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but such diseases include dietary deficiencies as well as

excesses. The profession is trying to take a lead in reducing ill-health due to dietary deficiencies-e.g., the fortification ofmargarine and bread, iodised salt, and the attempts to reducemalaria with a chloroquine-salt compound. The differencewith fluoride deficiency would appear to be that the vehicle isliquid, since I do not remember in the 1939-45 war beingoffered the choice of fortified and non-fortified foodstuffs.

Professor Sinclair cites John Locke: "That every man wasborn with the right to freedom of his person provided [my ita-lics] he did not offend or inconvenience others". Professor Sin-clair cites the possible addition of disulfiram, an anti-nicotinecompound, and a contraceptive as possible infringements ofthat freedom. Personally I would agree with the addition ofdisulfiram and an anti-nicotine compound to our water sup-plies as a permissible infringement of our "right to freedom"on the same grounds that crash-helmets are a legal require-ment and the very real possibility that victims of vehicle acci-dents may receive a lower compensation if they were not wear-ing seat-belts. In such cases the individuals’ right to freedomis infringed because such individuals are, in Locke’s phrase,"an inconvenience to others". Alcoholism and road accidentsplace a very severe strain on the N.H.S. The cost of dentaltreatment in England alone under the N.H.S. exceeds 140million a year, most of which is spent on treating caries andits complications. The provision of such sums, as for alcoholismand road accidents, is a gross inconvenience to others sinceother N.H.S. services are deprived.

There is, however, a further and more sinister addition to thefluoride story. In another medical journal I recently received anadvertisement for ’Dentamilk’. This organisation has "consult-ing rooms" in Wimpole Street.The selling point of dentamilk is that "it does not infringe

personal freedom"-but whose personal freedom? Theparents’ who force their child from "weaning to teenageyears" to drink this milk, even if they are lactase-deficient, orthe child’s?The leaflet also states that the cost of fluoridisation of the

water supply of a 50 million population is 7 500 000 perannum whereas the cost of the amount of fluorine for 10 mil-lion children to be added to their milk is only C150 000. Ifeach child has half a pint of milk a day costing 4p then thecost for 10 million children comes to 146 million per annum.It is highly unlikely that all the families concerned will be ableto pay for the milk for their children for some twelve yearsdaily. Who will pay? The N.H.S. or the rate-payers?

Doubtlessly in time this method of "selective fluoridation"will be developed as a milk powder and will then be hawkedaround the disadvantaged countries with high-pressure sales-manship as a better alternative to breast milk-which will notbe flouridised. Todd’ has shown that 63% of five-year-olds ina sample of children in England and Wales have active decayin their deciduous teeth, so why should we allow unfluoridisedmothers to breast-feed their children for eighteen months totwo years?

Department of Tropical Community Health,Liverpool School of Tropical Medicine,Pembroke Place,Liverpool L3 5QA. F. M. SHATTOCK

RAIL VERSUS ROAD

StR,—The widespread publicity given to the dangers ofsmoking has had some, very modest, success. At least, moresmokers are trying to give up, and none can claim they did notknow the risks. Advertising has been restricted, as a result ofthe campaign led by the medical profession.May I draw attention to the potential good that could be

1. Todd, J. E. Children’s Dental Health in England and Wales 1973. H.M. Sta-tionery Office, 1975.

done if more doctors took an interest in another, largely avoid-able, cause of death and disability-namely, road accidents?Thousands of deaths and several times as many injuries are astatistical certainty if the volume of road travel remains at itspresent level or continues to increase. During the Suez crisisaccident beds were used for minor surgery because there wereno road accidents in the busy home counties hospital where Iwas working; reduction in road travel would reduce thenumber of accidents. Compared with the cost of these acci.dents-in social-security payments and hospital costs-railsubsidies are negligible. A determined effort to encourage railat the expense of road usage would lead to a fall in accidents.Conversely, if the threatened rail cuts materialise, the volumeof accidents is bound to increase. I call on all doctors to dowhat they can individually to plead for the retention and evenextension of the rail network and to encourage this safer formof travel wherever it is possible. As far as the doctor or midwifeis concerned, the benefit of less congested roads would beobvious.

As with smoking, -road travel is encouraged by the vested in.terests (known collectively as the "road lobby") who seek to in-crease further the use of cars and all forms of road transport,and to this end misrepresent the relative costs of rail-e.g., byglossing over the fact that railways have to pay for the upkeepof tracks, whereas road building and upkeep is paid for by thetaxpayer.

31 Wimbotsham Road,Downham Market, Norfolk. CLARA ZILAHI

DISOPYRAMIDE DOSE

SIR,-Dr Jennings and his colleagues (Jan. 10, p. 51) havedemonstrated the efficacy of disopyramide in the prevention ofcardiac arrhythmias in the coronary-care unit. Although theabsence of a significant reduction in the incidence of ventric-ular fibrillation is disappointing, I can add some weight totheir proposal that inadequate dosage may be an explanation.The choice of dosage in initial trials is always difficult, but

since assay methods for disopyramide have been perfected itnow seems that the regimen of 100 mg every six hours may notbe ideal in patients who have had a myocardial infarct.From animal studies and the results of clinical trials in

North America, Karim suggested that a plasma concentrationof disopyramide of 2-3 fLwm1 is "associated with desirableanti-arrhythmic activity". Rangno et al. using repeated bolusinjections to the point of control of ventricular tachyarrhyth-mia, observed the minimum mean effective serum concentrationin six patients to be 4 llg/Ml.2 Single oral dose studies of dis-opyramide1 3 4 in heavy volunteers suggest that with an initialdose of 100 mg the peak plasma concentration, which maytake three hours to appear, is unlikely to be much above 2fLglml. Even this concentration may not be achieved bypatients; in four patients investigated within four hours ofmyocardial infarction, a 100 mg dose of disopyramide pro-duced a mean peak value of only z9 9 Ag/Ml. 4

Others will be encouraged by the experience of Jennings etal. to use disopyramide for arrhythmia prophylaxis and it iswith this in mind that I would make a plea for an initial load-ing dose to be used. On the basis of results obtained from cor-onary-care patients,4 an initial dose of 300 mg followed at sixhours by 200 mg with 100 mg disopyramide six-hourly there-after would produce peak plasma concentrations close to 3

g/ml, which would seem more appropriate to prophylactictherapy.

Department of Pharmacology and Therapeutics,Royal Infirmary,Sheffield S6 3DA. JOHN W. WARD

1. Kanm, A. Angiology, 1975, 26, suppl. p. 85.2. Rangno, R. E., Warnica, W., Ogilvie, R. I., Kneeft, J., Bridges, E. J. int

med. Res. 1976, 4, suppl. 1, p. 54.3. Ranney, R. G., Dean, R. R., Karim, A. Radzialowski, F. M. Archs int

Pharmacodyn. Ther. 1971, 191, 162.4. Ward, J. W., Kinghorn, G. R. J. int. med. Res. 1976, 4, suppl. 1, p. 49.