The thesis of this set of reviews is that substantial evidence for a causal relationship between hypercholesterolemia and atherosclerosis began to appear over 100 years ago and was already strong enough 40 years ago that it should have been persuasive. However, little or nothing was done about it, certainly not at the clinical level, until the 1990s. Even after the National Institutes of Health gave its blessings to treatment of hypercholesterolemia [after the 1984 Consensus Conference on Lowering Blood Cholesterol to Prevent Heart Disease (1)], practicing physicians paid little attention (2-4). In 1983, almost 50% of internists surveyed said they did not recommend any therapy, not even diet therapy, unless a cholesterol level was over 300 mg/dl! Over 40% of these internists recommended drug treatment only if the level was over 340; 27% said they never recommended drug treatment (3)! This history of the cholesterol controversy attempts to sort out the reasons it took so long to convince the profession and the public that correction of hypercholesterolemia should be a national public health goal.Part I of this series (5) dealt with the landmark work of Anitschkow (6), which strongly indicted hypercholesterolemia as a sufficient cause of experimental atherosclerosis, and with that of Gofman et al. (7), which strongly suggested that the same was true for the human disease and first demonstrated the complexity of lipoproteins. Part II dealt with the several early lines of evidence that linked blood cholesterol to coronary heart disease (CHD) in humans, including the early clinical trials showing that cholesterol lowering by diet modification could indeed reduce risk (8). Here in Part III, we deal with one of the underlying reasons for the early skepticism about the lipid hypothesis, and that was the absence, until the 1980s, of an accepted, detailed hypothesis for lesion development that mechanistically linked lipoproteins to the pathogenesis of CHD.
THE IMPORTANCE OF UNDERSTANDING MECHANISM IN GAINING ACCEPTANCE OF A HYPOTHESISThe lack of a well-delineated hypothesis is not necessarily a barrier to the acceptance of new directions in medical practice. The classic example is John Snow's demonstration that the 1854 cholera epidemic in London was attributable to contaminants in the water. When he removed the handle from the Broad Street pump, the number of cases in the area served by that pump promptly began to wane. Exactly what was in the water that caused the cholera would not be demonstrated for more than a quarter of a century. Still, the results of Snow's intervention were so dramatic that no one questioned the cause-andeffect relationship even in the absence of an explicit hypothesis . However, when the causal linkage is less obvious, the absence of a plausible hypothesis can be a significant deterrent to action.