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MATERNAL DIET AND LIPID COMPOSITION OF BREAST MILK
563 MANAGERIAL HIERARCHIES SIR,-Dr Clarke (Aug. 25, p. 441) referred to the bureaucratic nature of the new management structure. May I say his views are shared by many administrators ? " Whatever is said in grey books ", the nature of the tiers and the extent to which the chairman and members must rely on area officers" for advice and information must ultimately lead to a superior "/" subordinate " relationship in course of time. Having said this, however, the strength of the district management team is the presence on it of the consultant and general practitioner members who, fortunately for them, are free of hierarchical entanglements. I would not take the view that they will be impotent. Speaking as an I have usually found consultants very administrator, " potent ". Also, I would take the view that administrators at least have sufficient independence of spirit not to become subservient to bureaucratic dictates. The first allegiance of all members of district management teams must be to the needs of the district, and I am sure that area health authorities and their officers would not think highly of district officers who were not oriented in this direction. The one basic requirement for successful management at district level is full cooperation by all members of the district management team, free of sectional interests. Once you have got this, it is difficult to see what can prevail against it.
"
body during acute infections ... ". The metabolic losses of tissue protein during acute infections result in significantly increased protein needs during convalescence (my italics). The Expert Committee agrees with this since the letter states " the Expert Committee recognised that infections increase the need for protein and other nutrients ". The offence is pointed out in the next part of the letter-namely, since the extent of this extra need is unknown, the only realistic course was to specify safe levels for healthy subjects. The P.A.G. report gives no guidance as to how much higher "
the ’safe ’ level should be ". Everyone agrees that the amount of the extra is unknown, but everyone also agrees that there is a need for extra protein under these conditions. The three members of the committee appear to me to be reading more into the P.A.G. report than was stated-a fault that may be due to loose drafting of the latter, exemplified by the statement (often repeated in examination papers) that " protein needs do not take account of the effects of maldistribution ". Needs are not altered by maldistribution; availability is. Department of Nutrition, Queen Elizabeth Hospital, Campden Hill, London W8 7AH.
A. E. BENDER.
A. J. ARGENT, Leighton Hospital, Nr. Crewe CW1 4QJ.
Group Secretary, South Cheshire Hospital Management Committee.
ACUPUNCTURE ANÆSTHESIA
SIR, The hypothesis of Dr Bull (Aug. 25, p. 417) concerning the mechanism of acupuncture anaesthesia is interesting in so far as it fits in with many of the facts MATERNAL DIET AND LIPID COMPOSITION OF BREAST MILK
SIR,-Dr Wellby and her colleagues (Aug. 25, p. 458) by no means the first to show how the composition of
are
breast milk depends upon maternal diet. In 1959 Insull et aLl showed that the percentage of polyunsaturated fatty acids in human milk could be raised from the usual value of about 10 to well over 40 when a diet rich in corn oil was taken by the mother. Addenbrooke’s Hospital,
Cambridge.
DOUGLAS GAIRDNER.
HUMAN PROTEIN NEEDS
SiR,—The disagreement between the two groups of experts on protein requirements (Dr Harper and others, June 30, p. 1518) is apparent rather than real. Three members of the F.A.O./W.H.O. Expert Committee on Energy and Protein Requirements take exception to statement no. 20 of the Protein Advisory Group (P.A.G.) for stating that the levels of protein intake recommended as safe by the F.A.O./W.H.O. Committee " are inadequate for most children in developing countries ". The letter states " we do question that there is sufficient evidence to justify the implication of the P.A.G. report that most children in developing countries would be at less risk from malnutrition if provided with a different kind of diet with a protein content higher by some unspecified amount than the ’safe level ’ of protein currently recommended ". This, however, is not what the P.A.G. report stated, but " the dietary needs of most young children in developing countries are increased, however, not only by poorer absorption of dietary protein caused by intestinal parasites, and chronic damage to the gastrointestinal tract from repeated infections, but also by the extra protein lost from the 1.
Insull, W., Hirsch, J., James, A. T., Ahrens, 1959, 38, 443.
E. H.
J. clin. Invest.
which have been recorded in acupuncture anaesthesia (actually analgesia). The difficulty is, though, that many of the commonly described facts are somewhat open to doubt. I have performed acupuncture anxsthesia on over 100 occasions and have found that it works well only in about 10% of cases. In a further 65% the analgesia is mild and patchy, while in the remaining 25% there is no or nearly no analgesia. Some patients who belong to the middle (65%) group could be anaesthetised if the stimulus was increased to what for a Westerner are torture levels. The 10% of patients who react well belong to a group whom I call " strong reactors ", who may be recognised as follows:
(1) If these patients are given an average dose of many medicines they feel ill. They respond well to small doses. This is clearly not an allergy. (2) If a needle is placed subcutaneously in a limb and twisted the average patient feels pain over a small surrounding area. The " strong reactor " on the other hand feels pain in the whole limb and sometimes even in most of the body. In " strong reactors " acupuncture analgesia is not a hypnotic phenomenon, for it can be achieved in the correct area even if the patient is told it will occur elsewhere. It seems that acupuncture anaesthesia is akin to dental anxsthesia by white sound, which requires both mental suggestion and white sound to be effective-either alone being insufficient. This is somewhat similar to asthma, which may be influenced by both physical and mental means.
Contrary to what is mentioned by Dr Bull, the frequency of stimulation is of little importance; but the size of the stimulus is a major factor. Also, contrary to what is said, there is a correlation between many acupuncture points and the peripheral nervous system-though this is somewhat academic, since acupuncture points exist no more than do the coordinates of a star. I know of no reliable authentic report in the West of acupuncture anaesthesia working in 90% of cases-as it is supposed to. There are many initial enthusiastic reports,
"
body during acute infections ... ". The metabolic losses of tissue protein during acute infections result in significantly increased protein needs during convalescence (my italics). The Expert Committee agrees with this since the letter states " the Expert Committee recognised that infections increase the need for protein and other nutrients ". The offence is pointed out in the next part of the letter-namely, since the extent of this extra need is unknown, the only realistic course was to specify safe levels for healthy subjects. The P.A.G. report gives no guidance as to how much higher "
the ’safe ’ level should be ". Everyone agrees that the amount of the extra is unknown, but everyone also agrees that there is a need for extra protein under these conditions. The three members of the committee appear to me to be reading more into the P.A.G. report than was stated-a fault that may be due to loose drafting of the latter, exemplified by the statement (often repeated in examination papers) that " protein needs do not take account of the effects of maldistribution ". Needs are not altered by maldistribution; availability is. Department of Nutrition, Queen Elizabeth Hospital, Campden Hill, London W8 7AH.
A. E. BENDER.
A. J. ARGENT, Leighton Hospital, Nr. Crewe CW1 4QJ.
Group Secretary, South Cheshire Hospital Management Committee.
ACUPUNCTURE ANÆSTHESIA
SIR, The hypothesis of Dr Bull (Aug. 25, p. 417) concerning the mechanism of acupuncture anaesthesia is interesting in so far as it fits in with many of the facts MATERNAL DIET AND LIPID COMPOSITION OF BREAST MILK
SIR,-Dr Wellby and her colleagues (Aug. 25, p. 458) by no means the first to show how the composition of
are
breast milk depends upon maternal diet. In 1959 Insull et aLl showed that the percentage of polyunsaturated fatty acids in human milk could be raised from the usual value of about 10 to well over 40 when a diet rich in corn oil was taken by the mother. Addenbrooke’s Hospital,
Cambridge.
DOUGLAS GAIRDNER.
HUMAN PROTEIN NEEDS
SiR,—The disagreement between the two groups of experts on protein requirements (Dr Harper and others, June 30, p. 1518) is apparent rather than real. Three members of the F.A.O./W.H.O. Expert Committee on Energy and Protein Requirements take exception to statement no. 20 of the Protein Advisory Group (P.A.G.) for stating that the levels of protein intake recommended as safe by the F.A.O./W.H.O. Committee " are inadequate for most children in developing countries ". The letter states " we do question that there is sufficient evidence to justify the implication of the P.A.G. report that most children in developing countries would be at less risk from malnutrition if provided with a different kind of diet with a protein content higher by some unspecified amount than the ’safe level ’ of protein currently recommended ". This, however, is not what the P.A.G. report stated, but " the dietary needs of most young children in developing countries are increased, however, not only by poorer absorption of dietary protein caused by intestinal parasites, and chronic damage to the gastrointestinal tract from repeated infections, but also by the extra protein lost from the 1.
Insull, W., Hirsch, J., James, A. T., Ahrens, 1959, 38, 443.
E. H.
J. clin. Invest.
which have been recorded in acupuncture anaesthesia (actually analgesia). The difficulty is, though, that many of the commonly described facts are somewhat open to doubt. I have performed acupuncture anxsthesia on over 100 occasions and have found that it works well only in about 10% of cases. In a further 65% the analgesia is mild and patchy, while in the remaining 25% there is no or nearly no analgesia. Some patients who belong to the middle (65%) group could be anaesthetised if the stimulus was increased to what for a Westerner are torture levels. The 10% of patients who react well belong to a group whom I call " strong reactors ", who may be recognised as follows:
(1) If these patients are given an average dose of many medicines they feel ill. They respond well to small doses. This is clearly not an allergy. (2) If a needle is placed subcutaneously in a limb and twisted the average patient feels pain over a small surrounding area. The " strong reactor " on the other hand feels pain in the whole limb and sometimes even in most of the body. In " strong reactors " acupuncture analgesia is not a hypnotic phenomenon, for it can be achieved in the correct area even if the patient is told it will occur elsewhere. It seems that acupuncture anaesthesia is akin to dental anxsthesia by white sound, which requires both mental suggestion and white sound to be effective-either alone being insufficient. This is somewhat similar to asthma, which may be influenced by both physical and mental means.
Contrary to what is mentioned by Dr Bull, the frequency of stimulation is of little importance; but the size of the stimulus is a major factor. Also, contrary to what is said, there is a correlation between many acupuncture points and the peripheral nervous system-though this is somewhat academic, since acupuncture points exist no more than do the coordinates of a star. I know of no reliable authentic report in the West of acupuncture anaesthesia working in 90% of cases-as it is supposed to. There are many initial enthusiastic reports,