SIDEROPENIC DYSPHAGIA AND HIATUS HERNIA

SIDEROPENIC DYSPHAGIA AND HIATUS HERNIA

148 and a large element of chronic bronchitis and infection it is not effective. The case that will respond best’is the pure allergic asthma. I have a...

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148 and a large element of chronic bronchitis and infection it is not effective. The case that will respond best’is the pure allergic asthma. I have also used the nasal preparation to control perennial allergic rhinitis pending desensitisation, and in 3 patients with visible nasal polypi: these are shrinking and the airway is improving very satisfactorily.

The

successful use of dexamethasone aerosols is limited to allergic asthma and rhinitis, and it I find that the most effective must be used regularly. method is to start with 12-18 puffs a day, reducing the daily amount as soon as control is achieved. Although the total dosage at high levels is only 1-0-1-5 mg., some of which-said to be at least half-is inevitably lost, I have had two patients who put on excessive weight on 12 puffs a day. This gain in weight ceased on cutting the dose to a maintenance level, which they had omitted to do.

definitely

I am indebted to Messrs. Merck Sharp & Dohme for the opportunity to test their preparation (’ Decadron ’) and for a liberal supoly of ’Respihalers ’ both for intrabronchial and intranasal use. Derby Chest Clinic, H. MORROW BROWN. Derby.

FIBRINOLYTIC ACTIVITY OF BLOOD

SIR,-Your leading article of June 22 states that Atromid ’reduces the clot lysis-time, and hence increases the fibrinolytic activity of the blood. Since I was unable to attend the Buxton symposium I am not acquainted with ’

the evidence for this. number of substances given by mouth have been increase the fibrinolytic activity of the blood, tolerance to this effect seems to develop only too readily. This has been our experience with the sulphonylureas,l as it has with a number of oral anabolic steroids, including atromid. In two patients treated with atromid we observed a’ temporary and

Although a

found

to

not

very

impressive

increase of fibrinolytic activity, which we could subsequently mimic with methenelone. The drug was given in the recommended dosage of 8 capsules daily. The accom-

panying figure shows the results in one of these patients. It can be seen that both atromid and methenelone produced a transient reduction of lysis-time, followed by escape to the original level. The second patient showed a similar response to both drugs. We believe that the minimum requirement of effectiveness should be a sustained increase of fibrinolysis after 3 months’ treatment, and so far in our experience only androgens given by bjection2 and phenformin by mouthappear to satisfy this requirement. It may be that the experience of others in respect of atromid has been more encouraging, but evidence of a sustained effect on fibrinolysis is needed before adding to the other interesting properties of atromid that of an oral fibrinolvtic agent. Gloucestershire Royal Hospital, G. R. FEARNLEY. Gloucester.

1. 2. 3.

Fearnley, G. R., Chakrabarti, R., Vincent, C. T. Lancet, 1960, ii, 622. Fearnley, G. R., Chakrabarti, R. ibid. 1962, ii, 128. Chakrabarti, R., Fearnley, G. R. To be published.

CLINICAL RESEARCH IN BRITAIN

SIR,-It was stated in a Ministry memorandum on research that the type of research most suitable for peripheral hospitals was that arising naturally out of the conduct of clinical work. Presumably this would include such things as studies on the natural history of disease, the comparative value of diagnostic methods, and the results of treatment. Such work calls for a limited amount of help from a number of departments, often over a period of years. It is not the kind of work for which the whole-time assistance of a technician, or a piece of equipment, can be asked-help which can be obtained with comparative generosity from a number of sources. Instead it calls for relatively generous staffing of a number of departments such as laboratories, X-ray departments, and secretarial and records departments. Some peripheral hospitals may be so staffed, but probably most are barely staffed for ordinary clinical purposes.

possible solution would seem to lie in the provision of budget to be devoted solely to staffing for research purposes of such peripheral hospitals as wish it and can A

a

small

put up a reasonable case for such assistance. It would have to be stipulated clearly that such assistance should be restricted to research activities, or the staff appointed would soon be swallowed up in the day-to-day running of the

hospital.

North Middlesex Hospital, London, N.18.

DAVID FERRIMAN.

SIDEROPENIC DYSPHAGIA AND HIATUS HERNIA

SIR,-Mr. Smiley and his colleagues (July 6) suggest that hiatus hernia may induce

or

aggravate

a state

of iron

deficiency, possibly by causing a chronic loss of blood, and thereby give rise to sideropenic dysphagia (PatersonKelly syndrome). Our observations (unpublished) in this hospital lead us to believe that factors other than iron deficiency are equally important in the aetiology of this syndrome. Our cases have a similar age and sex distribution to those of Mr. Smiley and his colleagues, and we too have found a high incidence of histamine-fast achlorhydria and sideropenia, indicated by low serum-iron concentrations. Further investigation revealed three out of forty-five cases to have serumvitamin-B12levels less than 100 µµg. per ml., and these patients showed megaloblastic hxmopoiesis. Absorption of vitamin Bl2’ as indicated by the Schilling urinary excretion test, was subnormal in twenty-seven out of fifty-five cases (less than 12% of the oral dose excreted in twenty-four hours). Ten patients excreted less than 5% of the oral dose. .

Dysphagia localised to the post-cricoid region is recognised in pernicious aneemia, 12 and this condition was, in fact, found in two of Mr. Smiley’s cases. Our findings suggest that most patients with this type of dysphagia have severe gastric atrophy which may be associated with defective secretion of intrinsic factor leading to " latent pernicious ansemia ". This condition is often associated with iron deficiency, but the role of this deficiency is not clear. The Paterson-Kelly syndrome is rare in some populations, such as those in East Africa where the incidence of chronic iron deficiency is high3 4; and it seems likely that dysphagia occurs only when other factors are also present. A strong predisposition to gastric atrophy appears to be one such factor. A. JACOBS. Department of Pathology, Department of Medicine, Cardiff Royal Infirmary. 1. 2. 3. 4.

G. S. KILPATRICK.

Brown, A. Glasg. med. J. 1946, 27, 313. Jacobs, A. Brit. med. J. 1962, i, 91. Jacobs, A. ibid. 1963, i, 1711. Trowell, H. C. Non Infective Disease in Africa. London, 1960.