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AN ACCIDENTAL TATTOO
1226
continuing functioning recipient. There seem to
until
replaced
revitalised
by the
other examples of transplanted tissues protected by a similar " rinsing effect ":
are two
be
or
which
1. Vital cornea can be transplanted as homograft or even as heteroin animals, without being rejected. Like the aortic valve, the cornea is constantly being rinsed. The aqueous humour of the anterior chamber is renewed 9 times in 24 hours,s and the other surface of the cornea is being rinsed in the same way by the constant flow of tears. Apparently, the rinsing of both sides of the cornea protects it from inflammation and even from any immunological response. 2. Freeze-dried dura-mater homografts can be used successfully to close defects of the dura. At second craniotomies after 1-2 years, Metzand Hiibnerreported that large areas of the dura homograft had remained unchanged, and that newly formed tissue had invaded the graft only at the periphery. Freeze-dried dural homografts represent dead tissue; immunological response is unlikely, but inflammation and dissolution may be expected. Since no inflammation was found, I believe that the rinsing effect of the cerebrospinal fluid protected the graft.
graft
Summing up, aortic-valve, cornea, and dura-mater homografts seem to be specially protected from destruction by Neither immunological rejection nor constant rinsing. inflammatory destruction take place-the usual defensive reaction of the recipient to the graft or of the warm-blooded organism to the necrosis is ineffective. The behaviour of aortic-valve autografts, homografts, and heterografts should not be very different, and the results can be expected to be similar. University Surgical Clinic, Frankfurt on Main, West Germany.
HANS H. HIRSCH.
SKIN-GRAFTING OF FINGERTIP INJURIES SIR,-May I support Mr. Ferguson’s plea (May 20, p. 1110) for the domed graft in the treatment of the avulsed fingertip ? I found the method of great value when working in casualty departments for twenty years before 1963. Since your readers may not always have a suitable steel plate in an emergency, I submit to you the Edinburgh technique of taking pinch-grafts by lifting the skin of the donor area with the point of a cutting needle and removing the graft with an ordinary scalpel-blade. It is easy to judge the size of the graft to fit the defect; the donor site may be closed, if necessary, by a suture. These pinch-grafts are the same shape as Mr. Ferguson’s domes and they have the same virtues. Department of Surgery, General Hospital, West Hartlepool, Co. Durham
G. H. D. MCNAUGHT.
The basis for our work was the decreased contents of liver vitamin B12 in gastric-cancer patients noted in a previous study.10 Dr. Shearman and his co-workers, using a more direct method of determining intrinsic-factor deficiency in the stomach, have reached roughly the same conclusions that we did, although no mention of our work is listed in their references. Gastroenterology Section, University Department of Medicine, M. D. Anderson Hospital and Tumor Institute, Texas Medical Center, ROBERT S. NELSON. Houston 77025.
COAGULATION FIBRINOLYSIS SIR,-In your annotation (May 13, p. 1042) you state: " Despite the limitations and uncertainties of present methods, any information about the day-to-day or hour-to-hour behaviour of the coagulation-fibrinolysis system is welcome." I suggest that no information is better than misleading information, and that clinical investigations be postponed until contemplation and research yield reliable measurements, particularly for fibrinolysis. Let me illustrate this point with two widely used methods of measurement. 1. Dilute-clot-lysis time (Fearnley et aIY).-In this method lysis. time is dependent not only on the rate of clot-lysis but also on the quantity of substrate. Given identical rates of lysis of two diluteplasma samples, total lysis-times will be proportional to the quantity of clot-i.e., to the original plasma-fibrinogen concentrations. Therefore to have any meaning fibrinolysis-time should be expressed as a fraction in terms of the plasma-fibrinogen level at the time of clot-lysis measurement. When looked at in this way, fig. 1 in the article by Dr. Fearnley and Dr. Chakrabarti 12 shows no evidence that phenformin had a fibrinolytic potentiation effect. The shorter lysis-time resulting from phenformin seems to be solely attributable to the lower plasma-fibrinogen level it produced. 2. Plasma and serum plasminogen levels.-Straub et al,13 obtained a normal plasma range of 0-82-1-41 caseinolytic units by the commonly used method of Alkaersig et al.14 whilst Dr. Hirsh and his colleagues (Feb. 25, p. 418) give a normal plasma range of 2-5 units. Yet standardised, commercial preparations of plasminogen, streptokinase, and urokinase are available. I recently investigated the plasminogen-estimation method of Alkaersig et a1.14 and after the acidification-neutralisation step (advocated to destroy antiplasmin) found up to 50% loss of plasminogen reactivity to both streptokinase and urokinase. A serious underestimation of plasminogen in normal serum and plasma by this method can be demonstrated by adding purified plasminogen. When this is done only part of the plasminogen added to the plasma and the serum can be accounted for.
I feel that in a few years’ time most of the existing conclusions on fibrinolysis in health and disease will have to be discounted because of inadequacy of present methods of
investigation. Department of Experimental Pathology, University, Birmingham 15.
AN ACCIDENTAL TATTOO SIR,-Dr. Peonides (May 13, p. 1062) asks about clearing an unwanted tattoo. Attention should be called to the successful use of the laser in eliminating such lesions painlessly. Department of Pediatrics, New York University Medical Center, 550 First Avenue, New York 16.
L. EMMETT HOLT,
Jr.
Hogan, M. J., Zimmermann, L. E. Ophthalmic Pathology. London, 1962. Metz, R. Personal communication. Hübner, B. Personal communication. 8. Shearman, D. J. C., Finlayson, N. D. C., Wilson, R., Samson, R. R. Lancet, 1966, ii, 403. 9. Nelson, R. S., Howe, C. D. Cancer Res. 1963, 23, 1756.
letter has been shown
to
Dr. Fearnley, whose
reply follows.-ED.L SIR,-Dr. Wolf makes
a
number of pronouncements and
the dilute-blood-clot-lysis time which are at variance with my observations, but he does not cite supporting evidence. In my experience of several thousand determinations, there has been no correlation between lysistime and plasma-fibrinogen levels. (I am concerned only with native fibrinogen levels and not with the in-vitro addition of fibrinogen, since, apart from the possibility that available fibrinogen preparations may be contaminated by antifibrinolytic factors, it is very unlikely that conditions in native blood can be mimicked with validity by adding fibrinogen in vitro.) In patients with raised fibrinogen levels who are given fibrinolytic drugs and studied daily, reduction of lysis-time-
assumptions
GASTRIC FUNCTION IN GASTRIC CARCINOMA SiR,ŅIhave read with interest the recent article by Dr. Shearman and his co-workers (Feb. 18, p. 343), as well as the previous article by this group.Their results seem to confirm previous work in a larger number of cancer patients in whom intrinsic-factor deficiency was shown to exist by a less direct but valid method-that is, by excretion of 57Co-vitamin-B12’9 5. 6. 7.
* *This
P. WOLF.
about
10. Nelson, R. S., Doctor, V. M. Gastroenterology, 1962, 42, 414. 11. Fearnley, G. R., Balmforth, G., Fearnley, E. B. Clin. Sci. 1957, 16, 645. 12. Fearnley, G. R., Chakrabarti, R. Lancet, 1966, ii, 757. 13. Straub, P. W., Riedler, G., Frick, P. G. J. clin. Path. 1967, 20, 152. 14. Alkaersig, N., Fletcher, A. P., Sherry, S. J. clin. Invest. 1959, 38, 1086.
continuing functioning recipient. There seem to
until
replaced
revitalised
by the
other examples of transplanted tissues protected by a similar " rinsing effect ":
are two
be
or
which
1. Vital cornea can be transplanted as homograft or even as heteroin animals, without being rejected. Like the aortic valve, the cornea is constantly being rinsed. The aqueous humour of the anterior chamber is renewed 9 times in 24 hours,s and the other surface of the cornea is being rinsed in the same way by the constant flow of tears. Apparently, the rinsing of both sides of the cornea protects it from inflammation and even from any immunological response. 2. Freeze-dried dura-mater homografts can be used successfully to close defects of the dura. At second craniotomies after 1-2 years, Metzand Hiibnerreported that large areas of the dura homograft had remained unchanged, and that newly formed tissue had invaded the graft only at the periphery. Freeze-dried dural homografts represent dead tissue; immunological response is unlikely, but inflammation and dissolution may be expected. Since no inflammation was found, I believe that the rinsing effect of the cerebrospinal fluid protected the graft.
graft
Summing up, aortic-valve, cornea, and dura-mater homografts seem to be specially protected from destruction by Neither immunological rejection nor constant rinsing. inflammatory destruction take place-the usual defensive reaction of the recipient to the graft or of the warm-blooded organism to the necrosis is ineffective. The behaviour of aortic-valve autografts, homografts, and heterografts should not be very different, and the results can be expected to be similar. University Surgical Clinic, Frankfurt on Main, West Germany.
HANS H. HIRSCH.
SKIN-GRAFTING OF FINGERTIP INJURIES SIR,-May I support Mr. Ferguson’s plea (May 20, p. 1110) for the domed graft in the treatment of the avulsed fingertip ? I found the method of great value when working in casualty departments for twenty years before 1963. Since your readers may not always have a suitable steel plate in an emergency, I submit to you the Edinburgh technique of taking pinch-grafts by lifting the skin of the donor area with the point of a cutting needle and removing the graft with an ordinary scalpel-blade. It is easy to judge the size of the graft to fit the defect; the donor site may be closed, if necessary, by a suture. These pinch-grafts are the same shape as Mr. Ferguson’s domes and they have the same virtues. Department of Surgery, General Hospital, West Hartlepool, Co. Durham
G. H. D. MCNAUGHT.
The basis for our work was the decreased contents of liver vitamin B12 in gastric-cancer patients noted in a previous study.10 Dr. Shearman and his co-workers, using a more direct method of determining intrinsic-factor deficiency in the stomach, have reached roughly the same conclusions that we did, although no mention of our work is listed in their references. Gastroenterology Section, University Department of Medicine, M. D. Anderson Hospital and Tumor Institute, Texas Medical Center, ROBERT S. NELSON. Houston 77025.
COAGULATION FIBRINOLYSIS SIR,-In your annotation (May 13, p. 1042) you state: " Despite the limitations and uncertainties of present methods, any information about the day-to-day or hour-to-hour behaviour of the coagulation-fibrinolysis system is welcome." I suggest that no information is better than misleading information, and that clinical investigations be postponed until contemplation and research yield reliable measurements, particularly for fibrinolysis. Let me illustrate this point with two widely used methods of measurement. 1. Dilute-clot-lysis time (Fearnley et aIY).-In this method lysis. time is dependent not only on the rate of clot-lysis but also on the quantity of substrate. Given identical rates of lysis of two diluteplasma samples, total lysis-times will be proportional to the quantity of clot-i.e., to the original plasma-fibrinogen concentrations. Therefore to have any meaning fibrinolysis-time should be expressed as a fraction in terms of the plasma-fibrinogen level at the time of clot-lysis measurement. When looked at in this way, fig. 1 in the article by Dr. Fearnley and Dr. Chakrabarti 12 shows no evidence that phenformin had a fibrinolytic potentiation effect. The shorter lysis-time resulting from phenformin seems to be solely attributable to the lower plasma-fibrinogen level it produced. 2. Plasma and serum plasminogen levels.-Straub et al,13 obtained a normal plasma range of 0-82-1-41 caseinolytic units by the commonly used method of Alkaersig et al.14 whilst Dr. Hirsh and his colleagues (Feb. 25, p. 418) give a normal plasma range of 2-5 units. Yet standardised, commercial preparations of plasminogen, streptokinase, and urokinase are available. I recently investigated the plasminogen-estimation method of Alkaersig et a1.14 and after the acidification-neutralisation step (advocated to destroy antiplasmin) found up to 50% loss of plasminogen reactivity to both streptokinase and urokinase. A serious underestimation of plasminogen in normal serum and plasma by this method can be demonstrated by adding purified plasminogen. When this is done only part of the plasminogen added to the plasma and the serum can be accounted for.
I feel that in a few years’ time most of the existing conclusions on fibrinolysis in health and disease will have to be discounted because of inadequacy of present methods of
investigation. Department of Experimental Pathology, University, Birmingham 15.
AN ACCIDENTAL TATTOO SIR,-Dr. Peonides (May 13, p. 1062) asks about clearing an unwanted tattoo. Attention should be called to the successful use of the laser in eliminating such lesions painlessly. Department of Pediatrics, New York University Medical Center, 550 First Avenue, New York 16.
L. EMMETT HOLT,
Jr.
Hogan, M. J., Zimmermann, L. E. Ophthalmic Pathology. London, 1962. Metz, R. Personal communication. Hübner, B. Personal communication. 8. Shearman, D. J. C., Finlayson, N. D. C., Wilson, R., Samson, R. R. Lancet, 1966, ii, 403. 9. Nelson, R. S., Howe, C. D. Cancer Res. 1963, 23, 1756.
letter has been shown
to
Dr. Fearnley, whose
reply follows.-ED.L SIR,-Dr. Wolf makes
a
number of pronouncements and
the dilute-blood-clot-lysis time which are at variance with my observations, but he does not cite supporting evidence. In my experience of several thousand determinations, there has been no correlation between lysistime and plasma-fibrinogen levels. (I am concerned only with native fibrinogen levels and not with the in-vitro addition of fibrinogen, since, apart from the possibility that available fibrinogen preparations may be contaminated by antifibrinolytic factors, it is very unlikely that conditions in native blood can be mimicked with validity by adding fibrinogen in vitro.) In patients with raised fibrinogen levels who are given fibrinolytic drugs and studied daily, reduction of lysis-time-
assumptions
GASTRIC FUNCTION IN GASTRIC CARCINOMA SiR,ŅIhave read with interest the recent article by Dr. Shearman and his co-workers (Feb. 18, p. 343), as well as the previous article by this group.Their results seem to confirm previous work in a larger number of cancer patients in whom intrinsic-factor deficiency was shown to exist by a less direct but valid method-that is, by excretion of 57Co-vitamin-B12’9 5. 6. 7.
* *This
P. WOLF.
about
10. Nelson, R. S., Doctor, V. M. Gastroenterology, 1962, 42, 414. 11. Fearnley, G. R., Balmforth, G., Fearnley, E. B. Clin. Sci. 1957, 16, 645. 12. Fearnley, G. R., Chakrabarti, R. Lancet, 1966, ii, 757. 13. Straub, P. W., Riedler, G., Frick, P. G. J. clin. Path. 1967, 20, 152. 14. Alkaersig, N., Fletcher, A. P., Sherry, S. J. clin. Invest. 1959, 38, 1086.