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TONSILLECTOMY AND ADENOIDECTOMY
1205 suspect that folic-acid deficiency may occasionally the changes of partial villous atrophy in the small-
reason to
produce intestinal
mucosa.
Sefton General Hospital Liverpool 15.
J. FORSHAW.
PENTAZOCINE AND ASTHMA SiR,-Among major analgesics, opium derivatives or their synthetic equivalents still remain the most used. Unfortunately, all of them release histamine to some degree; and this, independently of their depressive effect on the bronchial muscles, prohibits their use in asthmatics. It has been suggested that pentazocine is an exception to this rule. We have included this drug in our study of the histamine-releasing of new compounds. 0-10 ml. of the solution (equivalent to 1.5 mg. pentazocine) was injected intradermally in 50 allergic patients: injection was painful but there was no oedema. Fisher rats (average weight 180 g.) were injected intradermally with pentazocine diluted in ’Tyrode ’ liquid, pH adjusted to 7. One group was given doses of 0-12, 0-25, 0-5, 1, or 2 g. A second group received 0-03, 0-3, 3, 30, or 300 g. A control group received histamine at doses of 0-12, 0-25, 0-5, 1, or 2 g.
properties
These intradermal injections were immediately followed by an intravenous injection of 0-5 ml. Evans-blue 5% solution. Animals were killed after twenty minutes. No extravasation of the solution into the dermic papule has been observed in rats given pentazocine. The controls, receiving histamine, were positive, as anticipated. Thus pentazocine does not seem to be a histamine-like product and does not release histamine. Its administration to patients with allergic diseases, and asthma in particular, would not, therefore, seem to be contraindicated. Institut d’Immuno-Biologie, Hopital Broussais, 96 Rue Didot,
G. M. HALPERN.
Paris XIVe.
TONSILLECTOMY AND ADENOIDECTOMY SiR,—There are so many points in the letter from Dr. Alpert and his colleagues (last week, p. 1149) which deserve comment that any adequate reply would be too long for publication in your correspondence columns. However, I should appreciate space to correct a gross error of fact in the letter as it
GOUT AND THE KIDNEY SIR,-Your leading article (May 4, p. 961) is interesting, but I wish to take strong exception to your statement that renal biopsy " has a significant morbidity and mortality ". Briefly, I would agree with Muehrcke and Pirani who rightly claim that " in general, the complications of renal biopsy are mild and transitory ".1 Wealso have the same experience. In fact, if a thoughtful selection of patients is observed, and if the biopsy "is performed by careful and experienced physicians, the mortality " approaches zero, almost asymptotically. The morbidity is extremely low and for all practical purposes negligible. On the other hand, the benefits derived from a renal biopsy are multiple and of great importance even to the individual patient. An example is the case described by Epstein and Becker, in which an unsuspected acute glomerulonephritis was discovered in a patient with longstanding diabetes. In my own experience, similar cases have also occurred-thus enabling the physician to apply treatment to a condition hitherto considered a manifestation of the underlying systemic disease. Therefore, I strongly object to the dismissal of the importance of kidney biopsy, as also to the naive reliance on renal-function tests. As for gout, I would refer the interested reader to an article published by us in 1966.4 It brings out some pertinent data we were able to collect in our long experience with this disease and its impact on the kidney. MARDOQUEO I. SALOMON.
** Renal biopsy produced symptoms or signs of complications in 9-8% of cases in one early series.5 Perirenal haematoma, a complication of some gravity, occurred in 0-6% of cases in this series and in 0-4% in another large and later series.6 Transfusion was required after biopsy in other cases. Sporadic deaths have been recorded.7 and not all may have been published. Intrarenal arteriovenous fistulae have been recognised after biopsy (11 out of 58 cases in one series).8 Nevertheless, most physicians would agree that these risks are acceptable when biopsy is used as a diagnostic tool: our objection was to its use purely as a research procedure. Under such circumstances, ’it is surely no justification that the mortality " approaches zero " or that complications are " in general " mild. Neither is it reasonable to suggest that incidental renal disease may be discovered: surely no-one would use renal biopsy as a screening procedure in healthy patients. We have yet to hear of physicians who accept renal biopsy as a safe research technique using their own kidneys as a source of normal control material.-ED. L.
appeared. In the first paragraph it is stated that: " In England and Wales in 1963 there was one death for each 1355 operations ." The authors then go on to refer to This serious risk ... ". Presumably the figure quoted is a misprint for 13,550, but the wording of the letter suggests that the error occurred before the letter was drafted and not in your office or printing works. Figures issued by the General Register Office after their careful analysis of all possible sources of information show that in England and Wales in 1963 there were 13 deaths associated with the operations of tonsillectomy and adenoidectomy. HIPE returns indicate that approximately 186,010 such operations were performed in the same year. These figures give an incidence of 1 death in every 14,300 operations. It is difficult to understand why Dr. Alpert and his colleagues should cite only the figures for England and Wales for 1963 when more recent figures for three subsequent years are readily available. In 1964 there were 3 deaths (from approximately 193,850 operations), in 1965 there were 11 deaths, and in 1966 there were 7 deaths. The numbers for 1967 are not available yet. Thus in England and Wales in the last three years for which figures are available there has been an average of 7 deaths per year and the incidence has been 1 in, approxi"
mately,
every
27,000 operations. D. RANGER.
VIRUS AND KIDNEY context of your annotation (April 13, p. 801) it the SiR.—In is of interest that certain widespread viruses can induce renal hypoplasia when used to infect susceptible hosts in utero or perinatally. These agents include rat virus, H-1 virus, and feline panleucopenia virus. The attack of these agents upon the kidney, which is an expression of their affinity for replicating tissues, is selectively centred on the nephrogenic zone of this
organ.9 Department of Pathology, Dartmouth Medical School, Hanover, New Hampshire 03755, U.S.A.
GEORGE MARGOLIS.
Muehrcke, R. C., Pirani, C. L. in Renal Disease (edited by D. A. K. Black). Oxford, 1967. 2. Salomon, M. I., Bruno, M. S., Ober, W. B. New Y. St. J. Med. 1962, 62, 3248. 3. Epstein, S. E., Becker, E. L. Ann. intern. Med. 1961, 54, 97. 4. Salomon, M. I., Zak, F. G. J. Am. Geriat. Soc. 1966, 14, 475. 5. Kark, R. M., Muehrcke, R. C., Pollak, V. E., Pirani, C. L., Kiefer, J. H. Archs Intern Med. 1958, 101, 439. 6. Muth, R. G. J. Urol. 1965, 94, 1. 7. Hampers, C. L., Prager, D. Archs Intern. Med. 1964, 114, 782. 8. Bennett, A. R., Wiener, S. N. Am. J. Rœntg. 1965, 95, 372. 9. Kilham, L., Margolis, G., Colby, E. D. Lab. Invest. 1967, 17, 465. 1.
reason to
produce intestinal
mucosa.
Sefton General Hospital Liverpool 15.
J. FORSHAW.
PENTAZOCINE AND ASTHMA SiR,-Among major analgesics, opium derivatives or their synthetic equivalents still remain the most used. Unfortunately, all of them release histamine to some degree; and this, independently of their depressive effect on the bronchial muscles, prohibits their use in asthmatics. It has been suggested that pentazocine is an exception to this rule. We have included this drug in our study of the histamine-releasing of new compounds. 0-10 ml. of the solution (equivalent to 1.5 mg. pentazocine) was injected intradermally in 50 allergic patients: injection was painful but there was no oedema. Fisher rats (average weight 180 g.) were injected intradermally with pentazocine diluted in ’Tyrode ’ liquid, pH adjusted to 7. One group was given doses of 0-12, 0-25, 0-5, 1, or 2 g. A second group received 0-03, 0-3, 3, 30, or 300 g. A control group received histamine at doses of 0-12, 0-25, 0-5, 1, or 2 g.
properties
These intradermal injections were immediately followed by an intravenous injection of 0-5 ml. Evans-blue 5% solution. Animals were killed after twenty minutes. No extravasation of the solution into the dermic papule has been observed in rats given pentazocine. The controls, receiving histamine, were positive, as anticipated. Thus pentazocine does not seem to be a histamine-like product and does not release histamine. Its administration to patients with allergic diseases, and asthma in particular, would not, therefore, seem to be contraindicated. Institut d’Immuno-Biologie, Hopital Broussais, 96 Rue Didot,
G. M. HALPERN.
Paris XIVe.
TONSILLECTOMY AND ADENOIDECTOMY SiR,—There are so many points in the letter from Dr. Alpert and his colleagues (last week, p. 1149) which deserve comment that any adequate reply would be too long for publication in your correspondence columns. However, I should appreciate space to correct a gross error of fact in the letter as it
GOUT AND THE KIDNEY SIR,-Your leading article (May 4, p. 961) is interesting, but I wish to take strong exception to your statement that renal biopsy " has a significant morbidity and mortality ". Briefly, I would agree with Muehrcke and Pirani who rightly claim that " in general, the complications of renal biopsy are mild and transitory ".1 Wealso have the same experience. In fact, if a thoughtful selection of patients is observed, and if the biopsy "is performed by careful and experienced physicians, the mortality " approaches zero, almost asymptotically. The morbidity is extremely low and for all practical purposes negligible. On the other hand, the benefits derived from a renal biopsy are multiple and of great importance even to the individual patient. An example is the case described by Epstein and Becker, in which an unsuspected acute glomerulonephritis was discovered in a patient with longstanding diabetes. In my own experience, similar cases have also occurred-thus enabling the physician to apply treatment to a condition hitherto considered a manifestation of the underlying systemic disease. Therefore, I strongly object to the dismissal of the importance of kidney biopsy, as also to the naive reliance on renal-function tests. As for gout, I would refer the interested reader to an article published by us in 1966.4 It brings out some pertinent data we were able to collect in our long experience with this disease and its impact on the kidney. MARDOQUEO I. SALOMON.
** Renal biopsy produced symptoms or signs of complications in 9-8% of cases in one early series.5 Perirenal haematoma, a complication of some gravity, occurred in 0-6% of cases in this series and in 0-4% in another large and later series.6 Transfusion was required after biopsy in other cases. Sporadic deaths have been recorded.7 and not all may have been published. Intrarenal arteriovenous fistulae have been recognised after biopsy (11 out of 58 cases in one series).8 Nevertheless, most physicians would agree that these risks are acceptable when biopsy is used as a diagnostic tool: our objection was to its use purely as a research procedure. Under such circumstances, ’it is surely no justification that the mortality " approaches zero " or that complications are " in general " mild. Neither is it reasonable to suggest that incidental renal disease may be discovered: surely no-one would use renal biopsy as a screening procedure in healthy patients. We have yet to hear of physicians who accept renal biopsy as a safe research technique using their own kidneys as a source of normal control material.-ED. L.
appeared. In the first paragraph it is stated that: " In England and Wales in 1963 there was one death for each 1355 operations ." The authors then go on to refer to This serious risk ... ". Presumably the figure quoted is a misprint for 13,550, but the wording of the letter suggests that the error occurred before the letter was drafted and not in your office or printing works. Figures issued by the General Register Office after their careful analysis of all possible sources of information show that in England and Wales in 1963 there were 13 deaths associated with the operations of tonsillectomy and adenoidectomy. HIPE returns indicate that approximately 186,010 such operations were performed in the same year. These figures give an incidence of 1 death in every 14,300 operations. It is difficult to understand why Dr. Alpert and his colleagues should cite only the figures for England and Wales for 1963 when more recent figures for three subsequent years are readily available. In 1964 there were 3 deaths (from approximately 193,850 operations), in 1965 there were 11 deaths, and in 1966 there were 7 deaths. The numbers for 1967 are not available yet. Thus in England and Wales in the last three years for which figures are available there has been an average of 7 deaths per year and the incidence has been 1 in, approxi"
mately,
every
27,000 operations. D. RANGER.
VIRUS AND KIDNEY context of your annotation (April 13, p. 801) it the SiR.—In is of interest that certain widespread viruses can induce renal hypoplasia when used to infect susceptible hosts in utero or perinatally. These agents include rat virus, H-1 virus, and feline panleucopenia virus. The attack of these agents upon the kidney, which is an expression of their affinity for replicating tissues, is selectively centred on the nephrogenic zone of this
organ.9 Department of Pathology, Dartmouth Medical School, Hanover, New Hampshire 03755, U.S.A.
GEORGE MARGOLIS.
Muehrcke, R. C., Pirani, C. L. in Renal Disease (edited by D. A. K. Black). Oxford, 1967. 2. Salomon, M. I., Bruno, M. S., Ober, W. B. New Y. St. J. Med. 1962, 62, 3248. 3. Epstein, S. E., Becker, E. L. Ann. intern. Med. 1961, 54, 97. 4. Salomon, M. I., Zak, F. G. J. Am. Geriat. Soc. 1966, 14, 475. 5. Kark, R. M., Muehrcke, R. C., Pollak, V. E., Pirani, C. L., Kiefer, J. H. Archs Intern Med. 1958, 101, 439. 6. Muth, R. G. J. Urol. 1965, 94, 1. 7. Hampers, C. L., Prager, D. Archs Intern. Med. 1964, 114, 782. 8. Bennett, A. R., Wiener, S. N. Am. J. Rœntg. 1965, 95, 372. 9. Kilham, L., Margolis, G., Colby, E. D. Lab. Invest. 1967, 17, 465. 1.