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are given diets providing the same number of caloriesfrom sources predominantly fat, protein, and carbo-hydrate respectively, they lose weight most rapidly if thediet consists largely of fat, less rapidly with protein,and least of all on carbohydrate. Indeed, weight gainwas sometimes recorded with the third type of diet.Although changes in the diet were not associated withany remarkable alteration in the basal metabolic-rate,they suggested that " the rate of katabolism of bodyfat may alter in response to changes in the compositionof the diet "; in support of this, they cited the increasedloss of insensible water on high-fat and high-proteindiets, compared with the reduced loss on high-carbo-hydrate diets. WERNER 14 has also compared the effectof high-fat and isocaloric high-carbohydrate diets on

weight-loss; he concluded that the slight differencesdemonstrated in 4 only of his 6 patients could readilybe accounted for by variations in salt and water balance.The meaning of KEKWICK and PAWAN’S 13 findings

may be obscured unless the close relation between watermetabolism and fat consumption is borne in mind. HOLT 15recalls that paediatricians are familiar with the reversibleloss of weight which infants undergo when transferredfrom a high-carbohydrate to a high-fat diet and viceversa, and he attributes this to changes in body-watercontent. In 1907, BENEDICT and MILNER 16 describeda subject under strict supervision in a calorimeter

’chamber, who when changed from a high-carbohydrateto a high-fat diet lost 2-7 kg. of body-weight in threedays, although in energy balance. In a recent study of7 fat patients, PASSMORE et al.17 18 calculated that withdaily energy deficits of approximately 2500-3000

calories, large quantities of tissue fat were beingmetabolised. Each of these patients lost as much as2-4 litres of body-water during the first week, incontrast to the much smaller losses, or even retention,of water found during the subsequent five weeks onthe same regimen. KEKWICK and PAWAN’S observationswere usually limited to periods of five to nine days on asingle dietary regimen, and it would be wrong to assumethat the striking losses of weight they found in some ofthese brief periods would continue at the same rate ifthe dietary regimen were prolonged.

CHALMERS et al.19 have now found that modificationsin the diet of obese patients may be associated withchanges in the excretion of

"

fat-mobilising activity "

in the urine, and that this activity is greatest in the urineof normal subjects when fasting, and of obese patientson a diet composed of 90% fat or protein, while it dis-appeared on a diet of 90% carbohydrate. Furtherevidence will be awaited with interest on the relation ofthis activity to the lipid-mobilising peptide in blooddescribed by SEIFTER and RAEDER 20 and to anothersubstance in blood associated with fat-transport activity,recently described by REiTH and THOMAS.2114. Werner, S. C. New Engl. J. Med. 1955, 252, 661.15. Holt, L. E. J. Amer. med. Ass. 1957, 164, 1890.16. Benedict, F. G., Milner, R. D. Bull. U.S. Off. Exp. Stas, 1907, no. 175.17. Passmore, R., Strong, J. A., Ritchie, F. J. Brit. J. Nutr. 1958, 12, 113.18. Strong, J. A., Passmore, R., Ritchie, F. J. ibid. p. 105.19. Chalmers, T. M., Kekwick, A., Pawan, G. L. S., Smith, I. Lancet,

1958, i, 866.20. Seifter, J., Baeder, D. H. Proc. Soc. exp. Biol., N.Y. 1957, 95, 469.21. Reith, W. S., Thomas, M. J. Nature, Lond. 1958, 182, 604.

Both YUDKIN and MACKARNESS recommend low-

carbohydrate diets with abundant protein. YUDKIXconsiders that the fat intake will then adjust itself;MACKARNESS, basing his argument on KEKWICK andPAWAN’S short-term experimental results, urges the

importance of increasing the intake of fat. The criticismthat diets consisting largely of protein and fat will provemore costly than many patients can afford is anticipatedand answered effectively, certainly for those who arelikely to read these two books. In view of the tendencytoday to associate myocardial infarction with cholesterolmetabolism, and this in turn with dietary fat, any regimenwhich seeks to increase the fat intake is bound to arouse

misgivings. This question was discussed last year

by YUDKIN,22 and he concluded that it was " difficultto support any theory which supposes a single or majordietary cause of coronary thrombosis ". He added that" relative overconsumption of food, associated withreduced physical exercise, may be one of several causesof the disease "-just indeed the conditions whichcreate obesity. The size of the problem posed byobesity may be obscured to some extent by its veryfamiliarity. Any effective and practicable systemproposed for its solution will depend for its success onplacing the responsibility for its execution where it

belongs-on the shoulders of the patient. For this

purpose, the greatest need is to enlighten the patient,and both YUDKIN and MACKARNESS have providedpalatable and even entertaining statements of the

problem, garnished with appropriate advice. Both will

appeal to some of the patients for whom they weredesigned.

22. Yudkin, J. Lancet, 1957, ii, 155.23. See Lancet, 1958, i, 1270. Russell, W. R. ibid. 1957, ii, 188.24. ibid. 1957, i, 1028.

Annotations

THE AFFAIR AT BATH (CONTINUED)LIKE proposals to abolish or amalgamate old regiments,

proposals to abolish or amalgamate old hospitals are aptto cause a sharp reaction. The reason is that a hospital,like a regiment, is something into which many peoplehave put their hearts, and to which they are irrationallydevoted. Planning of hospital services, like modernisationof the Army, is a necessity, and the view of the plannersmust be wide. But scope must still be found for the

people with a narrower and more intense vision of whatthey want for their particular town or for the group ofpatients they are treating. Planners are properly con-cerned with keeping things in proportion; but it is usuallyenthusiasts, who see things out of proportion, that makeprogress and set new standards. In the old days theycould fire others with their purpose and thus raise moneyfor a department or hospital; and Sir Harry Platt is notalone in thinking that, since our Governments are

unlikely to find enough capital for the National HealthService, this custom will have to be restored. 23The affair of the Royal National Hospital for

Rheumatic Diseases at Bath was, we thought, a case inwhich the planning authorities in the Ministry of Healthand the region did not attach enough importance to

exceptional conditions.24 Founded in 1742, the hospital

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had a reputation sufficient to justify the word " national "in the title it took in 1934. During the war it was badlybombed; but when peace returned, no repairs were done,because it was to have a new building for which the Cityof Bath had given a site. In 1948, when the NationalHealth Service absorbed its endowment fund of El 30,000(including E89,000 specifically given for rebuilding),nobody doubted that the plan would go forward, but,in relation to other needs, the regional board later

assigned low priority to this project. The Ministry,for its part, refused aid because it felt that, though morethan half the patients came from outside the region,the regional priorities were for the board to decide.

Presumably the Ministry felt, too, that the treatment ofrheumatic diseases could now be as satisfactorily under-taken at general hospitals, and that there was no longerany need to preserve and develop, nationally, a specialcentre for the purpose. For our part, however, we thoughtthat the arguments were still strongly in favour of havingsuch a centre; and we are therefore glad to know thatwhen, eventually, the regional board set up a subcom-mittee to go into the whole question of the care ofrheumatism in the region, this committee reportedunanimously in favour of the rebuilding of the hospitalat Bath.

For those who believe in the hospital and its potentialvalue, the situation is now more hopeful. The Ministrysticks to its view that the regional board must find themoney, but it may be prepared to help if the board putsup a strong case. Neither board nor Ministry, it seems,is exactly anxious to find, even over five years, the

E250,000 now required; and no doubt they have manyother things they would like to do with it-things thatmay be even more pressing. But to the outsider it muststill seem that E250,000 is a great deal less in value than theE130,000 which the N.H.S. acquired from the hospitalin 1948; and granted that the hospital is to be continuedat all, the revised scheme, though hopeful, is far from

extravagant.Installation of a lift shaft (beginning this month) will be

followed by rebuilding of the war-damaged wing and then byreconditioning of the other block. The new plan willhouse the nurses (at present in hired accommodation) andallows for the incorporation in the hospital of the researchunit, on which its special value will so largely in the enddepend.The Clinical Research Board and the Medical Research

Council have accepted responsibility for the research unit,and have appointed an advisory committee consisting ofprofessors of Bristol University and clinicians on the staff of thehospital. But, though the Clinical Research Board and theM.R.C., according to their normal practice, would pay forsalaries, the rooms in which the work is done will have to beprovided by the regional board or the Ministry. To have theunit anywhere but in the hospital building would be to startoff, once more, on the wrong foot.Meanwhile some useful help in another way may be given

by the British Rheumatic Association. Though most of the oldPump Room Hotel is to be pulled down and rebuilt as flats andshops, the hospital’s treatment centre for outpatients willremain in it, and the Association is thinking of taking over twofloors above this for use as a partly subsidised hostel for thepatients having treatment.With everyone now determined to make it a success,

the present compromise should turn out well, and theRoyal National Hospital for Rheumatic Diseases, as a

specialist hospital for arthritis, will have its chance ofshowing in which ways it can improve on the care given

at general hospitals and can advance knowledge. We areleft, however, with the larger problem of discovering how,in an organised service, anybody can get such a chanceif he wants it enough. Too often in these early years theN.H.S., intent on discharging its large responsibilities in abig way, has discouraged individual and local enterprise,as certainly happened at Bath. If Sir Harry Platt is right,we may yet have to rely on such enterprise for much ofthe hospital development which is now becoming so

obviously necessary.

1. Hjorth, N. Brit. J. Derm. 1957, 69, 319.2. Bowers, R. E. ibid. 1950, 62, 262.3. Savill, A. ibid. 1958, 70, 296.

A DOMESTIC DELILAH

A REMEDY for alopecia in the Ebers papyrus includesthe fat of the hippopotamus-a curiously bald beast tochoose as a source of pilary stimulation. Centuries ofmedical advance have added few hair restorers of morecertain value. In the scalp clinic of a dermatologicalMecca used to be heard the rhythmical exhortation"

tous les soirs vous allezfaire une frictim, "

,with, amongstother things, carbon disulphide. Where doctors fail,trichologists flourish. In quiet momenta jaaisturbed bythe clink of coin, these experts can be induced to confessthat their expensive secret consists in no more than

stopping their clients from inflicting physical or chemicalviolence on their scalps.Mothers are familiar with the temporary patch of

baldness on the back of a baby’s head when, active butnot yet sessile, the child rubs its head on the bed. A fewolder miscreants are known to pull out their hair, some-times swallowing the evidence. Adolescent girls smittenby the equine folly wear their hair in " pony tails ",which tends to drag the hair out at the temples. Thisform of baldness is endemic in Greenland, where thisstyle is traditiona1,1 It was not uncommon when curlersand felt slippers were de rigueur in the bistros of CamdenTown. Zealous massage or friction is often resorted to bythe balding, usually on the advice of barbers or doctors,and this may aggravate the baldness by twisting andbreaking the hair. 2 Overindulgence in bleaching andchemical waving makes the hair fragile, and loss of hairis seen in American Negro women who paradoxically wantto make their hair straight.A new source of traumatic alopecia has been described

by a doctor with special experience in the disorders of thescalp and hair. Dr. Agnes Savill 3 reports that patientsof each sex and various ages came to her complaining ofloss of hair, yet showing no disease to account for it. Allhad been using hair-brushes containing bristles made ofnylon instead of the old-fashioned hog bristles. In someof their brushes, hairs could be seen that had been pulledout at the roots, while others had been broken out andwere split longitudinally. It is not surprising that nylonshould be brutal to the hair. It is hard and makesindestructible pot-scourers. Some dentists have deploredthe use of nylon toothbrushes, and professional foot-ballers have protested against nylon studs as these inflictnasty injuries. Dr. Savill also blames the shape of theends of the bristles, which when they are cut off squareseem harsher than when they are rounded.

Clearly there must be special reasons why some peopleare affected when the majority presumably are not. Herpatients did not have any abnormality of the hair whichpredisposed them to this type of damage, and they all