1415 for the patients with atopic dermatitis, dermatographia, or non-reactive skin. They may also be useful in the patient for whom repeated needling may be harmful, such as the braindamaged child with allergies. In time, these problems with the R.A.S.T. will probably be ironed out and this form of testing may then replace skin test-
ing. Wayne Medical Center, Wayne, New Jersey 07470, U.S.A., and Department of Pediatrics, College of Medicine of New Jersey
MICHAEL S. MATTIKOW
COLONIC INVOLVEMENT IN SALMONELLOSIS
SIR Consequent to the article by Dr Mandal and Dr Mani (April 24, p. 887) I should like to update the experience gained since my earlier letter.’ Eight confirmed Salmonella typhimurium food-poisoning deaths after acute and subacute illnesses have been studied with the following results: Stomach.-Only one patient (or four showing no oxyntic cells) showed gastritis with crypt abscesses. This series confirms the well-established teaching that patients with previous gastric surgery (three) and/or achlorhydria are more susceptible to food-poisoning, other things being equal.2-4 Small intestine.-None had prominent Peyer’s patches. One or two
poor crypt abscesses occurred. Enteritis was minimal, my earlier findings’ and the biopsy results of
supporting
et al. Axon and Poole6 and others report cholera-like diarrhoea in salmonellosis, suggesting that, as in Vibrio cholerce infection, dysfunction without histological abnormality by conventional staining can be profound. Rout et aU reaffirm this concept. Earlier work8 reporting enteritis was performed on preconditioned guineapigs with artificially altered bowel motility. In summary, there is minimal gastroenteritis, but much evidence for enteropathy. Colon.-The contents were abnormal in all. Toxic dilatation occurred in one or two. Histology showed florid crypt abscesses in five, and other changes also. This diffuse colitis could be confused with idiopathic ulcerative colitis (or with in biopsy material, and may have occurred in one dysentery) case.9 10 Since ulcerative colitis and salmonellosis are both common, a comparison, based on limited experience, may prove useful. In ulcerative colitis: there are stromal as well as crypt abscesses, and a pure neutrophil polymorph response. Both features are absent in S. typhimurium cases, but are seen in other salmonella infections. In S. typhimurium stromal abscesses are absent (to date) and crypt abscesses are composed of mixed cell population (i.e., neutrophil and eosinophil polymorphs, lymphocytes, mononuclears, plasma cells, and exfoliated crypt cells). These features have also been seen in other salmonella infections and in dysentery which may also show similar polymorphic stromal abscesses. Appendix.-Six cases showed reparative changes but less advanced than in the colon of the same patient. Genuine surgical appendicitis can complicate this illness."’" General.-Only two patients were debilitated. Death was due most frequently to septicaemia and/or shock. One patient required disarticulation of the left leg at the hip because of
Gianella
1. 2. 3. 4.
Boyd, J. F. Lancet, 1969, ii, 901.
Nordbring, F. Acta med. scand. 1962, 171, 783. Gray, J. A., Trueman, A. M. Scott. med. J. 1971, 16, 255. Gianella, R. A., Broitman, S. A., Zamcheck, N. Ann. intern. Med. 1973, 78,
271. 5. Gianella, R.
gangrene. There were myriads of gram-positive bacilli in preexisting varicose veins showing phlebitis, and in the adjacent cellulitis. Gangrene was due to thrombus in the lower aorta. Kurtz 14 drew attention recently to leg abscesses containing S. heidelberg in the line of the long saphenous vein. From their studies, Dr Thomas and Mrs Tillett (May 22, p. 1129) suggest that S. typhimurium infection is more severe than other salmonella infections. My series shows persistent colonic changes at 23 days. I estimate that histological normality is restored in about one month (longer in the appendix). These findings cause me to be very cautious about suggesting a diagnosis of idiopathic ulcerative colitis on biopsy material from patients ill for less than (say) six weeks. I have examined tissue from two deaths due to S. heidelberg infection, one acute and one convalescent. The first15 showed
florid enteritis and colitis, and extensive venous thrombosis of colonic mucosa and submucosa. I have yet to see this last feature in S. typhimurium infection. The convalescent patient showed only minimal crypt abscesses in small and large intestines. Death was due to pulmonary-artery embolism from the right leg, raising again the possible sinister association of salmonella bacteræmia/septicæmia with coexisting (though minor) varicose veins. One death after 8 days’ illness from S. enteritidis food poisoning has been studied. From this solitary experience this organism is not well-named. The findings were: previous gastric surgery, reduced numbers of oxyntic cells, acute-onchronic gastritis, no enteritis, extensive colitis with crypt abscesses, and extensive capillary and venular thrombosis in the small and large intestines causing villous sloughing in the former. None of the eleven patients received clindamycin or linca-
mycin therapy. Brownlee
Laboratory, University Departments of Infectious Diseases Ruchill Hospital and Western Infirmary,
and
Pathology,
JAMES F. BOYD JAM
Glasgow
EAR, JANEU, AND HEART SIR,—A ritual which the Brahmins of India observe consists of winding a sacred thread, the 7-stranded Janeu, around the ear before defecation. This ritual may serve a physiological purpose in relation to bowel action, possibly through the medium of the auricular branch of the vagus (the so-called "alderman’s nerve", from its use in reviving jaded appetites). If such compression of the pinna stimulates the vagus, one might expect an effect on the heart also, and we have tested this idea on volunteers. The Doppler pulse was recorded before and after squeezing the pinna, using a transcutaneous Doppler blood velocity meter, with a 10 MHz probe. The flow velocity was simultaneously recorded on a magnetic tape recorder and a pen recorder. Our results (details of which will be published elsewhere) show that the simple non-invasive procedure of squeezing the whole pinna produces a temporary effect on the heart dynamics causing a small reduction in pulse-rate, a profound drop in the amplitude of the pulse, and a drop in the peak and mean flow velocity. We are investigating the possible clinical usefulness of this manoeuvre, including those situations where the Valsalva manoeuvre is diagnostic or therapeutic.
A., Broitman, S. A., Zamcheck, N. Am. J. dig. Dis. 1971, 16,
1007. 6. Axon, A. T. R., Poole, D. Lancet, 1973, i, 745. 7. Rout, W. R., Formal, S. B., Dammin, G. J., Gianella, R. A. Gastroenterology, 1974, 67, 59. 8. Takeuchi, A., Sprinz, H. Am. J. Path. 1967, 51, 137. 9. Dronfield, M. W., Fletcher, J., Langman, M. J. S. Br. med. J. 1974, i, 99. 10. Dronfield, M. W. Personal communication. 11. Geddes, A. M. Br. med. J. 1973, i, 98. 12. Dadswell, J. V. ibid. 1973, i, 740. 13. Thompson, R. G., Harper, I. A. ibid. 1973, ii, 300.
Queen Elizabeth Hospital for Children, London E2 8PS
S. R. SAXENA
King’s College Hospital,
D. SOLANKI MOHAN S. KATARIA
London SE5
14. 15.
Kurtz, J. B. Lancet, 1976, i,
201.
Burnett, R. A. Personal communication.
ing. Wayne Medical Center, Wayne, New Jersey 07470, U.S.A., and Department of Pediatrics, College of Medicine of New Jersey
MICHAEL S. MATTIKOW
COLONIC INVOLVEMENT IN SALMONELLOSIS
SIR Consequent to the article by Dr Mandal and Dr Mani (April 24, p. 887) I should like to update the experience gained since my earlier letter.’ Eight confirmed Salmonella typhimurium food-poisoning deaths after acute and subacute illnesses have been studied with the following results: Stomach.-Only one patient (or four showing no oxyntic cells) showed gastritis with crypt abscesses. This series confirms the well-established teaching that patients with previous gastric surgery (three) and/or achlorhydria are more susceptible to food-poisoning, other things being equal.2-4 Small intestine.-None had prominent Peyer’s patches. One or two
poor crypt abscesses occurred. Enteritis was minimal, my earlier findings’ and the biopsy results of
supporting
et al. Axon and Poole6 and others report cholera-like diarrhoea in salmonellosis, suggesting that, as in Vibrio cholerce infection, dysfunction without histological abnormality by conventional staining can be profound. Rout et aU reaffirm this concept. Earlier work8 reporting enteritis was performed on preconditioned guineapigs with artificially altered bowel motility. In summary, there is minimal gastroenteritis, but much evidence for enteropathy. Colon.-The contents were abnormal in all. Toxic dilatation occurred in one or two. Histology showed florid crypt abscesses in five, and other changes also. This diffuse colitis could be confused with idiopathic ulcerative colitis (or with in biopsy material, and may have occurred in one dysentery) case.9 10 Since ulcerative colitis and salmonellosis are both common, a comparison, based on limited experience, may prove useful. In ulcerative colitis: there are stromal as well as crypt abscesses, and a pure neutrophil polymorph response. Both features are absent in S. typhimurium cases, but are seen in other salmonella infections. In S. typhimurium stromal abscesses are absent (to date) and crypt abscesses are composed of mixed cell population (i.e., neutrophil and eosinophil polymorphs, lymphocytes, mononuclears, plasma cells, and exfoliated crypt cells). These features have also been seen in other salmonella infections and in dysentery which may also show similar polymorphic stromal abscesses. Appendix.-Six cases showed reparative changes but less advanced than in the colon of the same patient. Genuine surgical appendicitis can complicate this illness."’" General.-Only two patients were debilitated. Death was due most frequently to septicaemia and/or shock. One patient required disarticulation of the left leg at the hip because of
Gianella
1. 2. 3. 4.
Boyd, J. F. Lancet, 1969, ii, 901.
Nordbring, F. Acta med. scand. 1962, 171, 783. Gray, J. A., Trueman, A. M. Scott. med. J. 1971, 16, 255. Gianella, R. A., Broitman, S. A., Zamcheck, N. Ann. intern. Med. 1973, 78,
271. 5. Gianella, R.
gangrene. There were myriads of gram-positive bacilli in preexisting varicose veins showing phlebitis, and in the adjacent cellulitis. Gangrene was due to thrombus in the lower aorta. Kurtz 14 drew attention recently to leg abscesses containing S. heidelberg in the line of the long saphenous vein. From their studies, Dr Thomas and Mrs Tillett (May 22, p. 1129) suggest that S. typhimurium infection is more severe than other salmonella infections. My series shows persistent colonic changes at 23 days. I estimate that histological normality is restored in about one month (longer in the appendix). These findings cause me to be very cautious about suggesting a diagnosis of idiopathic ulcerative colitis on biopsy material from patients ill for less than (say) six weeks. I have examined tissue from two deaths due to S. heidelberg infection, one acute and one convalescent. The first15 showed
florid enteritis and colitis, and extensive venous thrombosis of colonic mucosa and submucosa. I have yet to see this last feature in S. typhimurium infection. The convalescent patient showed only minimal crypt abscesses in small and large intestines. Death was due to pulmonary-artery embolism from the right leg, raising again the possible sinister association of salmonella bacteræmia/septicæmia with coexisting (though minor) varicose veins. One death after 8 days’ illness from S. enteritidis food poisoning has been studied. From this solitary experience this organism is not well-named. The findings were: previous gastric surgery, reduced numbers of oxyntic cells, acute-onchronic gastritis, no enteritis, extensive colitis with crypt abscesses, and extensive capillary and venular thrombosis in the small and large intestines causing villous sloughing in the former. None of the eleven patients received clindamycin or linca-
mycin therapy. Brownlee
Laboratory, University Departments of Infectious Diseases Ruchill Hospital and Western Infirmary,
and
Pathology,
JAMES F. BOYD JAM
Glasgow
EAR, JANEU, AND HEART SIR,—A ritual which the Brahmins of India observe consists of winding a sacred thread, the 7-stranded Janeu, around the ear before defecation. This ritual may serve a physiological purpose in relation to bowel action, possibly through the medium of the auricular branch of the vagus (the so-called "alderman’s nerve", from its use in reviving jaded appetites). If such compression of the pinna stimulates the vagus, one might expect an effect on the heart also, and we have tested this idea on volunteers. The Doppler pulse was recorded before and after squeezing the pinna, using a transcutaneous Doppler blood velocity meter, with a 10 MHz probe. The flow velocity was simultaneously recorded on a magnetic tape recorder and a pen recorder. Our results (details of which will be published elsewhere) show that the simple non-invasive procedure of squeezing the whole pinna produces a temporary effect on the heart dynamics causing a small reduction in pulse-rate, a profound drop in the amplitude of the pulse, and a drop in the peak and mean flow velocity. We are investigating the possible clinical usefulness of this manoeuvre, including those situations where the Valsalva manoeuvre is diagnostic or therapeutic.
A., Broitman, S. A., Zamcheck, N. Am. J. dig. Dis. 1971, 16,
1007. 6. Axon, A. T. R., Poole, D. Lancet, 1973, i, 745. 7. Rout, W. R., Formal, S. B., Dammin, G. J., Gianella, R. A. Gastroenterology, 1974, 67, 59. 8. Takeuchi, A., Sprinz, H. Am. J. Path. 1967, 51, 137. 9. Dronfield, M. W., Fletcher, J., Langman, M. J. S. Br. med. J. 1974, i, 99. 10. Dronfield, M. W. Personal communication. 11. Geddes, A. M. Br. med. J. 1973, i, 98. 12. Dadswell, J. V. ibid. 1973, i, 740. 13. Thompson, R. G., Harper, I. A. ibid. 1973, ii, 300.
Queen Elizabeth Hospital for Children, London E2 8PS
S. R. SAXENA
King’s College Hospital,
D. SOLANKI MOHAN S. KATARIA
London SE5
14. 15.
Kurtz, J. B. Lancet, 1976, i,
201.
Burnett, R. A. Personal communication.
