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THE INTOLERANT COLON
1264 in with practical experience: correct posture and control of intra-abdominal pressure can do much to reduce strain on the back when heavy weights are lifted. Back strain
and
injury is an important industrial and medicolegal problem. Industry is becoming much more aware that there are right and wrong ways of lifting a weight; but there is still room for more instruction and training, which could drastically reduce the number of painful backs acquired in factory and yard. THE INTOLERANT COLON
CcELiAC disease has long been believed to be adversely affected by too much starchy food 1; but only about 10 years ago was this clinical impression rendered scientifically respectable.2-3 The inability of the small intestine in coeliac disease and idiopathic steatorrhoea to handle the breakdown products of gluten is currently thought to be due to an absolute or, more probably, a relative lack of one or more enzymes; and this deficiency is held by many to be of genetic origin. But there are difficulties in wholly accepting this idea. Known genetic enzyme defects are permanent, yet many cceliac children recover and come to tolerate a normal diet without clinical relapse. Again, although the disease in its severest form is extremely sensitive to gluten, especially early in remission, small amounts of gluten do not invariably provoke a relapse. Many patients who are ostensibly on glutenfree diets, but who secretly take normal food, will testify to this-somewhat sheepishly. Furthermore, before diets were coeliac children often employed, gluten-free recovered clinically; and reports of lasting remission due to psychotherapy alone 4 are difficult to reconcile with the idea that a genetically determined enzyme defect is solely responsible for the condition. Since, therefore, any enzyme deficiency there is can apparently be made good to some extent, it may be acquired rather than inherited. The question of the load of ingested gluten is also important: the 30 g. usually given to adults in tests of sensitivity is equivalent to about one small loaf of bread and might well cause many a normal gut to complain. Shapiro6 has described five cases of chronic or intermittent diarrhoea lasting 20 years or more; in each, the symptoms were cured or improved by restriction of bread intake alone. In two, follow-up has been continued for 4 or 5 years: in one, up to two slices of bread can now be eaten daily without ill effect, while in the other there is still " a tendency to relapse during mental stress " or with " dietary indiscretions". The other cases have been observed for up to 18 months only. In two cases, the stools were described as " porridgy". But, strangely, Shapiro does not say that any tests of absorption or gluten sensitivity were done, let alone jejunal biopsy. Although these observations cannot be evaluated without more evidence, to disregard them would be unwise. In most of the five cases, the diarrhoea seemed to follow an attack of what may or may not have been acute gastrointestinal infection. Shapiro claims that the likeliest cause of the assumed starch intolerance is a deficiency of starchsplitting enzymes; gluten, he maintains, cannot be responsible because remission followed restriction of bread alone, while other foods containing wheat gluten 1. Howland J. Trans. Amer. Pediat. Soc. 1921, 33, 11. 2. Dicke, W. K. Thesis, University of Utrecht, 1950. 3. Dicke, W. K., Weijers, A. A., van de Kamer, J. H. Acta Uppsala, 1953, 42, 34. 4. Prugh, D. G. Psychosom. Med. 1951, 13, 220. 5. Paulley, J. W. Amer. J. dig. Dis. 1959, 4, 352. 6. Shapiro, B. G. S. Afr. med. J. 1962, 36, 818.
pœdiat.,
eaten freely. This reasoning is probably faulty, since it takes no account of the effect of load. Nevertheless, his conclusion may "yet prove correct. Hurst7 believed in carbohydrate intestinal dys": a as result of pepsia rapid passage of intestinal contents through the small gut, undigested carbohydrate entered the large bowel, where its fermentation led to the liberation of gases and to flatulent distension of the colon. Present evidence is against hypermotility as the primary factor; but malabsorption from any cause could lead to the presence of fermenting carbohydrate and protein, and the production of acids and gases, in the colon-an organ noted for its irritability. Our understanding of the newly recognised sugar intolerances is more firmly based. Several different single or multiple specific enzyme defects have been demonstrated since Holzel et a1.8 first described infantile diarrhoea due to lack of intestinal lactase. Dahlqvist 9 points out that in the reported cases of sucrose intolerance due to lack of invertase, there has also been intolerance to maltose; in the cases of lactose intolerance, on the other hand, tolerance to maltose and sucrose has been normal. In most of these sugar intolerances symptoms have dated from childhood and have often been familial, which suggests that a genetic defect is responsible. Clinicians would do well to be alert to the possibility of carbohydrate (and possibly protein) intolerance as a cause of diarrhoea. A simple screening test seems to be required. Weijhers et al.10 recommend estimation of the stool lactic acid for this purpose: only if more than 1 gramme is excreted in 48 hours need full tolerance tests be done with saccharose, lactose, maltose, and starch. But present methods of estimating fxcal lactic acid are either too tedious or too costly for routine were
laboratory
use.
GOVERNMENT APPROVAL OF FLUORIDATION OF WATER-SUPPLIES
Mr. Enoch Powell, Minister of Health, announced in Parliament last Monday that, under section 28 of the National Health Service Act, he will approve schemes submitted to him by local health authorities for arranging with water undertakers to add fluoride to water-supplies where these are deficient in it. The Secretary of State will be applying the same policy in Scotland. The Government consider that the local authorities and water undertakers already had the necessary powers. In the three areas where studies have been made, the Government have undertaken to indemnify any local authority or water undertaker against the cost, direct or indirect, of legal action, and this undertaking will now
apply generally. At a press conference, Mr. Powell emphasised the safety, simplicity, and cheapness of fluoridation, and the dramatic improvement it effected in the dental health of children. From 60 to 70 local authorities had already expressed interest in this preventive health measure, and he believed the scheme would now go ahead quickly. Prof. R. F. WOOLMER, who held the chair of anaesthetics at the Royal College of Surgeons of England, died on Dec. 8 at the age of 54. Hurst, A., Knott, F. A. Quart. J. Med. 1931, 24, 171. Holzel, A., Schwarz, V., Sutcliffe, K. W. Lancet, 1959, i, 1126. Dahlqvist, A. in Symposium on the Small Intestine: Proceedings of the World Congress of Gastroensterology. Munich, 1962 (in the press). 10. Weijers, H. A., van de Kamer, J. H., Mossel, D. A. A., Dicke, W. K. Lancet, 1960, ii, 296. 7. 8. 9.
and
injury is an important industrial and medicolegal problem. Industry is becoming much more aware that there are right and wrong ways of lifting a weight; but there is still room for more instruction and training, which could drastically reduce the number of painful backs acquired in factory and yard. THE INTOLERANT COLON
CcELiAC disease has long been believed to be adversely affected by too much starchy food 1; but only about 10 years ago was this clinical impression rendered scientifically respectable.2-3 The inability of the small intestine in coeliac disease and idiopathic steatorrhoea to handle the breakdown products of gluten is currently thought to be due to an absolute or, more probably, a relative lack of one or more enzymes; and this deficiency is held by many to be of genetic origin. But there are difficulties in wholly accepting this idea. Known genetic enzyme defects are permanent, yet many cceliac children recover and come to tolerate a normal diet without clinical relapse. Again, although the disease in its severest form is extremely sensitive to gluten, especially early in remission, small amounts of gluten do not invariably provoke a relapse. Many patients who are ostensibly on glutenfree diets, but who secretly take normal food, will testify to this-somewhat sheepishly. Furthermore, before diets were coeliac children often employed, gluten-free recovered clinically; and reports of lasting remission due to psychotherapy alone 4 are difficult to reconcile with the idea that a genetically determined enzyme defect is solely responsible for the condition. Since, therefore, any enzyme deficiency there is can apparently be made good to some extent, it may be acquired rather than inherited. The question of the load of ingested gluten is also important: the 30 g. usually given to adults in tests of sensitivity is equivalent to about one small loaf of bread and might well cause many a normal gut to complain. Shapiro6 has described five cases of chronic or intermittent diarrhoea lasting 20 years or more; in each, the symptoms were cured or improved by restriction of bread intake alone. In two, follow-up has been continued for 4 or 5 years: in one, up to two slices of bread can now be eaten daily without ill effect, while in the other there is still " a tendency to relapse during mental stress " or with " dietary indiscretions". The other cases have been observed for up to 18 months only. In two cases, the stools were described as " porridgy". But, strangely, Shapiro does not say that any tests of absorption or gluten sensitivity were done, let alone jejunal biopsy. Although these observations cannot be evaluated without more evidence, to disregard them would be unwise. In most of the five cases, the diarrhoea seemed to follow an attack of what may or may not have been acute gastrointestinal infection. Shapiro claims that the likeliest cause of the assumed starch intolerance is a deficiency of starchsplitting enzymes; gluten, he maintains, cannot be responsible because remission followed restriction of bread alone, while other foods containing wheat gluten 1. Howland J. Trans. Amer. Pediat. Soc. 1921, 33, 11. 2. Dicke, W. K. Thesis, University of Utrecht, 1950. 3. Dicke, W. K., Weijers, A. A., van de Kamer, J. H. Acta Uppsala, 1953, 42, 34. 4. Prugh, D. G. Psychosom. Med. 1951, 13, 220. 5. Paulley, J. W. Amer. J. dig. Dis. 1959, 4, 352. 6. Shapiro, B. G. S. Afr. med. J. 1962, 36, 818.
pœdiat.,
eaten freely. This reasoning is probably faulty, since it takes no account of the effect of load. Nevertheless, his conclusion may "yet prove correct. Hurst7 believed in carbohydrate intestinal dys": a as result of pepsia rapid passage of intestinal contents through the small gut, undigested carbohydrate entered the large bowel, where its fermentation led to the liberation of gases and to flatulent distension of the colon. Present evidence is against hypermotility as the primary factor; but malabsorption from any cause could lead to the presence of fermenting carbohydrate and protein, and the production of acids and gases, in the colon-an organ noted for its irritability. Our understanding of the newly recognised sugar intolerances is more firmly based. Several different single or multiple specific enzyme defects have been demonstrated since Holzel et a1.8 first described infantile diarrhoea due to lack of intestinal lactase. Dahlqvist 9 points out that in the reported cases of sucrose intolerance due to lack of invertase, there has also been intolerance to maltose; in the cases of lactose intolerance, on the other hand, tolerance to maltose and sucrose has been normal. In most of these sugar intolerances symptoms have dated from childhood and have often been familial, which suggests that a genetic defect is responsible. Clinicians would do well to be alert to the possibility of carbohydrate (and possibly protein) intolerance as a cause of diarrhoea. A simple screening test seems to be required. Weijhers et al.10 recommend estimation of the stool lactic acid for this purpose: only if more than 1 gramme is excreted in 48 hours need full tolerance tests be done with saccharose, lactose, maltose, and starch. But present methods of estimating fxcal lactic acid are either too tedious or too costly for routine were
laboratory
use.
GOVERNMENT APPROVAL OF FLUORIDATION OF WATER-SUPPLIES
Mr. Enoch Powell, Minister of Health, announced in Parliament last Monday that, under section 28 of the National Health Service Act, he will approve schemes submitted to him by local health authorities for arranging with water undertakers to add fluoride to water-supplies where these are deficient in it. The Secretary of State will be applying the same policy in Scotland. The Government consider that the local authorities and water undertakers already had the necessary powers. In the three areas where studies have been made, the Government have undertaken to indemnify any local authority or water undertaker against the cost, direct or indirect, of legal action, and this undertaking will now
apply generally. At a press conference, Mr. Powell emphasised the safety, simplicity, and cheapness of fluoridation, and the dramatic improvement it effected in the dental health of children. From 60 to 70 local authorities had already expressed interest in this preventive health measure, and he believed the scheme would now go ahead quickly. Prof. R. F. WOOLMER, who held the chair of anaesthetics at the Royal College of Surgeons of England, died on Dec. 8 at the age of 54. Hurst, A., Knott, F. A. Quart. J. Med. 1931, 24, 171. Holzel, A., Schwarz, V., Sutcliffe, K. W. Lancet, 1959, i, 1126. Dahlqvist, A. in Symposium on the Small Intestine: Proceedings of the World Congress of Gastroensterology. Munich, 1962 (in the press). 10. Weijers, H. A., van de Kamer, J. H., Mossel, D. A. A., Dicke, W. K. Lancet, 1960, ii, 296. 7. 8. 9.