- Email: [email protected]
CARE OF THE PRE-SCHOOL HANDICAPPED
1303 HLA-B8 IN PIGEON-FANCIER’S LUNG
SiR,-Dr Flaherty and his colleagues (Sept. 13, p.507) have reported an increased frequency of HLA-B8 in 20 patients with farmer’s lung. We are studying patients with a similar disease, pigeon-fancier’s lung. Antibodies against pigeon antigens were sought by indirect immunofluorescence.1 On the basis of response to inhalation challenge in a dusty dovecote the patients were characterised as responders (20), patients with positive history only (4), or symptom-free pigeon fanciers
(4). HLA patterns were determined by the N.I.H. technique (23 at the A and B loci), and compared with those of 320 normal individuals living in and around Bonn. HLA-B8 was found in 40% of responders and in 17% of controls (r<0005). Among the 8 non-responders the frequency of B8 was normal. These data support the view that farmer’s lung and pigeon-fancier’s lung disease, both forms of extrinsic allergic alveolitis, are related. Dr Berrill and co-workers (Nov. 22, p. 1006) have reported a relation between allergic alveolitis and jejunal villous atrophy, and there is a remarkable increase in the frequency of HLA-B8 in gluten-sensitive enteropathy.2-4 However, in coeliac disease 84% of those with B8 also had A1 (in most cases the haplotype Al, B8 was found in family studies) while only 4 of the 8 inhalation responders with pigeon-fancier’s lung and B8 also carried Al. If this finding is confirmed, it could indicate that a hypothetical immune-response gene responsible for increased susceptibility to pigeonfancier’s disease is in looser linkage disequilibrium to HLA-B than is the hypothetical gene(s) for susceptibility to glutensensitive enteropathy. C. RITTNER Institute of Forensic Medicine, J. SENNEKAMP Medical Clinic, University of F. VOGEL Bonn, West Germany
antigens
DANGEROUS OFFENDERS
SIR,-Your leader of Nov. 1 (p. 856) drew attention to the problems in providing care for the mentally abnormal offender. We have been developing, in an open psychiatric hospital, a system of treatment for difficult and disruptive patients that could be relevant to the management of the dangerous offender. Long-acting tranquillisers (L.A.T.S) have been used in the management of chronic schizophrenia since 1966, and, when a community psychiatric nurse service became available at our hospital some two years ago, one of us (E.H.B.) stabilised all patients admitted to the hospital in terms of Section 55 of the Mental Health (Scotland) Act 1960 on fluphenazine decanoate prior to discharge, on the basis of a report5 that L.A.T.s offered the best chance of sustained symptom remission in chronic schizophrenia. Altogether ten patients have been discharged from Section 55 status to the community and, despite careful follow-up, three have defaulted from treatment. None, however, have been readmitted to hospital in terms of Part V of the Mental Health (Scotland) Act 1960. Experience gained in the management of chronic schizophrenics with L.A.T.S led us to try these drugs in borderline psychotic states and finally in the treatment of personality disorder and alcoholism. L.A.T.s are not open to abuse by the patient, and once the injection is administered we can be certain the patient has received his prescribed medication. To date we have offered some eighty patients with varying degrees of personality disorder and alcoholism medication with 1.
Sennekamp, J., Vogel, F., Stiens, R. Int. Archs Allergy appl. Immun. (in the press). 2. Falchuk, Z. M., Rogentine, G. N., Strober, W. J. clin. Invest. 1972, 51, 1602. 3.
Stokes, P. L., Asquith, P., Holmes, G. K. T., Mackintosh, P., Cooke, W. T. Lancet, 1972, ii, 162. 4. Rotthauwe, H. W., Rittner, C., Waiyawuth, V., Becker, M. Dt. med. Wschr. (in the press). 5. Johnston, D. A., Freeman, H. Practitioner, 1972, 208, 395.
The follow-up period in the majority of our cases is too short for any meaningful appraisal, but observations made at interview, together with reports obtained from relatives and friends, suggest a dramatic improvement in a small number together with some improvement in up to 35% of cases. Of the fourteen cases where the presenting condition has been a problem such as self-inflicted injury or disruptive behaviour, improvement has occurred in about 70% in the three to four month review period. Alcoholics attending the hospital have been found to have poorer response and a default-rate of some 40%. In the short term, however, we have noted that progress has been made in 50% of the patients started on L.A.T.s. The alcoholics improving on the depot medication reported that drink had ceased to be their central preoccupation, that the craving had disappeared, that appetite for food was restored, and that general interest began to reappear. Occasionally a patient would report that he could only drink one or two pints of beer and that if he attempted to drink more he would vomit. Of thirty-eight skid row alcoholics at the Talbot Night Shelter, thirty-one were started on L.A.T.s-fluphenazine decanoate 0-5ml once per week in fifteen cases and fluspirilene 2-4 mg once weekly in sixteen cases. Sixteen of these men returned at least once and five on four occasions. We collected blood-samples for alcohol levels at 9.30 to 10.30 in the morning, and the method of analysis by gas chromatography allowed separation of the ethyl and methyl alcohol fractions. In the four-week period we were allowed to operate our clinic, it became evident that the administration of fluphenazine decanoate and fluspirilene was associated with a reduction in the ethyl-alcohol levels and to a lesser extent the methyl-alcohol levels. Clinical examination suggested that six of the men had appeared to improve and that the reduced drinking was associated with an overall improvement in their general appearance and self-care, and as a result three were being considered for some type of hostel accommodation. In the bleak therapeutic area of alcoholism and personality disorder it has appeared to us that the administration of L.A.T.S could be an advance in medical management.
L.A.T.S.
Leverndale Hospital, 510 Crookston Road, Glasgow G53 7TU.
ERNEST H. BENNIE HERBERT G. KINNELL
CARE OF THE PRE-SCHOOL HANDICAPPED
SIR,-In reference to Miss Levitt’s letter (Nov. 8, p. 928) wish
we
report excellent results in our Child Awareness Proestablished to allow medical and allied health students gram, of the Upstate Medical Center to initiate and run programmes and workshops for emotionally disturbed, physically handicapped, and mentally retarded children. Gruver’ investigated the use of college students in a variety of mental-health settings, and found that staff members resisted the students and would not work with them because the students were not professionals. Brennenhowever, has stressed the view that the manpower shortage in mental-health care can best be alleviated by allowing college students, with their youth and dedication, to work among children alongside the professional. To make the best use of eager, motivated, and genuinely interested young adults to help with the many organisations in the city which serve handicapped children, first and second year students were invited to participate, during any free evening they wished, in programmes that were set up with the various community agencies. The agencies were very willing to have students take part, and were enthusiastic about the idea that the students should initiate new approaches that would complement the services the community already offered. The idea was that students would relate to the children on a person-to-person basis by establishing close friendships that are not always possible in a busy community service which must to
1. Gruver, G. G. Psychol. Bull. 1971, 76, 111. Brennen, E. C. Am. J. publ. Hlth, 1967, 10, 1767.
2.
1304
emphasise teaching and therapy during the day, and that they would organise social and recreational activities (art, ceramics, guitar, sewing, cards) for handicapped children in the evening hours. Engineering students designed and built therapeutic and recreational toys and equipment, suited to each child, at the Cerebral Palsy and Handicapped Children’s Center. This special equipment is not usually available commercially. Children living at a centre for emotionally and socially disturbed children were taken into town to the cinema, allowing them the chance to get away from their daily routine. The use of medical and allied health students has not led to any staff hostility, and cooperation between students and staff has been excellent. By having students work during their free evenings, facilities were more efficiently used and a valuable adjuvant to daytime staff-led programmes was realised. The students gained very valuable experience in communicating with handicapped children, in getting involved in community service, and in the methods of training and rehabilitation being used by the community-all lessons not easily learned in the lecture hall. Department of Pediatrics, Upstate Medical Center, Syracuse, N.Y., U.S.A.
ANDREW DAVID WEINBERG* RICHARD L. NEU
*Current address. 1607 80 Presidential Plaza,
Syracuse, N.Y. 13202, U.S.A.
EPIDEMIOLOGY OF BIRTH DEFECTS
SIR,-Roberts and his colleagues 1 have provided an excellent summary of two major problems in the epidemiology of birth defects-namely, the magnitude of early fetal loss and the consequences of our inability to measure it, and the apparent failure of epidemiology to identify significant environmental causes for the common major birth defects. They argue that an epidemiological search for environmental explanations for birth defects will probably be fruitless: I believe this conclusion to be premature. Spontaneous abortion is probably a natural mechanism for disposal of defective fetuses. But Roberts and Lowe conclude that "If nature resorts to abortion to maintain genetic stability by discarding as many as 3 in every 4 conceptions, it will be difficult for antiabortionists to oppose abortion on moral and ethical grounds." The value of induced abortion can be established without this weak argument, which attempts to equate the biological selectivity of spontaneous abortion withthe more random effect of induced abortion. In their second paper Roberts and Powell state that the strong interrelationship between specific malformations "casts doubt on the notion that multiple external factors are involved in the causation of human malformations." Only in the simplest meaning of teratogenesis is this statement true. As an alternative to the "extrinsic" or environmental explanation for common birth defects, they propose an "intrinsic" explanation. They refer to this as the "one single cause" hypothesis, and I presume they mean genetic mutation. I accept that the failure of epidemiology to identify an environmental teratogen for a common birth defect, or even to demonstrate significant time-space clustering, is difficult to reconcile with an environmental aetiology. However, I find it even more difficult to reconcile the epidemiological facts on anencephaly and spina bifida, for example, with a non-environmental Ttiology, especially in view of MacMahon and Yen’s3 demonstration of an epidemic of these malformations in the 1930s. As an alternative to both the simple environmental (extrinsic) and "one single cause" (intrinsic) explanations I have proposed the concept of "environmental preconditioning".4 This
concept explains the lack of time-space clustering on the basis of teratogenic susceptibility and specificity. Maternal susceptibility to teratogens has been virtually unexplored except for the rubells syndrome. In non-infectious teratogenesis susceptibility also seems to be an issue-not every daughter whose mother was given diethylstilboestrol goes on to develop vaginal carcinoma. Would not the lack of time-space clustering of common malformations be more understandable if teratogens were common agents to which most of the population was exposed, but to which only a very few were susceptible? And, if susceptibility persisted, would not that tend to cause specific defects to recur in families thereby mimicking a genetic mechanism ? We should at least explore the possibility that the epidemiological data on major malformations can be explained by teratogenic susceptibility before we abandon our search for environmental causes. New York State
Department of Health, Albany, N.Y. 12237, U.S.A.
JANERICH
BUMETANIDE
SIR,-Dr Pines (Nov. 29, p. 1093) criticises your appraisal of bumetanide (Nov. 1, p. 860) and supports this by reference to his own joint publication.’ This report was on an open asof bumetanide in a heterogeneous group of twentyfour patients who required diuretic therapy, twenty-three of whom had received frusemide at some time before hospital admission. Dr Pines’ letter should be interpreted cautiously. Firstly, patients with resistant cedema who are admitted to hospital often respond to bed rest and dietary salt restriction with a brisk diuresis, even though their diuretic therapy is unaltered. Secondly, although bumetanide is more potent than frusemide on a weight-for-weight basis,2 this in itself confers no advantages. Comparison of the pharmacological activity of these two high-ceiling diuretics can only be realistically made by carefully titrating the dose of each to achieve its optimum therapeutic effect. Dr Pines and his colleagues did not do this. Moreover, he originally stated that "Direct comparison of the efficacy of these two diuretics cannot be made in an open assessment of this nature." Finally, there is a discrepancy between the number of patients whose weight-loss was unrecorded (two out of twentythree patients in the letter, five patients in the paper2). sessment
Hoechst UK Ltd, Pharmaceutical Division, Hoechst House,
Salisbury Road, Hounslow, Middlesex TW4 6JH
PAUL A. NICHOLSON
DIURETIC-INDUCED ŒDEMA
SiR,—Soon after the report by MacGregor
et al. of two of diuretic-induced oedema,3 a patient with similar clinical features was admitted to our hospital. This 34-year-old woman had been taking diuretics for 6 years, because of oedema (idiopathic?) which was stated to have been present before any treatment and which was certainly present later; to control it, progressively larger doses of diuretic were required. During the past year, the drug used had been frusemide, 80 mg/day by mouth. On admission to hospital, the patient had slight oedema, but no other significant physical sign; she was kept, without any treatment, on a normal diet. Rapidly, she became grossly oedematous with serous effusions, and water retention reached a peak by day 5. During the next 10 days, excess fluid was gradually eliminated, with diuresis, without any medication. Serum-potassium was 2.5 meq/1 on the first day and rose to 3.9meq/1 at the end of the first week, while the daily urinary excretion of potassium remained con-
cases
1. 1. Roberts, C. J., Lowe, C. R. Lancet, 1975, i, 498. 2. Roberts, C. J., Powell, R. G. ibid. 1975, ii, 848. 3. MacMahon, B., Yen, S. ibid. 1971, i, 31. 4. Janerich, D. T. Am. J. Epidemiol. 1972, 95, 319. 5. Janerich, D. T. ibid. 1975, 101, 70.
DWIGHT T.
Pines, A., Streedharan, K. S., Nandi, A. R., Marsh. B. T. Br. J. clin. Pract. 1974, 28, 311. 2. Davies, D. I., Lant, A. F., Millard, N. R., Smith, A. J., Ward, J. W., Wilson, G. M. Clin. Pharmac. Ther. 1974, 15, 141. 3. MacGregor, G. A., Tasker, P. R. W., de Wardener, H. E. Lancet, 1975, i, 489.
SiR,-Dr Flaherty and his colleagues (Sept. 13, p.507) have reported an increased frequency of HLA-B8 in 20 patients with farmer’s lung. We are studying patients with a similar disease, pigeon-fancier’s lung. Antibodies against pigeon antigens were sought by indirect immunofluorescence.1 On the basis of response to inhalation challenge in a dusty dovecote the patients were characterised as responders (20), patients with positive history only (4), or symptom-free pigeon fanciers
(4). HLA patterns were determined by the N.I.H. technique (23 at the A and B loci), and compared with those of 320 normal individuals living in and around Bonn. HLA-B8 was found in 40% of responders and in 17% of controls (r<0005). Among the 8 non-responders the frequency of B8 was normal. These data support the view that farmer’s lung and pigeon-fancier’s lung disease, both forms of extrinsic allergic alveolitis, are related. Dr Berrill and co-workers (Nov. 22, p. 1006) have reported a relation between allergic alveolitis and jejunal villous atrophy, and there is a remarkable increase in the frequency of HLA-B8 in gluten-sensitive enteropathy.2-4 However, in coeliac disease 84% of those with B8 also had A1 (in most cases the haplotype Al, B8 was found in family studies) while only 4 of the 8 inhalation responders with pigeon-fancier’s lung and B8 also carried Al. If this finding is confirmed, it could indicate that a hypothetical immune-response gene responsible for increased susceptibility to pigeonfancier’s disease is in looser linkage disequilibrium to HLA-B than is the hypothetical gene(s) for susceptibility to glutensensitive enteropathy. C. RITTNER Institute of Forensic Medicine, J. SENNEKAMP Medical Clinic, University of F. VOGEL Bonn, West Germany
antigens
DANGEROUS OFFENDERS
SIR,-Your leader of Nov. 1 (p. 856) drew attention to the problems in providing care for the mentally abnormal offender. We have been developing, in an open psychiatric hospital, a system of treatment for difficult and disruptive patients that could be relevant to the management of the dangerous offender. Long-acting tranquillisers (L.A.T.S) have been used in the management of chronic schizophrenia since 1966, and, when a community psychiatric nurse service became available at our hospital some two years ago, one of us (E.H.B.) stabilised all patients admitted to the hospital in terms of Section 55 of the Mental Health (Scotland) Act 1960 on fluphenazine decanoate prior to discharge, on the basis of a report5 that L.A.T.s offered the best chance of sustained symptom remission in chronic schizophrenia. Altogether ten patients have been discharged from Section 55 status to the community and, despite careful follow-up, three have defaulted from treatment. None, however, have been readmitted to hospital in terms of Part V of the Mental Health (Scotland) Act 1960. Experience gained in the management of chronic schizophrenics with L.A.T.S led us to try these drugs in borderline psychotic states and finally in the treatment of personality disorder and alcoholism. L.A.T.s are not open to abuse by the patient, and once the injection is administered we can be certain the patient has received his prescribed medication. To date we have offered some eighty patients with varying degrees of personality disorder and alcoholism medication with 1.
Sennekamp, J., Vogel, F., Stiens, R. Int. Archs Allergy appl. Immun. (in the press). 2. Falchuk, Z. M., Rogentine, G. N., Strober, W. J. clin. Invest. 1972, 51, 1602. 3.
Stokes, P. L., Asquith, P., Holmes, G. K. T., Mackintosh, P., Cooke, W. T. Lancet, 1972, ii, 162. 4. Rotthauwe, H. W., Rittner, C., Waiyawuth, V., Becker, M. Dt. med. Wschr. (in the press). 5. Johnston, D. A., Freeman, H. Practitioner, 1972, 208, 395.
The follow-up period in the majority of our cases is too short for any meaningful appraisal, but observations made at interview, together with reports obtained from relatives and friends, suggest a dramatic improvement in a small number together with some improvement in up to 35% of cases. Of the fourteen cases where the presenting condition has been a problem such as self-inflicted injury or disruptive behaviour, improvement has occurred in about 70% in the three to four month review period. Alcoholics attending the hospital have been found to have poorer response and a default-rate of some 40%. In the short term, however, we have noted that progress has been made in 50% of the patients started on L.A.T.s. The alcoholics improving on the depot medication reported that drink had ceased to be their central preoccupation, that the craving had disappeared, that appetite for food was restored, and that general interest began to reappear. Occasionally a patient would report that he could only drink one or two pints of beer and that if he attempted to drink more he would vomit. Of thirty-eight skid row alcoholics at the Talbot Night Shelter, thirty-one were started on L.A.T.s-fluphenazine decanoate 0-5ml once per week in fifteen cases and fluspirilene 2-4 mg once weekly in sixteen cases. Sixteen of these men returned at least once and five on four occasions. We collected blood-samples for alcohol levels at 9.30 to 10.30 in the morning, and the method of analysis by gas chromatography allowed separation of the ethyl and methyl alcohol fractions. In the four-week period we were allowed to operate our clinic, it became evident that the administration of fluphenazine decanoate and fluspirilene was associated with a reduction in the ethyl-alcohol levels and to a lesser extent the methyl-alcohol levels. Clinical examination suggested that six of the men had appeared to improve and that the reduced drinking was associated with an overall improvement in their general appearance and self-care, and as a result three were being considered for some type of hostel accommodation. In the bleak therapeutic area of alcoholism and personality disorder it has appeared to us that the administration of L.A.T.S could be an advance in medical management.
L.A.T.S.
Leverndale Hospital, 510 Crookston Road, Glasgow G53 7TU.
ERNEST H. BENNIE HERBERT G. KINNELL
CARE OF THE PRE-SCHOOL HANDICAPPED
SIR,-In reference to Miss Levitt’s letter (Nov. 8, p. 928) wish
we
report excellent results in our Child Awareness Proestablished to allow medical and allied health students gram, of the Upstate Medical Center to initiate and run programmes and workshops for emotionally disturbed, physically handicapped, and mentally retarded children. Gruver’ investigated the use of college students in a variety of mental-health settings, and found that staff members resisted the students and would not work with them because the students were not professionals. Brennenhowever, has stressed the view that the manpower shortage in mental-health care can best be alleviated by allowing college students, with their youth and dedication, to work among children alongside the professional. To make the best use of eager, motivated, and genuinely interested young adults to help with the many organisations in the city which serve handicapped children, first and second year students were invited to participate, during any free evening they wished, in programmes that were set up with the various community agencies. The agencies were very willing to have students take part, and were enthusiastic about the idea that the students should initiate new approaches that would complement the services the community already offered. The idea was that students would relate to the children on a person-to-person basis by establishing close friendships that are not always possible in a busy community service which must to
1. Gruver, G. G. Psychol. Bull. 1971, 76, 111. Brennen, E. C. Am. J. publ. Hlth, 1967, 10, 1767.
2.
1304
emphasise teaching and therapy during the day, and that they would organise social and recreational activities (art, ceramics, guitar, sewing, cards) for handicapped children in the evening hours. Engineering students designed and built therapeutic and recreational toys and equipment, suited to each child, at the Cerebral Palsy and Handicapped Children’s Center. This special equipment is not usually available commercially. Children living at a centre for emotionally and socially disturbed children were taken into town to the cinema, allowing them the chance to get away from their daily routine. The use of medical and allied health students has not led to any staff hostility, and cooperation between students and staff has been excellent. By having students work during their free evenings, facilities were more efficiently used and a valuable adjuvant to daytime staff-led programmes was realised. The students gained very valuable experience in communicating with handicapped children, in getting involved in community service, and in the methods of training and rehabilitation being used by the community-all lessons not easily learned in the lecture hall. Department of Pediatrics, Upstate Medical Center, Syracuse, N.Y., U.S.A.
ANDREW DAVID WEINBERG* RICHARD L. NEU
*Current address. 1607 80 Presidential Plaza,
Syracuse, N.Y. 13202, U.S.A.
EPIDEMIOLOGY OF BIRTH DEFECTS
SIR,-Roberts and his colleagues 1 have provided an excellent summary of two major problems in the epidemiology of birth defects-namely, the magnitude of early fetal loss and the consequences of our inability to measure it, and the apparent failure of epidemiology to identify significant environmental causes for the common major birth defects. They argue that an epidemiological search for environmental explanations for birth defects will probably be fruitless: I believe this conclusion to be premature. Spontaneous abortion is probably a natural mechanism for disposal of defective fetuses. But Roberts and Lowe conclude that "If nature resorts to abortion to maintain genetic stability by discarding as many as 3 in every 4 conceptions, it will be difficult for antiabortionists to oppose abortion on moral and ethical grounds." The value of induced abortion can be established without this weak argument, which attempts to equate the biological selectivity of spontaneous abortion withthe more random effect of induced abortion. In their second paper Roberts and Powell state that the strong interrelationship between specific malformations "casts doubt on the notion that multiple external factors are involved in the causation of human malformations." Only in the simplest meaning of teratogenesis is this statement true. As an alternative to the "extrinsic" or environmental explanation for common birth defects, they propose an "intrinsic" explanation. They refer to this as the "one single cause" hypothesis, and I presume they mean genetic mutation. I accept that the failure of epidemiology to identify an environmental teratogen for a common birth defect, or even to demonstrate significant time-space clustering, is difficult to reconcile with an environmental aetiology. However, I find it even more difficult to reconcile the epidemiological facts on anencephaly and spina bifida, for example, with a non-environmental Ttiology, especially in view of MacMahon and Yen’s3 demonstration of an epidemic of these malformations in the 1930s. As an alternative to both the simple environmental (extrinsic) and "one single cause" (intrinsic) explanations I have proposed the concept of "environmental preconditioning".4 This
concept explains the lack of time-space clustering on the basis of teratogenic susceptibility and specificity. Maternal susceptibility to teratogens has been virtually unexplored except for the rubells syndrome. In non-infectious teratogenesis susceptibility also seems to be an issue-not every daughter whose mother was given diethylstilboestrol goes on to develop vaginal carcinoma. Would not the lack of time-space clustering of common malformations be more understandable if teratogens were common agents to which most of the population was exposed, but to which only a very few were susceptible? And, if susceptibility persisted, would not that tend to cause specific defects to recur in families thereby mimicking a genetic mechanism ? We should at least explore the possibility that the epidemiological data on major malformations can be explained by teratogenic susceptibility before we abandon our search for environmental causes. New York State
Department of Health, Albany, N.Y. 12237, U.S.A.
JANERICH
BUMETANIDE
SIR,-Dr Pines (Nov. 29, p. 1093) criticises your appraisal of bumetanide (Nov. 1, p. 860) and supports this by reference to his own joint publication.’ This report was on an open asof bumetanide in a heterogeneous group of twentyfour patients who required diuretic therapy, twenty-three of whom had received frusemide at some time before hospital admission. Dr Pines’ letter should be interpreted cautiously. Firstly, patients with resistant cedema who are admitted to hospital often respond to bed rest and dietary salt restriction with a brisk diuresis, even though their diuretic therapy is unaltered. Secondly, although bumetanide is more potent than frusemide on a weight-for-weight basis,2 this in itself confers no advantages. Comparison of the pharmacological activity of these two high-ceiling diuretics can only be realistically made by carefully titrating the dose of each to achieve its optimum therapeutic effect. Dr Pines and his colleagues did not do this. Moreover, he originally stated that "Direct comparison of the efficacy of these two diuretics cannot be made in an open assessment of this nature." Finally, there is a discrepancy between the number of patients whose weight-loss was unrecorded (two out of twentythree patients in the letter, five patients in the paper2). sessment
Hoechst UK Ltd, Pharmaceutical Division, Hoechst House,
Salisbury Road, Hounslow, Middlesex TW4 6JH
PAUL A. NICHOLSON
DIURETIC-INDUCED ŒDEMA
SiR,—Soon after the report by MacGregor
et al. of two of diuretic-induced oedema,3 a patient with similar clinical features was admitted to our hospital. This 34-year-old woman had been taking diuretics for 6 years, because of oedema (idiopathic?) which was stated to have been present before any treatment and which was certainly present later; to control it, progressively larger doses of diuretic were required. During the past year, the drug used had been frusemide, 80 mg/day by mouth. On admission to hospital, the patient had slight oedema, but no other significant physical sign; she was kept, without any treatment, on a normal diet. Rapidly, she became grossly oedematous with serous effusions, and water retention reached a peak by day 5. During the next 10 days, excess fluid was gradually eliminated, with diuresis, without any medication. Serum-potassium was 2.5 meq/1 on the first day and rose to 3.9meq/1 at the end of the first week, while the daily urinary excretion of potassium remained con-
cases
1. 1. Roberts, C. J., Lowe, C. R. Lancet, 1975, i, 498. 2. Roberts, C. J., Powell, R. G. ibid. 1975, ii, 848. 3. MacMahon, B., Yen, S. ibid. 1971, i, 31. 4. Janerich, D. T. Am. J. Epidemiol. 1972, 95, 319. 5. Janerich, D. T. ibid. 1975, 101, 70.
DWIGHT T.
Pines, A., Streedharan, K. S., Nandi, A. R., Marsh. B. T. Br. J. clin. Pract. 1974, 28, 311. 2. Davies, D. I., Lant, A. F., Millard, N. R., Smith, A. J., Ward, J. W., Wilson, G. M. Clin. Pharmac. Ther. 1974, 15, 141. 3. MacGregor, G. A., Tasker, P. R. W., de Wardener, H. E. Lancet, 1975, i, 489.