- Email: [email protected]
THE NEW N.H.S. CONSULTANT CONTRACT
796 DETECTION OF GLUTEN IN FLOUR
SiR,—The gliadin antiserum preparation reported by Dr Keyser and Professor Mahler1 is not novel. The literature contains a number of references on the use of antisera in the study of cereal endosperm proteins.2-16 To answer the question posed at the end of their letter it appears that antisera to wheat gliadins also react with rye proteins.4,8 It has incidentally been demonstrated that antibodies to wheat proteins can be found in human sera.17-19 Early in the century Osborne and his co-workers 20-22 demonstrated an immunological similarity between wheat, rye, and barley prolamins by a method based on prophylatic shock in suineaniss. Flour Milling & Baking Research Association,
Chorleywood, Rickmansworth, Herts WD3 5SH.
In conclusion, therefore, any meaningful association of Bell’s palsy with pregnancy awaits adequate demonstration. National Hospitals for Nervous Diseases, Maida Vale Hospital, London W9 1TL.
M.
J. AMINOFF.
COMPLETE DEFICIENCY OF GLUCOSE-6PHOSPHATE DEHYDROGENASE AND NEUTROPHIL DYSFUNCTION as
SIR,-Dr Gray and his colleagues (Sept. 8, p. 530) report unique and previously undescribed a variant of G.-6-P.D.
which is
J. A. D. EWART.
BELL’S PALSY AND PREGNANCY
SIR,-Dr O’Donovan (Sept. 22, p. 667) suggested that an increased susceptibility to Bell’s palsy during pregnancy. In support of this contention, he cites 7 cases of Bell’s palsy among patients attending a maternity hospital over a three-month period, but provides no data on the total number of pregnant patients attending this hospital nor on the incidence of Bell’s palsy among nonpregnant members of the local community over this same time. His data are therefore insufficient to either justify or invalidate the conclusion which he has reached, presumably, on the basis of clinical impression. Objective data are of particular importance in such circumstances, since it is well recognised that cases of Bell’s palsy may appear in clusters, suggesting that they are related to a common xtiological factor, possibly infective.23 there is
An association of Bell’s palsy with pregnancy was also suggested recently by Korczyn,24 who found that among a group of 9 women with Bell’s palsy it had occurred with a higher incidence than could have been expected by chance in the six months before or after delivery. At this time, however, specialist referral would seem much more likely than on other occasions, especially if patients are already attending a hospital antenatal clinic, so the significance of his observations is uncertain.
completely devoid of enzyme activity and crossG.-6-P.D. reacting protein. I reported a very similar case in 1972.1 The patient was a male African who eventually died from fulminating viral hepatitis. In Africans the enzyme deficiency is usually less severe and activities are around 15%. The mother was deficient A-(homozygous) and the quantitative assay of enzyme in the blood showed a very low enzyme content (0-009 i.u. per g. haemoglobin at 30°C, normal range 5-10 i.U. per g.). Cooper et awl. also found the leucocytes of G.-6-P.D.deficient patients to have defective capacity to kill Staphylococcus aeureus, Escherichia coli, and Serratia marcescens, bacteria which produce little or no hydrogen peroxide,
although Streptococcus fœcalis, a hydrogen-peroxideproducing bacterium, was killed instantly. Dr Gray and his colleagues confirm this observation. The leucocytes appear to have defective capacity to kill Salmonella typhi too (unpublished personal observation). Department of Medicine, Ghana Medical School, Accra, Ghana.
S. K. OWUSU.*
THE NEW N.H.S. CONSULTANT CONTRACT
SIR,-The letters of Dr Fearnley and Mr Rushforth (Sept. 22, p. 667) summarise the two points of view on this
important matter. For myself, I endorse wholeheartedly everything Dr Fearnley has written and hope that large numbers of our colleagues will do the same. To Mr Rushforth and those who share his view I would make
Keyser, J. W., Mahler, R. F. Lancet, Sept. 22, 1973, p. 678. Hall, O. Hereditas, 1959, 45, 495. Grabar, P., Benhamou, N., Daussant, J. Archs Biochem. Biophys. 1962, Supplement, 1, 187. 4. Elton, G. A. H., Ewart, J. A. D. J. Sci. Fd Agric. 1963, 14, 750. 5. Grabar, P., Daussant, J. Cereal Chem. 1964, 41, 523. 6. Hill, R. J., Djurtoft, R. J. Inst. Brew. 1964, 70, 416. 7. Benhamou-Glynn, N., Escribano, M. J., Grabar, P. Bull. Soc. Chim. biol. 1965, 47, 141. 8. Ewart, J. A. D. J. Sci. Fd Agric. 1966, 17, 279. 9. Beckwith, A. C., Heiner, D. C. Archs Biochem. Biophys. 1966, 117,
1. 2. 3.
239. 10. Nimmo, C. C., O’Sullivan, M. T. Cereal Chem. 1967, 44, 584. 11. Hamauzu, Z., Yonezawa, D., Shimomura, H. Agric. biol. Chem. 1967, 31, 448. 12. Ewart, J. A. D. J. Sci. Fd Agric. 1969, 20, 221. 13. Liuzzi, A., Angeletti, P. U. ibid. p. 207. 14. Booth, M. R., Ewart, J. A. D. J. Sci. Fd Agric. 1970, 21, 187. 15. Daussant, J., Renard, M. Febs Letters, 1972, 22, 301. 16. Piazzi, S. E., Riparbelli, G., Sordi, S., Cantagalli, P., Pocchiari, F., Silano, V. Cereal Chem. 1972, 49, 72. 17. Heiner, D. C., Lahey, M. E., Wilson, J. F., Peck, G. A. Am. J. Dis. Child. 1961, 102, 446. 18. Heiner, D. C., Lahey, M. E., Wilson, J. F., Gerrard, J. W., Schwackman, H., Khaw, K.-T. J. Pediat. 1962, 61, 813. 19. Wright, R., Taylor, K. B., Truelove, S. C., Aschaffenburg, R. Br.
20. 21. 22. 23. 24.
med. J. 1962, 2, 513. Wells, H. G., Osborne, T. B. J. infect. Dis. 1911, 8, 66. Wells, H. G., Osborne, T. B. ibid. 1913, 12, 341. Lake, G. C., Osborne, T. B., Wells, H. G. ibid. 1914, 14, 364. Leibowitz, U. Brain, 1969, 92, 109. Korczyn, A. D. Acta neurol. scand. 1971, 47, 603.
two
points. 1. A number of people appear to believe that every consultant can and should undertake private work. There are, however, some (e.g., chemical pathologists and psdiatric radiologists), who perform a vital and expert job in the hospital service, for whom there is virtually no private work. There are also others who have made a deliberate choice to work whole-time in, for example, the medical or surgical aspects of paediatrics or neurology because they find these fields interesting and wish to use the time not spent with patients in clinical investigation or teaching. I believe that the hospital service gains enormously from the preference shown by these people. (In view of Mr Rushforth’s remark, many of us find that these interests involve much emergency work.) If the misleading idea that everyone can and will turn their hand to private work is allowed to gain currency, then the Review Body will make this assumption when it prices 10 sessions of work. 2. Administrative
can
lead
to
great changes in
Owusu, S. K. Br. med. J. 1972, iv, 25. Cooper, M. R., Dechàtelet, L. R., McGall, C. E., Lavia, M. F., Spurr, C. L., Baehner, R. L. ibid. 1970, ii, 110. Present address: Department of Endocrinology, Queen Elizabeth Hospital, Birmingham B15 2TH.
1. 2. *
rulings
797 clinical practice in hospitals. I doubt whether those who negotiated official time-off and extra-duty payments for junior hospital staff realised the effect which the right to alternate evenings and weekends off would have. Continuity of care at house-officer level has now gone. I make no judgment in saying this, and house-officers still work long hours, but they can no longer have the same wide knowledge of everything that happens to their patients. What is right for juniors, who have no alternative to spending their preregistration year in hospital, is not necessarily right for consultants, who are senior members of a learned profession. I am certain that the majority of us took up the practice and study of our specialty because we thought it interesting, and we only thought secondarily of the financial rewards. None of us think these are unimportant but if we allow ourselves to assert that our working week is only 35 hours long this is a denial of our hopes and values when we decided to specialise. We expected to have a continuing responsibility, and interest and concern dictate that this must always be so. When we feel it necessary to visit the hospital in the evening or on a Sunday we do not want to have to wonder whether some busybody will remark that we have come for the sake of the extra-duty payment. The solution to these problems is given in the last paragraph of Dr Fearnley’s letter. Royal Aberdeen Children’s Hospital, Cornhill Road, Aberdeen AB9 2ZG.
that
PETER F.
on
A slow infusion of 15-20 ml. of this blood elicits both lesions well as an endotoxaemia in the normal recipient rabbit. The recipient dies almost as fast as the burned donor, which exhibits the same lesions. The liver on both donor and recipient at the time of death contains endotoxin in a titre that is a multiple of that in the plasma, but only in rabbits that harbour the conventional intra-intestinal gram-negative flora. None of these responses appear in similar rabbits available to us since March, 1972, which for unknown reasons are free or nearly free of live gram-negative bacteria, even though the endotoxin titre in the cascal content ranges from 125 to 1500 g. per g. But if they are preloaded 3-4 hours before the burn with a mixed 18-hour culture of gram-negative bacteria in milk, the burn elicits the lung and gut lesions, as well as endotoxxmia.
Thus, there is at least experimental evidence that the lesion is produced by circulating endotoxin. The
lung
likelihood that this is also true in man increases as the clinical evidence accumulates that endotoxaemia occurs in man in non-septic as well as septic disorders.3-5 The
inadequacy
of current treatment for the acute respiratorydistress syndrome requires an appraisal of the possible role
3. 4. 5.
from
JACOB
FINE.
a
DETERRING APPLICANTS ?
SIR,-I do not know whether my experience is unusual, but I have inquired about various advertised N.H.S. consultant posts in the past year and in several instances I have wondered whether the regional boards concerned were really trying to attract applicants. Recently, for example, a Scottish region, despite two extra telephone calls, did not send the further particulars until the week of the closing date, and this month I received details from a Metropolitan board with an application form that was due to be returned by the following day! In all instances the requests had been made on the day the posts were first advertised. Prospective candidates are in a difficult position to protest, but a cavalier attitude does seem to have developed within the administration of some boards. Perhaps in the reorganised service these matters will be taken care of within the new managerial efficiency, but who will bring this manipulative device to account ?
JONES.
as
2.
not
APPLICANT.
burns (June 30, p. 1491) deals with the high frequency of the acute respiratory-distress syndrome. The essential lesion now seems to be an increase in vascular permeability to plasma and, in the more 1 severe forms, to red cells. The high frequency of this lesion and of a coincident and similar lesion in the gut in both septic and non-septic shock suggest a common bloodborne cause. We have identified a vasoactive agent in the venous blood draining the site of a 30% immersion burn in rabbits.2
1.
endotoxaemia of intestinal origin, if in this disorder.
Boston City Hospital, 818 Harrison Avenue, Boston, Massachusetts 02118, U.S.A.
PRENATAL TREATMENT OF HEREDITARY DISEASES ?
CAUSE OF RESPIRATORY-DISTRESS SYNDROME
SIR,-Your editorial
an
septic focus, plays
Cuevas, P., de la Maza, L. M., Gilbert, J., Fine, J. Archs Surg. 1972, 104, 319. Cuevas, P., Ishiyama, M., Koizumi, S., Woodruff, P., Kaufman, A., Fine, J. Surgery Gynec. Obstet. (in the press). Levin, J., Edwin, P. T., Zanber, N., Oser, R. New Engl. J. Med. 1970, 283, 1313. Caridis, D. T., Reinhold, R. B., Woodruff, P. W. H., Fine, J. Lancet, 1972, 1, 1381. Das, J., Schwartz, A. A., Folkman, J. Surgery, 1973, 74, 235.
SIR,-Repeatedly, Press reports note interruption of by parental decision after antenatal detection of biochemically or chromosomally defective fetus because
pregnancy a
intrauterine treatment of the disorders is not available. It has been implied more or less explicitly 1.2 that, should treatment become available, it would almost inevitably become the best solution in pregnancies at high risk of genetic defects. I suggest that this view is unrealistic and untenable. Firstly, chances that useful treatment will soon be at hand For many conditions irreversible anatomical are slim. changes are probably present so early in gestation that their prevention or reversal in utero by drug or enzyme treatment seems highly improbable. For example, by the 14th week of intrauterine development neuronal membranous cytoplasmic bodies have been observed in a Tay-Sachs fetus.3 Antenatal diagnosis of this and other inherited biochemical diseases can at the earliest be reached by 20-22 weeks of amenorrhcea, from cultivated cells obtained by amniocentesis at 16 weeks. The first demonstration of corrective in-utero treatment of inheritable defects will have one day to be applied to man. I surmise that it will be virtually impossible to find a mother willing to accept the possibility of failure, when Should weighed against the alternative of abortion. in-utero treatment become available, there is no indication of absolute effectiveness. If failure of treatment results in a defective child, who will care for this infant ? Few mothers, offered the possibility of having a future normal baby, will knowingly take this chance, no matter how small it may be, even if some government or institution will guarantee the care of the infant. On the other hand, some parents may choose prenatal treatment rather than abortion because of religious or moral convictions or because the mother is older and 1. 2. 3.
Valenti, C. Ric. Clin. Lab. 1971, 1, 443. Littlefield, J. W. New Engl. J. Med. 1969, 280, 722. Volk, B. W., Adachi, M., Friedland, J., Schneck, L., Valenti, C. Proc. Soc. exp. Biol. Med. 1970, 135, 836.
SiR,—The gliadin antiserum preparation reported by Dr Keyser and Professor Mahler1 is not novel. The literature contains a number of references on the use of antisera in the study of cereal endosperm proteins.2-16 To answer the question posed at the end of their letter it appears that antisera to wheat gliadins also react with rye proteins.4,8 It has incidentally been demonstrated that antibodies to wheat proteins can be found in human sera.17-19 Early in the century Osborne and his co-workers 20-22 demonstrated an immunological similarity between wheat, rye, and barley prolamins by a method based on prophylatic shock in suineaniss. Flour Milling & Baking Research Association,
Chorleywood, Rickmansworth, Herts WD3 5SH.
In conclusion, therefore, any meaningful association of Bell’s palsy with pregnancy awaits adequate demonstration. National Hospitals for Nervous Diseases, Maida Vale Hospital, London W9 1TL.
M.
J. AMINOFF.
COMPLETE DEFICIENCY OF GLUCOSE-6PHOSPHATE DEHYDROGENASE AND NEUTROPHIL DYSFUNCTION as
SIR,-Dr Gray and his colleagues (Sept. 8, p. 530) report unique and previously undescribed a variant of G.-6-P.D.
which is
J. A. D. EWART.
BELL’S PALSY AND PREGNANCY
SIR,-Dr O’Donovan (Sept. 22, p. 667) suggested that an increased susceptibility to Bell’s palsy during pregnancy. In support of this contention, he cites 7 cases of Bell’s palsy among patients attending a maternity hospital over a three-month period, but provides no data on the total number of pregnant patients attending this hospital nor on the incidence of Bell’s palsy among nonpregnant members of the local community over this same time. His data are therefore insufficient to either justify or invalidate the conclusion which he has reached, presumably, on the basis of clinical impression. Objective data are of particular importance in such circumstances, since it is well recognised that cases of Bell’s palsy may appear in clusters, suggesting that they are related to a common xtiological factor, possibly infective.23 there is
An association of Bell’s palsy with pregnancy was also suggested recently by Korczyn,24 who found that among a group of 9 women with Bell’s palsy it had occurred with a higher incidence than could have been expected by chance in the six months before or after delivery. At this time, however, specialist referral would seem much more likely than on other occasions, especially if patients are already attending a hospital antenatal clinic, so the significance of his observations is uncertain.
completely devoid of enzyme activity and crossG.-6-P.D. reacting protein. I reported a very similar case in 1972.1 The patient was a male African who eventually died from fulminating viral hepatitis. In Africans the enzyme deficiency is usually less severe and activities are around 15%. The mother was deficient A-(homozygous) and the quantitative assay of enzyme in the blood showed a very low enzyme content (0-009 i.u. per g. haemoglobin at 30°C, normal range 5-10 i.U. per g.). Cooper et awl. also found the leucocytes of G.-6-P.D.deficient patients to have defective capacity to kill Staphylococcus aeureus, Escherichia coli, and Serratia marcescens, bacteria which produce little or no hydrogen peroxide,
although Streptococcus fœcalis, a hydrogen-peroxideproducing bacterium, was killed instantly. Dr Gray and his colleagues confirm this observation. The leucocytes appear to have defective capacity to kill Salmonella typhi too (unpublished personal observation). Department of Medicine, Ghana Medical School, Accra, Ghana.
S. K. OWUSU.*
THE NEW N.H.S. CONSULTANT CONTRACT
SIR,-The letters of Dr Fearnley and Mr Rushforth (Sept. 22, p. 667) summarise the two points of view on this
important matter. For myself, I endorse wholeheartedly everything Dr Fearnley has written and hope that large numbers of our colleagues will do the same. To Mr Rushforth and those who share his view I would make
Keyser, J. W., Mahler, R. F. Lancet, Sept. 22, 1973, p. 678. Hall, O. Hereditas, 1959, 45, 495. Grabar, P., Benhamou, N., Daussant, J. Archs Biochem. Biophys. 1962, Supplement, 1, 187. 4. Elton, G. A. H., Ewart, J. A. D. J. Sci. Fd Agric. 1963, 14, 750. 5. Grabar, P., Daussant, J. Cereal Chem. 1964, 41, 523. 6. Hill, R. J., Djurtoft, R. J. Inst. Brew. 1964, 70, 416. 7. Benhamou-Glynn, N., Escribano, M. J., Grabar, P. Bull. Soc. Chim. biol. 1965, 47, 141. 8. Ewart, J. A. D. J. Sci. Fd Agric. 1966, 17, 279. 9. Beckwith, A. C., Heiner, D. C. Archs Biochem. Biophys. 1966, 117,
1. 2. 3.
239. 10. Nimmo, C. C., O’Sullivan, M. T. Cereal Chem. 1967, 44, 584. 11. Hamauzu, Z., Yonezawa, D., Shimomura, H. Agric. biol. Chem. 1967, 31, 448. 12. Ewart, J. A. D. J. Sci. Fd Agric. 1969, 20, 221. 13. Liuzzi, A., Angeletti, P. U. ibid. p. 207. 14. Booth, M. R., Ewart, J. A. D. J. Sci. Fd Agric. 1970, 21, 187. 15. Daussant, J., Renard, M. Febs Letters, 1972, 22, 301. 16. Piazzi, S. E., Riparbelli, G., Sordi, S., Cantagalli, P., Pocchiari, F., Silano, V. Cereal Chem. 1972, 49, 72. 17. Heiner, D. C., Lahey, M. E., Wilson, J. F., Peck, G. A. Am. J. Dis. Child. 1961, 102, 446. 18. Heiner, D. C., Lahey, M. E., Wilson, J. F., Gerrard, J. W., Schwackman, H., Khaw, K.-T. J. Pediat. 1962, 61, 813. 19. Wright, R., Taylor, K. B., Truelove, S. C., Aschaffenburg, R. Br.
20. 21. 22. 23. 24.
med. J. 1962, 2, 513. Wells, H. G., Osborne, T. B. J. infect. Dis. 1911, 8, 66. Wells, H. G., Osborne, T. B. ibid. 1913, 12, 341. Lake, G. C., Osborne, T. B., Wells, H. G. ibid. 1914, 14, 364. Leibowitz, U. Brain, 1969, 92, 109. Korczyn, A. D. Acta neurol. scand. 1971, 47, 603.
two
points. 1. A number of people appear to believe that every consultant can and should undertake private work. There are, however, some (e.g., chemical pathologists and psdiatric radiologists), who perform a vital and expert job in the hospital service, for whom there is virtually no private work. There are also others who have made a deliberate choice to work whole-time in, for example, the medical or surgical aspects of paediatrics or neurology because they find these fields interesting and wish to use the time not spent with patients in clinical investigation or teaching. I believe that the hospital service gains enormously from the preference shown by these people. (In view of Mr Rushforth’s remark, many of us find that these interests involve much emergency work.) If the misleading idea that everyone can and will turn their hand to private work is allowed to gain currency, then the Review Body will make this assumption when it prices 10 sessions of work. 2. Administrative
can
lead
to
great changes in
Owusu, S. K. Br. med. J. 1972, iv, 25. Cooper, M. R., Dechàtelet, L. R., McGall, C. E., Lavia, M. F., Spurr, C. L., Baehner, R. L. ibid. 1970, ii, 110. Present address: Department of Endocrinology, Queen Elizabeth Hospital, Birmingham B15 2TH.
1. 2. *
rulings
797 clinical practice in hospitals. I doubt whether those who negotiated official time-off and extra-duty payments for junior hospital staff realised the effect which the right to alternate evenings and weekends off would have. Continuity of care at house-officer level has now gone. I make no judgment in saying this, and house-officers still work long hours, but they can no longer have the same wide knowledge of everything that happens to their patients. What is right for juniors, who have no alternative to spending their preregistration year in hospital, is not necessarily right for consultants, who are senior members of a learned profession. I am certain that the majority of us took up the practice and study of our specialty because we thought it interesting, and we only thought secondarily of the financial rewards. None of us think these are unimportant but if we allow ourselves to assert that our working week is only 35 hours long this is a denial of our hopes and values when we decided to specialise. We expected to have a continuing responsibility, and interest and concern dictate that this must always be so. When we feel it necessary to visit the hospital in the evening or on a Sunday we do not want to have to wonder whether some busybody will remark that we have come for the sake of the extra-duty payment. The solution to these problems is given in the last paragraph of Dr Fearnley’s letter. Royal Aberdeen Children’s Hospital, Cornhill Road, Aberdeen AB9 2ZG.
that
PETER F.
on
A slow infusion of 15-20 ml. of this blood elicits both lesions well as an endotoxaemia in the normal recipient rabbit. The recipient dies almost as fast as the burned donor, which exhibits the same lesions. The liver on both donor and recipient at the time of death contains endotoxin in a titre that is a multiple of that in the plasma, but only in rabbits that harbour the conventional intra-intestinal gram-negative flora. None of these responses appear in similar rabbits available to us since March, 1972, which for unknown reasons are free or nearly free of live gram-negative bacteria, even though the endotoxin titre in the cascal content ranges from 125 to 1500 g. per g. But if they are preloaded 3-4 hours before the burn with a mixed 18-hour culture of gram-negative bacteria in milk, the burn elicits the lung and gut lesions, as well as endotoxxmia.
Thus, there is at least experimental evidence that the lesion is produced by circulating endotoxin. The
lung
likelihood that this is also true in man increases as the clinical evidence accumulates that endotoxaemia occurs in man in non-septic as well as septic disorders.3-5 The
inadequacy
of current treatment for the acute respiratorydistress syndrome requires an appraisal of the possible role
3. 4. 5.
from
JACOB
FINE.
a
DETERRING APPLICANTS ?
SIR,-I do not know whether my experience is unusual, but I have inquired about various advertised N.H.S. consultant posts in the past year and in several instances I have wondered whether the regional boards concerned were really trying to attract applicants. Recently, for example, a Scottish region, despite two extra telephone calls, did not send the further particulars until the week of the closing date, and this month I received details from a Metropolitan board with an application form that was due to be returned by the following day! In all instances the requests had been made on the day the posts were first advertised. Prospective candidates are in a difficult position to protest, but a cavalier attitude does seem to have developed within the administration of some boards. Perhaps in the reorganised service these matters will be taken care of within the new managerial efficiency, but who will bring this manipulative device to account ?
JONES.
as
2.
not
APPLICANT.
burns (June 30, p. 1491) deals with the high frequency of the acute respiratory-distress syndrome. The essential lesion now seems to be an increase in vascular permeability to plasma and, in the more 1 severe forms, to red cells. The high frequency of this lesion and of a coincident and similar lesion in the gut in both septic and non-septic shock suggest a common bloodborne cause. We have identified a vasoactive agent in the venous blood draining the site of a 30% immersion burn in rabbits.2
1.
endotoxaemia of intestinal origin, if in this disorder.
Boston City Hospital, 818 Harrison Avenue, Boston, Massachusetts 02118, U.S.A.
PRENATAL TREATMENT OF HEREDITARY DISEASES ?
CAUSE OF RESPIRATORY-DISTRESS SYNDROME
SIR,-Your editorial
an
septic focus, plays
Cuevas, P., de la Maza, L. M., Gilbert, J., Fine, J. Archs Surg. 1972, 104, 319. Cuevas, P., Ishiyama, M., Koizumi, S., Woodruff, P., Kaufman, A., Fine, J. Surgery Gynec. Obstet. (in the press). Levin, J., Edwin, P. T., Zanber, N., Oser, R. New Engl. J. Med. 1970, 283, 1313. Caridis, D. T., Reinhold, R. B., Woodruff, P. W. H., Fine, J. Lancet, 1972, 1, 1381. Das, J., Schwartz, A. A., Folkman, J. Surgery, 1973, 74, 235.
SIR,-Repeatedly, Press reports note interruption of by parental decision after antenatal detection of biochemically or chromosomally defective fetus because
pregnancy a
intrauterine treatment of the disorders is not available. It has been implied more or less explicitly 1.2 that, should treatment become available, it would almost inevitably become the best solution in pregnancies at high risk of genetic defects. I suggest that this view is unrealistic and untenable. Firstly, chances that useful treatment will soon be at hand For many conditions irreversible anatomical are slim. changes are probably present so early in gestation that their prevention or reversal in utero by drug or enzyme treatment seems highly improbable. For example, by the 14th week of intrauterine development neuronal membranous cytoplasmic bodies have been observed in a Tay-Sachs fetus.3 Antenatal diagnosis of this and other inherited biochemical diseases can at the earliest be reached by 20-22 weeks of amenorrhcea, from cultivated cells obtained by amniocentesis at 16 weeks. The first demonstration of corrective in-utero treatment of inheritable defects will have one day to be applied to man. I surmise that it will be virtually impossible to find a mother willing to accept the possibility of failure, when Should weighed against the alternative of abortion. in-utero treatment become available, there is no indication of absolute effectiveness. If failure of treatment results in a defective child, who will care for this infant ? Few mothers, offered the possibility of having a future normal baby, will knowingly take this chance, no matter how small it may be, even if some government or institution will guarantee the care of the infant. On the other hand, some parents may choose prenatal treatment rather than abortion because of religious or moral convictions or because the mother is older and 1. 2. 3.
Valenti, C. Ric. Clin. Lab. 1971, 1, 443. Littlefield, J. W. New Engl. J. Med. 1969, 280, 722. Volk, B. W., Adachi, M., Friedland, J., Schneck, L., Valenti, C. Proc. Soc. exp. Biol. Med. 1970, 135, 836.