THE CHOICE OF DIURETIC
2791. Fiedler, A. Festschrift der Stadtkiankenhauses Dresden Friedrichstadt;part 2, 3, Dresden, 1899.2. Zuppinger, H. Wien. klin. Wschr. 1901, 14, 799.3. Stoeber, E. Z. Kinderheilk. 1952, 71, 319, 592.4. Gear, J. H. S. Papers and Discussions presented at the 3rd InternationaPoliomyelitis Conference; p. 61. Philadelphia, 1955.5. Javett, S. N., Heymann, S., Muwdel, E., Pepler, W. J., Lurie, H. E.,Gear, J., Measroch, V., Kirsch, Z. J. Pediat. 1956, 48, 1.6. Van Creveld, S., Dejager, H. Ann. Pdiat. 1956, 187, 100.7. Choremis, C. ibid. p. 444.8. Freundlich, E., Berkowittz, M., Elkon, A., Wilder, A. A.M.A. J. Dis.Child. 1958. 96, 43.9. Munk, J., Lederer, K. T. J. Fac. Radiol. Lond. 1958, 9, 195.10. Schmidt, E. C. H. Amer. J. Path. 1948, 24, 97.been initiated. Nearer home, a public much concerned withhealth and disease still imagines that the smell of sewage isunhealthy as well as unpleasant. From all this ignorancesprings antipathy, and from antipathy a conscious andnoisy antiscience-horoscopes, herbalists, and muck-and-magic farming.The popular remedy for this lack of communication ismore science teaching in schools; and, as this could affectthe career of every medical student, it is of special concernto our profession. Teaching science well is difficult, andgood teachers are rare-though not so rare as they were.The scientific curriculum contains a lot of facts (which areeasy to teach) and some general ideas (which are not):whereas the boy studying" the classics " may by the ageof 16 be seeing in a dim way what it is all about, his scien-tific coeval may merely be trying to memorise informa-tion. Since almost all educationists agree that their mainobject is to teach children how to learn and how to think,few really favour their early introduction to vocational asopposed to educational courses, and many, if not most,would rightly prefer boys and girls taking medicine topostpone for a year or two their present early start onpreparation for the 1st M.B. Is this to be one more of thevaluable things which we in this country are for somereason supposed to be no longer able to afford ? It is reallyimpossible to believe that anyone who has limited hisreading to scientific cram-books since the age of 16 is thebest candidate for a humane profession.EPIDEMIC PRIMARY INTERSTITIAL MYOCARDITISIN CHILDHOODDURING the past sixty years, acute interstitial myo-carditis has become a well-recognised clinical and patho-logical entity. Fiedler 1 described the first adult case in1899, and Zuppinger 2 recorded a similar condition in achild; since then many cases have been seen in all partsof the world. Between 1937 and 1944 there were 140cases in the Munich area 3 in children between the agesof one month and two years. Over 75% of these wereunder eight months old and only 1 child survived. Theepidemic was protracted, with 8-25 cases yearly in localisedareas in the city. During this period there was no increasedincidence of diseases known to be associated with myo-carditis. Coxsackie virus was responsible for outbreaksamong newborn babies in South Africa and SouthernRhodesia 4 at times when Bornholm disease was preva-lent, and in Amsterdam 6 during a period of " summergrippe". In Athens in 1956 there was a considerableincrease in the number of cases of interstitial myocarditiswhen 6 out of 8 cases were fatal.The most recent epidemic has been reported fromIsrael, where it was confined to Haifa and involved 57children, most of whom were aged between six andeighteen months. 8-10 Unlike most previously reportedepidemics, it involved no infants under six months ofage. Sporadic cases had occurred in previous yearsand there was a sharp rise of incidence during 1956,1. Vogl, A. Diuretic Therapy; p. 104. Baltimore, 1953.reaching a peak in February, 1957. No other epidemicconditions existed at the time, and no parents or siblingsof affected cases suffered from any other disease. Theclinical features were essentially those of acute cardiacfailure, which failed to respond to a number of drugs andwhich was fatal in 50 children. Munk and Lederer havedescribed the radiological appearances, in which the pre-dominant feature was general cardiac enlargementprogressing from slight dilatation, when the shape of theheart was well preserved, to extreme enlargement with aglobular cardiac shadow. All patients had passive pul-monary congestion and a few had pleural effusions. Thehistopathological evidence of severe interstitial infiltrationof the myocardium by lymphocyte-like cells was some-times accompanied by diffuse interstitial pneumonia orby areas of subendocardial fibrosis. A number of casesshowed interstitial inflammatory infiltration in other partsof the body-particularly the liver, diaphragm, psoasmuscle, and pericardium. On p. 263 of this issue Dr.Heichmann and Dr. Bassan record the electrocardio-graphic findings in 21 cases and point out that in no casewas a defect of the conduction mechanism seen; this wasconfirmed by the failure to find pathological changes inthe conducting tissue in spite of the severe abnormalitiesin the rest of the myocardium. Mice inoculated withpostmortem material failed to develop disease afterseveral passages, although an unidentified virus from theheart of a fatal case was grown on monkey-kidney tissueculture. 8 While it has been shown that Coxsackie viruscan cause myocarditis, particularly in small babies, thesetiology of most cases remains obscure. Schmidt 10 hasisolated an " encephalomyocarditis virus " from chim-panzees dying with interstitial myocarditis, but this virushas been recovered only from human patients withcerebrospinal conditions. The studies in the Haifaepidemic exclude the Coxsackie virus as well as theencephalomyocarditis virus or similar viruses as xtio-logical agents. Thus although it appears that acute inter-stitial myocarditis, whether sporadic or epidemic, is viralin origin, it is likely that several viruses may be responsible.THE CHOICE OF DIURETICFORTY years ago in a Vienna hospital, Vogl made achance observation which opened a new era of diuretictherapy. 1 While treating a syphilitic patient withan organic mercurial, he noted that it effected promptdiuresis. This led to the development of mersalyl andsimilar compounds which are universally used in themanagement of oedematous states. Organic mercurialsare cheap and their toxicity is low. Their chief disadvan-tage is that they must be administered parenterally.The mercurials now have competitors in the oral chloro-thiazides, and in the foreseeable future these will bejoined by the spirolactones and others with distinctivemodes of action." Diuresis and diuretics " was the topical theme of aconference held in June at Herrenchiemsee, under thechairmanship of Prof. H. Schwiegk, of Munich. Review-ing the physiology and pharmacology, Dr. R. F. Pitts(New York) suggested that the chlorothiazides andorganic mercurials interfered with the energy of the ion-pump in the kidney, perhaps by blocking different enzymesystems. Dr. R. Hess (Basle) has studied the histochem-istry of hydrolytic and oxidative enzymes in the nephronof the rat kidney in health and disease, in an effort to2802. Fleming, P. R., Zilva, J. F., Bayliss, R. I. S., Pirkis, J. Lancet, 1959, 1,1218.3. Kerr, D. N. S., Read, A. E., Sherlock, S. ibid. p. 1221.detect the site and mode of action of diuretics. Alterationsin mitochondrial activity in certain parts of the proximaland distal tubules were greater following organomercurialsthan other diuretics. In studies with Dr. E. M. Darmady,Dr. R. Gaunt (Summit, N.J.) demonstrated that labelledhydrochlorothiazide collected in the distal parts of theproximal convoluted tubules. He found that hydro-chlorothiazide caused much greater sodium, chloride,potassium, and water excretion than chlorothiazide,ranging from twenty times greater in the rat to five or tentimes greater in the dog. Its carbonic-anhydrase inhibi-tion was a tenth that of chlorothiazide. It antagonised thesodium-retaining effect of aldosterone and of deoxy-cortone acetate, enhanced the natriuretic and diureticeffects of prednisolone, and also enhanced the diureticeffect of alcohol as an antidiuretic-hormone inhibitor. Inman, hydrochlorothiazide is considered to be about tentimes more potent than chlorothiazide.23 3 A similarresponse can be expected from a daily dose of 1 g. chloro-thiazide or 100 mg. hydrochlorothiazide; the latter carriesno particular advantage for the patient except that heswallows a slightly smaller pill.Dr. C. K. Friedberg (New York) had analysed thevalue of diuretics in 1000 personally studied cases ofcongestive cardiac failure. The diuretic response wasexcellent or good in two-thirds, poor in a quarter, and onlyslight in the remainder. The poorest response was oftenrelated to a complicating factor such as subacute bacterialendocarditis, tricuspid regurgitation, or respiratory tractinfection. He continues to advocate the use of mercurialdiuretics by injection, despite the ease of administrationof the oral chlorothiazides. He still believes in the valueof a strict low-sodium diet and feels that patients takingoral chlorothiazide might become careless of their diet,much like a diabetic receiving insulin. He administerschlorothiazides mainly as interval therapy between coursesof mercurial diuretics and also when long-term diuretictherapy is indicated.In contrast, Dr. R. Richterich (Basle) has abandonedmercurial diuretics in favour of small doses of the chloro-thiazides. He is finding that satisfactory diuresis can beachieved by these oral drugs without restricting salt andwater intake. Likewise in Vienna, Dr. F. Wewalka hasabandoned mercurial diuretics in favour of chloro-thiazides because the latter provide a smoother controllablediuresis, whereas mercurial diuretics often provokemassive diuresis, exhausting to the patient and sometimesfollowed by an undesirable rebound phase of waterretention. Dr. F. Gross (Basle) pointed out that duringthis rebound phase there was an increase in aldosteronesecretion, which would be accompanied by sodium reten-tion likely to negate the results of the previous diuresis.Possibly chlorothiazide may usurp irksome dietary restric-tions in mild and transient states of salt and water reten-tion, but no good argument has yet been put forward forabandoning dietary sodium restriction in congestivecardiac failure or portal cirrhosis with ascites; inthese conditions all too often the patient respondswell to a rigid diet in hospital, only to relapse when hereturns home.Dr. Friedberg drew attention to certain undesirableeffects of the long-term use of the chlorothiazides-namely, cardiac arrhythmias, hyperuricxmia leading toattacks of gout, and increased urinary potassium excre-4. Read, A. E., Laidlaw, J., Haslam, R. M., Sherlock, S. Brit. med. J. 1958i, 963.5. Read, A. E., Laidlaw, J., Haslam, R. M., Sherlock, S. Clin. Sci. 195918, 409.6. August, J. T., Nelson, D. H., Thorn, G. W. New Engl. J. Med. 1958259, 917, 967.7. Lieberman, A. H. A.M.A. Arch. intern. Med. 1958, 102, 990.tion ; potassium excretion was increased still further if thepatient was also receiving corticosteroids. Dr. SheilaSherlock (London) also stressed the danger of increasedurinary potassium excretion following administration ofthe chlorothiazides in the management of decompensatedliver disease. The chlorothiazides may cause clinical andelectroencephalographic changes of impending hepaticcoma; but these changes can be corrected by adequatepotassium supplements.3-5 It is, therefore, essential togive potassium with the chlorothiazides whenever theseare administered for long periods, particularly in liverdisease.As regards the management of ascites, Dr. Sherlockreferred to the organic mercurials and the chlorothiazidesand also to intravenous infusions of albumin. Repeateddoses of 100 g. of albumin over long periods sometimesproduce satisfactory diuresis, but albumin is at presentprohibitively expensive and virtually unobtainable.The effect of aldosterone on electrolyte metabolism istwenty to thirty times greater than that of deoxycorticone.All the evidence suggests that aldosterone plays an im-portant part in maintaining fluid and electrolyte homceo-stasis. A low-sodium or high-potassium diet leads toincreased aldosterone secretion. It promotes sodiumretention and potassium excretion, and a close inverserelationship exists between sodium and aldosteroneexcretion in oedematous patients.6 7 It is not surprising,therefore, that the aldosterone-antagonising compounds-the steroidal spirolactones-should be tried in patientswith oedema. The earlier compounds were administeredparenterally, but Dr. W. Hollander (Boston) and Dr.Sherlock reported experience with a recent one SC9420, Spironolactone -which can be given by mouth. Itappears to be an effective diuretic, promoting sodiumexcretion with no accompanying potassium excretion.Thus far its scarcity precludes its free use, but it is clearlya promising addition. Theoretically it should cause apositive potassium balance. Thus, chlorothiazide com-bined with spirolactone would seem an attractivecombination for the management of obstinate oedema.. Dr. Hollander has noted that the combined use ofl chlorothiazide and a spirolactone potentiates not; only the diuretic effect but also the antihypertensive- effect.Dr. V. Friedberg (Mainz) attributes the poor diureticresponse to chlorothiazide in toxaemia of pregnancy to thelow plasma-volume. When this is corrected by intra-venous albumin, chlorothiazide causes satisfactory diuresis.He also believed that a poor antihypertensive effect ofchlorothiazide in pregnancy toxaemia was due to hypo-volaemia. Urinary aldosterone levels, although raisedin pregnancy, were found to be lower in toxxmicpatients than levels observed in normal cyesis at thesame stage. This apparent paradox of lower aldosteroneexcretion in the presence of sodium retention may berelated to the low progesterone levels in toxaemia ofpregnancy. Progesterone appears to exert its natriureticeffect only in the presence of adequate aldosteroneexcretion.The proceedings of this conference are to be published tSpringer-Verlag, Heidelberg.