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PULMONARY VENO-OCCLUSIVE DISEASE
546
reasonably suppose that severe ischaemia, as well as increased activity of the sympathetic nerves to the kidney, could bring about a dissociation of the combined renin within the kidney, and thus favour release of " free renin " into the blood-stream. Unfortunately there is, as yet, no experimental evidence for the existence of a B.p.-lowering compound of renin, so this part of my hypothesis is highly speculative. For this reason, as well as in the interest of brevity, I omitted it from mv orisinal statement (Auz. 6).
Physiology Research Laboratory, Veterans Administration Hospital, San Francisco, California 94121.
DAVID B. GORDON.
Professor Lucas and his colleagues3 found no change bladder calcification in children. The pathological chan caused by continued egg deposition in the bladder and urete is the replacement of normal by fibrous tissue, and calcification may
occur.
Although specific chemotherapy
may
remove
primary causal schistosomes it would not be expected to a& fibrous tissue and the secondary obstructive uropathic feature It is more difficult to explain the different findings children from Nigeria and Zanzibar. Factors to be consider: are the sizes of the series, the pathological findings in t:. lesions, the drugs used in treatment and their modes of actic: the duration and the intensity of infection, the degree : acquired immunity, and the possibility of re-exposure with: without reinfection. Both series were small, and an increase: sample-size might have modified the findings, a fact we appreciated by both groups of investigators. As discussed :’,Professor Lucas and his colleagues,3 it is possible that in mar children radiological abnormalities were due to granulomato lesions caused by egg deposition. Most of their children wer treated with‘ Ambilhar ’, a drug which in experimental infections was concentrated preferentially in the vitellogen:, glands of female worms and in the eggs deposited in the live and intestinal wall.5-7 Dodin8 cited the disappearance of. bilharzioma of the bladder, and a large intestinal granulam, in two different patients, a month after treatment with ambilhar Similar occurrences may explain the radiological improvemer in the Nigerian series. Further transverse and longitudinal studies of children ar: urgently needed to emphasise the serious public-healt’ problem posed by urinary bilharziasis. The impact of thi: disease is borne by the younger sections of the populations o: developing countries, upon whom the economic future rests, and an increase in its incidence and prevalence, parallel with water development, is inevitable. This small longitudinal study in adults shows that established urinary-tract lesions did not disappear after antimony treatment. Ambilhar, a drug more selective in its sites of action, may give hope of better results, although more information on its toxicity in field usage is needed. It seems imperative to ensure that children and adolescents receive adequate treatment to forestall the onset oi urinary-tract lesions, and continued chemotherapeutic research must produce a wider choice of acceptable, non-toxi: schistosomicides. World Health Organization/Medical Research Council/Tanzania, ,
-
PULMONARY VENO-OCCLUSIVE DISEASE
SIR,-Dr. Brown and Professor Harrison (July 9) suggest that pulmonary veno-occlusive disease can be clinically differentiated from primary pulmonary parenchymal disease, and state that the differential point is the presence of severe pulmonary hypertension only in the former. A common serious complication of sarcoid is heart-failure secondary to pulmonary involvement. Cor pulmonale can produce pulmonary-artery pressures even in excess of those in the patient described by Dr. Brown and Professor Harrison when heart-failure supervenes.2 Their patient was in heart failure. For this reason it seems that the distinction between veno-occlusive disease and diffuse pulmonary infiltrations, such as sarcoid, with cor pulmonale can be made onlv bv lung biopsv. John Moses United States Air Force Hospital, H. KLEIN. Minot, North Dakota 58701.
RADIOLOGICAL CHANGES AFTER TREATMENT OF VESICAL SCHISTOSOMIASIS
SIR,-From Nigeria, Professor Lucas and his colleagues3 described improvement in radiological appearances in eight of twelve children some 3 to 6 months after treatment. Dr. Forsyth and Professor Macdonald,4in Zanzibar, found that lesions had not regressed significantly in seven children after an interval of 15 months. I have
re-examined, with intravenous pyelography (LV.P.), African adult males, aged 20-40, 2 years after antieighteen monial treatment. The results were as follows:
Bilharziasis Chemotherapy Centre, P.O. Box 950, Tanga, Tanzania.
A. DAVIS.
TETANUS your annotation last week ca. for comment. I am not sure of the source of your informal" that, " With the expensive and demanding techniques :: curarisation and, artificially controlled respiration, the mortality-rate has been reduced to about 30% in the newboy and about 20% at other ages." I have never seen tetanus the newborn in this country, nor have I ever heard of ’ With regard to the method of treatment you mention in " adult, we have had a tetanus unit in this infirmary for over decade. This is of course a highly complicated technique though we managed to reduce the mortality to 20% in ’ early years. During the past eight years, we have reduced to something under 4%. The technique is admittedly complex that in my submission the Minister of Health sissue a directive to the effect that tetanus should not be treat in more than about three centres in Great Britain. As as the present system is perpetuated even an average .-’hospital is probably not likely to see more than about 1 in every two or three years, so that it would be imposttrain a tetanus unit.
SIR The terminal lines of
patients remained cured, and seven, one of whom was were excreting viable ova. No association between radiological change, and cure or failure, could be
Eleven a
reinfection,
demonstrated. The findings are expressed in terms of lesions, since patients commonly showed more than one abnormality on pyelography. Despite the difficulties of exact comparison and quantitative assessment of serial films, as noted by Dr. Forsyth and Professor Macdonald,the conclusions are plain. The appearance of most lesions was unchanged or had deteriorated. An " improved " appearance did not imply a return to normal. Bladder calcification, once established, remained; indeed, 1. 2. 3. 4.
Maycock, R. L., Bertrand, P., Morrison, C.E. Am. J. Med. 1963, 35, 67. Williams, J. F., Behnke, R. H. Ann. intern. Med. 1964, 60, 824. Lucas, A. O., Adeniyi-Jones, C. C., Cockshott, W. P., Gilles, H. M. Lancet, 1966, i, 631. Forsyth, D. M., Macdonald, G. ibid. p. 929.
-
5. 6. 7. 8.
Lambert, C. R. Ann. trop. Med. Parasit. 1964, 58, 292. Striebel, H. P., Kradolfer, F. Acta trop. 1966, suppl. 9, p 54 Sadun, E. H., Bruce, J. I., Moose, J. W., McMullen, D. B Dodin, A. ibid. p. 260.
reasonably suppose that severe ischaemia, as well as increased activity of the sympathetic nerves to the kidney, could bring about a dissociation of the combined renin within the kidney, and thus favour release of " free renin " into the blood-stream. Unfortunately there is, as yet, no experimental evidence for the existence of a B.p.-lowering compound of renin, so this part of my hypothesis is highly speculative. For this reason, as well as in the interest of brevity, I omitted it from mv orisinal statement (Auz. 6).
Physiology Research Laboratory, Veterans Administration Hospital, San Francisco, California 94121.
DAVID B. GORDON.
Professor Lucas and his colleagues3 found no change bladder calcification in children. The pathological chan caused by continued egg deposition in the bladder and urete is the replacement of normal by fibrous tissue, and calcification may
occur.
Although specific chemotherapy
may
remove
primary causal schistosomes it would not be expected to a& fibrous tissue and the secondary obstructive uropathic feature It is more difficult to explain the different findings children from Nigeria and Zanzibar. Factors to be consider: are the sizes of the series, the pathological findings in t:. lesions, the drugs used in treatment and their modes of actic: the duration and the intensity of infection, the degree : acquired immunity, and the possibility of re-exposure with: without reinfection. Both series were small, and an increase: sample-size might have modified the findings, a fact we appreciated by both groups of investigators. As discussed :’,Professor Lucas and his colleagues,3 it is possible that in mar children radiological abnormalities were due to granulomato lesions caused by egg deposition. Most of their children wer treated with‘ Ambilhar ’, a drug which in experimental infections was concentrated preferentially in the vitellogen:, glands of female worms and in the eggs deposited in the live and intestinal wall.5-7 Dodin8 cited the disappearance of. bilharzioma of the bladder, and a large intestinal granulam, in two different patients, a month after treatment with ambilhar Similar occurrences may explain the radiological improvemer in the Nigerian series. Further transverse and longitudinal studies of children ar: urgently needed to emphasise the serious public-healt’ problem posed by urinary bilharziasis. The impact of thi: disease is borne by the younger sections of the populations o: developing countries, upon whom the economic future rests, and an increase in its incidence and prevalence, parallel with water development, is inevitable. This small longitudinal study in adults shows that established urinary-tract lesions did not disappear after antimony treatment. Ambilhar, a drug more selective in its sites of action, may give hope of better results, although more information on its toxicity in field usage is needed. It seems imperative to ensure that children and adolescents receive adequate treatment to forestall the onset oi urinary-tract lesions, and continued chemotherapeutic research must produce a wider choice of acceptable, non-toxi: schistosomicides. World Health Organization/Medical Research Council/Tanzania, ,
-
PULMONARY VENO-OCCLUSIVE DISEASE
SIR,-Dr. Brown and Professor Harrison (July 9) suggest that pulmonary veno-occlusive disease can be clinically differentiated from primary pulmonary parenchymal disease, and state that the differential point is the presence of severe pulmonary hypertension only in the former. A common serious complication of sarcoid is heart-failure secondary to pulmonary involvement. Cor pulmonale can produce pulmonary-artery pressures even in excess of those in the patient described by Dr. Brown and Professor Harrison when heart-failure supervenes.2 Their patient was in heart failure. For this reason it seems that the distinction between veno-occlusive disease and diffuse pulmonary infiltrations, such as sarcoid, with cor pulmonale can be made onlv bv lung biopsv. John Moses United States Air Force Hospital, H. KLEIN. Minot, North Dakota 58701.
RADIOLOGICAL CHANGES AFTER TREATMENT OF VESICAL SCHISTOSOMIASIS
SIR,-From Nigeria, Professor Lucas and his colleagues3 described improvement in radiological appearances in eight of twelve children some 3 to 6 months after treatment. Dr. Forsyth and Professor Macdonald,4in Zanzibar, found that lesions had not regressed significantly in seven children after an interval of 15 months. I have
re-examined, with intravenous pyelography (LV.P.), African adult males, aged 20-40, 2 years after antieighteen monial treatment. The results were as follows:
Bilharziasis Chemotherapy Centre, P.O. Box 950, Tanga, Tanzania.
A. DAVIS.
TETANUS your annotation last week ca. for comment. I am not sure of the source of your informal" that, " With the expensive and demanding techniques :: curarisation and, artificially controlled respiration, the mortality-rate has been reduced to about 30% in the newboy and about 20% at other ages." I have never seen tetanus the newborn in this country, nor have I ever heard of ’ With regard to the method of treatment you mention in " adult, we have had a tetanus unit in this infirmary for over decade. This is of course a highly complicated technique though we managed to reduce the mortality to 20% in ’ early years. During the past eight years, we have reduced to something under 4%. The technique is admittedly complex that in my submission the Minister of Health sissue a directive to the effect that tetanus should not be treat in more than about three centres in Great Britain. As as the present system is perpetuated even an average .-’hospital is probably not likely to see more than about 1 in every two or three years, so that it would be imposttrain a tetanus unit.
SIR The terminal lines of
patients remained cured, and seven, one of whom was were excreting viable ova. No association between radiological change, and cure or failure, could be
Eleven a
reinfection,
demonstrated. The findings are expressed in terms of lesions, since patients commonly showed more than one abnormality on pyelography. Despite the difficulties of exact comparison and quantitative assessment of serial films, as noted by Dr. Forsyth and Professor Macdonald,the conclusions are plain. The appearance of most lesions was unchanged or had deteriorated. An " improved " appearance did not imply a return to normal. Bladder calcification, once established, remained; indeed, 1. 2. 3. 4.
Maycock, R. L., Bertrand, P., Morrison, C.E. Am. J. Med. 1963, 35, 67. Williams, J. F., Behnke, R. H. Ann. intern. Med. 1964, 60, 824. Lucas, A. O., Adeniyi-Jones, C. C., Cockshott, W. P., Gilles, H. M. Lancet, 1966, i, 631. Forsyth, D. M., Macdonald, G. ibid. p. 929.
-
5. 6. 7. 8.
Lambert, C. R. Ann. trop. Med. Parasit. 1964, 58, 292. Striebel, H. P., Kradolfer, F. Acta trop. 1966, suppl. 9, p 54 Sadun, E. H., Bruce, J. I., Moose, J. W., McMullen, D. B Dodin, A. ibid. p. 260.