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it may be better to add extra iron to brown ratherthan to white bread, and the importance of meat inthe diet.

The importance of meat has been underlined inwork by LAYRISSE, in Caracas, and FINCH, in Seattle,and their colleagues. They have devised methodsfor studying iron absorption by means of test mealscontaining iron in two forms. In one, animal and

vegetable food is marked with an " intrinsic tag ",which is 55Fe injected into the living animal orincorporated in the growing medium of the vege-tables ; in the other, solubilised ferric chloridelabelled with 59Fe is used as an " extrinsic tag " foradded iron. They found that such ferric chloridewas absorbed just as well as ferrous sulphate, thoughthey admit that the absorption is much better thanthat from the kind of iron salts, such as ferric ortho-phosphate and reduced iron, that are suitable forincorporation into commercial bread. Using thesemethods, LAYRISSE et al. 8 have reported their

investigations into the effect of iron fortification offood. Their subjects were 228 Venezuelan peasantswho were in apparent good health, though many hadiron depletion and even iron-deficiency anaemia. Thecriteria for anasmia were a haemoglobin of less than13 g. per 100 ml. for males and 12 g. per 100 ml. forfemales: 21-5% of the subjects were anxmic, 28.9%were " iron-deficient ", and 63% absorbed more than30% of a test dose of ferrous ascorbate and so were" iron-depleted ". Tagged maize and wheat wereprepared by growing in hydroponic culture with 55Fe.The tagged meat was veal obtained by injectinglabelled ferric citrate into 3-month-old calves and

killing them for meat 3 months later; the groundveal muscle was made into hamburgers in which about80% of the iron was present as haem iron and 15-20% as ferritin. The extrinsic tag of ferric chloridewas found to be absorbed in a fashion similar tonon-hsem iron present in foods used for diet. The

investigators knew that absorption from the non-haempool is influenced by the presence of animal protein,and this influence was found to be considerable inthe experiments with fortification iron. Thus, ironsalt added to a vegetable food showed very limitedabsorption; an intake of 60 mg. fortification iron ledto absorption of 0-3 mg. of iron; whereas a supplementof 5 mg. of iron eaten with a veal hamburger resultedin absorption of 0-85 mg. of iron, which is equivalentto the daily male requirement. When mixtures ofanimal and vegetable foods, such as are normallytaken, were given, the results for absorption offortification iron were intermediate. Absorption ofmeat iron was apparently not affected by the dose ofnon-hxm iron represented as vegetable food or iron

7. Cook, J. D., Layrisse, M., Martinez-Torres, C., Walter, R., Monsen,C., Finch, C. A. J. clin. Invest. 1972, 51, 805; Layrisse, M.,Martinez-Torres, C. Am. J. clin. Nutr. 1972, 25, 401.

8. Layrisse, M., Martinez-Torres, C., Cook, J. D., Walter, R., Finch,C. A. Blood, 1973, 41, 333.

salt. The investigators conclude : " all these studies

imply that food iron fortification is likely to beeffective only in individuals who take animal proteinas part of their diet. They also indicate why the ironcontent of the diets in certain countries such as India

may be high yet provide inadequate iron for a largesegment of the population. One must also questionthe efficacy of giving iron treatment with meals,particularly if these meals contain no animal proteinbut vegetable foods with strong inhibiting agents foriron absorption. The efficacy will vary whether ironis given before, during, or after meals."From several years’ work on the effect of adding

iron to flour emerges the sad conclusion that these

supplements are of little value to an iron-deficientpopulation. The solution of the iron-deficiencyproblem is to be found largely in improved public-health methods, such as better sanitation andeducation in hygiene, to reduce infestations with suchparasites as hookworm and bilharzia, and in educationabout the best possible use of food materials.Even in affluent Western societies the high and

increasing cost of meat and other animal-protein foodsis likely to increase the incidence of iron deficiency,especially in mothers with young families. The

problem of inadequate iron will not be easy to solve.

FOR DISTINGUISHED AND MERITORIOUSSERVICE IN THE CAUSE OF ... ?

THE word " distinguished " was once used ofdoctors mainly in their obituaries, or when they werebeing introduced as visiting lecturers-occasions when,as Johnson said of lapidary inscriptions, " a man isnot upon oath ". The problem of attaching identifi-able meaning to the term arose only when the SpensCommittee 1 opined that there would be, within theNational Health Service, " individual specialistswhose outstanding distinction would merit additionalreward ". Their invention of distinction awardsreflected the fact that, in the free medical marketoperating up to 1945, specialists’ incomes had a rangeof tenfold between highest and lowest. The earlyhistory is well known-a small committee dominatedby its chairman, Lord Moran, based its selection ofholders on personal judgment as well as objectivecriteria. Equally well known is the lack of equality intheir distribution, geographically and between special-ties, which predictably, where such large sums of

money were concerned, gave rise to continual com-plaint and criticism. The Pilkington Commission’

I

examined the system with care but concluded that itwas

" a practical and imaginative way of securing a

reasonable differentiation of income and providerelatively high earnings for the significant minority’."However, they recommended that C awards might beallocated, or potential holders nominated, by com-

1. Inter-departmental Committee on the Remuneration of Consultantsand Specialists. Cmmd. 1420. H.M. Stationery Office, 1948.

2. Royal Commission on Doctors’ and Dentists’ RemunerationCmmd. 939. H.M. Stationery Office, 1960.

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mittees in each hospital region. Their approval didnot silence criticism, which has become more voci-ferous, and a referendum of all consultants and seniorregistrars was lately held by the B.M.A.3 Inevitably,the result was impossible to interpret satisfactorilyand the inclination of the Association’s leaders was todismiss the findings and recommend no change, butnow the latest Annual Representative Meeting hasdisinterred the topic and voted to end secrecy of theawards. 4

Meanwhile, back at the Elephant, Health Trendshas published an account by the present chairman ofthe Advisory Committee on Distinction Awards,Sir Hector MacLennan, on the procedure for selec-tion-effectively a defence of the existing system. It isa bland, almost complacent, essay and an ingenuousreader would find it hard to quibble with the principlesit sets out. But does the system really work as

adequately as Sir Hector says ? The critic is baffledhere, for secrecy successfully denies him the facts onwhich to base effective argument, for crude figures ofdistribution-divided by region, specialty, and type ofhospital-reveal little save that geriatricians, an2es-

thetists, and psychiatrists are much less likely to berewarded than thoracic surgeons, neurosurgeons, andcardiologists. This paucity of facts has led to anattempt to extract more meaning from the informationby two social scientists from York. 5 Unfortunatelytheir ingenuity is defeated by the lack of assuredmeasures-of " responsibility " and "

efficiency ",for instance. (The premise that responsibility is

proportional to the number of junior staff per con-sultant and to the number of daily occupied beds perconsultant is one which is unlikely to satisfy mosthospital doctors.)There are two themes of criticism of distinction

awards which tend to become confused. One suggeststhat the system fails to distribute awards properly inrelation to distinction, while the other questionswhether distinction, as Sir Hector and his predecessorsrecognise it, is the proper criterion for handing out somuch money. It is important to distinguish thesepropositions if discussion is to be fruitful. Suggestionsfor altering the method of distribution of the Ell

million, while leaving the awards payable for" distinction " or " merit ", have not been notablypracticable, for distinction is a value judgment reachedby colleagues and, perhaps, laymen, when surveyingan individual in the perspective of his chosen sphereof practice. It has been stated on various occasionsthat awards would fall to the same holders if dis-tributed by popular vote of all doctors. This may beso, and the allocation may be fair, but as an editorialsaid over a decade ago " the real charge is not thatjustice is not (on the whole) done, but that it is notseen to be done". 6 Secrecy is the most obvious,and arguably the most important, defect of thepresent system, and it is understandable why itsabolition is the only concrete change recommendedby the B.M.A. If the system is as just as its proponents3. Br, med. J. 1973, i, suppl. p. 96.4. ibid. 1973, ii, suppl. p. 116.5. Lavers, R. J., Rees, M. in Problems and Progress in Medical Care.

London, 1972.6. Lancet, 1962, i, 847.

claim, one can only wonder why each chairman of theAwards Committee has in turn hotly defended its

secrecy. The Pilkington Commission accepted LordMoran’s warnings of dangers to patient/doctorrelationships; Lord Brain said the system would be" more difficult " if it were not secret; and the current

plausible argument from Sir Hector is that it protectsnonholders’ reputations; though 71 % of non-holdersseem willing to take the risk.3 3 The only reason thatthe system has so far survived is that the integrity ofthe members of the Awards Committee has neverbeen challenged, even though their judgment maysometimes be suspect. Surely, when criticism hasmounted to its present level, it would be prudent toabandon secrecy and allow the scheme to stand or fallby what is revealed.Even if the basic idea of distinction awards con-

tinues, secretly or not, it should be ensured thatholders satisfy certain basic criteria. It should be

required that, as well as being distinguished, a manwas really doing his share of the N.H.S. graft whichwas nominally his responsibility; and might not thereward of his distinction be modified if it dependedon the combined efforts of a large staff rather than onhis alone ? A small advance made in isolation may notbe more distinguished than the large output of a manunderpinned by numerous hirelings, but it is certainlymore meritorious. Do those many professors rumouredto be holders of the most generous awards reallycontribute enough to the N.H.S. to deserve the largeslice of its salary cake which goes to supplement thebread-and-butter of their university salaries ? Forthis money arises in the N.H.S. budget, not theUniversity Grants Committee’s.

Modifications such as these, though, would merelytinker with a 25-year-old idea which is now out ofdate, and a.new way must be found to produce " someconsiderable differentiation of income among con-

sultants ... in order that good work may be encouragedand rewarded, and that there may be a spread ofincome among consultants comparable with that inthe other professions ".2 One reason at least for

requiring a radical change is that recent ReviewBodies seemed to regard a distinction award as

something for the average man, so that basic salaryscales have become relatively lower. How else couldthe money be distributed ? To begin with, senioritymight reasonably be rewarded. It is not particularlyclever to get old in one’s job, but at present there istoo much pressure (particularly owing to super-annuation problems) on the middle-aged consultantto bear a work-load inappropriate to his years. It is,in any case, believed that awards are often given tosenior men to ease their later years. Then there is aplace for recognisable responsibility to be rewarded.This has been suggested often and always rejected;the Health Departments told the Pilkington Com-mission 2 that identification of posts of special responsi-bility would be difficult, mainly because of marginalcases. Provided that such posts were advertised foropen competition there should be no problem, and itmight encourage a healthy trend towards mobility of

7. Review Body on Doctors’ and Dentists’ Remuneration. Cmmd.4352. H.M. Stationery Office, 1970.

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able men. Particular responsibility for teaching-undergraduate and postgraduate-over and aboveclinical work deserves recognition, too. Finally, nowthat " shortage specialties " and grey-areas are

accepted problems in the hospital scene, is it notreasonable to offer incentive payments when posts arehard to fill ? General practice shows that such a

system can work. It might be possible to identifyother attributes for which awards could be given(Todd thinks waiting-lists should be looked at),but there should always be some left for the unusualman who does more or better work than might beexpected of him-in fact, a man who is personallydistinguished and meritorious. Whether awards ofthis sort in future should be for life, or renewable at5 or 10 year intervals, needs examination. It is up tothe profession to explore the possibilities and offerpractical suggestions to the Government, but it iseven more the Government’s responsibility to givesympathetic consideration to this major irritation toconsultants whose impatience at growing responsi-bilities combined with diminishing rewards increasesdaily.

TOXIC DILATATION OF THE COLON

EMPHASIS has again been placed upon early treat-ment to reduce the mortality of toxic dilatation of thecolon. In the latest series, the underlying disease wasulcerative colitis, though the condition is also seen inCrohn’s disease and ischoemic colitis. Adams 9 treated16 cases, 4 with antibiotics and steroids, and 12 by opera-tion after medical treatment had failed. He found thatall 7 patients whose colons were removed within fivedays of the onset of dilatation survived but 3 of the5 operated upon after five days died. In practice, it isdifficult to determine when the condition starts.

It may develop from any acute exacerbation and thereis no telling when it will do so. It occurs when ulcera-tion has caused full-thickness loss of mucosa and whatremains of the bowel wall beyond begins to disinte-grate. Then the bowel dilates under the influence of itsown internal pressures, which build up as fluidfseces and gas accumulate due to failure of effective

motility. This accounts for the dilatation. The con-dition is toxic because water, sodium, and potas-sium are lost; because these biochemical factors arecompounded by hypoalbuminasmia due to loss ofalbumin from the ulcerated surfaces; and because ofliver damage associated with portal bactersemia.

In a word, toxic dilatation is an end-point; it shouldnot be allowed to happen, for it carries a 30-50%mortality. But how to avoid it; what clinical signs mayindicate impending dilatation ? To await the evidenceof increasing abdominal girth and the paradoxicalfall in stool frequency is to beg the question. Thecondition has by then developed. The objectiveshould be recognition of the beginning of disintegra-tion-that is, full-thickness loss of mucosa-beforethe muscle is compromised. This can be achieved bylooking for mucosal islands on the straight X-ray of the8. Todd, J. W. Lancet, 1973, i, 1106.9. Adams, J. T. Archs Surg. 1973, 106, 678.

abdomen,10 for those islands will be distinguishableas soft-tissue shadows against the luminal gas onlywhen the mucosa which surrounded them has beenswept aV.1Y. Insertion of barium is both dangerousat this stage and uninformative, since the contrast

medium will reveal lesser irregularities simulatingmucosal islands; these lesser irregularities, or pseudo.polyps, will not be seen in a straight X-ray.Once mucosal islands are seen there is only one

course to follow-excision of the colon with ileostomy,and removal of the rectum later. On this regimen themortality can be brought to within the range of electiveproctocolectomy.10 Those who recoil at the thoughtthat all patients heading for toxic dilatation shouldnecessarily undergo operation in order to obtain atenfold reduction in mortality risk should bear inmind that the survivors of such an attack have tohave their large bowel removed later, usually within ayear-as Adams found in 3 of the patients fortunateenough to respond to steroids; the 4th had died inanother acute episode eight months after the firstattack of toxic dilatation.

A NEW ERA FOR THE M.R.C.

THE latest annual report of the Medical ResearchCouncil 11 marks the end of an era-and the beginningof a new. The M.R.C. has not publicly criticised theGovernment’s Rothschild-inspired policy, but in theopening pages of the report for 1972-73 can bediscerned a subtle mixture of diplomatic acceptance ofthe new facts of life and a determination to keep upformer standards. The white-paper decisions, which" did not entirely accord with the advice tendered tothe government by the research councils ", can, thereport says,

" neither alter the inherent characteristicsof scientific research nor diminish the responsibility ofall concerned to advance knowledge in the sciencesrelevant to the needs of human health and well-beingand to enable such knowledge to be applied in prac-tice ". The Council now stresses how often it hastaken the initiative in promoting research aimed atparticular objectives, but only five years ago a formersecretary to the M.R.C. was predicting a continuingshift towards more basic medical research in theCouncil’s policies.12 While the Council will continueto assess the important factors of scientific opportunityand feasibility it recognises that the Government" must be concerned with the practical and social aims

of research and will in future have much more influencein the making of certain categories of decision "; and" this need not be harmful and could well be desirablefrom both practical and scientific points of view ".This admitted, the Council goes on to warn of problemsthat could arise if departmental pressure to attainshort-term ends diverts research resources away from

longer-term projects. The M.R.C. will take comfortfrom the fact that the Department of Health’s chiefscientist is, so to speak, one of them and not a man

10. Brooke, B. N., Sampson, P. A. Lancet, 1964, ii, 1272.11. Medical Research Council Annual Report April 1972-March 1973.

House of Commons paper 355. H.M. Stationery Office. 90p.12. See Lancet, 1968, ii, 271.