180 JULY 20, 1963 CORRESPONDENCE BRITISH

MEDICAL JOURNAL

First, the whole of the forced inspiratory gated, while the M.E.F.R./M.I.F.R. is cytes seen in the centrifuged deposit is
spirogram is often completed within one the most sensitive. It will be seen that often a poor indication of the W.B.C.
se-cond, and this renders the time interval there is a twofold difference in the former excretion rate.' Since the infection may
irrelevant and results in the measurement ratio between healthy subjects and those be asymptomatic2 the clinical findings
of the inspiratory vital capacity. Secondly, having emphysema, compared with an cannot be used to distinguish between
there is a fundamental difference between eightfold difference in the latter ratio. urinary infection and contamination, and
the shape of the forced expiratory and We suggest that the inadequacy of the therefore the significance of any bacterial
inspiratory spirograms in that the former F.E.V.1/F.I.V.1 ratio arises from the fact growth may be difficult to establish. 1
has a fast and slow portion whereas the that the early, effective phase of forced have found that a quantitative count per-
latter is linear throughout nearly the expiration in the healthy individual is not formed the next day on refrigerated urine
whole of its course. This tends to favour maintained for a full second, so that it is often resolves this difficulty.
the value for F.I.V.1 and may explain possible to expire only about 80°b of the Drs. Guttmann and Stokes say that
why Dr. Chapman finds that the F.E.V.1/ vital capacity in one second; in anti- they do not culture routinely urines con-
F.l.V. ratio is usually less than 1. By thesis the forced inspiratory rate is more taining less than three leucocytes per one-
measuring the peak flow on the meter or uniform throughout, and while it is lower sixth field unless a special request is
the average flow rate of the first litre than the rate attained during the early made, and if most of the specimens they
on a spirometer we feel that a better phase of forced expiration most healthy examined contained fewer cells may they
comparison of expiratory and inspiratory subjects can inspire a volume equivalent not have excluded from their investiga-
flow can be made. to the vital capacity in less than one tions those cases in which quantitative
We were very interested in Dr. Lenox- second. culture would have proved most helpful ?
Smith's suggestion that compliance is an The M.E.F.R./M.I.F.R. ratio, which is The pour-plate technique for bacterial
important factor in the measurement of calculated from the same forced expira- counting is indeed laborious, but the
inspiratory flow, and we agree that a tory and inspiratory spirographs as are surface viable count, which is less so,
reduction in inspiratory flow is very com- required for F.E.V.1/F.I.V.1, avoids many has been used by workers in this coun-
monly seen in patients suffering from of the anomalous results which may be try3 and has been shown to give similar
pulmonary fibrosis.-We are, etc., obtained from both F.E.V.i/F.I.V., and results.4 Does it not have a place in
JEAN R. NAIRN. P.E.F.R./P.I.F.R. In the healthy subject the examination of selected urine speci-
Maryfield Hospital, R. S. MCNEILL. the M.E.F.R. represents the early, rapid mens such as those I have described.
Dundee. expiratory phase, while in the emphy- which are sent to the routine bacteriology
sematous patient it indicates the steady laboratory ?-I am, etc.,
expiratory phase achieved after the onset N. A. SIMMONS.
SIR,-We read with interest the corre- of the characteristic bronchial collapse Evelina Children's Hospital
mechanism. Consequently, the M.E.F.R. / of Guy's Hospital,
spondence resulting from the article by London S.E.I.
Dr. Jean R. Nairn and Dr. R. S. McNeill M.I.F.R. ratio demonstrates the selective
impairment of expiration which is a con- REFERENCES
(May 18, p, 1321) describing their modi- 1 Little, P. J., Lancet, 1962, 1, 1149.
fication of the Wright peak flow meter. stant feature of emphysema. While this 2 Kass, E. H., Trans. Ass. Amer. Phycns. 1956,
The difference of opinion between Dr. ratio, which is normally greater than 69, 56.
unity, tends to be reduced in other forms 3 Brumfiitt, W., Davies, B. I., and Rosser, E. ap
I. Lenox-Smith (June 8, p. 1543) and Dr. I., Lancet, 1961, 2, 1059.
T. T. Chapman (June 29, p. 1740) stimu- of obstructive airways disease, the lowest 4 Hentges, D. J., A mer. J. clin. Path.. 1962, 38,
lated us to compare for ourselves the values are obtained from emphysematous 304.
ratio of the forced expiratory and inspira- patients.
tory volumes in one second (F.E.V.1/ We therefore conclude that, of the three
F.I.V.1) with the ratio of the maximal types of investigation under considera- Dental Anaesthetics
expiratory and inspiratory flow rates tion, the M.E.F.R./M.I.F.R. ratio can
best be relied upon to detect variations SIR,-Dr. A. M. Danziger's letter
(M.E.F.R./M.I.F.R.), as described by (May 18, p. 1348) on dental anaesthetics
McNeill el al.,' and the ratio of the peak from the normal.
calls for comment. It is agreed that
expiratory and inspiratory flow rates We are grateful to Dr. C. Kelman Robert- specialist anaesthetists should be paid
(P.E.F.R./P.I.F.R.), using the modified son for permission to study patients under more for dental anaesthetics than general
peak flow meter. The results which we his care.
practitioners, but the suggestion that the
obtained from 10 healthy subjects and 4 -We are, etc., scope of the work carried out in the
emphysematous patients are given in the DAVID MORRIS. dental chair should be increased ought to
table. J. H. ROLLAND RAMSAY. be questioned on the following grounds:
We must agree with Dr. Chapman's Bangour General Hospital, (I) As Dr. J. G. Bourne has so con-
view, since our results suggest that the Broxburn, West Lothian.
vinciiigly proved,' there are dangers of
F.E.V.i/F.I.V.1 is the least sensitive of REFERENCE cerebral anoxia associated with short
the three parameters which we investi- McNeill, R. S., Malcolm, G. D., and Brown, anaesthetics in the upright position which
W. R., Thorax, 1959, 14. 225.
may be troublesome even to specialists.
Ag Se F.Ey.V M.E.F.R. P.E.F.R. (2) For technical reasons it is not possible
F.t.V., M.I.F.R. P.I.F.R. to give the best surgical attention to
Healthy Subjects
Methods of Urine Culture patients whilst they are being operated
D.M. 26 M. 0 90 1-25 1-05 SIR,-Few clinical bacteriologists upon in a dental chair. Surgical cleanli-
J.B.
I.M.
32
32
M. 0 85
M. 0 95
1-10
1.50
1 20
1 40
would disagree with the findings of Drs. ness and a satisfactory repair of the
E S. 28 M. 0 85 1-33 1 30 D. Guttmann and E. Joan Stokes (May tissues are difficult to achieve. Under
J. B.
M.B.
30
26
M. 0 95
F. 0-85
1]15
1-50
1-55
1 10
25, p. 1384) that the results of semi- such adverse conditions the removal of
C.M. 22 F. 0 98 1-15 1-07 quantitative urine culture such as they a large number of teeth with all their
S.B.
K.M.
18
22
F.
F.
1-30
1-30
1-45
1-35
1-35
1 25
have described are readily interpreted roots intact is, even after full mouth
W.M. 19 F. 1-35 0-95 1t35 and that quantitative bacterial counts radiographs, a procedure associated with
Averages 1 03 1 27 1-26
usually yield little additional information good fortune as well as skill. (3) With
when more than three leucocytes have the advent of very good local anaes-
Emphysematous Patients been seen per one-sixth field in the centri- thetics, the only clinical indications for
R.P.
J.K.
58
58
M.
M.
0*30
0 60
0 08
0.15
0 45
0-48
fuged deposit. However, interpretation general anaesthesia are acute infection
T1.B. 58 M. 0 53 0 15 0 35 of routine cultures of urine containing and mental derangement of varying de-
J.W. 61 M. 0 81 0-23 0 74 fewer leucocytes may be more difficult. gree (including, of course, nervousness).
Averages 0 56 0-15 0*51 Urinary tract infection may be present It would seem that dental anaesthetics
in these cases, for the number of leuco- in the chair when administered by a