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PENICILLIN IN THE TREATMENT OF DIPHTHERIA
290 I would like to make one comment on the work which has been done so far. Attention seems to have been focused on the pathology of the heart to the exclusion of the study of other parts which may also undergo morbid change, particularly the liver. It is possible, as was suggested at the meeting of the Royal Society of Tropical Medicine and Hygiene reported in your issue of May 29, that keloid of the skin, which is a common condition in India as well as Africa, may be related in some way to fibrosis of the heart. May it not also be possible that the dietary cirrhosis of the liver, so common amongst the malnourished of India and Africa alike, is a similar process with a different organ bearing the brunt? Moorshead Memorial Hospital, D. STEWART -L3CTEWART MCLAREN. McLAREN. Ganjam, Orissa, India.
PENICILLIN IN THE TREATMENT OF DIPHTHERIA
SIR,—I have read with interest your leading article on
the
pathogenesis of
of
diphtheria (May 22)
and your
5, Penicillin in Diphtheria. In 1945 we investigated the action of penicillin in the treatment of diphtheria.l We treated 27 cases of diphtheria of which 16 were bacteriologically positive and 11, annotation
June
though bacteriologically negative, were clinically typical. Of these infections, 20 were early and 7 moderately severe. The duration of the disease varied from one to eight days. The All the cases recovered without complications. three the was normal within days, patches temperature disappeared within two to five days, and throat swabs became negative within three to seven days of starting treatment. The average curative dose of penicillin was within the limit of 500,000 units. Penicillin at that time was scarce and costly and the dose schedule was 15,000 to 30,000 units intramuscularly every three hours. Frequent injections of penicillin are very trying for a child, but with larger doses the interval between injections may now be prolonged. Our observations have been corroborated by Calvet and Herrera2 and I think that penicillin is the treatment of choice in early and moderately severe cases of diphtheria. M. N. DE. Calcutta. TREATMENT OF LUPUS ERYTHEMATOSUS
SIR,—I think that an account of the following may be of interest and help to other practitioners.
case
A labourer, aged 58, had had lupus erythematosus since The rash extended over both cheeks and the whole 1950. of the nose, also a patch 2 in. in diameter just above the suprasternal notch. May to September, 1950.-Treated with quinine sulphate gr. 2 t.d.s. andSiccolarn’ cream. The only result was that he developed a crop of unpleasant boils on his neck. May to August, 1951.-Recurrence ; treated as above with the addition of 1 ml. of bismuth injection, weekly, with the same result as before. May to August, 1952.-Recurrence ; treated with mepacrine with the
same result, including the boils. June, 1953.-Relapse : this time treated with chloroquine 0-4 g. t.d.s. for three days, then once daily. No boils, and the rash cleared in twenty days. ,
May 12, 1954.—Severe relapse ; treated with chloroquine 0-6 g. t.d.s. for two days, 0-4 g. t.d.s. for four days, then 0-2 g. t.d.s. The rash began to fade on the ninth day of treatment, and was gone by May 28-i.e., after sixteen days. During this course the patient was also given vitamin-B tablets, but no local treatment. Again there were no boils and
no
side-effects.
Next year I intend to keep the doses until the rash clears. London, E.8.
patient
on
the
larger
J. ZEITLIN.
Brit. med. J. 1947, De, M. N., Chatterjee, J. R., Ganguli, L. i, 376. 2. Calvet, J. R., Herrera, R. G. Bol. Coll. mád. Habana, 1953, 4, 501. 1.
THE RENAL DUCTS
OF BELLINI
SIR,—Last year Duran-Jorda1 reported that after several hundred sections he was sceptical of the existence of openings of the ducts of Bellini, and that he was considering the possibility that in the normal kidney the urine is dialysed through a pelvic epithelium and not excreted by the ducts directly into the renal pelvis. In support of this view he adduced the phenomenon of pyelovenous backflow and the fact that " aseptic renal calculi are found at the tips of the papillae as though there were a barrier between the renal pelvis and the secretory system of the kidney." In a study of kidneys from neonates he had observed that often the terminal collecting-tubules contained a uricacid precipitate, and that these tubules did not end in the renal pelvis but appeared to join another duct of Bellini and to finish in a "hairpin bend." In the correspondence which followed Ross2 stated that it was easy to makeNeoprene’ casts of the ducts of Bellini by injection via the ureter, and that pyelotubular backflow, though less common than pyelovenous, was well known to urologists. He regarded these facts as militating against Duran-Jorda’s views and hoped that further histological proof would be forthcoming. We performed recently a necropsy on an infant aged 12 days, who was born prematurely weighing 31/2 lb. After birth she had progressive cardiac failure, and a patent ductus arteriosus was diagnosed. The ductus was tied as the only means of aiding the failing heart, but the infant died on the day after the operation. At necropsy routine blocks of tissue were taken from various organs, including the kidneys, which, apart from slight congestion, appeared macroscopically normal. The ureters and bladder also appeared normal, and urine had been passed freely during life. Quite by chance the histological section has passed through the whole of a renal papilla (see figure). The epithelial lining of the adjacent renal pelvis is complete. No smooth muscle can be seen in the papilla. In this photograph two ducts of Bellini can be seen opening directly into the renal pelvis with no evidence of a membrane covering their
examining accepting
openings. Although it is usually stated in textbooks of histology that lining the duct in its terminal portion are tall and columnar, the transitional epithelium of the renal pelvis is
the cells
continued for a short distance into the mouths of the ducts. - Other ducts on the papilla appear to have no direct com1.
Duran-Jorda, F. Lancet, 1953, i, 727, 900. Ibid, pp. 799, 950.
2. Ross, J. A.
PENICILLIN IN THE TREATMENT OF DIPHTHERIA
SIR,—I have read with interest your leading article on
the
pathogenesis of
of
diphtheria (May 22)
and your
5, Penicillin in Diphtheria. In 1945 we investigated the action of penicillin in the treatment of diphtheria.l We treated 27 cases of diphtheria of which 16 were bacteriologically positive and 11, annotation
June
though bacteriologically negative, were clinically typical. Of these infections, 20 were early and 7 moderately severe. The duration of the disease varied from one to eight days. The All the cases recovered without complications. three the was normal within days, patches temperature disappeared within two to five days, and throat swabs became negative within three to seven days of starting treatment. The average curative dose of penicillin was within the limit of 500,000 units. Penicillin at that time was scarce and costly and the dose schedule was 15,000 to 30,000 units intramuscularly every three hours. Frequent injections of penicillin are very trying for a child, but with larger doses the interval between injections may now be prolonged. Our observations have been corroborated by Calvet and Herrera2 and I think that penicillin is the treatment of choice in early and moderately severe cases of diphtheria. M. N. DE. Calcutta. TREATMENT OF LUPUS ERYTHEMATOSUS
SIR,—I think that an account of the following may be of interest and help to other practitioners.
case
A labourer, aged 58, had had lupus erythematosus since The rash extended over both cheeks and the whole 1950. of the nose, also a patch 2 in. in diameter just above the suprasternal notch. May to September, 1950.-Treated with quinine sulphate gr. 2 t.d.s. andSiccolarn’ cream. The only result was that he developed a crop of unpleasant boils on his neck. May to August, 1951.-Recurrence ; treated as above with the addition of 1 ml. of bismuth injection, weekly, with the same result as before. May to August, 1952.-Recurrence ; treated with mepacrine with the
same result, including the boils. June, 1953.-Relapse : this time treated with chloroquine 0-4 g. t.d.s. for three days, then once daily. No boils, and the rash cleared in twenty days. ,
May 12, 1954.—Severe relapse ; treated with chloroquine 0-6 g. t.d.s. for two days, 0-4 g. t.d.s. for four days, then 0-2 g. t.d.s. The rash began to fade on the ninth day of treatment, and was gone by May 28-i.e., after sixteen days. During this course the patient was also given vitamin-B tablets, but no local treatment. Again there were no boils and
no
side-effects.
Next year I intend to keep the doses until the rash clears. London, E.8.
patient
on
the
larger
J. ZEITLIN.
Brit. med. J. 1947, De, M. N., Chatterjee, J. R., Ganguli, L. i, 376. 2. Calvet, J. R., Herrera, R. G. Bol. Coll. mád. Habana, 1953, 4, 501. 1.
THE RENAL DUCTS
OF BELLINI
SIR,—Last year Duran-Jorda1 reported that after several hundred sections he was sceptical of the existence of openings of the ducts of Bellini, and that he was considering the possibility that in the normal kidney the urine is dialysed through a pelvic epithelium and not excreted by the ducts directly into the renal pelvis. In support of this view he adduced the phenomenon of pyelovenous backflow and the fact that " aseptic renal calculi are found at the tips of the papillae as though there were a barrier between the renal pelvis and the secretory system of the kidney." In a study of kidneys from neonates he had observed that often the terminal collecting-tubules contained a uricacid precipitate, and that these tubules did not end in the renal pelvis but appeared to join another duct of Bellini and to finish in a "hairpin bend." In the correspondence which followed Ross2 stated that it was easy to makeNeoprene’ casts of the ducts of Bellini by injection via the ureter, and that pyelotubular backflow, though less common than pyelovenous, was well known to urologists. He regarded these facts as militating against Duran-Jorda’s views and hoped that further histological proof would be forthcoming. We performed recently a necropsy on an infant aged 12 days, who was born prematurely weighing 31/2 lb. After birth she had progressive cardiac failure, and a patent ductus arteriosus was diagnosed. The ductus was tied as the only means of aiding the failing heart, but the infant died on the day after the operation. At necropsy routine blocks of tissue were taken from various organs, including the kidneys, which, apart from slight congestion, appeared macroscopically normal. The ureters and bladder also appeared normal, and urine had been passed freely during life. Quite by chance the histological section has passed through the whole of a renal papilla (see figure). The epithelial lining of the adjacent renal pelvis is complete. No smooth muscle can be seen in the papilla. In this photograph two ducts of Bellini can be seen opening directly into the renal pelvis with no evidence of a membrane covering their
examining accepting
openings. Although it is usually stated in textbooks of histology that lining the duct in its terminal portion are tall and columnar, the transitional epithelium of the renal pelvis is
the cells
continued for a short distance into the mouths of the ducts. - Other ducts on the papilla appear to have no direct com1.
Duran-Jorda, F. Lancet, 1953, i, 727, 900. Ibid, pp. 799, 950.
2. Ross, J. A.