- Email: [email protected]
FLUORIDE TOXICITY
962
appointment than by the actual needs of patients. When they themselves become peripheral consultants they will be unable to adequately use their research training because of insufficient time due to insufficient junior staff who are elsewhere being trained in research methods. The crux of their argument seems, in fact, to be the fear that teaching hospitals and postgraduate institutions will become ordinary hospitals within the National Health Service. Yet surely nothing could be more valuable than that the senior researchers and teachers in these institutions should be brought more in contact with the realities of the greater part of the Health Service, and perhaps be tempted to use their undoubted gifts in trying to solve some of the ordinary human problems of helping patients (and to teach their trainees to do the same) within the context of a chronically overloaded system. Conversely, the peripheral consultants and the general practitioners, with reduced service commitments, will themselves be enabled to have time to stand back a little from their work and to use their research training to critically evaluate what they are doing, which can only result in benefit to their patients. More fundamentally, at the root of the Central Manpower Committee’s proposals there seems to be the beginning of a decision on the choice which Western medicine will ultimately have to face:" whether the problems of disease can be finally solved by value-free " science-by diverting money and manpower from the old, the chronically ill, and the non-metropolitan to these research and training institutions in the hope that positive results will filter back to this unglamorous fringe-or whether we should be trying to produce more socially critical doctors who will fight for the human needs of their patients.1 I would suggest that the former policy of centralisation of resources has been an overall failure, and that the demoralised state of the periphery, manned by those who have dropped off Lord Moran’s ladder, provides ample evidence that the two policies cannot coexist. The C.M.C.’s proposals must be seen as a move, albeit a small one, in the right direction-towards the patientand are thus to be welcomed. Hackney Hospital,
SAM BAXTER.
London E9 6BE.
ADOPTION
SiR,—Your Talking Politics section by David McKie (Sept. 8, p. 559) discussed adoption and the hope that new legislation might be considered by the Government in the future. Parent to Parent Information on Adoption Services was formed early in 1971 to help to find permanent homes for children with special needs. At first our main concern was with mixed-race children, for many of whom adoption had not been seriously considered. More recently we have also been concerned with children who have passed infancy and especially children with medical handicaps. We have been able to demonstrate that it is not for lack of potential adoptive parents that these children stay in care, but very often because they are labelled " unadoptable " and no further efforts are made to find them permanent new near
families.
Many newborn infants with minor health problems are kept under observation for months or even years before plans have been made for their future. These children not only have a medical problem to contend with but also have been unnecessarily denied parental affection and security, often resulting in emotional instability. If all possible medical advice and encouragement could be given to new
parents, with frank discussions
1. Tudor Hart,
J. Lancet, Oct. 6, 1973, p. 778.
as to
the child’s
would be no shortage of families prepared adopt these babies. Once they are part of a family any subsequent medical problems will be accepted and coped with as would any parent caring for natural children. There have been many successful adoptions of children with incredible handicaps, for they are being placed with people who are prepared to understand their problems and
prognosis, there to
limitations and plan for the child’s future. It can mean a great deal to such children to know that they have been adopted and accepted for what they are, and in spite of their handicap. We know of many cases where children have made dramatic progress overcoming enormous handicaps once they have experienced security and affection. We appeal to doctors carrying out pre-adoption medical examinations not to use the label " unadoptable ". We believe that no child is unadoptable and that parents can be found prepared to give encouragement and help through the love and security of a permanent home. SHEILAGH CRAWFORD, Parent to Parent Information on Adoption Services, 26 Belsize Grove, London NW3.
Chairman, HILARY CHAMBERS, Secretary.
FLUORIDE TOXICITY
SIR,-On this controversial subject, it is a matter of opinion whether you were right to select those references that suited your argument, but you should not have made a statement that is demonstrably untrue (Oct. 20, p. 889). You state: " Again, those who oppose fluoridation insist that to increase the fluoride content of drinking-water from 0-2 to anything between 1-0 and 2-6 parts per million will double the incidence of Down’s syndrome." Rubbish! I oppose fluoridation of public water-supplies; unlike you, I have taken the trouble to have two discussions in the U.S. with Dr Rapoport about his work on fluoride and Down’s syndrome, I have read the less extensive work in this country of my friend Dr Berry to which you refer, and the work of Stoker in Australia to which you do not; I believe further studies are required before Rapoport’s work and conclusions are dismissed. Through the courtesy of Professor Jolly I have had the opportunity of seeing cases of severe fluoride poisoning in Punjab. He1 has called attention to the importance of other factors in water or food that affect the toxicity of fluoride. For instance, in the village of Mandi Baretta (mean water fluoride only 0-73 p.p.m.) 81-2% of 284 children examined (aged 5-15 years) had dental fluorosis; 2-4% adult (over 21 years) males and 4-2% adult females had skeletal fluorosis. Jolly and his colleagues show that other chemical constituents of water affect toxicity: this is decreased by higher total hardness, higher magnesium hardness, increased chloride, increased total solids, and decreased alkalinity. The waters of the BartlettCameron study, on which you place so much emphasis, were not comparable in constituents other than fluoride (Bartlett, 8-0 p.p.m. F, dissolved solids 1698-4, chloride
319’0; Cameron, respectively, 0-4, 435-2, 63’0).2 Your authors from India (Oct. 20, p. 877) also suggest that other dietary factors such as calcium may have played a part in their cases. My former colleague, the late Dr Dagmar Wilson, with colleagues,3 concluded from a preliminary study of Oxfordshire villages that used surfacewell waters varying between 0-3 and 1-2 p.p.m. F that fluorine in association with defective nutrition might Jolly, S. S., Prasad, S., Sharma, R., Chander, R. Fluoride, 1973, 6, 4. 2. Leone, N. C., Shimkin, M. B., Arnold, F. A., Stevenson, C. A., Zimmerman, E. R., Geiser, P. A., Lieberman, S. E. Publ. hlth Rep., Wash. 1954, 69, 925. 3. Kemp, F. H., Murray, M. M., Wilson, D. C. Lancet, 1942, ii, 93. 1.
963 A favour the development of spondylosis deformans. later study of this area, in which the then Ministry of Health took part, revealed no such changes, and the authors4 (including Dr Berry) suggested that deficiency of calcium in the earlier wartime study might have played a part. Could it not do so today when we have rickets
small tracheostomy tube will allow expiratory flow around the tube, avoiding the danger of weakening the tube by fenestration.
into
a
to occur
E. F. BATTERSBY
reappearing ? most important variable in our diet in this is tea, known to be rich in fluoride. If the tea is made with soft water and if drunk without milk it will tend to provide the person with more fluoride, since calcium decreases toxicity. I believe this was probably responsible for the osteosclerosis and hence lower-limb paresis from fluoride in the patient who did not use a water containing appreciable fluoride for at least 52 of his 57 years 5; had he used water fluoridated at 1 p.p.m. he would have obtained more fluoride and presumably developed his Neural-tube malformations (spina disability earlier. bifida and anencephaly) have been correlated with teadrinking,6 with soft water,7 or with both.8 What is your conclusive evidence that fluoride could not possibly play a part in these causes of death ? You mention that Heasman and Martin9 found no significant difference in congenital malformations in fluoride and control areas, but the former were (as they indicated) probably mainly hard waters which could have accounted for the significantly lower mortality in these from coronary and other heartdisease in the northern towns (but they did not comment on the fact that there was no significant difference in the overall mortality, and that there was a higher non-heart mortality in the fluoride towns). I do not share your arrogance, and I cannot aspire to the omniscience which Sir George Godber assumes in his last two reports.10 I continue to believe that water fluoridated at 1 p.p.m. can harm an occasional person and the practice is an undesirable infringement of personal liberty.
Perhaps the
context
HUGH SINCLAIR.
Oxford.
FENESTRATED TRACHEOSTOMY TUBES
SIR,-We
cannot
agree with Mr Freeman’s statement
(Aug. 4, p. 259) that silver tracheostomy
tubes are suitable in most instances in the treatment of neonates and infants. The hazards of tracheostomy in children with silver tubes were described by Venables 11 in 1959. Our early experience and also experience with cases referred from other hospitals confirm that the rigid type of tracheostomy tube is unsuitable and often dangerous to the infant’s trachea. We have now performed more than 400 tracheostomies in patients younger than one year using the Great Ormond Street P.v.c. tube designed by Aberdeen 12in 1965. This type of tube is preferable to the silver tracheostomy tube and is manufactured in Britain by J. G. Franklin and Sons and in the United States by Dow Corning from silastic. The advantages of a fenestrated tube with an expiratory valve have not been conclusively demonstrated in the neonatal and infant age-group. In older children, where speech is required, the use of a speaking valve inserted Eley, A. J., Kemp, F. H., Kerley, P. J., Berry, W. T. C. ibid. 1957, ii, 712. 5. Webb-Peploe, M. M., Bradley, W. G. J. Neurol. Neurosurg. Psychiat. 1966, 29, 577. 6. Knox, E. G. Br. J. prev. soc. Med. 1972, 26, 219. 7. Stocks, P. ibid. 1970, 24, 67.
4.
8. Times, Aug. 24, 1973. 9. Heasman, M. A., Martin, A. E. Mon. Bull. Min. Hlth Lab. Serv.
1962, 21, 150. 10. On the State of the Public Health. H.M. Stationery 1973. 11. Venables, A. W. Med. J. Aust. 1959, ii, 141. 12. Aberdeen, E. Proc. R. Soc. Med. 1965, 58, 900.
Office, 1972,
for Sick Children, Great Ormond Street, London WC1N 3JH.
Hospital
J. N. G. EVANS W. J. GLOVER D. J. HATCH J. STARK D. J. WATERSTON.
RAISED PLASMA-T.S.H. LEVELS IN THYROTOXIC PATIENTS TREATED WITH IODINE-131
SIR,-Dr Fowler and his colleagues (Oct. 6, p. 801) raise several points which require comment. (i) Dr Toft and his colleagues (Sept. 22, p. 644) have" adopted our definition of " preclinical hypothyroidism (a raised serum-T.s.H. in the absence of symptoms),1 we have now abandoned this term in favour of although " subclinical hypothyroidism ".2 Little is known of the natural history of this condition, and preliminary data suggest that only a small proportion of subjects will Dr progress to symptomatic (clinical) thyroid failure. Fowler has chosen to adopt a quite different definition3 (the association of circulating thyroid antibodies and hypercholesterolasmia), and has demonstrated that a proportion of highly selected subjects with these features proceed to overt hypothyroidism. These data cannot, therefore, be directly compared with those presented by the Edinburgh workers nor with our own.2 Dr Fowler also states that nearly half his patients had degenerative arterial disease-but since this was one of the groups which he had initially selected for study, this cannot reflect the true frequency of cardiovascular disease in either subclinical hypothyroidism (our definition) or in
preclinical hypothyroidism (his definition). (ii) Dr Fowler has presented data 4 demonstrating that serum-T.S.H. was raised (4-2 to 20 fLu per ml.) in those subjects whom he has defined as having preclinical hypothyroidism. He has also suggested that a raised T.S.H. plays a part in the production of raised lipid levels. This is directly contradictory to his unsupported suggestion that raised lipid levels may be seen in this condition before the T.S.H. rises. (iii) Dr Fowler seriously misquotes our recent work5 when he states that the serum-triglyceride level remains raised in subjects with hypothyroidism following treatment with physiological doses of thyroxine. Our recent paper demonstrated that the serum-triglyceride level is elevated in some subjects with adequately treated thyroid failure, and although the mean values were higher than in a group of age and sex matched controls drawn from a normal population without thyroid failure, the difference was not statistically significant. The prevalence of a raised triglyceride was in fact identical in the two groups. Many factors (the majority unrelated to thyroid failure) play a part in the production of a high serum-triglyceride concentration, and 15%of the normal population have a triglyceride concentration in excess of 160 mg. per 100 ml. (unpublished observations). The finding that the triglyceride level remains raised in some patients after treatment is, therefore, to be expected. One might add that even if our data had demonstrated that an excess of 1. Evered, D. C., Hall, R. Br. med. J. 1972, i, 290. 2. Evered, D. C., Ormston, B. J., Smith, P. A., Hall, R., Bird, T. ibid. 1973, i, 657. 3. Fowler, P. B. S. Swale, J., Andrews, H. Lancet, 1970, ii, 488. 4. Fowler, P. B. S. Br. med. J. 1972, i, 247. 5. Evered, D. C., Young, E. T., Ormston, B. J., Menzies, R., Smith, P. A., Hall, R. ibid. 1973, iii, 131.
appointment than by the actual needs of patients. When they themselves become peripheral consultants they will be unable to adequately use their research training because of insufficient time due to insufficient junior staff who are elsewhere being trained in research methods. The crux of their argument seems, in fact, to be the fear that teaching hospitals and postgraduate institutions will become ordinary hospitals within the National Health Service. Yet surely nothing could be more valuable than that the senior researchers and teachers in these institutions should be brought more in contact with the realities of the greater part of the Health Service, and perhaps be tempted to use their undoubted gifts in trying to solve some of the ordinary human problems of helping patients (and to teach their trainees to do the same) within the context of a chronically overloaded system. Conversely, the peripheral consultants and the general practitioners, with reduced service commitments, will themselves be enabled to have time to stand back a little from their work and to use their research training to critically evaluate what they are doing, which can only result in benefit to their patients. More fundamentally, at the root of the Central Manpower Committee’s proposals there seems to be the beginning of a decision on the choice which Western medicine will ultimately have to face:" whether the problems of disease can be finally solved by value-free " science-by diverting money and manpower from the old, the chronically ill, and the non-metropolitan to these research and training institutions in the hope that positive results will filter back to this unglamorous fringe-or whether we should be trying to produce more socially critical doctors who will fight for the human needs of their patients.1 I would suggest that the former policy of centralisation of resources has been an overall failure, and that the demoralised state of the periphery, manned by those who have dropped off Lord Moran’s ladder, provides ample evidence that the two policies cannot coexist. The C.M.C.’s proposals must be seen as a move, albeit a small one, in the right direction-towards the patientand are thus to be welcomed. Hackney Hospital,
SAM BAXTER.
London E9 6BE.
ADOPTION
SiR,—Your Talking Politics section by David McKie (Sept. 8, p. 559) discussed adoption and the hope that new legislation might be considered by the Government in the future. Parent to Parent Information on Adoption Services was formed early in 1971 to help to find permanent homes for children with special needs. At first our main concern was with mixed-race children, for many of whom adoption had not been seriously considered. More recently we have also been concerned with children who have passed infancy and especially children with medical handicaps. We have been able to demonstrate that it is not for lack of potential adoptive parents that these children stay in care, but very often because they are labelled " unadoptable " and no further efforts are made to find them permanent new near
families.
Many newborn infants with minor health problems are kept under observation for months or even years before plans have been made for their future. These children not only have a medical problem to contend with but also have been unnecessarily denied parental affection and security, often resulting in emotional instability. If all possible medical advice and encouragement could be given to new
parents, with frank discussions
1. Tudor Hart,
J. Lancet, Oct. 6, 1973, p. 778.
as to
the child’s
would be no shortage of families prepared adopt these babies. Once they are part of a family any subsequent medical problems will be accepted and coped with as would any parent caring for natural children. There have been many successful adoptions of children with incredible handicaps, for they are being placed with people who are prepared to understand their problems and
prognosis, there to
limitations and plan for the child’s future. It can mean a great deal to such children to know that they have been adopted and accepted for what they are, and in spite of their handicap. We know of many cases where children have made dramatic progress overcoming enormous handicaps once they have experienced security and affection. We appeal to doctors carrying out pre-adoption medical examinations not to use the label " unadoptable ". We believe that no child is unadoptable and that parents can be found prepared to give encouragement and help through the love and security of a permanent home. SHEILAGH CRAWFORD, Parent to Parent Information on Adoption Services, 26 Belsize Grove, London NW3.
Chairman, HILARY CHAMBERS, Secretary.
FLUORIDE TOXICITY
SIR,-On this controversial subject, it is a matter of opinion whether you were right to select those references that suited your argument, but you should not have made a statement that is demonstrably untrue (Oct. 20, p. 889). You state: " Again, those who oppose fluoridation insist that to increase the fluoride content of drinking-water from 0-2 to anything between 1-0 and 2-6 parts per million will double the incidence of Down’s syndrome." Rubbish! I oppose fluoridation of public water-supplies; unlike you, I have taken the trouble to have two discussions in the U.S. with Dr Rapoport about his work on fluoride and Down’s syndrome, I have read the less extensive work in this country of my friend Dr Berry to which you refer, and the work of Stoker in Australia to which you do not; I believe further studies are required before Rapoport’s work and conclusions are dismissed. Through the courtesy of Professor Jolly I have had the opportunity of seeing cases of severe fluoride poisoning in Punjab. He1 has called attention to the importance of other factors in water or food that affect the toxicity of fluoride. For instance, in the village of Mandi Baretta (mean water fluoride only 0-73 p.p.m.) 81-2% of 284 children examined (aged 5-15 years) had dental fluorosis; 2-4% adult (over 21 years) males and 4-2% adult females had skeletal fluorosis. Jolly and his colleagues show that other chemical constituents of water affect toxicity: this is decreased by higher total hardness, higher magnesium hardness, increased chloride, increased total solids, and decreased alkalinity. The waters of the BartlettCameron study, on which you place so much emphasis, were not comparable in constituents other than fluoride (Bartlett, 8-0 p.p.m. F, dissolved solids 1698-4, chloride
319’0; Cameron, respectively, 0-4, 435-2, 63’0).2 Your authors from India (Oct. 20, p. 877) also suggest that other dietary factors such as calcium may have played a part in their cases. My former colleague, the late Dr Dagmar Wilson, with colleagues,3 concluded from a preliminary study of Oxfordshire villages that used surfacewell waters varying between 0-3 and 1-2 p.p.m. F that fluorine in association with defective nutrition might Jolly, S. S., Prasad, S., Sharma, R., Chander, R. Fluoride, 1973, 6, 4. 2. Leone, N. C., Shimkin, M. B., Arnold, F. A., Stevenson, C. A., Zimmerman, E. R., Geiser, P. A., Lieberman, S. E. Publ. hlth Rep., Wash. 1954, 69, 925. 3. Kemp, F. H., Murray, M. M., Wilson, D. C. Lancet, 1942, ii, 93. 1.
963 A favour the development of spondylosis deformans. later study of this area, in which the then Ministry of Health took part, revealed no such changes, and the authors4 (including Dr Berry) suggested that deficiency of calcium in the earlier wartime study might have played a part. Could it not do so today when we have rickets
small tracheostomy tube will allow expiratory flow around the tube, avoiding the danger of weakening the tube by fenestration.
into
a
to occur
E. F. BATTERSBY
reappearing ? most important variable in our diet in this is tea, known to be rich in fluoride. If the tea is made with soft water and if drunk without milk it will tend to provide the person with more fluoride, since calcium decreases toxicity. I believe this was probably responsible for the osteosclerosis and hence lower-limb paresis from fluoride in the patient who did not use a water containing appreciable fluoride for at least 52 of his 57 years 5; had he used water fluoridated at 1 p.p.m. he would have obtained more fluoride and presumably developed his Neural-tube malformations (spina disability earlier. bifida and anencephaly) have been correlated with teadrinking,6 with soft water,7 or with both.8 What is your conclusive evidence that fluoride could not possibly play a part in these causes of death ? You mention that Heasman and Martin9 found no significant difference in congenital malformations in fluoride and control areas, but the former were (as they indicated) probably mainly hard waters which could have accounted for the significantly lower mortality in these from coronary and other heartdisease in the northern towns (but they did not comment on the fact that there was no significant difference in the overall mortality, and that there was a higher non-heart mortality in the fluoride towns). I do not share your arrogance, and I cannot aspire to the omniscience which Sir George Godber assumes in his last two reports.10 I continue to believe that water fluoridated at 1 p.p.m. can harm an occasional person and the practice is an undesirable infringement of personal liberty.
Perhaps the
context
HUGH SINCLAIR.
Oxford.
FENESTRATED TRACHEOSTOMY TUBES
SIR,-We
cannot
agree with Mr Freeman’s statement
(Aug. 4, p. 259) that silver tracheostomy
tubes are suitable in most instances in the treatment of neonates and infants. The hazards of tracheostomy in children with silver tubes were described by Venables 11 in 1959. Our early experience and also experience with cases referred from other hospitals confirm that the rigid type of tracheostomy tube is unsuitable and often dangerous to the infant’s trachea. We have now performed more than 400 tracheostomies in patients younger than one year using the Great Ormond Street P.v.c. tube designed by Aberdeen 12in 1965. This type of tube is preferable to the silver tracheostomy tube and is manufactured in Britain by J. G. Franklin and Sons and in the United States by Dow Corning from silastic. The advantages of a fenestrated tube with an expiratory valve have not been conclusively demonstrated in the neonatal and infant age-group. In older children, where speech is required, the use of a speaking valve inserted Eley, A. J., Kemp, F. H., Kerley, P. J., Berry, W. T. C. ibid. 1957, ii, 712. 5. Webb-Peploe, M. M., Bradley, W. G. J. Neurol. Neurosurg. Psychiat. 1966, 29, 577. 6. Knox, E. G. Br. J. prev. soc. Med. 1972, 26, 219. 7. Stocks, P. ibid. 1970, 24, 67.
4.
8. Times, Aug. 24, 1973. 9. Heasman, M. A., Martin, A. E. Mon. Bull. Min. Hlth Lab. Serv.
1962, 21, 150. 10. On the State of the Public Health. H.M. Stationery 1973. 11. Venables, A. W. Med. J. Aust. 1959, ii, 141. 12. Aberdeen, E. Proc. R. Soc. Med. 1965, 58, 900.
Office, 1972,
for Sick Children, Great Ormond Street, London WC1N 3JH.
Hospital
J. N. G. EVANS W. J. GLOVER D. J. HATCH J. STARK D. J. WATERSTON.
RAISED PLASMA-T.S.H. LEVELS IN THYROTOXIC PATIENTS TREATED WITH IODINE-131
SIR,-Dr Fowler and his colleagues (Oct. 6, p. 801) raise several points which require comment. (i) Dr Toft and his colleagues (Sept. 22, p. 644) have" adopted our definition of " preclinical hypothyroidism (a raised serum-T.s.H. in the absence of symptoms),1 we have now abandoned this term in favour of although " subclinical hypothyroidism ".2 Little is known of the natural history of this condition, and preliminary data suggest that only a small proportion of subjects will Dr progress to symptomatic (clinical) thyroid failure. Fowler has chosen to adopt a quite different definition3 (the association of circulating thyroid antibodies and hypercholesterolasmia), and has demonstrated that a proportion of highly selected subjects with these features proceed to overt hypothyroidism. These data cannot, therefore, be directly compared with those presented by the Edinburgh workers nor with our own.2 Dr Fowler also states that nearly half his patients had degenerative arterial disease-but since this was one of the groups which he had initially selected for study, this cannot reflect the true frequency of cardiovascular disease in either subclinical hypothyroidism (our definition) or in
preclinical hypothyroidism (his definition). (ii) Dr Fowler has presented data 4 demonstrating that serum-T.S.H. was raised (4-2 to 20 fLu per ml.) in those subjects whom he has defined as having preclinical hypothyroidism. He has also suggested that a raised T.S.H. plays a part in the production of raised lipid levels. This is directly contradictory to his unsupported suggestion that raised lipid levels may be seen in this condition before the T.S.H. rises. (iii) Dr Fowler seriously misquotes our recent work5 when he states that the serum-triglyceride level remains raised in subjects with hypothyroidism following treatment with physiological doses of thyroxine. Our recent paper demonstrated that the serum-triglyceride level is elevated in some subjects with adequately treated thyroid failure, and although the mean values were higher than in a group of age and sex matched controls drawn from a normal population without thyroid failure, the difference was not statistically significant. The prevalence of a raised triglyceride was in fact identical in the two groups. Many factors (the majority unrelated to thyroid failure) play a part in the production of a high serum-triglyceride concentration, and 15%of the normal population have a triglyceride concentration in excess of 160 mg. per 100 ml. (unpublished observations). The finding that the triglyceride level remains raised in some patients after treatment is, therefore, to be expected. One might add that even if our data had demonstrated that an excess of 1. Evered, D. C., Hall, R. Br. med. J. 1972, i, 290. 2. Evered, D. C., Ormston, B. J., Smith, P. A., Hall, R., Bird, T. ibid. 1973, i, 657. 3. Fowler, P. B. S. Swale, J., Andrews, H. Lancet, 1970, ii, 488. 4. Fowler, P. B. S. Br. med. J. 1972, i, 247. 5. Evered, D. C., Young, E. T., Ormston, B. J., Menzies, R., Smith, P. A., Hall, R. ibid. 1973, iii, 131.