue of The Lancet containing a lament for the inadequacy of the Government’s new white-paper ? 10
Hampstead Grove, London N.W.3.
z*
does not condemn Project 70, but mentions it raises. It has been repeatedly shown that human relations are more important than physical environment. An atmosphere of hopelessness can be found in small new geriatric hospitals as well as in old institutions. The artificiality of a new town and its effect on the elderly is a moot point, but evidence of the ill effect of moving old people is enough to warrant consideration. Old people are rotting in miserable overcrowded institutional wards. A plan like Project 70 which may improve their lot should be seriously investigated, but to ignore its disadvantages will benefit no-one.-ED. L. some
Our
BARBARA ROBB P. G. M. THOMSON.
note
problems
developing displacement syndrome, complicated by replacement, I wish I had been more cautious. After ten years of postgraduate training and post-training work in foreign countries (some more advanced than mine, some more rewarding), and on both sides of the Atlantic, and exposure to many different cultures and five major languages, I was finally about to re-enter my homeland with the intention’of definitely settling down there. I was full of misgivings and uncertainties about both country and work, undecided among conflicting philosophies. Five miles from the frontier I was seized by an acute attack of replacement fear. For three days and many hundred miles I drove back and forth, undecided. Being aware of my state of alienation but unable to overcome it, I remembered Dr. Jean Lamour, a kind soul with a providential name, an old mate in Boston and now living not too far from the scene. Jean, who had once been around the world, readily diagnosed what Dr. Goodall would perhaps call chronic displacement, plus overdose and fear of weaning. Jean and his wife relieved my anguish by the orthodox method of merely revealing the diagnosis (and the less orthodox one of telling their own troubles). Next day I crossed the border and became a displaced person in his own place: a displacedreplaced person. Eighteen months later new symptoms of displacement are appearing-perhaps a matter of disreplacement ? F. CARDENAL. 1.
Rowntree, L. G. Archs
intern.
Med. 1923, 32, 157.
TREATMENT OF STATUS ASTHMATICUS to the therapeutic measures advocated by Mr. Marchand and Dr. Hasselt (Jan. 29) and Dr. Thompson (Feb. 26) for treatment of status asthmaticus I would suggest diuretics of the thiazide group-given together with an antibiotic (chloramphenicol or tetracycline). I have found them extremely valuable in easing the breathing in this distressful condition, especially in children who respond particularly well. Fever if any drops to normal, the patient micturates freely, dyspnoea recedes, and relief is obtained in a few hours. " Large quantities of urine may be passed as an attack subsides according to Savill.1
SIR,-In addition
T. M. SUSAI.
SiR,—We consider the statements made by Dr. Grant (Feb. 12) on the use of massive doses of steroids both timely and appropriate. In our experience, in pursuance of which we have to treat a patient with status asthmaticus at least once every day of the year, there have, never been any complications associated with large doses of steroids on the short-term basis required to bring this ailment under rapid control. Perhaps it 1. Savill’s 1950.
System of Clinical Medicine (edited by
E. C.
Warner). London,
is-pure
water.
National Poisons Information Service, Guy’s Hospital, London S.E.1.
ROY GOULDING.
FLUORIDES AND THE LOCOMOTOR SYSTEM SiR,—The knowledge of the possible relations of fluoride ingestion to various rheumatic disorders has been extensively described in your leading article (May 28). A more direct cause and effect relation to bone changes has been reported, and is a European condition as distinct from the pronounced osteosclerosis with bony exostoses that you describe as of Eastern origin. The condition described as " periostitis deformans " by Professor Soriano of Barcelona is no doubt the same as the " ankylosing hyperostosis " first referred to by Jacques Forestier in 1964. Soriano states categorically that the vehicle causing the hyperfluoridosis is the common wine of the district, to which great amounts of sodium fluoride are added for preservation. The article makes no mention of any associated malnutrition, but the author leaves little doubt as to the fluoride intake being directly related to the osteophytic outgrowths in this condition. Charterhouse Rheumatism Clinic, 54—60 Weymouth Street, London W.1.
HARRY COKE.
THE DISPLACEMENT SYNDROME SIR,-Dr. Goodall’s intercepted letter (May 14) should help many to beware of unnecessary displacement. I used to be a believer in unlimited powers of adaptation. Now, after
PROJECT 70
SiR,—Thank you for your notice last week of Project 70; we should like to point out that this plan aims at solving the problem of financing better accommodation for the aged, rather than the quite distinct one of staffing, which has to be solved in any event. It should, however, be easier to attract good staff for the small, modern units provided by our scheme than for the huge, antiquated communities resulting from the isolation of mental hospitals. In a symposium held this year at Severalls Hospital, Dr. Stephen Horsley expressed the opinion that the main cause of staff shortage is the atmosphere of hopelessness. Letters received by AEGIS (Aid for the Elderly in Government Institutions) from staff who have left this branch of nursing endorse his opinion. May we ask in what way the proposed new towns would be " artincial " communities ? Is it seriously suggested that the inclusion of a proportion of the elderly in new towns is more artificial than their segregation in mental hospitals ? Your note speaks of old people being " moved around " as if they were to be shunted about like goods trucks in a marshalling yard. Those affected would, however, change hospital sites but once. Surely much depends on the way that they are prepared for such moves, the spirit in which the journey is undertaken, and the reception given on arrival. We do not of course profess to offer a total panacea for a complex problem. We have, however, made a serious attempt at resolving a part of the Government’s hospital rebuilding difficulties. Might we not have hoped for a more cordial welcome in an issue of The Lancet containing a lament for the inadequacy of the Government’s new white-paper ? 10
Hampstead Grove, London N.W.3.
z*
does not condemn Project 70, but mentions it raises. It has been repeatedly shown that human relations are more important than physical environment. An atmosphere of hopelessness can be found in small new geriatric hospitals as well as in old institutions. The artificiality of a new town and its effect on the elderly is a moot point, but evidence of the ill effect of moving old people is enough to warrant consideration. Old people are rotting in miserable overcrowded institutional wards. A plan like Project 70 which may improve their lot should be seriously investigated, but to ignore its disadvantages will benefit no-one.-ED. L. some
Our
BARBARA ROBB P. G. M. THOMSON.
note
problems
developing displacement syndrome, complicated by replacement, I wish I had been more cautious. After ten years of postgraduate training and post-training work in foreign countries (some more advanced than mine, some more rewarding), and on both sides of the Atlantic, and exposure to many different cultures and five major languages, I was finally about to re-enter my homeland with the intention’of definitely settling down there. I was full of misgivings and uncertainties about both country and work, undecided among conflicting philosophies. Five miles from the frontier I was seized by an acute attack of replacement fear. For three days and many hundred miles I drove back and forth, undecided. Being aware of my state of alienation but unable to overcome it, I remembered Dr. Jean Lamour, a kind soul with a providential name, an old mate in Boston and now living not too far from the scene. Jean, who had once been around the world, readily diagnosed what Dr. Goodall would perhaps call chronic displacement, plus overdose and fear of weaning. Jean and his wife relieved my anguish by the orthodox method of merely revealing the diagnosis (and the less orthodox one of telling their own troubles). Next day I crossed the border and became a displaced person in his own place: a displacedreplaced person. Eighteen months later new symptoms of displacement are appearing-perhaps a matter of disreplacement ? F. CARDENAL. 1.
Rowntree, L. G. Archs
intern.
Med. 1923, 32, 157.
TREATMENT OF STATUS ASTHMATICUS to the therapeutic measures advocated by Mr. Marchand and Dr. Hasselt (Jan. 29) and Dr. Thompson (Feb. 26) for treatment of status asthmaticus I would suggest diuretics of the thiazide group-given together with an antibiotic (chloramphenicol or tetracycline). I have found them extremely valuable in easing the breathing in this distressful condition, especially in children who respond particularly well. Fever if any drops to normal, the patient micturates freely, dyspnoea recedes, and relief is obtained in a few hours. " Large quantities of urine may be passed as an attack subsides according to Savill.1
SIR,-In addition
T. M. SUSAI.
SiR,—We consider the statements made by Dr. Grant (Feb. 12) on the use of massive doses of steroids both timely and appropriate. In our experience, in pursuance of which we have to treat a patient with status asthmaticus at least once every day of the year, there have, never been any complications associated with large doses of steroids on the short-term basis required to bring this ailment under rapid control. Perhaps it 1. Savill’s 1950.
System of Clinical Medicine (edited by
E. C.
Warner). London,