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ESSENTIAL FATTY ACIDS, LIPID METABOLISM, AND ATHEROSCLEROSIS
857
border. Its tip was congested and contained a tumour the size of a lentil. Very many ascarids could be felt in the small The diverticulum was removed and its stump intestine.
invaginated without narrowing the lumen of the ileum. The postoperative course was complicated by persistent paralytic ileus, with abdominal distension and vomiting, which subsided only after continuous gastric suction for 48 hours. An enema returned black blood and clots in great quantity. Intravenous fluids were given. On Nov. 26 the Hb was 72%, and 600 ml. blood was transfused. On the third postoperative day the child was allowed out of bed, and on Dec. 5 he was discharged. The diverticulum was 4 cm. long, and 1-3 cm. wide at the base. The mucosa was generally of the small-intestine type, but at the tip of the diverticulum was an islet of gastric mucosa. Just near this was an ulcer, smaller than the ectopic tissue, not very deep, covered with a clot of blood. Microscopic examination of the specimen (Dr. H. Breazu, Ploesti) showed at this level a deep layer of tubular glands of gastric type.
The
diagnosis was difficult in that the patient had had previous alimentary-tract hxmorrhages, the illness started with fever, X-ray examination was inconclusive, and there was no umbilical anomaly to point to a diverno
ticulum. The ulcer is usually situated near the point where the mucosa of the ileum joins that of the diverticulum, but in this case this region was normal. An ulcer at the tip of the diverticulum is very rare, and we have found only one report of such a case.2 When one of these ulcers bleeds, operation is always necessary, for death may be caused by continued hsemorrhage into the gut, perforation followed by generalised peritonitis, or ulceration of the mesodiverticulum with
intraperitoneal hxmorrhage.3 Cimpina Hospital, Rumania.
CONSTANTIN CEPLEANU ION TUTICA.
HOOKWORM AND ANÆMIA
SiR,ŇThe association between hookworm infestation iron-deficiency anxmia is almost traditional. Bilharz first described hookworm in Egypt in 1851. Three years later his pupil Griesinger4 linked hookworm infestation with the disease called Egyptian chlorosis. Ashford’s5 description (1900) of patients in Puerto Rico with severe anxmia and heavy infestation with the worms received wide recognition. Thereafter ancylostomiasis was regularly added to the list of causes of iron deficiency in stanand
dard textbooks of medicine. Loss of blood at the site of attachment of the worms was generally thought to be the immediate cause of the anaemia. But in recent years some serious doubts have been expressed. The load of worms, as judged by the ova count in the fxces, rarely correlates with the severity of the anaemia. Furthermore patients with an apparently heavy infestation are not always anaemic. The suspicion has grown that the association between hookworm and ansemia is fortuitous, since people infested with the worm commonly live on diets composed chiefly of cereals, poor in proteins, calcium, and ascorbic acid. On such a diet defective absorption of iron would be expected. Foy and Kondi 6-two hsematologists with wide experience in the " tropics-have summarised present views as follows: The consensus of opinion then is that hookworms are not a common cause of anaemia, but until more critical work has been done it is better to leave the question open." 2. Moore, C. T. Surg. Gynec. Obstet. 1956, 103, 569. 3. Weese, K. Zbl Chir. 1954. 79, 588. 4. Griesinger, W. Arch. physiol. Heilkunde, 1854, 13, 555. 5. Ashford, B. K. N.Y. med. J. 1900, 71, 552. 6. Foy, H., Kondi, A. J. trop. Med. (Hyg.) 1957, 60, 105.
At this moment of uncertainty we wish to draw attention to the original observations of Boycott and Haldane7 who investigated the cause of severe anaemia among tinminers in Cornwall. This had been attributed to bad air, but this explanation they quickly put out of court. Boycott and Haldane found that the men were heavily infested with Ancylostoma duodenale, the larvae of which penetrated their clothing soaked in mine water. Some of the men had less than 40% of haemoglobin. Such a degree of anxmia in an adult male could not possibly be attributed to any defect in the common British diet of that time. Boycott and Haldane added a remarkable observation. Using the carbon-monoxide method for measuring bloodvolume, developed in Edinburgh by Haldane and Lorrain Smith,8 they showed that in some of the anaemic Cornish miners the blood-volume was increased, so that the anaemia was due to hsemodilution rather than to loss of blood from the gastrointestinal tract. We suggest that a properly financed research project into the association between hookworm and anaemia is now overdue. A. P. MEIKLEJOHN Departments of Medicine and Physiology, R. PASSMORE. of University Edinburgh. ESSENTIAL FATTY ACIDS, LIPID METABOLISM, AND ATHEROSCLEROSIS
SIR,-Irr The Lancet of April 5 Dr. Keys takes statements contained in our paper which Feb. 15. If we have misquoted Dr. Keys, we are very sorry indeed. I should, however, like to in field out the of that, point dietary fats, it is very difficult not to misquote Dr. Keys, inasmuch as his concepts and statements have differed very radically from one year to the next. Perhaps this is to some degree unavoidable in a field in which knowledge is progressing very rapidly. We should, however, like to suggest that the presentation of precise mathematical formulations that enable one to predict precisely that John Smith’s cholesterol level will be precisely so much, in response to precisely so much saturated and unsaturated fat, is very premature indeed. As noted in our paper of Feb. 15, not only the relative but the absolute amount of polyunsaturated fat required to produce a given fall in the level of cholesterol and other plasma-lipids varies markedly with the age of the patient, and the presence of known atherosclerosis. Older individuals with obvious vascular disease may for a time require complete removal of saturated fat from the diet and the administration of large amounts of linoleicacid-containing fat, in order to obtain a significant and maintained fall in lipids. Young normal individuals may respond to quite modest amounts of polyunsaturated fats in the presence of appreciable amounts of saturated fat. We can agree in part with Dr. Keys’ present thoughts -that is, those of his thoughts stated in his letter in the 5 issue of The Lancet-regarding the relatively April " neutral " properties of oleic acid as compared to carbohydrate, if one considers only the effects upon plasmacholesterol levels. However, the effects upon plasmatriglyceride are very different, inasmuch as, at least in our experience, there is a very marked rise in plasmatriglyceride when carbohydrate is substituted for any type of fat in the diet. This is not observed when highly purified ethyl oleate is administered. Conceivably, the
exception to appeared on
7. Boycott, A. 8. Haldane, J.
E., Haldane, J. S. J. Hyg., Camb. 1903, 3, 95. S., Lorrain Smith, J. J. Physiol. 1900, 25, 33.
858
elevated triglyceride level with high carbohydrate feeding is in some way related to marked acceleration of lipo-
genesis. A
final
comment
concerning " essential-fatty-acid
essential nutrient, by definition, is one which cannot be synthesised in the body in adequate amount. If it is not supplied in the diet, its absence will eventually be associated with abnormalities of structure and/or function. Linoleic acid appears to fulfil the requirements of this definition. The fact that, in abnormal
deficiency
":
an
individuals, relatively large quantities are required to produce the desired metabolic effects seems to us beside the point, insofar as essentiality is concerned. When we have a solid understanding of the way in which linoleic acid lowers plasma-lipid levels, we will be in a much better position to talk of physiologic versus pharmacologic effects. "
Institute for Metabolic Research, Highland Alameda County Hospital, Oakland, California.
"
LAURANCE W. KINSELL.
ABSENCE FROM WORK ON A MEDICAL CERTIFICATE
SIR,-Dr. Ashworth (April 5) must be given the benefit of the doubt in case he is really trailing his coat. However, he reports the case of the father of two sick children whose wife is working in fear of dismissal, in which it seems indefensible to issue a National Insurance medical certificate. Humanity should be satisfied, by all means, by giving a note for the respective employer of father or mother stating that their children are ill and require the attention of a parent; but " to confuse humanity with " expeditiousness seems wrong. To advocate this wide interpretation of sickness certification, whilst expedient, will in fact discredit the National Health Service further (or rather the general practitioner) and substantiate the employers’ mistrust of medical certificates. Such interpretation will encourage all the other parents, who as yet are too self-respecting, to follow this example at the next opportunity. Sickness benefit for a parent is not to be confused with payment for parental duties. The statement which the doctor signs on form Med. 1 is that his patient is incapable of work. The specious argument-that 5 % or 3 % of E840 million is a negligible sum, which can be ignored and is cheap at the price for wrongful application of sickness benefits-holds no water. There are many necessary improvements in the Health Service which could be carried out if this sum were available.
Arising from this I should like to raise another issue. seems to me impossible to give an honest note in a large proportion of requests for a day or two’s absence. If pressed, one could write a full report in which the It
cons could be stated, and for which the proper fee would be charged. While giving what is in effect a " duplicate of a panel " note for, say, 2s., is a reasonable proposition and a convenience to employer and employee, to certify for 2s. that a man is unfit to work -today but will be recovered from his lumbago tomorrow is a convenience only to the dishonest. By this means a man can blackmail his employer-who may well know that he was at a football match-into paying him a bonus. This policy has brought certification into contempt both by employer and employee, as I well know from speaking to both: Anyone ", they say, can get time off if they pay their doctor 2s." I believe that employers would get less absenteeism if they relied upon a written statement from the workerthe majority of whom are honest-and it would save the genuine patient the inconvenience of waiting in the surgery. It would save the drug-bill the cost of innumerable bottles of medicine which one feels bound to give to relieve symptoms in patients one has decided are not fit for work, and I am sure it would improve the status of doctors if they did not show themselves so ready to be deceived. I know that this has been debated more than once by the B.M.A., but on the grounds I have given I would appeal for a discontinuation of the practice of what is in effect, though not intent, misleading certification.
pros and
"
"
Shirley, Solihull, Warwickshire.
W. BRIAN GOUGH.
PORTABLE BED-BOARDS
SIR,-Thousands of people with backache, due to intervertebral-disc and other lesions, now prefer to sleep on hard beds. These people must avoid the well-sprung mattress. Holidays and visits away from home are spoiled by backache through sleeping in comfort. I have had made for me what might be described as a small tap-mat-made of hard wood and backed with canvas. This can be rolled up, put in a car, and carried round with ease-then laid under a mattress. When rolled
E. V. KUENSSBERG.
SiR,-Many of us will have been given food for thought by Dr. Ashworth’s excellent article. One is relieved to see the relative smallness of unjust claims, and this is probably easily offset by those who work when, by all the rules, they should be in bed (though most of us could say from experience that this has surprisingly few illeffects). Unless there is clear evidence to the contrary, one has to accept that the patient is giving the facts as he knows them. To start on the assumption that one is being misled, as I suppose a professional referee has to do, would make life impossible; and, anyway, in self-defence one has. to play for safety. A patient who collapses with pneumonia or coronary disease after being sent off to work lends no credit to the profession; nor is the man who has to be sent home with a temperature after seeing his doctor on the way to work when his temperature was normal. As Dr. Ashworth says, one may have to observe a patient for a time before making a firm decision.
Above, portable bed-boards; below, rolled for transport.
border. Its tip was congested and contained a tumour the size of a lentil. Very many ascarids could be felt in the small The diverticulum was removed and its stump intestine.
invaginated without narrowing the lumen of the ileum. The postoperative course was complicated by persistent paralytic ileus, with abdominal distension and vomiting, which subsided only after continuous gastric suction for 48 hours. An enema returned black blood and clots in great quantity. Intravenous fluids were given. On Nov. 26 the Hb was 72%, and 600 ml. blood was transfused. On the third postoperative day the child was allowed out of bed, and on Dec. 5 he was discharged. The diverticulum was 4 cm. long, and 1-3 cm. wide at the base. The mucosa was generally of the small-intestine type, but at the tip of the diverticulum was an islet of gastric mucosa. Just near this was an ulcer, smaller than the ectopic tissue, not very deep, covered with a clot of blood. Microscopic examination of the specimen (Dr. H. Breazu, Ploesti) showed at this level a deep layer of tubular glands of gastric type.
The
diagnosis was difficult in that the patient had had previous alimentary-tract hxmorrhages, the illness started with fever, X-ray examination was inconclusive, and there was no umbilical anomaly to point to a diverno
ticulum. The ulcer is usually situated near the point where the mucosa of the ileum joins that of the diverticulum, but in this case this region was normal. An ulcer at the tip of the diverticulum is very rare, and we have found only one report of such a case.2 When one of these ulcers bleeds, operation is always necessary, for death may be caused by continued hsemorrhage into the gut, perforation followed by generalised peritonitis, or ulceration of the mesodiverticulum with
intraperitoneal hxmorrhage.3 Cimpina Hospital, Rumania.
CONSTANTIN CEPLEANU ION TUTICA.
HOOKWORM AND ANÆMIA
SiR,ŇThe association between hookworm infestation iron-deficiency anxmia is almost traditional. Bilharz first described hookworm in Egypt in 1851. Three years later his pupil Griesinger4 linked hookworm infestation with the disease called Egyptian chlorosis. Ashford’s5 description (1900) of patients in Puerto Rico with severe anxmia and heavy infestation with the worms received wide recognition. Thereafter ancylostomiasis was regularly added to the list of causes of iron deficiency in stanand
dard textbooks of medicine. Loss of blood at the site of attachment of the worms was generally thought to be the immediate cause of the anaemia. But in recent years some serious doubts have been expressed. The load of worms, as judged by the ova count in the fxces, rarely correlates with the severity of the anaemia. Furthermore patients with an apparently heavy infestation are not always anaemic. The suspicion has grown that the association between hookworm and ansemia is fortuitous, since people infested with the worm commonly live on diets composed chiefly of cereals, poor in proteins, calcium, and ascorbic acid. On such a diet defective absorption of iron would be expected. Foy and Kondi 6-two hsematologists with wide experience in the " tropics-have summarised present views as follows: The consensus of opinion then is that hookworms are not a common cause of anaemia, but until more critical work has been done it is better to leave the question open." 2. Moore, C. T. Surg. Gynec. Obstet. 1956, 103, 569. 3. Weese, K. Zbl Chir. 1954. 79, 588. 4. Griesinger, W. Arch. physiol. Heilkunde, 1854, 13, 555. 5. Ashford, B. K. N.Y. med. J. 1900, 71, 552. 6. Foy, H., Kondi, A. J. trop. Med. (Hyg.) 1957, 60, 105.
At this moment of uncertainty we wish to draw attention to the original observations of Boycott and Haldane7 who investigated the cause of severe anaemia among tinminers in Cornwall. This had been attributed to bad air, but this explanation they quickly put out of court. Boycott and Haldane found that the men were heavily infested with Ancylostoma duodenale, the larvae of which penetrated their clothing soaked in mine water. Some of the men had less than 40% of haemoglobin. Such a degree of anxmia in an adult male could not possibly be attributed to any defect in the common British diet of that time. Boycott and Haldane added a remarkable observation. Using the carbon-monoxide method for measuring bloodvolume, developed in Edinburgh by Haldane and Lorrain Smith,8 they showed that in some of the anaemic Cornish miners the blood-volume was increased, so that the anaemia was due to hsemodilution rather than to loss of blood from the gastrointestinal tract. We suggest that a properly financed research project into the association between hookworm and anaemia is now overdue. A. P. MEIKLEJOHN Departments of Medicine and Physiology, R. PASSMORE. of University Edinburgh. ESSENTIAL FATTY ACIDS, LIPID METABOLISM, AND ATHEROSCLEROSIS
SIR,-Irr The Lancet of April 5 Dr. Keys takes statements contained in our paper which Feb. 15. If we have misquoted Dr. Keys, we are very sorry indeed. I should, however, like to in field out the of that, point dietary fats, it is very difficult not to misquote Dr. Keys, inasmuch as his concepts and statements have differed very radically from one year to the next. Perhaps this is to some degree unavoidable in a field in which knowledge is progressing very rapidly. We should, however, like to suggest that the presentation of precise mathematical formulations that enable one to predict precisely that John Smith’s cholesterol level will be precisely so much, in response to precisely so much saturated and unsaturated fat, is very premature indeed. As noted in our paper of Feb. 15, not only the relative but the absolute amount of polyunsaturated fat required to produce a given fall in the level of cholesterol and other plasma-lipids varies markedly with the age of the patient, and the presence of known atherosclerosis. Older individuals with obvious vascular disease may for a time require complete removal of saturated fat from the diet and the administration of large amounts of linoleicacid-containing fat, in order to obtain a significant and maintained fall in lipids. Young normal individuals may respond to quite modest amounts of polyunsaturated fats in the presence of appreciable amounts of saturated fat. We can agree in part with Dr. Keys’ present thoughts -that is, those of his thoughts stated in his letter in the 5 issue of The Lancet-regarding the relatively April " neutral " properties of oleic acid as compared to carbohydrate, if one considers only the effects upon plasmacholesterol levels. However, the effects upon plasmatriglyceride are very different, inasmuch as, at least in our experience, there is a very marked rise in plasmatriglyceride when carbohydrate is substituted for any type of fat in the diet. This is not observed when highly purified ethyl oleate is administered. Conceivably, the
exception to appeared on
7. Boycott, A. 8. Haldane, J.
E., Haldane, J. S. J. Hyg., Camb. 1903, 3, 95. S., Lorrain Smith, J. J. Physiol. 1900, 25, 33.
858
elevated triglyceride level with high carbohydrate feeding is in some way related to marked acceleration of lipo-
genesis. A
final
comment
concerning " essential-fatty-acid
essential nutrient, by definition, is one which cannot be synthesised in the body in adequate amount. If it is not supplied in the diet, its absence will eventually be associated with abnormalities of structure and/or function. Linoleic acid appears to fulfil the requirements of this definition. The fact that, in abnormal
deficiency
":
an
individuals, relatively large quantities are required to produce the desired metabolic effects seems to us beside the point, insofar as essentiality is concerned. When we have a solid understanding of the way in which linoleic acid lowers plasma-lipid levels, we will be in a much better position to talk of physiologic versus pharmacologic effects. "
Institute for Metabolic Research, Highland Alameda County Hospital, Oakland, California.
"
LAURANCE W. KINSELL.
ABSENCE FROM WORK ON A MEDICAL CERTIFICATE
SIR,-Dr. Ashworth (April 5) must be given the benefit of the doubt in case he is really trailing his coat. However, he reports the case of the father of two sick children whose wife is working in fear of dismissal, in which it seems indefensible to issue a National Insurance medical certificate. Humanity should be satisfied, by all means, by giving a note for the respective employer of father or mother stating that their children are ill and require the attention of a parent; but " to confuse humanity with " expeditiousness seems wrong. To advocate this wide interpretation of sickness certification, whilst expedient, will in fact discredit the National Health Service further (or rather the general practitioner) and substantiate the employers’ mistrust of medical certificates. Such interpretation will encourage all the other parents, who as yet are too self-respecting, to follow this example at the next opportunity. Sickness benefit for a parent is not to be confused with payment for parental duties. The statement which the doctor signs on form Med. 1 is that his patient is incapable of work. The specious argument-that 5 % or 3 % of E840 million is a negligible sum, which can be ignored and is cheap at the price for wrongful application of sickness benefits-holds no water. There are many necessary improvements in the Health Service which could be carried out if this sum were available.
Arising from this I should like to raise another issue. seems to me impossible to give an honest note in a large proportion of requests for a day or two’s absence. If pressed, one could write a full report in which the It
cons could be stated, and for which the proper fee would be charged. While giving what is in effect a " duplicate of a panel " note for, say, 2s., is a reasonable proposition and a convenience to employer and employee, to certify for 2s. that a man is unfit to work -today but will be recovered from his lumbago tomorrow is a convenience only to the dishonest. By this means a man can blackmail his employer-who may well know that he was at a football match-into paying him a bonus. This policy has brought certification into contempt both by employer and employee, as I well know from speaking to both: Anyone ", they say, can get time off if they pay their doctor 2s." I believe that employers would get less absenteeism if they relied upon a written statement from the workerthe majority of whom are honest-and it would save the genuine patient the inconvenience of waiting in the surgery. It would save the drug-bill the cost of innumerable bottles of medicine which one feels bound to give to relieve symptoms in patients one has decided are not fit for work, and I am sure it would improve the status of doctors if they did not show themselves so ready to be deceived. I know that this has been debated more than once by the B.M.A., but on the grounds I have given I would appeal for a discontinuation of the practice of what is in effect, though not intent, misleading certification.
pros and
"
"
Shirley, Solihull, Warwickshire.
W. BRIAN GOUGH.
PORTABLE BED-BOARDS
SIR,-Thousands of people with backache, due to intervertebral-disc and other lesions, now prefer to sleep on hard beds. These people must avoid the well-sprung mattress. Holidays and visits away from home are spoiled by backache through sleeping in comfort. I have had made for me what might be described as a small tap-mat-made of hard wood and backed with canvas. This can be rolled up, put in a car, and carried round with ease-then laid under a mattress. When rolled
E. V. KUENSSBERG.
SiR,-Many of us will have been given food for thought by Dr. Ashworth’s excellent article. One is relieved to see the relative smallness of unjust claims, and this is probably easily offset by those who work when, by all the rules, they should be in bed (though most of us could say from experience that this has surprisingly few illeffects). Unless there is clear evidence to the contrary, one has to accept that the patient is giving the facts as he knows them. To start on the assumption that one is being misled, as I suppose a professional referee has to do, would make life impossible; and, anyway, in self-defence one has. to play for safety. A patient who collapses with pneumonia or coronary disease after being sent off to work lends no credit to the profession; nor is the man who has to be sent home with a temperature after seeing his doctor on the way to work when his temperature was normal. As Dr. Ashworth says, one may have to observe a patient for a time before making a firm decision.
Above, portable bed-boards; below, rolled for transport.