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TREATMENT OF CHRONIC BRONCHITIS
1287 IMPORTANCE OF THE ILEUM IN THE ABSORPTION OF VITAMIN B12 SIR,-The observations made by Dr. Trevor Cooke and his colleagues last week and those of other workers whom they quote suggest that the site of vitamin-B12 absorption in man is in the ileum. Our own unpublished observations on the absorption of labelled vitamin B12 in patients with partial resection and localised disease of the small intestine support this view. We wish to stress that the differing opinions to which Dr. Trevor Cooke and his colleagues refer are solely concerned with the question of whether vitamin-B12 absorption in the rat occurs in the proximal small intestine in addition to the middle and distal parts (see Dr. Booth and Dr. Mollin’s letters of Nov. 16 and 30 and our letters of Nov. 23 and Dec. 7). This would appear to be largely a question of different usage of the term " proximal " in relation to experiments on the small intestine. R. H. GIRDWOOD Department of Medicine, ANDREW DOIG. University of Edinburgh. TREATMENT OF CHRONIC BRONCHITIS seems incredible that the article by Dr. Moyes and the late Dr. Kershaw (Dec. 4) about the treatment of chronic bronchitis should make no mention whatsoever of cigarette smoking. After all, the mortality-rate from this disease is six times as great in heavy smokers, three times as great in moderate " smokers, and twice as great in light " smokers, as in non-smokers.l Before any expensive drug therapy is prescribed for this condition, "no smoking" must surely be the order ? May we therefore ask Dr. Moyes for details of his patients’ smoking histories-past and present please ? Without this information the proper assessment of his prednisolone therapy is impossible. J. P. ANDERSON.
SIR,-It
"
University Department of Medicine, Queen Mary Hospital, Hong Kong.
"
PRODUCTION OF FIBRINOLYTIC ACTIVITY WITHIN ARTERIES SIR,—Dr. Fearnley and Dr. Ferguson, in their preliminary communication of Nov. 23 entitled Arteriovenous Difference in Natural Fibrinolysis, considered that their interpretation of the findings reported was in accord with the results of experimental observations made in this department. This is misleading. It has never been our thesis that fibrinolysis developed only in veins. Indeed in one of the papers 2 quoted it was stated that, following restoration of the circulation in a limb previously rendered ischæmic, the major fibrinolytic activity develops either in the capillary bed or in the arterial tree within that part of the limb subjected to arrest of the arterial supply ". The investigation of the latter possibility has proved exceedingly difficult. It has been shown that fibrinolytic activity develops within veins in response to a variety of stimuli.2-4 As was to be expected arteries have been found to respond in the same way as veins, but they do so with even greater intensity especially in what would appear to be the reflex production of activity in other vessels in the homolateral and contralateral limbs.5 Regrettably local anæsthetics (procaine and lignocaine) have been found 5 to be potent stimulants to the development of fibrinolytic activity within both arteries and veins. The fibrinolytic activity of a specimen of blood obtained by arterial puncture performed under local anæsthesia is therefore largely a measure of a complex response by the arterial tree to the local "
anæsthetic. Doll, R., Bradford Hill, A. Brit. med. J. 1956, ii, 1071. Kwaan, H. C., McFadzean, A. J. S. Clin. Sci. 1956, 15, 245. Kwaan, H. C., MeFanzean, A. J. S., Lo, R. ibid. 1957, 16, 241. Kwaan, H. C., McFadzean, A. J. S., Lo, R. ibid. p. 255. 5. Kwaan, H. C., McFadzean, A. J. S., Lo, R. Data to be published.
A. J. S. MCFADZEAN.
A DIAGNOSTIC SIGN
SiR,-May I direct attention to the significance of brown markings on the skin of the abdomen due to hotwater-bottle burns’F In my patients with these markings there have been complaints of severe pain and, at laparotomy, I have always found an organic cause for the pain even when other investigations, both radiological and pathological, had failed to reveal any abnormalitv. Sydney Hospital and the EDWARD WILSON. St. George Hospital, Sydney. FULMINATING INFLUENZA
"
"
1. 2. 3. 4.
Because of a number of factors, one of which is the rate of flow in the artery, this measure does not accurately represent the total activity imparted to the blood. The fibrinolytic activity in blood obtained from veins either in the same limb as the anaesthetised arterial segment or in the contralateral limb has proved even more complicated in its origins. Since in my opinion arterial puncture without local an2esthesia. is unjustified the difficulties in controlling a study of the development of fibrinolytic activity within arteries in humans seem insurmountable at the moment.
SiR,-The following example of Waterhouse-Friderich-
syndrome in a fatal case of influenza may be of interest view of the findings of Dr. Roberts (Nov. 9) and the opinion expressed by Dr. Librach (Dec. 7), on the rarity of this condition except in meningococcal infections. sen
in
A girl, aged 3, was perfectly well at 7.30 P.M. when she had been watching television. Two hours later she woke up with pain in the left arm, after which she became breathless and delirious. She was treated with penicillin and sulphonamides, and next morning was admitted gravely ill to hospital, where she died shortly afterwards. At necropsy the lips were cyanosed and the skin showed many petechial haemorrhages and ecchymosis. There was only surface congestion of the brain, and no evidence of meningitis. The trachea was bright red, but the epithelium was intact. The lungs were deeply congested, but there was no evidence of bronchopneumonia. The only other positive finding was massive bilateral adrenal haemorrhage. To the naked eye no functioning adrenal tissue remained. Blood-culture during life had yielded staphylococci (coagulase-negative) only. Swabs taken at necropsy from the left lung gave a scanty growth of Staphylococcus aureus (coagulasepositive). There was also a heavy growth of Ho--mophilus Influenza virus A was influenzce from a tracheal swab. isolated from a portion of lung. On histological examination, the lung showed marked congestion of the alveolar walls and oedema. Many spaces contained an early fibrinous inflammatory exudate. The bronchiolar mucosa was intact. Histological examination of the adrenals showed only a minimal amount of functional adrenal tissue, with heavy intercellular haemorrhage.
This seems, therefore, to be a case of acute adrenal with no evidence of meningococcal infection. in which influenza virus A was isolated from the
haemorrhage,
lungs. I should like to thank Dr. R. R. Gordon for the clinical details of this case, and Dr. J. E. M. Whitehead for the viroexaminations. Group Pathology Laboratory, City General Hospital,
logical
Sheffield.
g
A. J. N. WARRACK.
SiR,-I should be grateful if you would allow me to the point of my letter (Nov. 23) to Dr. Rawlins (Dec. 7).
clarify
Tracheotomy may be a lifesaving measure in fulminating influenza. This is agreed. Bronchoscopy is a very different matter. This is of fundamental importance. A second, third, and fourth bronchoscopy may well be
SIR,-It
"
University Department of Medicine, Queen Mary Hospital, Hong Kong.
"
PRODUCTION OF FIBRINOLYTIC ACTIVITY WITHIN ARTERIES SIR,—Dr. Fearnley and Dr. Ferguson, in their preliminary communication of Nov. 23 entitled Arteriovenous Difference in Natural Fibrinolysis, considered that their interpretation of the findings reported was in accord with the results of experimental observations made in this department. This is misleading. It has never been our thesis that fibrinolysis developed only in veins. Indeed in one of the papers 2 quoted it was stated that, following restoration of the circulation in a limb previously rendered ischæmic, the major fibrinolytic activity develops either in the capillary bed or in the arterial tree within that part of the limb subjected to arrest of the arterial supply ". The investigation of the latter possibility has proved exceedingly difficult. It has been shown that fibrinolytic activity develops within veins in response to a variety of stimuli.2-4 As was to be expected arteries have been found to respond in the same way as veins, but they do so with even greater intensity especially in what would appear to be the reflex production of activity in other vessels in the homolateral and contralateral limbs.5 Regrettably local anæsthetics (procaine and lignocaine) have been found 5 to be potent stimulants to the development of fibrinolytic activity within both arteries and veins. The fibrinolytic activity of a specimen of blood obtained by arterial puncture performed under local anæsthesia is therefore largely a measure of a complex response by the arterial tree to the local "
anæsthetic. Doll, R., Bradford Hill, A. Brit. med. J. 1956, ii, 1071. Kwaan, H. C., McFadzean, A. J. S. Clin. Sci. 1956, 15, 245. Kwaan, H. C., MeFanzean, A. J. S., Lo, R. ibid. 1957, 16, 241. Kwaan, H. C., McFadzean, A. J. S., Lo, R. ibid. p. 255. 5. Kwaan, H. C., McFadzean, A. J. S., Lo, R. Data to be published.
A. J. S. MCFADZEAN.
A DIAGNOSTIC SIGN
SiR,-May I direct attention to the significance of brown markings on the skin of the abdomen due to hotwater-bottle burns’F In my patients with these markings there have been complaints of severe pain and, at laparotomy, I have always found an organic cause for the pain even when other investigations, both radiological and pathological, had failed to reveal any abnormalitv. Sydney Hospital and the EDWARD WILSON. St. George Hospital, Sydney. FULMINATING INFLUENZA
"
"
1. 2. 3. 4.
Because of a number of factors, one of which is the rate of flow in the artery, this measure does not accurately represent the total activity imparted to the blood. The fibrinolytic activity in blood obtained from veins either in the same limb as the anaesthetised arterial segment or in the contralateral limb has proved even more complicated in its origins. Since in my opinion arterial puncture without local an2esthesia. is unjustified the difficulties in controlling a study of the development of fibrinolytic activity within arteries in humans seem insurmountable at the moment.
SiR,-The following example of Waterhouse-Friderich-
syndrome in a fatal case of influenza may be of interest view of the findings of Dr. Roberts (Nov. 9) and the opinion expressed by Dr. Librach (Dec. 7), on the rarity of this condition except in meningococcal infections. sen
in
A girl, aged 3, was perfectly well at 7.30 P.M. when she had been watching television. Two hours later she woke up with pain in the left arm, after which she became breathless and delirious. She was treated with penicillin and sulphonamides, and next morning was admitted gravely ill to hospital, where she died shortly afterwards. At necropsy the lips were cyanosed and the skin showed many petechial haemorrhages and ecchymosis. There was only surface congestion of the brain, and no evidence of meningitis. The trachea was bright red, but the epithelium was intact. The lungs were deeply congested, but there was no evidence of bronchopneumonia. The only other positive finding was massive bilateral adrenal haemorrhage. To the naked eye no functioning adrenal tissue remained. Blood-culture during life had yielded staphylococci (coagulase-negative) only. Swabs taken at necropsy from the left lung gave a scanty growth of Staphylococcus aureus (coagulasepositive). There was also a heavy growth of Ho--mophilus Influenza virus A was influenzce from a tracheal swab. isolated from a portion of lung. On histological examination, the lung showed marked congestion of the alveolar walls and oedema. Many spaces contained an early fibrinous inflammatory exudate. The bronchiolar mucosa was intact. Histological examination of the adrenals showed only a minimal amount of functional adrenal tissue, with heavy intercellular haemorrhage.
This seems, therefore, to be a case of acute adrenal with no evidence of meningococcal infection. in which influenza virus A was isolated from the
haemorrhage,
lungs. I should like to thank Dr. R. R. Gordon for the clinical details of this case, and Dr. J. E. M. Whitehead for the viroexaminations. Group Pathology Laboratory, City General Hospital,
logical
Sheffield.
g
A. J. N. WARRACK.
SiR,-I should be grateful if you would allow me to the point of my letter (Nov. 23) to Dr. Rawlins (Dec. 7).
clarify
Tracheotomy may be a lifesaving measure in fulminating influenza. This is agreed. Bronchoscopy is a very different matter. This is of fundamental importance. A second, third, and fourth bronchoscopy may well be