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specificity and correlate poorly with disease activity. Although thedisease is strongly associated with the presence of the HLA B27antigen, it does not affect all B27 positive individuals, and both B27negative and positive AS patients show the same skeletalmanifestations. Osteofluorosis, resulting from fluoride toxicity, hasa similar radiological appearance to AS, and the two disorders maybe somewhat similar clinically. However, the management of thesetwo conditions is completely different. Research workers at the AllIndia Institute of Medical Sciences (AIIMS) in New Delhi havenow devised a diagnostic test which incorporates the measurementof circulating levels of sialic acid (SA) and glycosaminoglycans(GAG). The mean ratio SA/GAG shows a statistically significantdecrease in patients with osteofluorosis whereas it is raised in

patients with AS. In conditions such as osteoporosis, osteoarthrosis,and idiopathic backache the SA/GAG ratio showed no statisticallysignificant change when compared with control values.Dr A. K. Susheela, of the fluoride and fluorosis research

laboratories at AIIMS, says, "Since sialic acid and glycosaminogly-cans are two significant components in mineralised bone matriximportant for the maintenance of bone structure and calcification,we expected that bone disorders would bring about a change in theircontents. Although bone biopsy procedures can be adopted for

quantitative analysis of sialic acid and glycosaminoglycans, they areseldom practical, as patients invariably refuse biopsy, In fact thereduction in mean ratio of circulating SA/GAG to 30-50% is one ofthe earliest signs of fluoride toxicity when no clinical symptoms aredetectable. The test is of particular value to industrial toxicologists,as Dr Susheela and colleagues discovered while monitoring fluoridetoxicity in smelter workers in the aluminium industry. In thesmelter room aluminium is separated from its ore, and cryolite,which contains fluoride 50% by weight, is used as flux. The processis carried out at temperatures up to 2000°C, and workers areexposed to fumes with very high fluoride levels. Dr Susheela founda decreased SA/GAG ratio in the majority of the workers, indicatingfluoride toxicity; but a few showed an increase in the SA/GAGratio. These workers had ankylosing spondylitis, not osteofluorosis,and were not entitled to compensation for fluoride toxicity from themanagement. Measurement of urinary fluoride levels was formerlsthe only test for detecting fluoride toxicity but was unreliablebecause kidney function is impaired in advanced fluoride toxicity.Industrial toxicologists now have a reliable test for identifyinggenuine cases of fluoride toxicity.16/5, Doctors’ Lane,New Delhi-110 001, India BBUPESH MANGLA

In England Now

WE moved recently to a flat. Our previous house suddenlybecame too big, too quiet, and too empty when the children left tocreate places of their own. The garden, once a constant source ofpleasure, seemed to grow in size every year and become somethingof a burden. Even my roses were more demanding. Our new abodehas a garden, true, but it is a communal one and we all contribute tothe cost of a part-time jobbing agriculturist. It is a new experience toask his permission (cloaked in the guise of seeking advice) to plantsome spring bulbs and a few favourite floribundas. Indeed, it waswhen exploring the policies that I came across a small plot of herbs.These, I discovered, were being grown by my neighbour, a lady ofmature years and decided views. She has her own opinions oforthodox medicine and believes strongly in the virtues of nature’sremedies. We have become great friends. I am instructing her on theprinciples of community medicine, and she is teaching me aboutherbs. Feverfew, she tells me, helps a headache; dandelion leaf teaallays anxiety; meadowsweet (beautiful name) defeats diarrhoea;sticklewort soothes stomach aches; camomile pacifies piles; thymecalms colic; and almost everything counteracts constipation. Wehave many interesting conversations. To keep my end up, I let herread The Lancet every week when I have finished with it; so we haveboth followed the correspondence about comfrey tea with greatinterest.

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IT is faintly possible that regular readers of this column may bewondering how I am progressing with my self-taught swimming,the vicissitudes of which I have reported on previous occasions.The truth is I have hit a snag. I do not know what the snag is

called, but, like Sherlock Holmes when referring to Irene Adler, Icall her The Woman. Whenever I go for my dip she seems to bethere, and she has taken on herself, unasked (and unencouraged),the role of mentor. My wife reckons she is a retired gymmistress-and she would know, I suppose, having been a blue-kneed schoolgirl on the hockey field in her time. I know nothing ofgym mistresses-at my (very) minor public school we had a chap wecalled "Our Popular Young Sportsmaster". He believed we meantit, though he was, in fact, neither young nor popular-the latterstemming from the inordinately intimate interest he took in us whenwe were having our post-exercise showers. (Such was the innocenceof youth in those days that we did not, at the time, associate theseproclivities with his sudden departure from the school following a

visit to the headmaster by two men in fawn trenchcoats and trilbyhats.)Anyhow, be she retired gym mistress or (the theory I favour) an

ex-drill sergeant from the commandos, The Woman has decided totake me in hand. I try getting to the pool at opening time and beingfirst in; I am splashing around, doing what I fondly kid myself is abreast stroke, when suddenly a stentorian voice will bellow, "Comealong, pull with those arms!". Or, more often, as I go blue in the facehaving once more flooded my respiratory tract, there will be a cry of"You’re not breathing!"-a fact of which I am only too aware,Lately she has been threatening to take me into the deep end "Togive you confidence", whereas it would, I know, destroy the fragiletrust that I have managed, after over fifty years of paralytic fear, toestablish with the water. My wife, who fmds the whole businessmore amusing than I feel is compatible with the spirit of hermarriage vows, says she is sure The Woman means well. I reply,sourly, that if everyone who meant well was hanged the worldwould, in my view, be a better place.

So my swimming progress has halted; fear of the water hasdiminished to be replaced by fear of the public humiliation of theharangues of The Woman, and I do not know how to get rid of her.As I have remarked before in this column, once upon a time to letslip I was a psychiatrist was enough to send people scampering infear; but, alas, no longer. Indeed, I have nightmares of beingdragged out of my depth and then held while The Woman pours outall her problems to me-a situation which, I am sure, never evencrossed the mind of Sigmund Freud.

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"ASK your pharmacist", exhorts the advertisement presentlyappearing in many national magazines, "you’ll be taking goodadvice". I didn’t particularly need advice but I did need ’Dioralyte’as a precautionary measure for a Mediterranean holiday with twochildren under 4. Admittedly, my pharmacist did not emerge fromhis dispensing room during my consultation, but the assistant whoserved me took the initiative, exclaiming at the cost of dioralsne(later checking in MIMS suggested that the price may not be sohigh elsewhere) and offering a cheaper alternative. Luckily, I hadtime, before setting off to warmer parts, to read the productinformation and to discover that ’Diocare’ (morphinehydrochloride plus oral rehydration salts; Beecham) is not

equivalent to dioralyte and should not be given to children under 6.Luckily also, though not a pharmacist or a doctor, I was able toassess the value of this "good advice". Should a medicine like this besold by an unqualified assistant?