Realism and addicts.
Journal: BMJ (1967)

group which acts as an oxygen-activating unit in cytochrome oxidase.Unfortunately this theory too falls foul of the facts, which have an unpleasant habit of invalidating all the theories about this disease as fast as they are put forward.As S. B. Osborn and J. M. Walshe" pointed out earlier this year, it is possible for a patient with Wilson's disease, treated with pencillamine, to live a perfectly normal life with no symptoms of disease and with no detectable copper or caeruloplasmin in his serum-always provided that the drug is continued and the patient maintained in copper balance.So this would suggest an excretory function for caeruloplasmin.But this theory comes up against the work of the Albert Einstein group of workers,'2 who have shown, at least for rabbits, that the copper of catabolized caeruloplasmin " is not directly or preferentially excreted by hepatic, pancreatic, intestinal, or renal routes."Blue blood may be all very well in preventing Wilson's disease, but the way in which it mediates this function is as obscure as its role in ennobling the nobility. Obstructive Airways DiseaseThe clinical features of the bronchial and emphysematous types of obstructive airways disease have been defined by A. C. Dornhorst1 and T. Simpson2 and their physiological characteristics by C. Ogilvie' and by W. A. Briscoe and A. Cournand.'The careful and detailed studies of C. M. Fletcher, B. Burrows, and others5 6 firmly established the criteria whereby these two types can be distinguished.These workers have also tackled the semantic problem posed by the indiscriminate use of the terms "chronic bronchitis" and " emphysema," the first being favoured in Britain and the second in America.Using standardized clinical, radiographic, and physiological techniques, they compared 50 patients from a " bronchitis " clinic in London with 50 patients attending an "emphysema " clinic in Chicago.7 Apart from a rather greater incidence of disabling chest illness in London, there was no real difference in the pattern of obstructive airways disease for the two cities.In particular, the frequency of the bronchial and emphysematous forms was the same.N. L.Jones, Burrows, and Fletcher8 have now extended this study by carrying out an annual review of the original 100 patients over a period of three years.During this time progress and mortality were remarkably similar in the two cities, but the incidence of disabling chest illness was higher among the London patients.However, a detailed questionary showed that bronchitic exacerbations were not in fact more frequent in London than in Chicago but only more disabling in terms of the time spent in bed or off work.The authors attribute this to differences in working conditions, sickness benefits, and cost of treatment between the two cities rather than to differences in the behaviour of the disease process itself.This recent survey also gives valuable information on the relative prognosis of the two types of obstructive airways disease.The mortality was higher in the bronchial (36%) than in the emphysematous group (15%), and this was related to the greater incidence of hypercapnia among the bronchitic patients.It might have been thought that the complications of bronchitis (infection, hypercapnia, and right heart failure) would prove more amenable to treatment than the irreversible lung changes of emphysema.The actual finding of a much -higher death rate for bronchitis surely points to the need for a reappraisal of therapeutic methods used in this formidable disease.The thorough techniques of investigation evolved by Fletcher and his co-workers could well provide the basis for a study of this kind.