989

NON-TREATMENT OF DEFECTIVE NEWBORNS

SIR,-A self-righteous minority in the United States was grantedpower (for a mercifully short time) by government action: until ajudge ruled differently, zealots were permitted to impose their viewsof the meaning of life on agony-stricken parents with a defectivebaby. Signs were posted in American nurseries inviting facelesspersons ("identity of callers will be held confidential") to report"discriminatory failure to feed and care for handicapped infants"over a toll-free hot-line to Washington. The busybodies could walkaway scot-free from the consequences on affected families of their

sneaky action.Physicians reacted by asking for an early court ruling against the

obnoxious intrusion into decisions about medical care, and it was

granted. Our profession was quick to see the dangers of invasion bygovernment and self-appointed moralists into medicine’s domain. Ifind it curious, however, that we have found it difficult to

understand the outrage felt by families when doctors overrideparental wishes concerning heroic measures in the treatment ofdefective babies.

90 La Cuesta Drive,Greenbrae, California 94904, USA WILLIAM A. SILVERMAN

SIR,-Your Round the World correspondent draws attention(April 16) to an interesting US case in which a widow was awardedheavy damages against a nursing home because its administratorhad permitted "right-to-life" campaigners, a doctor and four

nurses, to enter the establishment to question her senile, dyinghusband whose renal dialysis treatment was about to be ended. Shewas awarded damages on the grounds that her dying husband’sprivacy had been violated.The equivalent organisation in the UK has been similarly

engaged, though its chief concern to date has been not to prolong thelives of the senile dying but to save the lives of severely handicappedbabies in cases where both parents and doctors have concluded thatno good purpose would be served by attempting to prolong lifebecause the resulting quality of life would be unacceptably low. Onhalf a dozen occasions, as a result of the deployment of hospitalinformers,’ UK "right-to-lifers" have sought to persuade theDirector of Public Prosecution to bring murder charges againstdoctors. The most notable of these cases that came to court was thatof Dr Leonard Arthur of Derby in 1981. The charge was eventuallyreduced from murder to attempted murder, and then was thrownout by the jury. A public opinion poll published in The Times (Nov10,1981) at the conclusion of the trial, showed that only 7% of thepublic thought that a doctor should be charged in suchcircumstances. It is from this very small minority that the right-to-life movement draws its membership. 2

Is it not high time the DPP looked into this matter? In the Houseof Commons on April 21, 1982, Mr Kenneth Clarke said that "allnurses have a duty of confidentiality to their patients" and could bedisciplined by the General Nursing Council or Central MidwivesBoard if there was a breach of confidentiality. Since these bodieshave proved so inadequate, is it not now a matter for the courts, ifdoctor-patient confidentiality is to be preserved? However, no right-to-life informer has been brought to trial in the UK for violating theequivalent of privacy-namely, medical confidentiality.17 Dunstan Road,London NW118AG MADELEINE SIMMS

CYTOTOXIC TEST FOR FOOD INTOLERANCE

SIR,-The leucocyte cytotoxic test (LCT) is now used, on a verysmall scale, to assist in the diagnosis of non-atopic cases of foodmtolerance. The technique is highly controversial, being disputedby some as being non-reproducible,3 non-objective,4 inaccurate, 5

1 New Standard Jan 15, 1981.2 Simms M Severely handicapped infants. Prospect (in press).3 Lehman CW The leucocytic food allergy test: a study of its reliability Effect of diet and

sublingual food drops on this test Ann Allergy 1980; 45: 150-58.4 Haddad ZH Nonacceptable, unproven tests for allergy. JAMA 1982; 247: 3106-11.5 Lieberman P, Crawford L, Bjelland J, Connell B, Rice H. Controlled study of the

cytotoxic food test JAMA 1975, 231: 728-30.

and showing a lack of clinical correlation,6 while others find the testreproducible and useful for food allergy sufFerers.-11 Using theLCT Updegraffl2 claims a 70% success rate, as opposed to 20%with the usual intradermal skin tests.The LCT was introduced by Black13 in 1956 and refined by

Bryan and Bryan.14 The patient’s buffy coat is mixed with driedfood allergens. After incubation the granulocytes are examinedmicroscopically for viability, the degree of which is related to thefood’s toxicity to the patient.In a recent study of 123 patients, forty-eight commonly eaten

foods were examined for cytotoxicity, and wheat (60%), whole milk(53%), malt (51%), peanut (46%), and cheese and haricot beans(42%), gave positive results most frequently. Studies are nowunderway to correlate exclusion of LCT-positive foods with clinicalresponse, followed by rechallenge.Food intolerance is a clinical problem which ultimately requires

the patient to eliminate each food for accurate diagnosis, and thisrequires much diligence by the patient. The strict dietary controlrequired sometimes means that the diet is not rigidly adhered to and,for this reason, both doctor and patient can be left helpless. In suchcases, the initial elimination of LCT-positive foods could provebeneficial if it enables the causative foods to be identified. If this is

unsuccessful, the doctor can still continue with his normalelimination diet routine. Since alternative means of diagnosing foodintolerance are needed laboratory tests such as the LCT may have aplace in the elimination diet protocol.Larkhall Laboratories,London SW15 2PY P. G. S. FENNELL

SIR,-I write in support of your editorial on self-referrallaboratories and food allergy testing (April 9, p 802). In the pastmonth, I have seen two patients whose lives have been made moremiserable by self-referral to such laboratories.A woman with multicentric reticulohistiocytosis and progressive

destructive arthropathy referred herself for "food allergy testing"and was told she was allergic to many foods and other environmentalallergens. Her life now is even more miserable because of a strict dietand we are unable to persuade her that this is unlikely to have anyeffect on her disease. An actress with mild chronic urticaria referredherself for food allergy testing and multiple positives were reported.She then came to our clinic because the laboratory had suggestedthat, after several tests, she have yet another one (at great expense),and she had come to the end of her tether, both emotionally andfinancially.Some sort of control over these pseudoscientific diagnostic allergy

laboratories is certainly needed.

Department of Dermatology,St Helier Hospital,Carshalton, Surrey SM5 1AA KLAUS MISCH

SIR,-Your April 9 editorial runs the danger of throwing asubstantial baby out with the bath water. Combining the two issuesof self-referral to laboratories and the validity of the tests done bythese laboratories, and lumping together all "unorthodox"

diagnostic techniques as being unsound "black box medicine" do noservice to doctors or to patients. As medical director of the

laboratory which introduced the Bryan cytotoxic test into the UK

6. Benson TE, Arkins JA. Cytotoxic testing for food allergy: evaluation of reproducibilityand correlation. J Allergy Clin Immunol 1976; 58: 471-76.

7 Bryan WTK, Bryan MP. Allergy in otolaryngology In: Paparella MM, ed.

Otolaryngology, 2nd ed: Vol III. Philadelphia: WB Saunders, 1980: 2017-44.8. Boyles JH The validity of using the cytotoxic food test in clinical allergy. Ear, Nose

Throat J 1977; 56: 35-43.9. Ulett GA, Perry SK. Cytotoxic testing and leucocyte increase as an index to food

sensitivity. Ann Allergy 1974, 33: 23-32.10. Hughes EC, Gottscalk GH, Kaufmann D. Effect of time of blood sampling on in vitro

tests for food sensitivities. Ear Nose Throat J 1982; 61: 34-4911. Ruokonen J, Holopainen E, Palra T, Backman A. Secretory otitis media and allergy,

with special reference to the cytotoxic leucocyte test. Allergy 1981; 36: 59-68.12. Updegraff TR. Food allergy and cytotoxic tests. Ear Nose Throat J 1977; 56: 48-64.13. Black AP. A new diagnostic method in allergic disease. Pediatrics 1956; 17: 716-24.14 Bryan WT, Bryan MP. The application of in vitro cytotoxic reactions to clinical

diagnosis of food allergy. Laryngoscope 1960; 70: 810-24.

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and which has always conducted its business according to strictprofessional ethics, I take exception to several statements in theeditorial, not least with its third-hand report that the cytotoxic testhas been shown "to be of no value". The article referred to, like so

many similar articles on cytotoxic testing and on food allergy ingeneral, demonstrates an inability to grasp the essential conceptof masked allergy. The paper does not show in a carefullycontrolled manner that the test is of no value. It should, moreover,be set against the many studies which record consistent clinicalsuccess with the cytotoxic test. The technique in question has nosimilarity to methods such as the radionic examination of hair,which has been shown to be less successful than change at

diagnosing disease. ’

As a clinician using unorthodox methods alongside orthodoxones-and I trust you would allow me to be of a "lively and originalmind" and not a charlatan-I find the entrenched resistance to new

concepts in medicine of pillars of the medical establishment to be amore serious obstacle to successful patient care than innovativeactions taken by patients and non-medical practitioners, often as aresult of this resistance.

York Medical and Nutritional Laboratory,York YO1 2ES N. P. D. DOWNING

DRUG CLINICS TODAY

SIR,-As a medical sociologist I would like to comment on pointsraised by Dr Ghodse (March 19, p 636) and Dr Dally (April 9, p826).

Firstly, it should be made clearer to your readers that mostmembers of the Association of Independent Doctors in Addictionare not NHS general practitioners, but private practitioners.Dally suggests that confining treatment of non-therapeutic

addiction to NHS drug dependence units will not "be good for thosewho like to walk safely in the streets and sleep securely at night".The crime level associated with addiction in the UK is very low andrelated mainly to fraud and to burglaries of surgeries, pharmacies,and drug wholesalers. Large and brutal crime syndicates organisethe cultivation, refinement, import and supply of heroin-but thisdeplorable activity does not threaten private citizens unconnectedwith the trade. It is surely alarmist of Dally to raise the spectre of thefiendish addict who will mug and terrorise if restrictions are placedon the prescribing of opioids to them by private practitioners.

During my research into the work of some typical London NHSdrug clinics I learnt that a major difference of approach betweenthem and private doctors was over type, dosage, and administrativeroute of opioids. A proportion of the low level of oral methadoneprescribed by clinic doctors does find its way to the "street".

However, private doctors frequently accede to the requests ofaddicts to prescribe vastly higher doses of methadone and heroinand in injectable form than NHS staff consider to be sound medicalpractice. This overprescribing fuels the black market. Furthermore,no clinic doctor would prescribe dihydrocodeine or oral

methylphenidate, because addicts crush them up for intravenoususe. At a conference last month organised by University CollegeHospital, London, on the role of the clinics, representativesattended from the NHS and statutory and non-statutory agenciesdealing with addiction. Great and repeated concern was expressedboth at the tendency of private doctors to overprescribe and at theirwillingness to prescribe the above drugs and dipipanone.

I obseived patients to leave an NHS clinic stable on a lowish oralmethadone dose and go on to a private doctor’s list to obtain highdoses of injectable heroin. I have seen such patients, no longer ableto meet the financial commitment to that practitioner, return toaheNHS for treatment of severe intravenous heroin dependence andoften with other problems resulting from the prescription to themby that same doctor of barbiturates and stimulants.

Keynes College,University of Kent,Canterbury, Kent LORRAINE HEWITT

ULTRASTRUCTURAL MARKERS OF AIDS

SIR,-Over the past three years, we have examined

ultrastructurally a variety of tissues (at biopsy) and blood buffy coatcells obtained from 64 patients with the acquired immunodeficiencysyndrome (AIDS). All patients had the typical immunologicalpicture and, clinically, they spanned the entire gamut of infectiousand neoplastic processes seen in AIDS. Sources sampled includedblood, skin, lymph node, liver, lung, marrow, colon, kidney,cerebral cortex, and pericardium.Two types of cytoplasmic inclusion were seen. Tubuloreticular

structures (lupus inclusions, TRS) were present in 80% of thepatients. In 21 cases where specimens from more than one sourcewere available, TRS were present in 95%. TRS consisted ofanastomosing branching tubules of about 24 nm outer diameterlocated within cisternae of endoplasmic reticulum (fig 1). Cell typescontaining TRS included lymphocytes, monocytes, endothelialcells, tissue macrophages, and, infrequently, fibroblasts and lymphnodal interdigitating cells and dendritic reticulum cells.We have designated the second type of structure "test tube and

ring shaped forms" (TRF). ’These consisted of concentricallyarranged, endoplasmic reticulum cisternae with a layer ofelectron-dense material interposed in the cytosol between them.Longitudinal sections were tube-shaped and cross-sectionswere ring-shaped (fig 2). The dense material was resistant to lipidsolvents, as demonstrated by examination of de-paraffinisedmaterial (fig 3). TRF were seen in 39% of the patients, but werepresent in 76% of the patients with specimens from more than onebody source. They were present in lymphocytes and, rarely, in othercell types. In two cases, TRS were present within the inner cisternaof some TRF. TRF were less frequent than TRS and never occurredin their absence.TRS are found in systemic lupus erythematosus and other

collagen-vascular and autoimmune diseases, viral infections, andsome diseases of obscure etiology.2 They have been described insolitary cases of AIDS3,4 and can be induced by a and interferonsbut not by y (immune) interferon.5 AIDS patients have an acid-labile form ora-interferon in their serum. 6

1. Stahl RE, Friedman-Kien AE, Dublin R, Marmor M, Zolla-Pazner S. Immunologicalabnormalities in homosexual men: Relationship to Kaposi’s sarcoma. Am J Med1982; 73: 171-78

2. Helder AW, Feltkamp-Vroom TM. Tubuloreticular structures and antinuclear

antibodies in autoimmune and non-autoimmune diseases. J Pathol 1976, 119:49-56.

3. Gyorkey F, Sinkovics JG, Gyorkey P. Tubuloreticular structures in Kaposi’s sarcomaLancet 1982; ii: 984-85.

4. Rutsaert J, Melot C, Ectors M, Cornil A, De-Prez C, Flament-Durand J. Infectiouspulmonary and neurologic complications of Kaposi’s sarcoma. Anatomo-clinicalcorrelation with an ultrastructural study. Ann Anat Pathol(Paris) 1980,25: 125-38.

5. Rich SA, Owens TR, Bartholomew LE, Gutterman JV. Immune interferon does notstimulate formation of alpha and beta interferon induced human lupus inclusionsLancet 1983; i: 127-28.

6. DeStefano E, Friedman RM, Friedman-Kien AE, Goedert JJ, Henrickson D, PrebleOT, Sonnabend JA, Vilcek J. Acid-labile leukocyte interferon in homosexual menwith Kaposi’s sarcoma and lymphadenopathy. J Inf Dis 1982; 146: 451-55

Fig 1-Tubuloreticular structure (S) in endothelial cell.

L=lumen of capillary. (x 50 000.)