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SUNFLOWER-SEED OIL AND SERUM-LIPIDS
428 a matter of vital importance to the future of preventive medicine, and we should therefore give all the support we can to research work such as that which is being carried out at Haughley.
surely
Keats House, Guy’s
Hospital, London, S.E.1.
T. T. STAMM.
UNMARRIED PARENTHOOD
SIR,-The approach shown by Dr. Cordeaux’s letter last week is unphysiological. Young men, whether they know it or not, have to experiment to discover which of the socially acceptable patterns of eating and drinking available suit them best ; the need for similar experimenting in the doubly difficult (since two people have to be satisfied) field of sex must be obvious. Every branch of medicine must carry its quota of preventable tragedies ; but until the adoption societies can meet all the demands they receive for children I do not feel that that of the unmarried mother is very serious ; and I would prefer to ask your readers’ sympathy for couples who, because they are so well aware of the responsibilities of marriage, or perhaps cannot see a way of assuming them without jeopardising a worth-while career, defer matrimony until the late 30s. Many such couples, influenced by the propaganda of moral societies, abstain from intercourse in the misplaced trust that the mature affection and respect they feel for one another must lead to satisfactory physical consummation. No serious person doubts that morality is of the highest importance to any civilised society. But morality is not the same as dogma ; and moral agencies that dabble with sex without submitting their dogmata to continual scrutiny in the light of changing circumstances and increasing knowledge must carry a large share of responsibility for the divorces, delinquencies, frustrations, and ill health that spring directly from the failures in sexual adjustment. J. F. TUTHILL. X RAYS AND LEUKÆMIA
SiR,-I should like to congratulate Dr. Rabinowitch on his thoughtful letters (Dec. 15 and Jan. 26) and also to offer some further observations of my own. It is perhaps unfortunate that Dr. Alice Stewart’s preliminary communication (Sept. 1) on the possible relationship between malignant disease in childhood and diagnostic X rays in pregnancy received so much publicity. Many
doctors
and-with
doubt whether Dr. Stewart’s controls It is well known that X-ray examinations are much more commonly performed in the first pregnancy than in subsequent ones ; to be strictly comparable therefore the case and control groups should have been matched for parity. This point was raised by Dr. Ellis and Dr. Lewis (Sept. 15), Dr. Stewart’s reply being that " they were deliberately not matched for birth rank " and that " the child population dying of leukemia and cancer nowadays includes a disproportionately large number of first-born children and twins." But, if the control group had contained a similar " disproportionately large number of first-born children and twins," we should have expected more than 45 of the 547 mothers to have been X-rayed during pregnancy -perhaps even 85-in which case Dr. Stewart’s argument falls completely to the ground. 3. There is
are
reason to
acceptable.
In my opinion, Dr. Stewart has provided no convincing of any danger to the foetus during antenatal X-ray examinations. I would strongly suggest, therefore, that there shall be no change in the attitude of obstetricians and radiologists towards X rays in pregnancy until such time as Dr. Stewart completes and publishes her
proof
investigations. FRANK REID. SUNFLOWER-SEED OIL AND SERUM-LIPIDS SiR,-Bronte -Stewart et al.l reported that oral admin. istration of sunflower-seed oil or of a marine animal oil lowers the level of cholesterol and -lipoproteins in the serum, even when a high-fat diet is taken. The iodine value of the oil they used was 130-138, and its linoleic-acid content 60%. We have given sunflower-seed oil to six men, with occlusive vascular disease. (Its iodine value was 132’S, and it contained 59-3% linoleic acid, with palmitic 5-6%, stearic 2-2%, arachidonic 0-9%, and oleic 32.0%.) All but case 4 were treated as outpatients and had been on a low-fat diet for some months previously. The daily consumption of the oil (usually 100 g. in three or four doses) and the period of administration are shown in the chart. Apart from occasional diarrhoea and slight temporary nausea there were no gastro-intestinal disturbances, and no undue difficulties in continuing the treatment. Oral administration of sunflower-seed oil to this small group of patients, in whom the initial serum-cholesterol 1.
Bronte-Stewart, B., Antonis, A., Eales, L., Brock, J. 1956, i, 521.
F. Lancet.
more
excuse-patients seem to have accepted headline announcements such as : " X-ray Examinations Cause of Cancer in Children" proof that a case has been established. Much apprehension has been caused and there is evidence of a growing tendency to discard one of the most valuable diagnostic procedures in the elucidation of difficult obstetric problems. Personally, I can see no grounds for such fears in Dr. Stewart’s article, for the following reasons :
as
as
1. Only 85 of the 547 cases of leukaemia or cancer were exposed to antenatal irradiation. 2. 45 of the 547 controls were similarly irradiated, without any known ill effects to the fcetus. It is a reasonable assumption, therefore, that at least 45 of the malignant cases received a similar harmless This leaves only dose of X rays. 40 (7-3%) of the 547 cases in which leuksemia or cancer might have been caused by diagnostic irradiation.
Serum-cholesterol and phospholipid levels in six patients. The shaded areas indicate the periods during which sunflower-seed oil was given ; the figures represent the dose (g.) given each day.
429 EFFECT OF SUNFLOWER-SEED
OIL ON
CHOLESTEROL AND
PHOSPIIOLIPID LEVELS
(3) Acidity is most adequately estimated with a pH meter. If indicators have to be relied on it is probably better to use several. One can then detect increases of acidity which,
although not quite large enough to turn Topfer’s reagent (pH 3), suffice to show that secretion has occurred. Nevertheless we have always been able, except in absolute achlorhydria where the pH remains between 6 and 8, to obtain samples acid to Topfer’s reagent, and we test each sample at the bedside with this indicator.
and phospholipid levels were not excessively high, produced varying responses, those of cases 2 and 3 being In the others serumthe least striking (see table). cholesterol levels fell appreciably, with a tendency to rise during treatment in case 5. When the treatment was stopped (cases 1, 2, 5, and 6) or the dose of oil was reduced (case 4), these values tended to rise again
promptly. In
case 4, anticoagulant therapy, which had ceased four only days before sunflower-seed oil was given, may have influenced the earlier cholesterol concentrations. Anticoagulants had also been given in case 5-five months previously. Other patients with much higher initial serum-cholesterol and phospholipid levels have given more encouraging results with this treatment. These results correspond with those of Bronte-Stewart et aI., and seem to support their suggestion that serumlipid levels may be materially affected by the dietary intake of unsaturated fatty acids. "
We wish to thank Mr. A. D.
Wilson, of Unilever Ltd., who
supplied the oil, together with analytical data concerning its composition. We also thank Dr. Robert Gaddie, biochemist, General Hospital, Birmingham, for several of the blood analyses.
>
Queen Elizabeth Hospital, Birmingham.
G. E. OWEN WILLIAMS GARFIELD THOMAS.
most direct methods of confirming the of subacute combined degeneration of the cord are those which demonstrate an inability to absorb vitamin B12 or a deficiency of it in the serum. Dr. Berlyne and his colleagues (Feb. 9) describe a test of vitamin-B12 absorption which makes small demands on skill and labour, although it requires expensive apparatus. We think, however, that there is more to be said for gastric analysis than Dr. Berlyne and his colleagues say, and we would like to emphasise yet again the fallacies in conventional tests of gastric function.
SIR,-The
diagnosis
(1) The tube must be in the body of the stomach and not coiled near the cardia. To ensure this, it is best to pass the tube (once the tip is in the oesophagus) with the patient prone. The final position should be checked either by a radiograph or, more easily, with a magnet-tipped tube and compass.l (2) The secretory stimulus must be prolonged as well as powerful, so that where secretion is slow there is time for the antacid effect of saliva and other non-acid secretions which the fasting stomach may contain to be overcome. This requirement is not met by a single injection of histamine.2 We give, if necessary, four injections of 0-5 mg. of histamine acid phosphate at intervals of twenty minutes. 2.
Cardiff.
MANUAL ARTIFICIAL RESPIRATION IN THE SITTING POSTURE was interested to read the article by Dr. Ruben (Jan. 19). May I, however, query his Henning statement that " during the intermittent flexion of the body the abdominal viscera press not only on the diaphragm but also on the vena cava, thus possibly helping to pump the blood towards the heart." Should this stimulation of the circulation be put forward in a manner suggesting that it is good treatment ? "l Would it not tend to overload the right side of the heart which is already having difficulty in pumping blood round the inactive lungs ?‘ In such cases, stimulation of the circulation is usually recommended after breathing has recommenced. A. H. M. CAMPBELL.
SiB,—I
NEW DRUGS. OLD DANGERS
SiR,-Your leading article of Feb.
9 wisely advises us there is a clear indication for it, and has firmly established its superiority over its more familiar predecessors," adding that " then the occasional reaction is a risk that is to
RADIOACTIVE VITAMIN B12 IN THE DIAGNOSIS OF NEUROLOGICAL DISORDERS
1.
We have used gastric sampling in this way in cases where subacute combined degeneration was suspected, and have had help from it similar to that which Dr. Berlyne and his colleagues have had from their test with radioactive vitamin B12’ In particular, we have demonstrated the ability to secrete acid in 3 patients who, as result of ordinary testing, had been described as having " histamine-fast achlorhydria." We hope that Dr. Berlyne and his colleagues will use a gastric test of the kind we describe in conjunction with their further studies, which may then not render gastric analysis " outmoded." A. H. JAMES Royal Infirmary, C. A. PALLIS.
James, A. H. Lancet, 1951, i, 209. Watkinscn, G., James, A. H. Clin. Sci. 1951, 10,
255.
drug " only when when hospital trial
use a new
justified." By implication the drugs quoted have not passed these tests-phenylbutazone, probably because there are safer alternatives available, and chlorpromazine and meprobromate probably because the disability to be relieved often scarcely justifies the known risk. But we wonder whether carbimazole has not a more established place ?’? Like many widely used drugs unfortunately it is occasionally toxic, but probably less frequently than any available similar anti-thyroid drug 1: one alternative (perchlorate) may be less toxic, but a full assessment of its risk is not yet available, and its different anti-thyroid action gives a less satisfactory clinical control. Proper supervision of the use of such a drug should include provisions to ensure the early and full treatment of any toxic effects, and it is possible that some of the fatalities from carbimazole and similar drugs have occurred when these have failed-either when the carbimazole has not been stopped on the first symptoms2 or when the infection complicating the agranulocytosis has not been controlled.3 To any patients given carbimazole we give clear instructions to stop taking the drug and report immediately if pyrexia, sore throat, or other unusual symptoms develop, and blood-counts on these 1. Burrell, C. D., Fraser, R., Doniach, D. Brit. med. J. 2. Burrell, C. D. Ibid, p. 1456. 3. Tait, G. B. Lancet, Feb. 9, 1957, p. 303.
1956, i, 1453.
surely
Keats House, Guy’s
Hospital, London, S.E.1.
T. T. STAMM.
UNMARRIED PARENTHOOD
SIR,-The approach shown by Dr. Cordeaux’s letter last week is unphysiological. Young men, whether they know it or not, have to experiment to discover which of the socially acceptable patterns of eating and drinking available suit them best ; the need for similar experimenting in the doubly difficult (since two people have to be satisfied) field of sex must be obvious. Every branch of medicine must carry its quota of preventable tragedies ; but until the adoption societies can meet all the demands they receive for children I do not feel that that of the unmarried mother is very serious ; and I would prefer to ask your readers’ sympathy for couples who, because they are so well aware of the responsibilities of marriage, or perhaps cannot see a way of assuming them without jeopardising a worth-while career, defer matrimony until the late 30s. Many such couples, influenced by the propaganda of moral societies, abstain from intercourse in the misplaced trust that the mature affection and respect they feel for one another must lead to satisfactory physical consummation. No serious person doubts that morality is of the highest importance to any civilised society. But morality is not the same as dogma ; and moral agencies that dabble with sex without submitting their dogmata to continual scrutiny in the light of changing circumstances and increasing knowledge must carry a large share of responsibility for the divorces, delinquencies, frustrations, and ill health that spring directly from the failures in sexual adjustment. J. F. TUTHILL. X RAYS AND LEUKÆMIA
SiR,-I should like to congratulate Dr. Rabinowitch on his thoughtful letters (Dec. 15 and Jan. 26) and also to offer some further observations of my own. It is perhaps unfortunate that Dr. Alice Stewart’s preliminary communication (Sept. 1) on the possible relationship between malignant disease in childhood and diagnostic X rays in pregnancy received so much publicity. Many
doctors
and-with
doubt whether Dr. Stewart’s controls It is well known that X-ray examinations are much more commonly performed in the first pregnancy than in subsequent ones ; to be strictly comparable therefore the case and control groups should have been matched for parity. This point was raised by Dr. Ellis and Dr. Lewis (Sept. 15), Dr. Stewart’s reply being that " they were deliberately not matched for birth rank " and that " the child population dying of leukemia and cancer nowadays includes a disproportionately large number of first-born children and twins." But, if the control group had contained a similar " disproportionately large number of first-born children and twins," we should have expected more than 45 of the 547 mothers to have been X-rayed during pregnancy -perhaps even 85-in which case Dr. Stewart’s argument falls completely to the ground. 3. There is
are
reason to
acceptable.
In my opinion, Dr. Stewart has provided no convincing of any danger to the foetus during antenatal X-ray examinations. I would strongly suggest, therefore, that there shall be no change in the attitude of obstetricians and radiologists towards X rays in pregnancy until such time as Dr. Stewart completes and publishes her
proof
investigations. FRANK REID. SUNFLOWER-SEED OIL AND SERUM-LIPIDS SiR,-Bronte -Stewart et al.l reported that oral admin. istration of sunflower-seed oil or of a marine animal oil lowers the level of cholesterol and -lipoproteins in the serum, even when a high-fat diet is taken. The iodine value of the oil they used was 130-138, and its linoleic-acid content 60%. We have given sunflower-seed oil to six men, with occlusive vascular disease. (Its iodine value was 132’S, and it contained 59-3% linoleic acid, with palmitic 5-6%, stearic 2-2%, arachidonic 0-9%, and oleic 32.0%.) All but case 4 were treated as outpatients and had been on a low-fat diet for some months previously. The daily consumption of the oil (usually 100 g. in three or four doses) and the period of administration are shown in the chart. Apart from occasional diarrhoea and slight temporary nausea there were no gastro-intestinal disturbances, and no undue difficulties in continuing the treatment. Oral administration of sunflower-seed oil to this small group of patients, in whom the initial serum-cholesterol 1.
Bronte-Stewart, B., Antonis, A., Eales, L., Brock, J. 1956, i, 521.
F. Lancet.
more
excuse-patients seem to have accepted headline announcements such as : " X-ray Examinations Cause of Cancer in Children" proof that a case has been established. Much apprehension has been caused and there is evidence of a growing tendency to discard one of the most valuable diagnostic procedures in the elucidation of difficult obstetric problems. Personally, I can see no grounds for such fears in Dr. Stewart’s article, for the following reasons :
as
as
1. Only 85 of the 547 cases of leukaemia or cancer were exposed to antenatal irradiation. 2. 45 of the 547 controls were similarly irradiated, without any known ill effects to the fcetus. It is a reasonable assumption, therefore, that at least 45 of the malignant cases received a similar harmless This leaves only dose of X rays. 40 (7-3%) of the 547 cases in which leuksemia or cancer might have been caused by diagnostic irradiation.
Serum-cholesterol and phospholipid levels in six patients. The shaded areas indicate the periods during which sunflower-seed oil was given ; the figures represent the dose (g.) given each day.
429 EFFECT OF SUNFLOWER-SEED
OIL ON
CHOLESTEROL AND
PHOSPIIOLIPID LEVELS
(3) Acidity is most adequately estimated with a pH meter. If indicators have to be relied on it is probably better to use several. One can then detect increases of acidity which,
although not quite large enough to turn Topfer’s reagent (pH 3), suffice to show that secretion has occurred. Nevertheless we have always been able, except in absolute achlorhydria where the pH remains between 6 and 8, to obtain samples acid to Topfer’s reagent, and we test each sample at the bedside with this indicator.
and phospholipid levels were not excessively high, produced varying responses, those of cases 2 and 3 being In the others serumthe least striking (see table). cholesterol levels fell appreciably, with a tendency to rise during treatment in case 5. When the treatment was stopped (cases 1, 2, 5, and 6) or the dose of oil was reduced (case 4), these values tended to rise again
promptly. In
case 4, anticoagulant therapy, which had ceased four only days before sunflower-seed oil was given, may have influenced the earlier cholesterol concentrations. Anticoagulants had also been given in case 5-five months previously. Other patients with much higher initial serum-cholesterol and phospholipid levels have given more encouraging results with this treatment. These results correspond with those of Bronte-Stewart et aI., and seem to support their suggestion that serumlipid levels may be materially affected by the dietary intake of unsaturated fatty acids. "
We wish to thank Mr. A. D.
Wilson, of Unilever Ltd., who
supplied the oil, together with analytical data concerning its composition. We also thank Dr. Robert Gaddie, biochemist, General Hospital, Birmingham, for several of the blood analyses.
>
Queen Elizabeth Hospital, Birmingham.
G. E. OWEN WILLIAMS GARFIELD THOMAS.
most direct methods of confirming the of subacute combined degeneration of the cord are those which demonstrate an inability to absorb vitamin B12 or a deficiency of it in the serum. Dr. Berlyne and his colleagues (Feb. 9) describe a test of vitamin-B12 absorption which makes small demands on skill and labour, although it requires expensive apparatus. We think, however, that there is more to be said for gastric analysis than Dr. Berlyne and his colleagues say, and we would like to emphasise yet again the fallacies in conventional tests of gastric function.
SIR,-The
diagnosis
(1) The tube must be in the body of the stomach and not coiled near the cardia. To ensure this, it is best to pass the tube (once the tip is in the oesophagus) with the patient prone. The final position should be checked either by a radiograph or, more easily, with a magnet-tipped tube and compass.l (2) The secretory stimulus must be prolonged as well as powerful, so that where secretion is slow there is time for the antacid effect of saliva and other non-acid secretions which the fasting stomach may contain to be overcome. This requirement is not met by a single injection of histamine.2 We give, if necessary, four injections of 0-5 mg. of histamine acid phosphate at intervals of twenty minutes. 2.
Cardiff.
MANUAL ARTIFICIAL RESPIRATION IN THE SITTING POSTURE was interested to read the article by Dr. Ruben (Jan. 19). May I, however, query his Henning statement that " during the intermittent flexion of the body the abdominal viscera press not only on the diaphragm but also on the vena cava, thus possibly helping to pump the blood towards the heart." Should this stimulation of the circulation be put forward in a manner suggesting that it is good treatment ? "l Would it not tend to overload the right side of the heart which is already having difficulty in pumping blood round the inactive lungs ?‘ In such cases, stimulation of the circulation is usually recommended after breathing has recommenced. A. H. M. CAMPBELL.
SiB,—I
NEW DRUGS. OLD DANGERS
SiR,-Your leading article of Feb.
9 wisely advises us there is a clear indication for it, and has firmly established its superiority over its more familiar predecessors," adding that " then the occasional reaction is a risk that is to
RADIOACTIVE VITAMIN B12 IN THE DIAGNOSIS OF NEUROLOGICAL DISORDERS
1.
We have used gastric sampling in this way in cases where subacute combined degeneration was suspected, and have had help from it similar to that which Dr. Berlyne and his colleagues have had from their test with radioactive vitamin B12’ In particular, we have demonstrated the ability to secrete acid in 3 patients who, as result of ordinary testing, had been described as having " histamine-fast achlorhydria." We hope that Dr. Berlyne and his colleagues will use a gastric test of the kind we describe in conjunction with their further studies, which may then not render gastric analysis " outmoded." A. H. JAMES Royal Infirmary, C. A. PALLIS.
James, A. H. Lancet, 1951, i, 209. Watkinscn, G., James, A. H. Clin. Sci. 1951, 10,
255.
drug " only when when hospital trial
use a new
justified." By implication the drugs quoted have not passed these tests-phenylbutazone, probably because there are safer alternatives available, and chlorpromazine and meprobromate probably because the disability to be relieved often scarcely justifies the known risk. But we wonder whether carbimazole has not a more established place ?’? Like many widely used drugs unfortunately it is occasionally toxic, but probably less frequently than any available similar anti-thyroid drug 1: one alternative (perchlorate) may be less toxic, but a full assessment of its risk is not yet available, and its different anti-thyroid action gives a less satisfactory clinical control. Proper supervision of the use of such a drug should include provisions to ensure the early and full treatment of any toxic effects, and it is possible that some of the fatalities from carbimazole and similar drugs have occurred when these have failed-either when the carbimazole has not been stopped on the first symptoms2 or when the infection complicating the agranulocytosis has not been controlled.3 To any patients given carbimazole we give clear instructions to stop taking the drug and report immediately if pyrexia, sore throat, or other unusual symptoms develop, and blood-counts on these 1. Burrell, C. D., Fraser, R., Doniach, D. Brit. med. J. 2. Burrell, C. D. Ibid, p. 1456. 3. Tait, G. B. Lancet, Feb. 9, 1957, p. 303.
1956, i, 1453.