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HARDNESS OF LOCAL WATER-SUPPLIES AND MORTALITY FROM CARDIOVASCULAR DISEASE
213 has been devoted to the problem of reappraising the treatment, and perhaps abandoning it as the child grows older... evidence collected suggests that parents have been regarded with inadequate interest and respect and that the problems of adolescence have been either ignored or treated routinely."1 Only by observation and documentation of careful reappraisal of these patients, at least until the age of 21, can the contribution of patient therapeutic measures be estimated. Diagnostic and Evaluation Center for Handicapped Children, Department of Pediatrics, The Johns Hopkins Hospital, Baltimore 5, Maryland, U.S.A.
’r-’—.—— RICHARDSON REDERICK FREDERICK ICHARDSON Director.
A DISPOSABLE
RESERVOIR FILTER FOR THE MELROSE N.E.P. HEART-LUNG MACHINE SIR,-This filter of nylon gauze was designed to overcome the difficulties of manufacturing and cleaning stainless-steel mesh. On the principle of a tea-strainer in two parts, the metal ring at the top of the nylon-gauze strainer is of greater diameter than the lugged supporter. The supporting ring has a short and a handle, choked filter can be
rapidly
discarded,
and
new
a
the usual autoclaving process, but it must be upside down, and not in contact with any other object. the London Chest Hospital for
satisfactory.
The filter is made by Henry Simon Ltd., Cheadle Heath, Stockport, Cheshire, and the supporter ring is made by G.U. Manufacturing Co. Ltd., 33, Devonshire Street, London, W.1. The London Chest Hospital Hospital, London, E.2.
R N. R. N G. G ATHERSTONE. ATHERSTONE ATHERSTONB.
HARDNESS OF LOCAL WATER-SUPPLIES AND MORTALITY FROM CARDIOVASCULAR DISEASE SiR,—In their interesting article2 Professor Morris and his colleagues confirm the findings of Schroeder 3in America and Kobayashi5 in Japan that a high incidence of mortality from cardiovascular disease appears to be associated with a reduction in the hardness of drinking water.
These workers seem to have difficulty in correlating these two findings, and we should like to suggest that the increased incidence of cardiovascular disease may be associated with the reduction in the magnesium content of the water-supply. Work carried out in South Africa by Bersohn and Oelofse 6 demonstrated a high level of serum-magnesium in the Bantu native, with a comparative freedom from coronary-artery disease, in contradistinction to resident Europeans whose lower 1. Crothers, B., Payne, R. S. Natural History of Cerebral Palsy. Harvard University Press, 1959. 2. Morris, J. N., Crawford, M. D., Heady, J. A. Lancet, 1961, 3. Schroeder, H. A. J. Amer. med. Ass. 1960, 172, 1902. 4. Schroeder, H. A. J. chron. Dis. 1960, 12, 586. 5. Kobayashi, J., Ber. Ohara. Inst. 1957, 11, 12. 6. Bersohn, I., Oelofse, P. J. Lancet, 1957, i, 1020.
i,
860.
was
accompanied by high susceptibility
to
R. S. PARSONS T. C. BUTLER E. P. SELLARS.
Hobart, Tasmania.
PORPHYRIA
one
dropped into place. The nylon-gauze filter is sterilised by
This filter has been used at the past year, and has proved entirely
serum-magnesium
this condition. It is of interest to note that Selyeproduced, in experimental animals, cardiac necrosis and calcification of the aorta by the administration of steroids but that no lesion developed when magnesium was also given. Arnold 8 and his coworkers found that cattle grazing on bauxite soil, deficient in magnesium, all developed extensive cardiovascular calcification. Over the last quarter of a century, Malkiel-Shapiro et al.9 have routinely treated coronary-artery disease with parenteral magnesium sulphate with satisfactory clinical results, although little in the way of biochemical investigations were undertaken. During the past four years, we have treated a large number of cases with magnesium sulphate, and full clinical and biochemical investigations have been carried out before and during treatment.10 11 In all cases, there was striking clinical improvement; disappearance of anginal pain; increased exercise tolerance; reversion of the electrocardiograph pattern to normal; and absence of reinfarction. Biochemical investigations revealed, before treatment, a low serum-magnesium level and high concentrations of cholesterol, lecithin, and beta-lipoproteins, all of which reverted to normal after the administration of magnesium. It is well known that there is a high rate of cardiovascular disease in Australia, and we feel that this may be associated with the fact that the water-supply is mainly derived from the catchment of rainwater, low in magnesium.
are, in the field of porphyrin SiR,-Working, attempting to form coherent ideas in this complex field, may we join company with Dr. Barnes, of Johannesburg (May 13), in welcoming your editorial (April 29). Our experience of the porphyrias is considerable (176 cases) and we feel justified in offering the following comments. as we
metabolism and
We do
not
wish
to
argue
an
alternative classification
at
length here. Such argument is set out in a current review of the subject.12 We fully agree that no classification is likely to be wholly satisfactory until more is known of the biochemical interrelationships of the porphyrias. Whatever gaps there may be in our knowledge, any currently advanced divisions take into account such biochemical differences as are known to exist. We emphasise that not only the urinary but also the faecal porphyrin excretion must be considered. Protocols of published cases frequently lack this vital information. The revised classification of Waldenstrom 13 has enjoyed considerable favour. It is simple, and has biochemical and genetic justification. We have preferred to use this classification though with alternative terminology.12 It is worth reiterating that in any family with protocoproporphyria (Watson’s groups 11 B and C) three clinical syndromes -the acute attack, cutaneous lesions, or both together-may occur not only in different sibs but at different times in the same patient. Watson’s doubt concerning group II C as a separate entity is reflected in the double interrogation mark in table 3 of his paper. 14 Furthermore, the disorder may show itself solely as an excessive fscal excretion of porphyrin. In our experience this pattern of faecal excretion is present not only during remission but also in the acute phase of the disorder. We suggest that the term "mixed" porphyria (group II B) be abandoned since it is too vague. Protocoproporphyria is a term which has merit in that it emphasises a fundamental must
7. 8. 9. 10. 11. 12. 13. 14.
Selye, H. Amer. Heart J. 1958, 55, 805. Arnold, R. M., Fincham, I. H. J. comp. Path. Ther. 1950, 60, 51. Malkiel-Shapiro, B., Bersohn, I., Terner, P. Med. Proc. 1956, 2, 455. Parsons, R. S., Butler, T. C., Sellars, E. P. ibid. 1959, 5, 487. Parsons, R. S., Butler, T. C., Sellars, E. P. ibid. 1960, 6, 579. Eales, L. Annu. Rev. Med. 1961, 12, 251. Waldenström, J. Amer. J. Med. 1957, 22, 758. Watson, C. J. New Engl. J. Med. 1960, 263, 1205.
’r-’—.—— RICHARDSON REDERICK FREDERICK ICHARDSON Director.
A DISPOSABLE
RESERVOIR FILTER FOR THE MELROSE N.E.P. HEART-LUNG MACHINE SIR,-This filter of nylon gauze was designed to overcome the difficulties of manufacturing and cleaning stainless-steel mesh. On the principle of a tea-strainer in two parts, the metal ring at the top of the nylon-gauze strainer is of greater diameter than the lugged supporter. The supporting ring has a short and a handle, choked filter can be
rapidly
discarded,
and
new
a
the usual autoclaving process, but it must be upside down, and not in contact with any other object. the London Chest Hospital for
satisfactory.
The filter is made by Henry Simon Ltd., Cheadle Heath, Stockport, Cheshire, and the supporter ring is made by G.U. Manufacturing Co. Ltd., 33, Devonshire Street, London, W.1. The London Chest Hospital Hospital, London, E.2.
R N. R. N G. G ATHERSTONE. ATHERSTONE ATHERSTONB.
HARDNESS OF LOCAL WATER-SUPPLIES AND MORTALITY FROM CARDIOVASCULAR DISEASE SiR,—In their interesting article2 Professor Morris and his colleagues confirm the findings of Schroeder 3in America and Kobayashi5 in Japan that a high incidence of mortality from cardiovascular disease appears to be associated with a reduction in the hardness of drinking water.
These workers seem to have difficulty in correlating these two findings, and we should like to suggest that the increased incidence of cardiovascular disease may be associated with the reduction in the magnesium content of the water-supply. Work carried out in South Africa by Bersohn and Oelofse 6 demonstrated a high level of serum-magnesium in the Bantu native, with a comparative freedom from coronary-artery disease, in contradistinction to resident Europeans whose lower 1. Crothers, B., Payne, R. S. Natural History of Cerebral Palsy. Harvard University Press, 1959. 2. Morris, J. N., Crawford, M. D., Heady, J. A. Lancet, 1961, 3. Schroeder, H. A. J. Amer. med. Ass. 1960, 172, 1902. 4. Schroeder, H. A. J. chron. Dis. 1960, 12, 586. 5. Kobayashi, J., Ber. Ohara. Inst. 1957, 11, 12. 6. Bersohn, I., Oelofse, P. J. Lancet, 1957, i, 1020.
i,
860.
was
accompanied by high susceptibility
to
R. S. PARSONS T. C. BUTLER E. P. SELLARS.
Hobart, Tasmania.
PORPHYRIA
one
dropped into place. The nylon-gauze filter is sterilised by
This filter has been used at the past year, and has proved entirely
serum-magnesium
this condition. It is of interest to note that Selyeproduced, in experimental animals, cardiac necrosis and calcification of the aorta by the administration of steroids but that no lesion developed when magnesium was also given. Arnold 8 and his coworkers found that cattle grazing on bauxite soil, deficient in magnesium, all developed extensive cardiovascular calcification. Over the last quarter of a century, Malkiel-Shapiro et al.9 have routinely treated coronary-artery disease with parenteral magnesium sulphate with satisfactory clinical results, although little in the way of biochemical investigations were undertaken. During the past four years, we have treated a large number of cases with magnesium sulphate, and full clinical and biochemical investigations have been carried out before and during treatment.10 11 In all cases, there was striking clinical improvement; disappearance of anginal pain; increased exercise tolerance; reversion of the electrocardiograph pattern to normal; and absence of reinfarction. Biochemical investigations revealed, before treatment, a low serum-magnesium level and high concentrations of cholesterol, lecithin, and beta-lipoproteins, all of which reverted to normal after the administration of magnesium. It is well known that there is a high rate of cardiovascular disease in Australia, and we feel that this may be associated with the fact that the water-supply is mainly derived from the catchment of rainwater, low in magnesium.
are, in the field of porphyrin SiR,-Working, attempting to form coherent ideas in this complex field, may we join company with Dr. Barnes, of Johannesburg (May 13), in welcoming your editorial (April 29). Our experience of the porphyrias is considerable (176 cases) and we feel justified in offering the following comments. as we
metabolism and
We do
not
wish
to
argue
an
alternative classification
at
length here. Such argument is set out in a current review of the subject.12 We fully agree that no classification is likely to be wholly satisfactory until more is known of the biochemical interrelationships of the porphyrias. Whatever gaps there may be in our knowledge, any currently advanced divisions take into account such biochemical differences as are known to exist. We emphasise that not only the urinary but also the faecal porphyrin excretion must be considered. Protocols of published cases frequently lack this vital information. The revised classification of Waldenstrom 13 has enjoyed considerable favour. It is simple, and has biochemical and genetic justification. We have preferred to use this classification though with alternative terminology.12 It is worth reiterating that in any family with protocoproporphyria (Watson’s groups 11 B and C) three clinical syndromes -the acute attack, cutaneous lesions, or both together-may occur not only in different sibs but at different times in the same patient. Watson’s doubt concerning group II C as a separate entity is reflected in the double interrogation mark in table 3 of his paper. 14 Furthermore, the disorder may show itself solely as an excessive fscal excretion of porphyrin. In our experience this pattern of faecal excretion is present not only during remission but also in the acute phase of the disorder. We suggest that the term "mixed" porphyria (group II B) be abandoned since it is too vague. Protocoproporphyria is a term which has merit in that it emphasises a fundamental must
7. 8. 9. 10. 11. 12. 13. 14.
Selye, H. Amer. Heart J. 1958, 55, 805. Arnold, R. M., Fincham, I. H. J. comp. Path. Ther. 1950, 60, 51. Malkiel-Shapiro, B., Bersohn, I., Terner, P. Med. Proc. 1956, 2, 455. Parsons, R. S., Butler, T. C., Sellars, E. P. ibid. 1959, 5, 487. Parsons, R. S., Butler, T. C., Sellars, E. P. ibid. 1960, 6, 579. Eales, L. Annu. Rev. Med. 1961, 12, 251. Waldenström, J. Amer. J. Med. 1957, 22, 758. Watson, C. J. New Engl. J. Med. 1960, 263, 1205.