- Email: [email protected]
SKELETAL FLUOROSIS
1056
patients. This appears an inevitable process with growth in size to really large proportions. In a unit of reasonable size communications to all levels are much easier. Lastly, let us not forget why these buildings were placed where they are and built as they are. The scale and site of the buildings stand for, and must to some extent (whether we like it or not) help to perpetuate, an attitude of mind. I write because I feel that Dr. Pilkington’s admirable letter, while having the positive merit of encouraging the continuing improvement of large mental hospitals, might tend to take the steam out of the really urgent need for much smaller and more human-sized units in the communities they serve. Severalls Hospital, H.
JACOBS.
Colchester.
EXTRAPULMONARY INFLUENZAL INFECTION
SIR,-I
was interested to see from your annotation that visceral invasion by the influenza virus is
Mr. Fletcher will observe that the reference in my letter of 8 to the fact that 200,000 children have become victims of definite life-time mottling is quoted at the end of the pertinent paragraph, and I suggest he 4reads the original document in full. As Nesin wrote in 1956 " the number of critics capable of examining the fluoridation program on the basis of its scientific and statistical claims have increased tremendously, so today we find many importantly placed individuals seriously questioning almost every aspect of the fluoridation proposal". Exner5 writes of the recent legal interrogation of Dr. H. Trendley Dean: It is because all claims of the fluoridators are based directly or indirectly on writings of Dr. Dean that his cross examination of May 13th, 1960, has such far reaching importance. It destroys once and for all, the scientific basis of fluoridation ".
April
"
Institute of
Pathology, Royal Infirmary,
(March 4) being increasingly recognised.
You did not refer to the 30 cases of encephalitis we reported from India.l These were all associated with the influenza epidemic of 1957. Several cases occurred almost simultaneously in small groups. Jaundice, presumably the result of liver involvement, was present in a third. The clinical course was characteristic. As against the negligible overall mortality in the 1957 epidemic of Asian influenza in India, the mortality in this group was very high: 17 of the 30 patients died. At necropsy, performed in all 17, typical pulmonary lesions of influenza were invariably seen. The virus was isolated from the lungs in 5 cases, and from the brain in 1. We were unable to find any reference to similar cases in the literature. Symptoms and signs of this type may not be uncommon, but may easily be missed because of pressure of work in epidemics. Tata Main Hospital, Jamshedpur 1, India.
S. KAUL.
SKELETAL FLUOROSIS
SIR,-May I briefly reply and Mr. Fletcher (May 6) ?
to
the letters of Dr. Patton
The data in Galagan and Lamson’s paper2 on dental fluorosis observed in temperate climates in the U.S.A. is that from Dr. H. Trendley Dean, the recognised father " of fluoridation. It is stated that fluorosis was present in 12%, and questionable in a further 35%of the children examined in a community where the water fluoride concentration was " mildin 2% and 0-9 p.p.m. This fluorosis is described as "very mild " in 10%. The attached photograph shows one "
of Dr. Dean’s admitted cases of " mild " fluorosis. It is this appearance which I had in mind when I referred in my letter (April 8) to less objectionable mottling occurring in the temperate zone. To many of us this degree of mottling is quite objectionable and as others have stated " the determination of whether damage resulting from dental fluorosis is ’ objectionable ’ is a matter for the person whose teeth are affected and not for the arbitrary assertion of public officials ".3 1. 2. 3.
Kapila, C. C., Kaul, S., Kapur, S. C., Kalayanam, T. S., Banerjee, D. Brit. med. J. 1958, ii, 1311. Galagan, D. J., Lamson, G. G. J. publ. Hlth Rep., Wash. 1953, 68, 497. Medical-Dental Adhoc Committee on Evaluation of Fluoridation Report. New York City, 1959.
R. A. HOLMAN.
Cardiff.
BRONCHODILATORS AND CORTICOSTEROIDS IN ASTHMA
SIR,-It is of great interest to see the considerable extension of our preliminary workreported by Dr, Hume and Dr. Rhys Jones.’ I have continued to find the method of practical value in selected cases and can confirm the correctness of the general trend of their observations. I
am
sorry to
see
the rather free
use
of the word
" emphy-
sema ", if only because a few patients with the clinical diagnosis "
emphysema " with a persistently severe obstructive ventilatory defect and a persistently poor response to ordinary bronchodilator drugs occasionally respond dramatically to steroids together with bronchodilator therapy. The pattern of response then conforms to that of the asthmatic patient, although normal values are never reached for F.E.v.i.,, or for F.E.V.l.O expressed as a percentage of the vital capacity. This group is admittedly small, but it is striking; a lead is usually given by the presence of sputum eosinophilia. Probably these patients do have some " emphysema "; but if this term is taken to imply structural change and if the diagnosis is assumed when the bronchodilator response is poor and apparently unpredictable, then a small proportion with an obstructive defect which can be reversed only by steroids will be over-
of
looked. As regards the haphazard response of the F.E,V’l’O to bronchodilator drugs in structural emphysema, an observation I can confirm, it is of interest that if the vital-capacity response is plotted in the same way, a predictable curve similar to, but smaller than, that of an asthmatic is obtained. This statement is true only if the vital capacity is estimated in the conventional unhurried manner, and not if it is taken from a forced expiratory spirogram. This finding strongly supports the authors’ suggestion that the haphazard response of the F.E.V.l.O in emphysema has a mechanical basis. The evidence for the suggestion that the curve of patient B in fig. 2 represents the effect of emphysema plus reversible bronchoconstriction does not seem clear to me. My experience suggests that this patient’s vital capacity would also be low (as is her F.E.v.i.;,), and that the F.E.v.i.o expressed as a percentage of the vital capacity would be in the normal or lownormal range rather than below 40% as is the rule in established emphysema. In other words, this curve is a typical response of a patient with a mixed obstructive and restrictive defect, and does not differ essentially from that of patient A except in the range of response. If this guess is wrong, then on what grounds is the diagnosis of emphysema based ? University Department of Medicine, Royal Melbourne Hospital, BRYAN GANDEVIA. Victoria, Australia. Nesin, B. C. J. Maine Water Utilities Ass. March, 1956.
4. 5. Exner, F. B.
Fluoridation, 1960. The Greater New York Committee Opposed to Fluoridation, 342, Madison Avenue, New York, 17. 6. Hume, K. M., Gandevia, B. Thorax, 1957, 12, 276. 7. Hume, K. M., Rhys Jones, E. Lancet, 1960 ii, 1319.
patients. This appears an inevitable process with growth in size to really large proportions. In a unit of reasonable size communications to all levels are much easier. Lastly, let us not forget why these buildings were placed where they are and built as they are. The scale and site of the buildings stand for, and must to some extent (whether we like it or not) help to perpetuate, an attitude of mind. I write because I feel that Dr. Pilkington’s admirable letter, while having the positive merit of encouraging the continuing improvement of large mental hospitals, might tend to take the steam out of the really urgent need for much smaller and more human-sized units in the communities they serve. Severalls Hospital, H.
JACOBS.
Colchester.
EXTRAPULMONARY INFLUENZAL INFECTION
SIR,-I
was interested to see from your annotation that visceral invasion by the influenza virus is
Mr. Fletcher will observe that the reference in my letter of 8 to the fact that 200,000 children have become victims of definite life-time mottling is quoted at the end of the pertinent paragraph, and I suggest he 4reads the original document in full. As Nesin wrote in 1956 " the number of critics capable of examining the fluoridation program on the basis of its scientific and statistical claims have increased tremendously, so today we find many importantly placed individuals seriously questioning almost every aspect of the fluoridation proposal". Exner5 writes of the recent legal interrogation of Dr. H. Trendley Dean: It is because all claims of the fluoridators are based directly or indirectly on writings of Dr. Dean that his cross examination of May 13th, 1960, has such far reaching importance. It destroys once and for all, the scientific basis of fluoridation ".
April
"
Institute of
Pathology, Royal Infirmary,
(March 4) being increasingly recognised.
You did not refer to the 30 cases of encephalitis we reported from India.l These were all associated with the influenza epidemic of 1957. Several cases occurred almost simultaneously in small groups. Jaundice, presumably the result of liver involvement, was present in a third. The clinical course was characteristic. As against the negligible overall mortality in the 1957 epidemic of Asian influenza in India, the mortality in this group was very high: 17 of the 30 patients died. At necropsy, performed in all 17, typical pulmonary lesions of influenza were invariably seen. The virus was isolated from the lungs in 5 cases, and from the brain in 1. We were unable to find any reference to similar cases in the literature. Symptoms and signs of this type may not be uncommon, but may easily be missed because of pressure of work in epidemics. Tata Main Hospital, Jamshedpur 1, India.
S. KAUL.
SKELETAL FLUOROSIS
SIR,-May I briefly reply and Mr. Fletcher (May 6) ?
to
the letters of Dr. Patton
The data in Galagan and Lamson’s paper2 on dental fluorosis observed in temperate climates in the U.S.A. is that from Dr. H. Trendley Dean, the recognised father " of fluoridation. It is stated that fluorosis was present in 12%, and questionable in a further 35%of the children examined in a community where the water fluoride concentration was " mildin 2% and 0-9 p.p.m. This fluorosis is described as "very mild " in 10%. The attached photograph shows one "
of Dr. Dean’s admitted cases of " mild " fluorosis. It is this appearance which I had in mind when I referred in my letter (April 8) to less objectionable mottling occurring in the temperate zone. To many of us this degree of mottling is quite objectionable and as others have stated " the determination of whether damage resulting from dental fluorosis is ’ objectionable ’ is a matter for the person whose teeth are affected and not for the arbitrary assertion of public officials ".3 1. 2. 3.
Kapila, C. C., Kaul, S., Kapur, S. C., Kalayanam, T. S., Banerjee, D. Brit. med. J. 1958, ii, 1311. Galagan, D. J., Lamson, G. G. J. publ. Hlth Rep., Wash. 1953, 68, 497. Medical-Dental Adhoc Committee on Evaluation of Fluoridation Report. New York City, 1959.
R. A. HOLMAN.
Cardiff.
BRONCHODILATORS AND CORTICOSTEROIDS IN ASTHMA
SIR,-It is of great interest to see the considerable extension of our preliminary workreported by Dr, Hume and Dr. Rhys Jones.’ I have continued to find the method of practical value in selected cases and can confirm the correctness of the general trend of their observations. I
am
sorry to
see
the rather free
use
of the word
" emphy-
sema ", if only because a few patients with the clinical diagnosis "
emphysema " with a persistently severe obstructive ventilatory defect and a persistently poor response to ordinary bronchodilator drugs occasionally respond dramatically to steroids together with bronchodilator therapy. The pattern of response then conforms to that of the asthmatic patient, although normal values are never reached for F.E.v.i.,, or for F.E.V.l.O expressed as a percentage of the vital capacity. This group is admittedly small, but it is striking; a lead is usually given by the presence of sputum eosinophilia. Probably these patients do have some " emphysema "; but if this term is taken to imply structural change and if the diagnosis is assumed when the bronchodilator response is poor and apparently unpredictable, then a small proportion with an obstructive defect which can be reversed only by steroids will be over-
of
looked. As regards the haphazard response of the F.E,V’l’O to bronchodilator drugs in structural emphysema, an observation I can confirm, it is of interest that if the vital-capacity response is plotted in the same way, a predictable curve similar to, but smaller than, that of an asthmatic is obtained. This statement is true only if the vital capacity is estimated in the conventional unhurried manner, and not if it is taken from a forced expiratory spirogram. This finding strongly supports the authors’ suggestion that the haphazard response of the F.E.V.l.O in emphysema has a mechanical basis. The evidence for the suggestion that the curve of patient B in fig. 2 represents the effect of emphysema plus reversible bronchoconstriction does not seem clear to me. My experience suggests that this patient’s vital capacity would also be low (as is her F.E.v.i.;,), and that the F.E.v.i.o expressed as a percentage of the vital capacity would be in the normal or lownormal range rather than below 40% as is the rule in established emphysema. In other words, this curve is a typical response of a patient with a mixed obstructive and restrictive defect, and does not differ essentially from that of patient A except in the range of response. If this guess is wrong, then on what grounds is the diagnosis of emphysema based ? University Department of Medicine, Royal Melbourne Hospital, BRYAN GANDEVIA. Victoria, Australia. Nesin, B. C. J. Maine Water Utilities Ass. March, 1956.
4. 5. Exner, F. B.
Fluoridation, 1960. The Greater New York Committee Opposed to Fluoridation, 342, Madison Avenue, New York, 17. 6. Hume, K. M., Gandevia, B. Thorax, 1957, 12, 276. 7. Hume, K. M., Rhys Jones, E. Lancet, 1960 ii, 1319.