THE LANLET, AUGus r 19, 1978
TDB
READING FILE
CIRCULATED
sistent with file notion that rCLurrcnt Awitnous
tllcCi*-
ation is initialed by a C:11-nILQiated respon,c.
Concordance studies on a small number of pairs of
twins ha%-c provided 5omc cvic!-.-ncc that
-1scertibilitv to
recurrent aplithous ulcers is Penctic3liv
influenced. One
might therefore -rect the 31ter---d immune
rz~ponsivc-
ness to be linked with 11I.A type. but rc%ults
here have
been confliciiric."-` Circulating immune
conipluxcs
have been detccEcd, by two tccluial-ucs, in the
tilvid of
some pircnis %%iih recurrent apliThous Wcur. and
Bcht;ct'; syndrome. 11 " Sertim C, is rais- ~ in
both con-
ditions, ..norc so ;n ikhqct's." ImmunorrbLlin and
cornrleffient ar~: dumomtrut,L! in but
the relevance of tht-se i% ~.)ubtlul tincc t~~v.
are to be
found in nomml inucosa." In lichi;et'% synj~,;nje,
but
not in recurrent ap~ithous tilccrs, t.he saln-a
ind jejunal
secretion lack sccretury cornponcrit.- Th~-.
reduction in
Syrnplorns of,.-.er,cd with disoJi-ini
cromogh.citc," an
inhIbiicr of lype-l-induced histzrnine rc!L.2sc,
also sug-
gests that there is a humoral component in the
patho-
gencs.s of the disca,;e. A
011C 2ttractive unifying concept of the
pathogencsis of I
recurrent aphihous tilcers is based on the
benclitt in
sonic paticnEs of levarnisole therapy." Discussing
!heir
Oiniril trial, I.chricr and his colleagues
f:-hionabli- iua-
&-sted that in health a suppre~sor FCCII
FCrUllltilln
hib:.s H-cell ~vnthc%is Of 2niibz;d%, 3aiinst oral
mucosa.
A~:,thous-ulce`r patients, they rzi,tulatzcf. have
3 weak
st,pprcssp.: T-ccll pc-puiation'Wh3ch i~
sufficientiv stimu-
12 ted by Icvamisolc2" to control tht. ulcers.
Alternativ6y,
in the normal subic- or-il muco-,al or skin
antigens nlay
circu!ate in low coriccmi-ations in he blood..
triduc-rig
spci:iiic unresponsiveness in T but not H cells."
" This
low closc tolcr.-ncc could be abrogated in
recurrent ap!l-
t;.ous uIccratien by oral microbial haptcns
binding to
the mucosa I,: inducr autoun;ibody IbMl3'lOrI or
cyto-
toxic T cel Is.
I his emphosis on immunctlopical mechanisms has
been challengcd. In a Glasgow sur.-cy,-3
defi,~icncws of
iron, folate, and vitamin H,r %%-ere detccted in
17-7'C' of
130 aphll`101.154#11cr p::ti--nts, comoarej %vith
8.5"' of'
matched controls. Ch2llacornbe a-i colleagues-"
found
only iron deficiency (not anxm-i to be commonCr In
2 phthous-ulcer pati'cnts tha;j ill contrais. A
Birmincharn
-astrocntCrOI-TZlC31 unt! then rrorted trial S out
of 33
patic..:s presenting with 3phtho .us ulcers had
hislolozl.
cal c;.Angcs in jcjunal biopsy specim:ns
compatible with
cirliac d;;ease. The oral ulceration in these 8
paticnts
9. 1.,:k, M F., A.. R.., C., Sr,.p, 1. 1. 0-,'
191".. 43,
11). ru.. P.. Ryd,,. L P.. Wri-k..O.
11. Mlb,. A. E., WAW. D.M.. C R~1. 1977. 56.
110, J-bc. z.. J. flatchcicr. 1. It Kenratv. L A-
Ut-r. 1. Arghs
D- 197% 113. 17.;.
:i. D.. i.ch-. r a. -,d,' W". i.:W.
T jl.j.
16. B.nd - -
, 1! 1'. ~ 0,.! Jlcz1.h . Lh-,d..J by X iE. DW.
b-..:.. '11. 1916.
17. AIJ N. 1: R. k W - Sqx-. A.. V--,
%1. o-uift. 11 A.-AW.., N. J. L~11.
18 F-. 11. 1%
M I-cb-, I., Z.n. N.. t..-. 926.
N.
21.
22.8, :: !' ',1-3 1.
23"L"T, D. F--.... I W. .11-A W.. 1. H.
". - 8'. -;. 7. M
h.J, -A'.. S I.. It.,,k-. P., LA.--- T. 8, 1.
-1.,% 15-'. 15. 37.
413
remitted completcly on a gluten-frec diet."
Subsequent
work suggests that this is a sizeable
:.,crc~tiniatc of the
prevoleticeofundcrlyiiigctrliacdise3se
inaphihous-ulccr
patients." 11 Ifowevi,r, gluten could be taxic
locally in
the oral mucosa, since tire oral ulcers of
hmmatologically
normal patients with normal ;cjunil biopsies
1:~mmc
fc%;rcr and less PainfUl On 2 griumn-Irce diet."
1-urthcr
studies of the development of the oral
Icsions-pirticu-
larly immunological charactcrisation of the early
infil-
trate-might re,cal basic diffcrcnccs or c,,ential
simi-
4.ritics bvwcen unconipficowd aphihar :n recurrent
aphthous ulceration and Bchcct's syndrc.nc an:j
those
clinically irdistinguishable ulcer- whicti in a
%m4il
mi.orit-.* of paticrits are the pre~nqma -ymptorn
-f An
undc.-!Ying g:ncralised deficicniv dis,:rder. But
Pt pres-
ent there is much in favour o[ Tourainc':-` view
that
recurrent ap;ithous ulcers and Behi;ct's syndrome
reprc-
snt opposite ends ufan "aphtho,as" spectrum.
PASSIVE SMOKING AND ANGINA
T11F.RE is growing awarcricss of the diiconif~rt
caused
to ordinary pecph. (i.e.. ijon-smokcrs) by thc!e
who
imoke in their presence. Niany normal pcop!e
c=plain
of slinging of the ~yc, or di,,,~on,for, in the
nose or throat
in the presence of smoker!, and 3',
of non-smokcrs
stated that thev winded if people si::jkcd in
their home!.
Discomfort can be ,orsc for sufferers fiam asthma
or
bronchitis. Until !ately there has been sc.nt
c,-idcrce on
the effect of pomi,c smokinE: on patients %vith
heart dis-
ease. Art-now ha--. aKadv shown that after
siriokina, a
zign-ettel or travcllin(
z in heavy Loc Angeles trutlic2 the
patirm with angina nceus less cxerc~,c urric to
bring on
P.ain. 'Iis la,cst study sho-.-.-s that even
expo-,urr to Oil:
cigarc it:
smoke of others significamly reduce 0~c
duration olexercisc Icadins
g to ?ncina.
!0 paticr.-s with anglna of them ex-smokers and 2
light smokers had not smoked for sixteen hours)
were exposed to 3 smokers in a -.all rnorn who
con-
loined fi%-c cicare-tes cacri over t,-.o h-_-;--,.
Th.- room
was Othcr well ventilated or not A-entilatcd. In
bu,h situ-
zt,.ons the resting heart-rate, b!,,c-! pressure,
and carboxy-
h~rnoglobin levels were increascJ but tuore so
when
th~ patients u---rc in the non-%cnWile~ room. The
duration of cirercise until anc:.-ia devclor..d
was dc-
creased by ?2-, arier passive s-noking in he wel',
venti-
lated room asid by 38'; in the rl.)n-venttvitt-d
room. It
was coriclude-I that passive smokuig 2~:L:ra.jies
angina.
Whc~hcr this was due to carboh It ono.~id.-. in
nicotine,
or to other compounds of tobacco micice -!Iich
in,:Iude
nitrites of oxy;en and h,drocca c,-;inide) -~,a~
not
known. The re,sibilitv of the r-ch lov-,:31 ~ircct
of
Cxcrcac in : :tuffy sawLy rourn wa-, considered.
Carb~,a rucirnxid-c scern-t to b- if-.- ~h;-f
suspcct. Exro-
sure to low 1,!vels of inhaled carbon monoxidc was
found
to decTeast cxrrz,.~.c tolerai.cc in raticrits
-with angina
23. R.. fl.- It. X., P.. C~;- Vr- T. fi,. mej. y.
1976, s.
26. D. M.M. All--- F. G. S--
n Lll-'b,. A. E.-M,Aj. 1, Ucu.i- kh-bi- J.
!necrra-
.."I ~.- ~ - 11--
Ar~... 117- At~- - :131'
21. 1-,.- A. M - _%,-r~
1. A,-- M. A. j-+. D 0%69, 329.
2.A--.*,-
3. A,..- M J, -0. I.AW. 1-31. 299. -, 1
00
0 _1
BATCo document for Province of British Columbia 23
April 1999


414
pcctoris,' and also in patictits with intermittent
cliudi-
cation.'
The riost cffcctive ndvice a doctor can give his
patient
after a coron:ry attack vt to szop tinoking: tl,is
halves
the rclipse-ratc. Aronc-'s swdv indicatcs that
patients
with coronary hcart-discase should also avoid
places of
heavy pollittion with inbiccn sinokc, such as
smoking
corr.partnients in trams-, srm,kv pubs, and
exposure to
tot-3cco s-iiokc at work. in ollicc. r1r in
la,.tory. In Bri-
tain the Sccre!.lrv Of SUMC f-r P-311h a,,d Social
Ser-
vices has promised to takc: 2ci!= to incrca5.-
no-swokine
areas in public r1accs,*vct he his aCtuail '-Jonc
little. Sit-
ting ncxt to smokers iii c-ri-nittec. %vhic~
includ,-s pint
and cigar users, mav be linzardous as %veil as
unpleasant.
13 cing nursed in a hospital Led next to a sr-okcr
ma% also
inc;-,!ase the risk for a pinctit -ith chest or
heart-dis-
case. We can ha.-J1y c%rct the Secretary of State
to act
m(irc firmly timil doc,or~ :!rid othcr hci!tli
v-orkcrs have
tried to put their o%%-n houces and hospitals in
order. It
is time \vc acccpted no-smokiiir as normil
behaviour in
211 health committees. We should also see that the
norm
for aciite hospital wards should be non-smoking.
This
has already bi:cn implcnientcd with success in
several
hospitals.
I-reedom for the noo-stricker must be accompanied
by
freedom fe: the smoker who will not or cannot
stop-
Hwpaals sh,u:d have dcfincd areas ,here smokin e
is
allowed, pr.-ferabl%. not in dav rooms or i6evison
lounges used by othtir paticrits. The maiority of
patients
whc dn not smoke sh(,-Id bc free to be nursed and
;Jax
in pl~::cs free from iolincre, smoke. Aronow has
sho%vn
that it is not only the ~omibrt but also the
health of pa-
tients which will,'in this way, be protected.
ON KEEPING A COOL HEAD
THFRE i-_- something special about keeping a cool
head. Not simply kccping coc!, but keeping a coc!
head.
At first only the dc37er ca;s had ducts to blow
cnol air
towards one's face %,hen rcquircd; now they nearly
all
do. People sponge thzmselves with cold water in
the
heat; -: is the face that gets it first. Space
travellers, nre-
men, znd otf-s who need cooling at work have
Special
cooling helmets designed for them, vhich arc more
help-
ful than dc,-;ccs 10 (.001 Other parts of the
bodv.'-' Hot
rodents smear saliva over their facts, not having
any
s~czt glands to mention, but do not expend much an
the;rbacks.
Crude physiological analysis talks of a body core,
in
thcorv a:wavs at 37cC, and an insulating Mantle
all
roun(i it. Thc'rc is no hint here of anything
spcial about
.he head,: cool any part of the surface, and the
core will
to some zxtcnt cGol. Yci there m clear mdence -hat
fice
and head cooling are P3rticuliriv clTective in the
heat,
and neck cooling much Im so.' The subicct gains an
im-
pres-on of rapid benefit, ard it is more than an
imr-es-
4. W-n. E. W.. A~Jd-. R. J.. S.-k I. ht.. . I.J.-
1. A-1- V. S.. S-rwr, E. A., libelf.M. W. C-1--
1971.49. -11.
4 Sh _, . E.y prd. 1970.29.36
7.K-0,v. S. A.. T-I.... S. A.-.. WcW ?.,f,-p-,
AJ,J. 1971, 42,
6..
s. I- " A.. 511-r. .1 1-,d. I - 14'.1.1030.
E. 197.40,661.
THE LANCET, AUGUST 19, 1979
sion; experiments in clovible chambers, one for
the head
and one for tl,t rest. showed that icniperaturc
changes
in the head chamber ~% cre follm, ed by the onset
and off-
set of sweating much more promptly than %vere
chanGes
in the other ch:inibcr.
The clue to what is going on comes from unilateral
temperature mcnsurcments. When ternrer3ture is
mca-
surcd close to the t,-rnpniiic membranes and also
on each
side of the mouth, then a chance t)f outside
t-rerature
applied to just one sidL: of the face promptly
alters
mouth temperature ard tymp3nic temTeraturc, b"t on
the Fame side only.1"rhe mechanism is
counicircurrent
hc--t cxchangc. Such excEnnicc is familiar encugh
in the
wav in which cold blood returning from the skin
ofarms
anti legs can coul outgoing arterial blood, by
flotving
centrally in vcnx COMit3ntCS side by side with the
arierics.11 The advantage in cold weather is
clcir: in~icncl
of hot bloti,f irri%itig at t~c cold skin and
losing a grcat
deal ofhe3t. it arrives precooled and loses much
less. In
hot weather, the blood returns mostiv bv another
route,
in the dilated subcutaneous veins. which have no
Close
rclation to arterics.
So much is well known; Claude Bernard noticed the
essentials in 187V But what about heat exchange in
the
human neck? Distances are not great, but the
internal
jugular vcin receives blood from the surface ofthe
face,
and does run closcly along the common carotid
ancry.
Of the organs pcrf~scd bv the common carotid
-rter'
Y,
one--the brain-is profoundly sensitive to the
tempera-
wrc of the blood perfusing i and organises act'
rc-
I' 'vc
sponscs bv the rcst of the body in changes as s
all ,a
0-01'CY Thlis chaiages in the of the skin,
though not moving much heat into.or out of the
body,
mn rapidly change the temperature of
in!ernal-higular-
v-:in blood a little, and therefore the
temperature of
common car-tid b!ood a little; the brain responds
a lot
to a little chnngc here. Possibly the reputation
of tea as
a cooling drink originates from sonic such c!Tcct.
The tea
is usually drunk when it is above body
tempt-rature, and
s~, cannot fail to heat tl,,: bodv; but the
transient effect
as it goes down and warms the urgoing blood !tarts
or
amplifies swcating. The drinLer, the tea once
down, f5ccls
his brain cooling and hiinsclf swca;ing, and is
p1c2",l.
Ifeat exchang
gc is again the rationale underlying that
curious ncurov2scul3r complex, the cavernous
sinus.
Carotid-2rterv blood runs through r2thCf than
beside
the flow or v'enous blood. This fiviturc, improved
by
breaking up the artery into numerous small
di6sinns
and thus increasing its surface area, allovvs zhe
oryx to
keep a cool brain in a hot desert. The vcnous blob
is
returning from the nasai cavity, %here- it has
been
cooled by evaporation of,.% --tcr. The arterial
bltod p.iss-
ing through its may !,3se so much heit that the
orvx can
stand 3 rectal tempuraturc of 41,-!"C P,r huurs
observable ill cffccts."And cvt:n the dug, when he
runs,
can keep his brain as much as I. PC beilow the
tempc:a-
ture ofcarotid blood, by the s3me3frangement. "
10 M,Cffl,,y, T. V_MC-k. R. D., IFti R. D 41.
1975. 39.114,
B.,;". fl. C.. Le", L. It.. E,.-b-.L L. D.,. R.,
F-, R. r!:-.
1. 1W.t. 111,76.
13- A--g,r. 1. 1 f. S- A- ' 961.204, 3 31.
14 11-A ...... 1, .-k; V. 61. C..b,W- 1972.
1 J. O.k,,. M. A , Ch-r-- L %. S--. 1977,1191.
711.
00
k-1.1
011
_~o
C0
BATCo document for Province of British Columbia 23
April 1999