586 reduced lung volumes with a normal One cannot diagnose restrictive impairment on F.E.V.1/F.V.C.%. the basis of a reduced F.E.V.1/F.V.C.%. What happened to the other 4 subjects? Are we to assume that despite their reduced F.E.V./F.V.C.% they had no impairment? The statement that 7 men had radiological evidence of chronic obstructive airways disease is a bit too simplistic. What were the criteria for chronic obstructive airways disease? Is this the same as airways obstruction? Are the authors referring to radiological evidence of overdistention or emphysema? Either way, the evidence that chronic low exposure to cadmium fumes is associated with the development of pulmonary impairment is singularly lacking.1
pairment
have
West Virginia University Medical Center,
Morgantown, West Virginia 26506, U.S.A.
W. KEITH C. MORGAN
ABNORMAL BLOOD VISCOSITY IN RAYNAUD’S PHENOMENON
SIR--Like Dr Goyle and Mr Dormandy (June 19, p. 1317), also studying the abnormal blood viscosity found in Raynaud’s phenomenon. In three patients with Raynaud’s disease we measured blood, plasma, and serum viscosity (Wells-Brookfield 1/4 RVT microviscosimeter, at a shear-rate of 750, 375, 150, 75, 37.5, 18-75, and 3.75 S-l at 37°C), packed-red-cell volume, and plasma-fibrinogen concentration before, during, and after the appearance of Raynaud’s phenomenon induced by immersing the hand in iced water. Blood-samples, which were anticoagulated with ethylene diamine tetra-acetic acid (E.D.T.A.) 10% (01ml in 8 ml of blood), were taken from the antecubital
we are
arm at the time of appearance of Raynaud’s phenomHyperviscosity was particularly pronounced in one of the three patients studied. Blood viscosity reached its highest levels at the lowest shear-rates (see figure) and fell rapidly after the disappearance of the vascular phenomenon. In the opposite arm a much smaller increase in blood viscosity was noted in
affected enon.
of the three cases. No variations were evident in
two
plasma
and
serum
viscosity,
packed-red-cell volume, or plasma-fibrinogen concentration. The same experience was repeated also in two control subjects. No variations were found in any of the parameters observed. These results seem to suggest that blood viscosity changes specifically in relation to the disease. Our findings agree with those of Goyle and Dormandy and those of Pringle et al.They found a higher systemic blood viscosity in patients with Raynaud’s disease, and we noteda further local transient increase during the Raynaud’s phenomenon itself. The interpretation of these findings is not easy: we do not know if they are the cause or the consequence of the phenomenon. In Raynaud’s phenomenon catecholamine concentrations in venous blood are increased;2 catecholamines enhance vascular smooth-muscle contraction, and we are now studying whether they also cause the rise in blood viscosity.’ The two mechanisms may potentiate each other in determinating the ischaemic phase of Raynaud’s phenomenon.
Istituto di Semeiotica Università di Siena, Nuovo Policlinico, 53100 Siena, Italy
Medics,
SANDRO FORCONI MAURIZIO GUERRINI DONATO AGNUSDEI FRANCO LAGHI PASINI TULLIO DI PERRI
HOSPITAL CARE FOR THE ELDERLY
SIR Honest_ Serving Man (Aug. 28, p. 454) is wrong in thinking that the Department of Health is drawing false assumptions about geriatrics. It is true that where a good geri atric physician is appointed the turnover increases and the waiting-list goes down. But this need not mean he has turned to a different patient group, or that he is curing, in the usual sense, a majority of those invalid patients called "geriatric".
Blood viscosity (ahear-rate 3.75 S-I) in three patients with Raynaud’s disease before, during, and after the cooling-induced phenomenon.
veins of both the arm in which Raynaud’s phenomenon had been induced and the opposite arm. At all shear-rates studied blood viscosity rose sharply in the 1. Stanescu, D., Veriter, C., Frans, A., Goncette, L., Roels, H., Brasseur, L. Am. Rev. resp. Dis. 1976, 113, 92.
Lauwerys, R.,
Acute medical wards have the choice of two alternatives when a general practitioner requests admission of an elderly patient. They may, according to the strength of his case, accept the patient or refuse him. In a doubtful case, a humane decision may result in the arrival of a "bed blocker" in the ward. Given the same request, the geriatric physician would arrange a visit to the patient’s home forthwith. This is the vital moment at which an agreement can be reached with the family to provide a brief respite by hospital admission for a week or two, with a promise of further inpatient or day-patient relief later as necessary. In this way, a bed which might otherwise be blocked by one patient for a year could be used by twelve patients for a month or twenty six for a fortnight. This represents an enormous gain in service potential, even if the geriat. ric physician achieves no "cures" at all. In fact, many of these elderly invalids are found to have complicating illness that is amenable to treatment-infections, nutritional disorders, metabolic disturbances and the like—so that the quality of their lives has been improved considerably by these short admissions. In a situation where we cannot suddenly create extra beds or extra clinicians, a pooling of geriatric and general medical resources is logical. One of the important resources that tht geriatric physician can bring to medicine is this screening machinery. It should not be beyond our wit to work out, m 1. 2. 3.
Pringle, R., Walder, D. N., Weaver, J. P. A. Lancet, 1965, i, 1086. Peacock, J. H. Circulation Res. 1959, 7, 821. Forconi, S., Guerrini, M., Agnusdei, D., Di Perri, T. G. Ital. Cardiol. (in the
press).
587 each area, a practical linkage between geriatric and general physicians that serves the public better. This linkage should give our junior staff a broad enough experience to ensure that the next generation of consultants can work together in better
harmony. Royal Devon and Exeter Exeter, Devon
Hospital,
WILLIAM B. WRIGHT
through contamination of cigarettes or pipe tobacco by cadmium-oxide dust from the hands or clothes. The results also show the need for strict where workers are exposed
in industries toxic metals with low boilingpoints ; besides cadmium, mercury, arsenic, and selenium, could well be suspected of contaminating cigarettes and increasing exposure. Further work is in progress. Experimental work has been
smoking regulations
to
started to study the release of cadmium from taminated with different cadmium compounds.
CONTAMINATION OF CIGARETTES AND PIPE TOBACCO BY CADMIUM-OXIDE DUST
SIR,—Cigarette smoking significantly increases the normal body burden of cadmium in man.I-3 A cigarette contains some 1-2 g of cadmium.4-6 Since exposure via air is usually high in industrial operations involving cadmium, the amount of cadmium retained through smoking has not been thought to increase significantly the body burdens of exposed workers. smokers with less than 1 year of exposure had higher blood-levels of cadmium than did non-smokers exposed for more than 10 years.7 This finding prompted us to study the cadmium contamination of cigarettes and pipe tobacco handled during working hours. A preliminary investigation showed that cigarettes and pipe tobacco obtained from workers in a nickel-cadmium battery factory and handled as usual before smoking contained 2.4-15.2µg Cd/g (3 cigarettes) and 60 and 222 µg Cd/g (2 samples of pipe tobacco) as compared to 1 - 3-1.8µg/g in cigarettes taken from new packs. Cigarettes kept in the pockets of workers had 1.7,2.3, and 2.5 µg/g. In two industries with current exposure levels below 20 µg Cd/m3 air, one producing a copper-cadmium alloy and the other the battery factory, 9 smokers were given cigarettes and 4 were given pipe tobacco. Reference samples were taken from 4 new packs of cigarettes and from 4 new bags of pipe tobacco. Cigarette smokers were given 1 cigarette and told to handle it as they would ordinarily do before lighting it. It was then put into a test tube. The workers kept the packs, and smoked all but two cigarettes which were returned to the investigator. Pipe smokers filled their pipes and the tobacco was then removed and put into a test tube. They then kept the tobacco bag until about 2 fillings were left. The bags were then
However, cadmium-exposed
National Swedish Environment Protection Board, S-104 01 Stockholm 60, Sweden
con-
MAGNUS PISCATOR TORD KJELLSTRÖM BIRGER LIND
FINE COTTON THREAD METHOD OF LACRIMATION
women
returned. The samples were dry ashed in a programmable muffle oven at 4500C and cadmium was dissolved with 1 mol/1 nitric acid. Cadmium was analysed by atomic-absorption spectrophotometry using background correction with a deuterium lamp. The reference samples for both cigarettes and pipe tobacco had a median cadmium concentration of 1. 0 µg/g with ranges of 0.9-1.1 and 08-11 µg/g, respectively. The cadmium content in the cigarettes handled by the workers varied between 0.9 and 26 µg/g, median value 1.1, and that in the cigarettes in the packs kept in the workers’ pockets varied from 1.1to 27 :Jglg, median value 1 2. Pipe tobacco which had been handled had a cadmium content varying between 20 and 315 µg/g, median 43, while pipe tobacco kept in the pocket had between 1.77 and 9.11 ug,/g, median 5.7. The results clearly show that smoking during working hours may cause an additional exposure to cadmium, not only through the original content of cadmium in tobacco but also
2.
Department of Environmental Hygiene, Karolinska Institute, and Department of Environmental Hygiene,
cigarettes
SIR,-A comparison between the amount of lacrimal fluid secreted by the eyes permits the site of a facial-nerve lesion to be identified. Thomsen and Zilstorff reported the importance of the tear test in the diagnosis of acoustic tumours. 85% of 125 patients with medium or large acoustic tumours showed lacrimal deficiency with the modified Schirmer’s second method (nasolacrimal reflex test) using benzine fumes. Although Schirmer’s first methodusing filter-paper has been used most frequently, it is rather crude, and the results are often inconsistent. To reduce irritation to the conjunctiva and save time, the following new tear test was devised. Instead of filter-paper, a fine white cotton thread 05mm in diameter and 70 mm in length (I used Daruma tackling thread) is used as the absorbing agent and trigeminal stimulator. 3 mm of one end is dyed with 10% fluorescein to aid in the measurement of the wetted portion of the thread, as in the lacrimal drainage function test (the fluorescein dye disappearance test3) and the colorimetric test (the fluorescein dye dilution test4). The stained end of the thread is inserted into the unanaesthetised left lateral upper conjunctival sac. The patient is instructed to close the eyes. After 5 to 30 seconds the patient is told to open the eyes and the thread is removed. Immediately, with another thread, the right eye is tested in the same way. The lengths of the stained portions are compared. One test consists of three or more consecutive measurements. A patient with a small acoustic tumour limited to the right internal auditory canal was tested with this new method thirteen times and always showed lacrimal deficiency on the affected side:
1. Lewis, G P., Couglin, L., Jusko, W., Hartz, S. Lancet, 1972, i, 291. Lewis, G P., Jusko, W. J., Couglin, L. L., Hartz, S. J. chron. Dis. 1972,
25, 717,
3 Shuman, M S., Voors, A. W., Gallagher, P. N. Bull. envir. Contamin. Toxicol 1974, 5, 570. 4. Szadkowski, D., Schultze, H., Scholler, K. H., Lehnert, G., Arch. Hyg. Bakt 1969, 153, 1. 5. Nandi, M, Sloane, D., Jick, H., Shapiro, S., Lewis, G. P. Lancet, 1969, ii, 1329 6 Menden, E
E., Elia, V. J., Michael, L. W., Petering, H. G., Envir. Sci.
Technol. 1972, 6, 830. 7 Piscator,
M, Adamsson, E., Elinder, C. G., Pettersson, B., Steninger, P.
18th International ber, 1975.
Congress
on
Occupational Health, Brighton, Septem-
Department of Otolaryngology, Faculty of Medicine, Kyoto University, Kyoto, Japan 1. 2. 3. 4.
KATSUAKI KURIHASHI
Thomsen, J., Zilstorff, K. Acta otolar. 1975, 80, 276. Schirmer, O. Albrecht v. Graefes Arch. Ophthal. 1903, 56, 197. Zappia, B. J., Milder, B. Am. J. Ophthal. 1972, 74, 161. Nover, A., Wolfgang, J. Klin. Mbl. Augenheilk. 1952, 121, 419.
pairment
have
West Virginia University Medical Center,
Morgantown, West Virginia 26506, U.S.A.
W. KEITH C. MORGAN
ABNORMAL BLOOD VISCOSITY IN RAYNAUD’S PHENOMENON
SIR--Like Dr Goyle and Mr Dormandy (June 19, p. 1317), also studying the abnormal blood viscosity found in Raynaud’s phenomenon. In three patients with Raynaud’s disease we measured blood, plasma, and serum viscosity (Wells-Brookfield 1/4 RVT microviscosimeter, at a shear-rate of 750, 375, 150, 75, 37.5, 18-75, and 3.75 S-l at 37°C), packed-red-cell volume, and plasma-fibrinogen concentration before, during, and after the appearance of Raynaud’s phenomenon induced by immersing the hand in iced water. Blood-samples, which were anticoagulated with ethylene diamine tetra-acetic acid (E.D.T.A.) 10% (01ml in 8 ml of blood), were taken from the antecubital
we are
arm at the time of appearance of Raynaud’s phenomHyperviscosity was particularly pronounced in one of the three patients studied. Blood viscosity reached its highest levels at the lowest shear-rates (see figure) and fell rapidly after the disappearance of the vascular phenomenon. In the opposite arm a much smaller increase in blood viscosity was noted in
affected enon.
of the three cases. No variations were evident in
two
plasma
and
serum
viscosity,
packed-red-cell volume, or plasma-fibrinogen concentration. The same experience was repeated also in two control subjects. No variations were found in any of the parameters observed. These results seem to suggest that blood viscosity changes specifically in relation to the disease. Our findings agree with those of Goyle and Dormandy and those of Pringle et al.They found a higher systemic blood viscosity in patients with Raynaud’s disease, and we noteda further local transient increase during the Raynaud’s phenomenon itself. The interpretation of these findings is not easy: we do not know if they are the cause or the consequence of the phenomenon. In Raynaud’s phenomenon catecholamine concentrations in venous blood are increased;2 catecholamines enhance vascular smooth-muscle contraction, and we are now studying whether they also cause the rise in blood viscosity.’ The two mechanisms may potentiate each other in determinating the ischaemic phase of Raynaud’s phenomenon.
Istituto di Semeiotica Università di Siena, Nuovo Policlinico, 53100 Siena, Italy
Medics,
SANDRO FORCONI MAURIZIO GUERRINI DONATO AGNUSDEI FRANCO LAGHI PASINI TULLIO DI PERRI
HOSPITAL CARE FOR THE ELDERLY
SIR Honest_ Serving Man (Aug. 28, p. 454) is wrong in thinking that the Department of Health is drawing false assumptions about geriatrics. It is true that where a good geri atric physician is appointed the turnover increases and the waiting-list goes down. But this need not mean he has turned to a different patient group, or that he is curing, in the usual sense, a majority of those invalid patients called "geriatric".
Blood viscosity (ahear-rate 3.75 S-I) in three patients with Raynaud’s disease before, during, and after the cooling-induced phenomenon.
veins of both the arm in which Raynaud’s phenomenon had been induced and the opposite arm. At all shear-rates studied blood viscosity rose sharply in the 1. Stanescu, D., Veriter, C., Frans, A., Goncette, L., Roels, H., Brasseur, L. Am. Rev. resp. Dis. 1976, 113, 92.
Lauwerys, R.,
Acute medical wards have the choice of two alternatives when a general practitioner requests admission of an elderly patient. They may, according to the strength of his case, accept the patient or refuse him. In a doubtful case, a humane decision may result in the arrival of a "bed blocker" in the ward. Given the same request, the geriatric physician would arrange a visit to the patient’s home forthwith. This is the vital moment at which an agreement can be reached with the family to provide a brief respite by hospital admission for a week or two, with a promise of further inpatient or day-patient relief later as necessary. In this way, a bed which might otherwise be blocked by one patient for a year could be used by twelve patients for a month or twenty six for a fortnight. This represents an enormous gain in service potential, even if the geriat. ric physician achieves no "cures" at all. In fact, many of these elderly invalids are found to have complicating illness that is amenable to treatment-infections, nutritional disorders, metabolic disturbances and the like—so that the quality of their lives has been improved considerably by these short admissions. In a situation where we cannot suddenly create extra beds or extra clinicians, a pooling of geriatric and general medical resources is logical. One of the important resources that tht geriatric physician can bring to medicine is this screening machinery. It should not be beyond our wit to work out, m 1. 2. 3.
Pringle, R., Walder, D. N., Weaver, J. P. A. Lancet, 1965, i, 1086. Peacock, J. H. Circulation Res. 1959, 7, 821. Forconi, S., Guerrini, M., Agnusdei, D., Di Perri, T. G. Ital. Cardiol. (in the
press).
587 each area, a practical linkage between geriatric and general physicians that serves the public better. This linkage should give our junior staff a broad enough experience to ensure that the next generation of consultants can work together in better
harmony. Royal Devon and Exeter Exeter, Devon
Hospital,
WILLIAM B. WRIGHT
through contamination of cigarettes or pipe tobacco by cadmium-oxide dust from the hands or clothes. The results also show the need for strict where workers are exposed
in industries toxic metals with low boilingpoints ; besides cadmium, mercury, arsenic, and selenium, could well be suspected of contaminating cigarettes and increasing exposure. Further work is in progress. Experimental work has been
smoking regulations
to
started to study the release of cadmium from taminated with different cadmium compounds.
CONTAMINATION OF CIGARETTES AND PIPE TOBACCO BY CADMIUM-OXIDE DUST
SIR,—Cigarette smoking significantly increases the normal body burden of cadmium in man.I-3 A cigarette contains some 1-2 g of cadmium.4-6 Since exposure via air is usually high in industrial operations involving cadmium, the amount of cadmium retained through smoking has not been thought to increase significantly the body burdens of exposed workers. smokers with less than 1 year of exposure had higher blood-levels of cadmium than did non-smokers exposed for more than 10 years.7 This finding prompted us to study the cadmium contamination of cigarettes and pipe tobacco handled during working hours. A preliminary investigation showed that cigarettes and pipe tobacco obtained from workers in a nickel-cadmium battery factory and handled as usual before smoking contained 2.4-15.2µg Cd/g (3 cigarettes) and 60 and 222 µg Cd/g (2 samples of pipe tobacco) as compared to 1 - 3-1.8µg/g in cigarettes taken from new packs. Cigarettes kept in the pockets of workers had 1.7,2.3, and 2.5 µg/g. In two industries with current exposure levels below 20 µg Cd/m3 air, one producing a copper-cadmium alloy and the other the battery factory, 9 smokers were given cigarettes and 4 were given pipe tobacco. Reference samples were taken from 4 new packs of cigarettes and from 4 new bags of pipe tobacco. Cigarette smokers were given 1 cigarette and told to handle it as they would ordinarily do before lighting it. It was then put into a test tube. The workers kept the packs, and smoked all but two cigarettes which were returned to the investigator. Pipe smokers filled their pipes and the tobacco was then removed and put into a test tube. They then kept the tobacco bag until about 2 fillings were left. The bags were then
However, cadmium-exposed
National Swedish Environment Protection Board, S-104 01 Stockholm 60, Sweden
con-
MAGNUS PISCATOR TORD KJELLSTRÖM BIRGER LIND
FINE COTTON THREAD METHOD OF LACRIMATION
women
returned. The samples were dry ashed in a programmable muffle oven at 4500C and cadmium was dissolved with 1 mol/1 nitric acid. Cadmium was analysed by atomic-absorption spectrophotometry using background correction with a deuterium lamp. The reference samples for both cigarettes and pipe tobacco had a median cadmium concentration of 1. 0 µg/g with ranges of 0.9-1.1 and 08-11 µg/g, respectively. The cadmium content in the cigarettes handled by the workers varied between 0.9 and 26 µg/g, median value 1.1, and that in the cigarettes in the packs kept in the workers’ pockets varied from 1.1to 27 :Jglg, median value 1 2. Pipe tobacco which had been handled had a cadmium content varying between 20 and 315 µg/g, median 43, while pipe tobacco kept in the pocket had between 1.77 and 9.11 ug,/g, median 5.7. The results clearly show that smoking during working hours may cause an additional exposure to cadmium, not only through the original content of cadmium in tobacco but also
2.
Department of Environmental Hygiene, Karolinska Institute, and Department of Environmental Hygiene,
cigarettes
SIR,-A comparison between the amount of lacrimal fluid secreted by the eyes permits the site of a facial-nerve lesion to be identified. Thomsen and Zilstorff reported the importance of the tear test in the diagnosis of acoustic tumours. 85% of 125 patients with medium or large acoustic tumours showed lacrimal deficiency with the modified Schirmer’s second method (nasolacrimal reflex test) using benzine fumes. Although Schirmer’s first methodusing filter-paper has been used most frequently, it is rather crude, and the results are often inconsistent. To reduce irritation to the conjunctiva and save time, the following new tear test was devised. Instead of filter-paper, a fine white cotton thread 05mm in diameter and 70 mm in length (I used Daruma tackling thread) is used as the absorbing agent and trigeminal stimulator. 3 mm of one end is dyed with 10% fluorescein to aid in the measurement of the wetted portion of the thread, as in the lacrimal drainage function test (the fluorescein dye disappearance test3) and the colorimetric test (the fluorescein dye dilution test4). The stained end of the thread is inserted into the unanaesthetised left lateral upper conjunctival sac. The patient is instructed to close the eyes. After 5 to 30 seconds the patient is told to open the eyes and the thread is removed. Immediately, with another thread, the right eye is tested in the same way. The lengths of the stained portions are compared. One test consists of three or more consecutive measurements. A patient with a small acoustic tumour limited to the right internal auditory canal was tested with this new method thirteen times and always showed lacrimal deficiency on the affected side:
1. Lewis, G P., Couglin, L., Jusko, W., Hartz, S. Lancet, 1972, i, 291. Lewis, G P., Jusko, W. J., Couglin, L. L., Hartz, S. J. chron. Dis. 1972,
25, 717,
3 Shuman, M S., Voors, A. W., Gallagher, P. N. Bull. envir. Contamin. Toxicol 1974, 5, 570. 4. Szadkowski, D., Schultze, H., Scholler, K. H., Lehnert, G., Arch. Hyg. Bakt 1969, 153, 1. 5. Nandi, M, Sloane, D., Jick, H., Shapiro, S., Lewis, G. P. Lancet, 1969, ii, 1329 6 Menden, E
E., Elia, V. J., Michael, L. W., Petering, H. G., Envir. Sci.
Technol. 1972, 6, 830. 7 Piscator,
M, Adamsson, E., Elinder, C. G., Pettersson, B., Steninger, P.
18th International ber, 1975.
Congress
on
Occupational Health, Brighton, Septem-
Department of Otolaryngology, Faculty of Medicine, Kyoto University, Kyoto, Japan 1. 2. 3. 4.
KATSUAKI KURIHASHI
Thomsen, J., Zilstorff, K. Acta otolar. 1975, 80, 276. Schirmer, O. Albrecht v. Graefes Arch. Ophthal. 1903, 56, 197. Zappia, B. J., Milder, B. Am. J. Ophthal. 1972, 74, 161. Nover, A., Wolfgang, J. Klin. Mbl. Augenheilk. 1952, 121, 419.
