- Email: [email protected]
DIETARY FIBRE AND ENERGY INTAKE
368 the agar plates.
All samples were tested for IgM, and 50 samples were tested for cx2-macroglobulin, but neither of these proteins was detectable with commercially available immunoquantitation plates. This study represents to our knowledge the largest number of individual determinations of amniotic-fluid proteins at 16-20 weeks’ gestation. Furthermore, the values obtained correlate well with other reports and demonstrate that the determinations can be made with commercially available reagents. Section of Pathology and Laboratories, LAC-USC Medical Center, C. GOLDSMITH 1200 N. State Street, G. D’ABLAING Los Angeles, California 90033,
S. CHANDOR.
U.S.A. 1.
Monaghan, J. M., Horn,
D. B., Brock, D.
cells are of T-cell origin or, perhaps, modified reticulum cells that do not bind immunoglobulins to their surface. These studies are supported by Judith Segal Foundation and the Chief Scientist, Ministry of Health. Chaim Sheba Medical Centre, Tel-Hashomer, and Tel-Aviv University Medical School, Israel.
MIRIAM BINIAMINOV BRACHA RAMOT.
Leech, J. Lancet, 1973, ii, 265. Arend, W. P., Mannik, M. J. Immun. 1973, 110, 1455. Matchett, K. M., Huang, A. T., Kremer, W. B. J. clin. Invest. 1973, 52, 1908. 4. Ramot, B., Biniaminov, M., Many, A., Aghai, E. Israel J. med. Sci. 1973, 9, 657. 5. Order, S. E., Hellman, S. Lancet, 1972, i, 571. 6. De Vita, V. T. New Engl. J. Med. 1973, 289, 801.
1. 2. 3.
J. H. Lancet, 1973, ii,
619.
2. 3.
Gitlin, D., Biasucci, A. J. clin. Invest. 1969, 48, 1433. Queenan, J. T., Gadow, E. C., Bachner, P., Kubarych, S. F. Am. J. Obstet. Gynec. 1970, 108, 406. 4. Sutcliffe, R. G., Brock, D. J. H. J. Obstet. Gynœc. Br. Cwlth, 1973, 80, 721.
POSSIBLE T-LYMPHOCYTE ORIGIN OF REED-STERNBERG CELLS SIR,-Leech presented evidence which suggested a Blymphocyte origin for the Reed-Sternberg (R.s.) cell in Hodgkin’s disease.l Our results with 3 lymph-node biopsy specimens from patients with Hodgkin’s disease and 3 reactive lymph-nodes did not accord with this
suggestion. Membrane-associated immunoglobulins are one of the markers of the B lymphocyte, which is detected by direct immunofluorescence with fluoresceinated anti-immunoglobulins. However, monocytes, macrophages, and reticulum cells have immunoglobulin receptors on their membranes, and on incubation with immunoglobulins most of these cells become coated with immunoglobulins. Thus further incubation with anti-immunoglobulins will make these cells fluorescent, like the B lymphocytes.22 It is very difficult to distinguish fluorescent lymphocytes from monocytes and fluorescent R.s. cells from reticulum cells. The lymph-node biopsy specimens were teased apart, and the cells suspended in Eagle’s medium and tested for viability by the trypan-blue exclusion method. After appropriate washing, the cells were incubated with fluoresceinated anti-immunoglobulins and examined with ultraviolet light and phase-contrast microscopy. In all the lymph-nodes examined, both those involved in Hodgkin’s disease and the reactive ones, most macrophages and reticulum cells were fluorescent, usually with anti-IgG. In 1 of 3 nodes from patients with Hodgkin’s disease it was very difficult to distinguish between R.s. and reticulum cells; yet some of the R.s. cells seemed to have small fluorescent granules on their membranes. In the other two cases we were able to demonstrate fluorescence on the reticulum-cell membranes, although the R.S. cells were negative. In one of these cases pleural fluid, rich in mesothelial and R.s. cells, was also examined. Since it was easy to distinguish between these two types of cells, it was clear that the mesothelial cells were fluorescent, while the R.s. cells were again negative. Published reports and our own previous studies 3,4 indicate that T cells are depleted in patients with Hodgkin’s disease. Order and Hellman5 and De Vita6 believe that T-derived lymphocytes infected by a virus are modified and attacked either by normal T cells or by reactive B cells. Since we were unable to detect membrane fluorescence on the R.S. cells, our results would support the idea that these
UNUSUAL COMPLICATION OF LIVER BIOPSY SIR,-A 62-year-old man was admitted to hospital because of a brisk hæmatemesis. In this known alcoholic, facial telangiectasia, parotid swelling, gynscomasda, and sparse body hair were evident on admission. The liver edge was felt four finger breadths below the right costal margin. No ascites, asterixis, splenomegaly, or abdominal discoloration was present. In the fourth hospital week after satisfactory response to oesophageal tamponade in the first week and further supportive measures, a liver biopsy was done, using a Menghini needle with an infracostal approach. The tissue revealed fatty metamorphosis. The procedure seemed uneventful, but 3 days later a faint bluish discoloration was noted around the umbilicus, and three distinct ecchymotic spots were visible within the umbilicus. The patient was discharged 1 week after the liver biopsy. We believe that extravasation occurred into the previously obliterated segment of the umbilical vein, resulting in blood traversing to the surface of the umbilicus. Kessler and Zimmon1 stated that " as the umbilical vein approaches the umbilicus, it tapers to multiple, fine, fibrous strands that extend to the umbilicus ". The associated periumbilical discoloration may have resulted from blood within the umbilical vein, rather than the usually considered frank intra-abdominal hæmorrhage.2 Saint Francis Hospital, 2260 Liliha Street, Honolulu, Hawaii 96817, U.S.A. 1.
Kessler,
R. E.,
CHARLES K. TASHIMA.
Zimmon, D. S. Surgery Gynec. Obstet. 1967, 124,
594.
2. Furste, W. Archs
Surg. 1959, 79, 600.
DIETARY FIBRE AND ENERGY INTAKE
grateful for Dr James’s and Dr Cummings’s 61) detailed discussion of my hypothesise but I am afraid they have misunderstood it. I did not claim that adding fibre to the diet automatically reduces energy intake or sugar intake. This may be true if unpalatably large amounts of fibre are swallowed. However, a person wishing to take more fibre by eating bran may well add sugar to the bran to make it more palatable, and so increase SIR,—I
(Jan. 12,
am
p.
both his sugar and energy intake. The aim of my paper was to support and develop Cleave’s concept that the fibre-depletion involved in sugar-refining and white-flour milling alters the physical state of the diet, which becomes artificially easier and quicker to ingest, and less satisfying for a given energy intake than traditional unrefined diets. Perhaps misunderstanding could have been avoided if the paper had been entitled Fibre Depletion, a Spur to Energy Intake. I cannot take seriously the suggestion that a high-fibre
369
(I prefer the term full-fibre) diet can lead to malnutrition in children. Vegetarianism would have died a natural death long ago if this was true. Variety is an axiom of good nutrition, and if a maize-meal/porridge diet favours kwashiorkor this is surely due to the lack of variety, not to the use of whole maize as opposed to refined corn flour. Dr James and Dr Cummings quote unpublished work support their statement that faecal fat and nitrogen on a high-fibre diet are largely unavailable because associated with the fibre. I shall be interested to see these data when they are published. If this is true, I shall be quite happy to modify my suggestion that small intestinal function is reduced by fibre. This is in any case the third and least important of the mechanisms postulated as obstructing energy intake.
to
It would indeed be naive to " hail fibre as a panacea for the diseases of civilisation ". A panacea is a remedy. My paper did not suggest that fibre is a remedy for obesity but rather a prophylactic against it. As for the preventive action required, it is not to add fibre to our food but to stop taking fibre away from it. The difference is subtle but crucial. Department of Medicine, Bristol Royal Infirmary, Bristol BS2 8HW.
K. W. HEATON.
1. Heaton, K. W. Lancet, 1973, ii, 1418.
ORAL CONTRACEPTION AND SEX RATIO AT BIRTH
SIR,-Attention is being concentrated on the possibility that oral contraception before pregnancy increases the chance that infants delivered subsequently will be female. I,2 Such an effect on sex ratio at birth would have important social consequences. We have investigated our own material in the past two years. The total series consisted of 560 babies, and the sex ratio was 0-4589 (257/303)-i.e., 45-89% of the newborns were male (p > 030). Where the mother had taken oral contraceptives for more than 2 years the percentage of female babies increased further. In this latter group the sex ratio was 0.3411 (58/112) (p < 002). After use of ari LU.C.D. the sex ratio was 0.5135 (46/40)-similar to the general world ratio at birth (0-5146). We have considered the possible involvement of immune mechanisms in this phenomenon. Significant reduction of cell-mediated immunity has been demonstrated in women taking contraception-pills. 3,4 Other reports suggest that histocompatibility differences between mother and fetus play a role at implantation, and male blastocysts bearing Ylinked antigen would be more successfully implanted than female blastocysts.5 If the maternal cell-mediated immunity after oral contraception is really depressed, the role of antigen difference may possibly decrease at implantation and hence fewer male blastocysts will be implanted, with a resultant diminution of the sex ratio at birth. The preponderance of female babies in our own material might support this hypothesis. Department of Obstetrics and
Gynæcology, University Medical School, W.H.O. Clinical Research Centre Human Reproduction, H-6725 Szeged, Hungary.
on
T. L. KESERÜ A. MARÁZ J. SZABÓ.
1. Crawford, J. S. Lancet, 1973, i, 858. 2. James, W. ibid. p. 1061. 3. Hagen, C., Froland, A. ibid. 1972, i, 1185. 4. Irvine, W. J. Res. Reproduction, I.P.P.F. 1973, 5, no. 5. 5. Kirby, D. R. S. in Ovo-Implantation; p. 86. Basle, 1970.
Medicine and the Law
Order for Disclosure of Hospital’s Medical Records ON Feb. 14, 1969, a patient attended a hospital for dental She alleged that, for the purpose, or in the course, of that treatment, she was given an anaesthetic injection in a negligent manner with the result that she sustained a serious and permanent disability of her left hand. She consulted solicitors and entrusted them to act for her in connection with a claim for damages for her alleged injuries against the hospital committee. The solicitors made certain inquiries, obtained medical opinion, but took no steps to start legal proceedings. As a result, the patient’s claim against the hospital committee became statute barred in February, 1972. The patient then consulted other solicitors, and, in February, 1973, she issued a writ against her former solicitors claiming damages for breach of contract or breach of duty. The statement of claim and the defence in her action against her former solicitors were served by April, 1973. In July, 1973, the patient applied to a High Court master in chambers for, and obtained, pursuant to Order 24, rule 7A(2) of the Rules of the Supreme Court, an order requiring the hospital committee to disclose to her the medical case-notes and other records relating to her treatment at the hospital. The hospital committee appealed against that order on the ground that the patient was not "a party to any proceedings in which a claim in respect of personal injuries is made" within the meaning of section 32(1) of the Administration of Justice Act 1970, and also contended that her claim against her former solicitors was a claim in respect of a lost cause of action or a lost chance; that it was not a claim in respect of personal injuries; and that the claim referred to in section 32(1) was limited to a claim against the person or persons causing the injury or against those vicariously liable. treatment.
Mr Justice BOREHAM said that there were a number of decisions in which the words " in respect of " had been considered by the courts. In each of those decisions the words were given their ordinary and unrestricted meaning and there was no discernible reason why they should not be similarly interpreted in section 32(1). The words " in " respect of conveyed some connection between the patient’s claim and the personal injuries sustained by her. On the further question whether there was in the proceedings brought by her against her former solicitors a connection or relation between her claim and her personal injuries, it was sufficient to say that the nature and extent of her personal injuries formed an essential ingredient in the proof of her claim-unless she could prove such injuries she would fail. In those circumstances, whatever her cause of action-whether or not in contract-there was a clear and firm connection or relation between her claim and her personal injuries. In his Lordship’s judgment, to quote section 32(1), she was " a party to ... proceedings in which claim in respect of personal injuries to a person ... is made ". As such she was entitled to the order made by the master in chambers and the appeal would be dismissed with costs. Leave to appeal granted. a
Paterson v. Northampton and District Hospital Management Committee. Queen’s Bench Division : BorehamJ., Feb. 22, 1974. Counsel and solicitors: Charles Colston (Bower, Cotton and Bower for Becke Phipps and Co., Northampton) for the hospital committee; Alan Cooper (Williams and Co., Bedford) for the patient.
P. R. K. MENON, Barrister-at-Law.
All samples were tested for IgM, and 50 samples were tested for cx2-macroglobulin, but neither of these proteins was detectable with commercially available immunoquantitation plates. This study represents to our knowledge the largest number of individual determinations of amniotic-fluid proteins at 16-20 weeks’ gestation. Furthermore, the values obtained correlate well with other reports and demonstrate that the determinations can be made with commercially available reagents. Section of Pathology and Laboratories, LAC-USC Medical Center, C. GOLDSMITH 1200 N. State Street, G. D’ABLAING Los Angeles, California 90033,
S. CHANDOR.
U.S.A. 1.
Monaghan, J. M., Horn,
D. B., Brock, D.
cells are of T-cell origin or, perhaps, modified reticulum cells that do not bind immunoglobulins to their surface. These studies are supported by Judith Segal Foundation and the Chief Scientist, Ministry of Health. Chaim Sheba Medical Centre, Tel-Hashomer, and Tel-Aviv University Medical School, Israel.
MIRIAM BINIAMINOV BRACHA RAMOT.
Leech, J. Lancet, 1973, ii, 265. Arend, W. P., Mannik, M. J. Immun. 1973, 110, 1455. Matchett, K. M., Huang, A. T., Kremer, W. B. J. clin. Invest. 1973, 52, 1908. 4. Ramot, B., Biniaminov, M., Many, A., Aghai, E. Israel J. med. Sci. 1973, 9, 657. 5. Order, S. E., Hellman, S. Lancet, 1972, i, 571. 6. De Vita, V. T. New Engl. J. Med. 1973, 289, 801.
1. 2. 3.
J. H. Lancet, 1973, ii,
619.
2. 3.
Gitlin, D., Biasucci, A. J. clin. Invest. 1969, 48, 1433. Queenan, J. T., Gadow, E. C., Bachner, P., Kubarych, S. F. Am. J. Obstet. Gynec. 1970, 108, 406. 4. Sutcliffe, R. G., Brock, D. J. H. J. Obstet. Gynœc. Br. Cwlth, 1973, 80, 721.
POSSIBLE T-LYMPHOCYTE ORIGIN OF REED-STERNBERG CELLS SIR,-Leech presented evidence which suggested a Blymphocyte origin for the Reed-Sternberg (R.s.) cell in Hodgkin’s disease.l Our results with 3 lymph-node biopsy specimens from patients with Hodgkin’s disease and 3 reactive lymph-nodes did not accord with this
suggestion. Membrane-associated immunoglobulins are one of the markers of the B lymphocyte, which is detected by direct immunofluorescence with fluoresceinated anti-immunoglobulins. However, monocytes, macrophages, and reticulum cells have immunoglobulin receptors on their membranes, and on incubation with immunoglobulins most of these cells become coated with immunoglobulins. Thus further incubation with anti-immunoglobulins will make these cells fluorescent, like the B lymphocytes.22 It is very difficult to distinguish fluorescent lymphocytes from monocytes and fluorescent R.s. cells from reticulum cells. The lymph-node biopsy specimens were teased apart, and the cells suspended in Eagle’s medium and tested for viability by the trypan-blue exclusion method. After appropriate washing, the cells were incubated with fluoresceinated anti-immunoglobulins and examined with ultraviolet light and phase-contrast microscopy. In all the lymph-nodes examined, both those involved in Hodgkin’s disease and the reactive ones, most macrophages and reticulum cells were fluorescent, usually with anti-IgG. In 1 of 3 nodes from patients with Hodgkin’s disease it was very difficult to distinguish between R.s. and reticulum cells; yet some of the R.s. cells seemed to have small fluorescent granules on their membranes. In the other two cases we were able to demonstrate fluorescence on the reticulum-cell membranes, although the R.S. cells were negative. In one of these cases pleural fluid, rich in mesothelial and R.s. cells, was also examined. Since it was easy to distinguish between these two types of cells, it was clear that the mesothelial cells were fluorescent, while the R.s. cells were again negative. Published reports and our own previous studies 3,4 indicate that T cells are depleted in patients with Hodgkin’s disease. Order and Hellman5 and De Vita6 believe that T-derived lymphocytes infected by a virus are modified and attacked either by normal T cells or by reactive B cells. Since we were unable to detect membrane fluorescence on the R.S. cells, our results would support the idea that these
UNUSUAL COMPLICATION OF LIVER BIOPSY SIR,-A 62-year-old man was admitted to hospital because of a brisk hæmatemesis. In this known alcoholic, facial telangiectasia, parotid swelling, gynscomasda, and sparse body hair were evident on admission. The liver edge was felt four finger breadths below the right costal margin. No ascites, asterixis, splenomegaly, or abdominal discoloration was present. In the fourth hospital week after satisfactory response to oesophageal tamponade in the first week and further supportive measures, a liver biopsy was done, using a Menghini needle with an infracostal approach. The tissue revealed fatty metamorphosis. The procedure seemed uneventful, but 3 days later a faint bluish discoloration was noted around the umbilicus, and three distinct ecchymotic spots were visible within the umbilicus. The patient was discharged 1 week after the liver biopsy. We believe that extravasation occurred into the previously obliterated segment of the umbilical vein, resulting in blood traversing to the surface of the umbilicus. Kessler and Zimmon1 stated that " as the umbilical vein approaches the umbilicus, it tapers to multiple, fine, fibrous strands that extend to the umbilicus ". The associated periumbilical discoloration may have resulted from blood within the umbilical vein, rather than the usually considered frank intra-abdominal hæmorrhage.2 Saint Francis Hospital, 2260 Liliha Street, Honolulu, Hawaii 96817, U.S.A. 1.
Kessler,
R. E.,
CHARLES K. TASHIMA.
Zimmon, D. S. Surgery Gynec. Obstet. 1967, 124,
594.
2. Furste, W. Archs
Surg. 1959, 79, 600.
DIETARY FIBRE AND ENERGY INTAKE
grateful for Dr James’s and Dr Cummings’s 61) detailed discussion of my hypothesise but I am afraid they have misunderstood it. I did not claim that adding fibre to the diet automatically reduces energy intake or sugar intake. This may be true if unpalatably large amounts of fibre are swallowed. However, a person wishing to take more fibre by eating bran may well add sugar to the bran to make it more palatable, and so increase SIR,—I
(Jan. 12,
am
p.
both his sugar and energy intake. The aim of my paper was to support and develop Cleave’s concept that the fibre-depletion involved in sugar-refining and white-flour milling alters the physical state of the diet, which becomes artificially easier and quicker to ingest, and less satisfying for a given energy intake than traditional unrefined diets. Perhaps misunderstanding could have been avoided if the paper had been entitled Fibre Depletion, a Spur to Energy Intake. I cannot take seriously the suggestion that a high-fibre
369
(I prefer the term full-fibre) diet can lead to malnutrition in children. Vegetarianism would have died a natural death long ago if this was true. Variety is an axiom of good nutrition, and if a maize-meal/porridge diet favours kwashiorkor this is surely due to the lack of variety, not to the use of whole maize as opposed to refined corn flour. Dr James and Dr Cummings quote unpublished work support their statement that faecal fat and nitrogen on a high-fibre diet are largely unavailable because associated with the fibre. I shall be interested to see these data when they are published. If this is true, I shall be quite happy to modify my suggestion that small intestinal function is reduced by fibre. This is in any case the third and least important of the mechanisms postulated as obstructing energy intake.
to
It would indeed be naive to " hail fibre as a panacea for the diseases of civilisation ". A panacea is a remedy. My paper did not suggest that fibre is a remedy for obesity but rather a prophylactic against it. As for the preventive action required, it is not to add fibre to our food but to stop taking fibre away from it. The difference is subtle but crucial. Department of Medicine, Bristol Royal Infirmary, Bristol BS2 8HW.
K. W. HEATON.
1. Heaton, K. W. Lancet, 1973, ii, 1418.
ORAL CONTRACEPTION AND SEX RATIO AT BIRTH
SIR,-Attention is being concentrated on the possibility that oral contraception before pregnancy increases the chance that infants delivered subsequently will be female. I,2 Such an effect on sex ratio at birth would have important social consequences. We have investigated our own material in the past two years. The total series consisted of 560 babies, and the sex ratio was 0-4589 (257/303)-i.e., 45-89% of the newborns were male (p > 030). Where the mother had taken oral contraceptives for more than 2 years the percentage of female babies increased further. In this latter group the sex ratio was 0.3411 (58/112) (p < 002). After use of ari LU.C.D. the sex ratio was 0.5135 (46/40)-similar to the general world ratio at birth (0-5146). We have considered the possible involvement of immune mechanisms in this phenomenon. Significant reduction of cell-mediated immunity has been demonstrated in women taking contraception-pills. 3,4 Other reports suggest that histocompatibility differences between mother and fetus play a role at implantation, and male blastocysts bearing Ylinked antigen would be more successfully implanted than female blastocysts.5 If the maternal cell-mediated immunity after oral contraception is really depressed, the role of antigen difference may possibly decrease at implantation and hence fewer male blastocysts will be implanted, with a resultant diminution of the sex ratio at birth. The preponderance of female babies in our own material might support this hypothesis. Department of Obstetrics and
Gynæcology, University Medical School, W.H.O. Clinical Research Centre Human Reproduction, H-6725 Szeged, Hungary.
on
T. L. KESERÜ A. MARÁZ J. SZABÓ.
1. Crawford, J. S. Lancet, 1973, i, 858. 2. James, W. ibid. p. 1061. 3. Hagen, C., Froland, A. ibid. 1972, i, 1185. 4. Irvine, W. J. Res. Reproduction, I.P.P.F. 1973, 5, no. 5. 5. Kirby, D. R. S. in Ovo-Implantation; p. 86. Basle, 1970.
Medicine and the Law
Order for Disclosure of Hospital’s Medical Records ON Feb. 14, 1969, a patient attended a hospital for dental She alleged that, for the purpose, or in the course, of that treatment, she was given an anaesthetic injection in a negligent manner with the result that she sustained a serious and permanent disability of her left hand. She consulted solicitors and entrusted them to act for her in connection with a claim for damages for her alleged injuries against the hospital committee. The solicitors made certain inquiries, obtained medical opinion, but took no steps to start legal proceedings. As a result, the patient’s claim against the hospital committee became statute barred in February, 1972. The patient then consulted other solicitors, and, in February, 1973, she issued a writ against her former solicitors claiming damages for breach of contract or breach of duty. The statement of claim and the defence in her action against her former solicitors were served by April, 1973. In July, 1973, the patient applied to a High Court master in chambers for, and obtained, pursuant to Order 24, rule 7A(2) of the Rules of the Supreme Court, an order requiring the hospital committee to disclose to her the medical case-notes and other records relating to her treatment at the hospital. The hospital committee appealed against that order on the ground that the patient was not "a party to any proceedings in which a claim in respect of personal injuries is made" within the meaning of section 32(1) of the Administration of Justice Act 1970, and also contended that her claim against her former solicitors was a claim in respect of a lost cause of action or a lost chance; that it was not a claim in respect of personal injuries; and that the claim referred to in section 32(1) was limited to a claim against the person or persons causing the injury or against those vicariously liable. treatment.
Mr Justice BOREHAM said that there were a number of decisions in which the words " in respect of " had been considered by the courts. In each of those decisions the words were given their ordinary and unrestricted meaning and there was no discernible reason why they should not be similarly interpreted in section 32(1). The words " in " respect of conveyed some connection between the patient’s claim and the personal injuries sustained by her. On the further question whether there was in the proceedings brought by her against her former solicitors a connection or relation between her claim and her personal injuries, it was sufficient to say that the nature and extent of her personal injuries formed an essential ingredient in the proof of her claim-unless she could prove such injuries she would fail. In those circumstances, whatever her cause of action-whether or not in contract-there was a clear and firm connection or relation between her claim and her personal injuries. In his Lordship’s judgment, to quote section 32(1), she was " a party to ... proceedings in which claim in respect of personal injuries to a person ... is made ". As such she was entitled to the order made by the master in chambers and the appeal would be dismissed with costs. Leave to appeal granted. a
Paterson v. Northampton and District Hospital Management Committee. Queen’s Bench Division : BorehamJ., Feb. 22, 1974. Counsel and solicitors: Charles Colston (Bower, Cotton and Bower for Becke Phipps and Co., Northampton) for the hospital committee; Alan Cooper (Williams and Co., Bedford) for the patient.
P. R. K. MENON, Barrister-at-Law.