- Email: [email protected]
GARLIC PYELOGRAPHY
732
they result from periodic hypothalmic excitation provoked by a hypothetical inherent biorhythm, the effects of which are mediated autonomically. To date, there is no better explanation. Hahnemann Medical College & Hospital of Philadelphia,
Philadelphia, Pennsylvania 19102, U.S.A.
HOBART A. REIMANN.
GARLIC PYELOGRAPHY
SIR,-Apropos Dr Snell’s observation (July 7, p. 43) on garlic and the newborn, it does not seem to be commonly known in this country that in heavy garlic consumers there is no need to inject radio-opaque dyes to display the renal tract, especially where the ureters are somewhat atonic as in late pregnancy. This phenomenon was commonly seen in Maltese ladies from the antenatal clinics who, for one reason or another, were submitted to straight X-ray of the abdomen. Fairway, Tubwell Lane, Crowborough, Sussex.
R. L. MACPHERSON.
SJÖGREN’S
SYNDROME IN BEHCET’S DISEASE
SIR,-Dr Morgenstern and Dr Shearn1 describe hyperplasia of the thymus in Behcet’s disease, which suggests a role for immunological factors in its pathogenesis. Also suggestive are the reported association with lymphoma2 and the presence in the serum of patients with
Behçet’s disease of antibodies to human oral mucous membrane.3 Because it may have similar implications, we report the occurrence of salivary-gland abnormalities indistinguishable from those found in Sjogren’s syndrome in a patient with Behçet’s disease. A 38-year-old housewife had episodes of polyarthritis involving the knees, elbows, and wrists, which coincided with high fever, abdominal pain, and bloody diarrhoea. During several such episodes oral and genital ulcers as well as conjunctival inflammation were observed. Tests for lupus-erythematosus cells, rheumatoid factor, and antinuclear antibodies were repeatedly negative, as were stool cultures and investigations for parasites or their ova. X-ray examination of oesophagus, stomach, and small intestine were normal, but the colon showed widespread mucosal ulcers. Secretory parotid sialography revealed punctate sialectasia with abnormal retention of the dye in a film taken 24 hours later. Biopsy of the minor salivary glands of the lip4 showed infiltration by lymphocytes and plasma cells and duct-cell proliferation characteristic of Sjogren’s syndrome. Schirmer’s paper-strip tear measurement and Rose Bengal staining tests were normal.
Because Sjogren’s syndrome has been associated almost exclusively with diseases in which autoimmunity has been implicated,5 the finding of salivary-gland involvement akin to that found in Sjogren’s syndrome in a patient with Behcet’s disease further suggests a role of autoimmunity in the pathogenesis of this disease. Department of Immunology and Rheumatology, Instituto Nacional de la Nutrición, México 22 D.F.
JORGE RAMÍREZ-PEREDO JOSÉ A. CETINA DONATO ALARCON-SEGOVIA.
Morgenstern, N. L., Shearn, M. A. Lancet, 1973, i, 482. O’Duffy, J. D., Carney, J. A., Deodhar, S. Ann. intern. Med. 1971, 75, 561. 3. Oshima, Y., Shimizu, T., Yokohari, R., et al. Ann. rheum. Dis. 1963, 22, 36. 4. Chisholm, D. M., Mason, D. K. J. clin. Path. 1968, 21, 656. 5. Alarcon-Segovia, D., Diaz-Jouanen, E., Fishbein, E. Ann. intern. Med. 1973, 79, 31.
1. 2.
HUMAN PROTEIN AND ENERGY
REQUIREMENTS ? SIR,-Your leader (Aug. 18, p. 363) suggests that the success of the international agencies is to be judged by their ability to convene committees of international experts who can pronounce upon human nutrient requirements. But the convening of a committee is surely in itself no In examining the latest report on great achievement. protein and energy requirements, one must go beyond your review and question both the physiological basis for the recommendations and their implications. After many years of discussion, estimates of human protein requirements have now been reduced to such a level as to eliminate the world " protein gap ", although for reasons which were pointed out by three members of the W.H.O. committee,2 the Protein Advisory Group of the United Nations seems most unwilling to accept these new recommendations. The P.A.G. apparently finds support even within the W.H.O. expert committee, for one member felt it necessary to record a personal opinion to the effect that the safe level of protein intake should be 25% higher than the consensus view. There appears to be no disagreement amongst the committee in arriving at figures for energy requirement. This is surprising in view of the relatively inferior methodology and lack of data in this subject as compared with the protein field. The fundamental assumption made is that people in energy balance are eating the amount of energy they require. This assumption is not self-evident. It seems likely that, within wide limits, energy expenditure is a function of energy intake, since available evidence suggests energy balance can be achieved at widely different planes of nutrition. 3-7 The committee do in fact deferentially quote a 70-year-old reference to this effect,8 but then proceed to ignore it. Thus they arrive at a fixed requirement for " reference man " when in fact a range of intakes over which any individual could achieve energy balance would be more meaningful and not carry any connotations of absolute certainty. We are not alone in this view. In a recent letter to Nature 9 four scientists eminent in the field of human energetics admitted that we have no idea how much food man requires. Interestingly, two of the signatories were closely associated with the production of the latest W.H.O. recommendations. Apart from the practice of fixing a requirement we also view with reservation the committee’s continued use of the factorial method for assessing energy expenditure. Without detailing our criticisms of the physiological assumptions made when using this method, we feel that it is sufficient to point out that application of the method to the data recently obtained during the International Biological Programme would indicate that the energy intake of apparently healthy and active Ethiopians 10 and New Guineans 11 is considerably below their factorially estimated
requirements. Many of our criticisms could be regarded as being of academic interest and the report could be defended on the grounds of necessity and that it is the best that can be 1. Wld Hlth Org. tech. Rep. Ser. 1973, no. 522. 2. Harper, A. E., Payne, P. R., Waterlow, J. C. Lancet, 1973, i, 1518. 3. Neumann, R. O. Archs Hyg. 1902, 45, 1. 4. Gulik, A. Am. J. Physiol. 1922, 60, 3. 5. Keys, A., Brozek, J., Herschel, A., Mickelson, O., Taylor, H. L. The Biology of Human Starvation. Minneapolis, 1950. 6. Miller, D. S., Mumford, P. M. Am. J. clin. Nutr. 1967, 20, 1212. 7. Miller, D. S., Mumford, P. M., Stock, M. J. ibid. p. 1223. 8. Atwater, W. O., Benedict, F. G. Bull. Off. exp. Stn. U.S. Dept. Agric. 1902, 109. 9. Durnin, J. V. G. A., Edholm, O. G., Miller, D. S., Waterlow, J. C. Nature, 1973, 242, 418. 10. Miller, D. S., Rivers, J. Proc. nutr. Soc. 1972, 31, 32A. 11. Durnin, J. V. G. A., Norgan, N. G. Meeting of Royal Society, June 21, 1973. (in the press).
they result from periodic hypothalmic excitation provoked by a hypothetical inherent biorhythm, the effects of which are mediated autonomically. To date, there is no better explanation. Hahnemann Medical College & Hospital of Philadelphia,
Philadelphia, Pennsylvania 19102, U.S.A.
HOBART A. REIMANN.
GARLIC PYELOGRAPHY
SIR,-Apropos Dr Snell’s observation (July 7, p. 43) on garlic and the newborn, it does not seem to be commonly known in this country that in heavy garlic consumers there is no need to inject radio-opaque dyes to display the renal tract, especially where the ureters are somewhat atonic as in late pregnancy. This phenomenon was commonly seen in Maltese ladies from the antenatal clinics who, for one reason or another, were submitted to straight X-ray of the abdomen. Fairway, Tubwell Lane, Crowborough, Sussex.
R. L. MACPHERSON.
SJÖGREN’S
SYNDROME IN BEHCET’S DISEASE
SIR,-Dr Morgenstern and Dr Shearn1 describe hyperplasia of the thymus in Behcet’s disease, which suggests a role for immunological factors in its pathogenesis. Also suggestive are the reported association with lymphoma2 and the presence in the serum of patients with
Behçet’s disease of antibodies to human oral mucous membrane.3 Because it may have similar implications, we report the occurrence of salivary-gland abnormalities indistinguishable from those found in Sjogren’s syndrome in a patient with Behçet’s disease. A 38-year-old housewife had episodes of polyarthritis involving the knees, elbows, and wrists, which coincided with high fever, abdominal pain, and bloody diarrhoea. During several such episodes oral and genital ulcers as well as conjunctival inflammation were observed. Tests for lupus-erythematosus cells, rheumatoid factor, and antinuclear antibodies were repeatedly negative, as were stool cultures and investigations for parasites or their ova. X-ray examination of oesophagus, stomach, and small intestine were normal, but the colon showed widespread mucosal ulcers. Secretory parotid sialography revealed punctate sialectasia with abnormal retention of the dye in a film taken 24 hours later. Biopsy of the minor salivary glands of the lip4 showed infiltration by lymphocytes and plasma cells and duct-cell proliferation characteristic of Sjogren’s syndrome. Schirmer’s paper-strip tear measurement and Rose Bengal staining tests were normal.
Because Sjogren’s syndrome has been associated almost exclusively with diseases in which autoimmunity has been implicated,5 the finding of salivary-gland involvement akin to that found in Sjogren’s syndrome in a patient with Behcet’s disease further suggests a role of autoimmunity in the pathogenesis of this disease. Department of Immunology and Rheumatology, Instituto Nacional de la Nutrición, México 22 D.F.
JORGE RAMÍREZ-PEREDO JOSÉ A. CETINA DONATO ALARCON-SEGOVIA.
Morgenstern, N. L., Shearn, M. A. Lancet, 1973, i, 482. O’Duffy, J. D., Carney, J. A., Deodhar, S. Ann. intern. Med. 1971, 75, 561. 3. Oshima, Y., Shimizu, T., Yokohari, R., et al. Ann. rheum. Dis. 1963, 22, 36. 4. Chisholm, D. M., Mason, D. K. J. clin. Path. 1968, 21, 656. 5. Alarcon-Segovia, D., Diaz-Jouanen, E., Fishbein, E. Ann. intern. Med. 1973, 79, 31.
1. 2.
HUMAN PROTEIN AND ENERGY
REQUIREMENTS ? SIR,-Your leader (Aug. 18, p. 363) suggests that the success of the international agencies is to be judged by their ability to convene committees of international experts who can pronounce upon human nutrient requirements. But the convening of a committee is surely in itself no In examining the latest report on great achievement. protein and energy requirements, one must go beyond your review and question both the physiological basis for the recommendations and their implications. After many years of discussion, estimates of human protein requirements have now been reduced to such a level as to eliminate the world " protein gap ", although for reasons which were pointed out by three members of the W.H.O. committee,2 the Protein Advisory Group of the United Nations seems most unwilling to accept these new recommendations. The P.A.G. apparently finds support even within the W.H.O. expert committee, for one member felt it necessary to record a personal opinion to the effect that the safe level of protein intake should be 25% higher than the consensus view. There appears to be no disagreement amongst the committee in arriving at figures for energy requirement. This is surprising in view of the relatively inferior methodology and lack of data in this subject as compared with the protein field. The fundamental assumption made is that people in energy balance are eating the amount of energy they require. This assumption is not self-evident. It seems likely that, within wide limits, energy expenditure is a function of energy intake, since available evidence suggests energy balance can be achieved at widely different planes of nutrition. 3-7 The committee do in fact deferentially quote a 70-year-old reference to this effect,8 but then proceed to ignore it. Thus they arrive at a fixed requirement for " reference man " when in fact a range of intakes over which any individual could achieve energy balance would be more meaningful and not carry any connotations of absolute certainty. We are not alone in this view. In a recent letter to Nature 9 four scientists eminent in the field of human energetics admitted that we have no idea how much food man requires. Interestingly, two of the signatories were closely associated with the production of the latest W.H.O. recommendations. Apart from the practice of fixing a requirement we also view with reservation the committee’s continued use of the factorial method for assessing energy expenditure. Without detailing our criticisms of the physiological assumptions made when using this method, we feel that it is sufficient to point out that application of the method to the data recently obtained during the International Biological Programme would indicate that the energy intake of apparently healthy and active Ethiopians 10 and New Guineans 11 is considerably below their factorially estimated
requirements. Many of our criticisms could be regarded as being of academic interest and the report could be defended on the grounds of necessity and that it is the best that can be 1. Wld Hlth Org. tech. Rep. Ser. 1973, no. 522. 2. Harper, A. E., Payne, P. R., Waterlow, J. C. Lancet, 1973, i, 1518. 3. Neumann, R. O. Archs Hyg. 1902, 45, 1. 4. Gulik, A. Am. J. Physiol. 1922, 60, 3. 5. Keys, A., Brozek, J., Herschel, A., Mickelson, O., Taylor, H. L. The Biology of Human Starvation. Minneapolis, 1950. 6. Miller, D. S., Mumford, P. M. Am. J. clin. Nutr. 1967, 20, 1212. 7. Miller, D. S., Mumford, P. M., Stock, M. J. ibid. p. 1223. 8. Atwater, W. O., Benedict, F. G. Bull. Off. exp. Stn. U.S. Dept. Agric. 1902, 109. 9. Durnin, J. V. G. A., Edholm, O. G., Miller, D. S., Waterlow, J. C. Nature, 1973, 242, 418. 10. Miller, D. S., Rivers, J. Proc. nutr. Soc. 1972, 31, 32A. 11. Durnin, J. V. G. A., Norgan, N. G. Meeting of Royal Society, June 21, 1973. (in the press).