Correspondence
Letters to the Editor should not exceed 500 words.
Fibrosing Alveolitis
SIR,-The use of the title " fibrosing
alveolitis " for your leader on the paper' by
my colleagues Drs. Livingstone, Lewis, Reid,
and Jefferson (22 August, p. 464) is, I be-
lieve, the first time this term has appeared in
print in this sense. As hitherto I have voiced
my advocacy of it only in informal discus-
sions, perhaps you will permit me now to
explain why I think its general adoption
would make it easier for us to talk to each
other about patients whom we know or be-
lieve to have lung changes of the sorts to
which such names as " Hamman-Rich
disease " and " idiopathic diffuse interstitial
fibrosis of the lungs" have been applied.
As you point out, the disease which
Hamman and Rich2 described was an acute
one, as indicated by their title " acute diffuse
interstitial fibrosis of the lungs." I suspect
that only a minority of those who indiscrimi-
natingly confer eponymy upon Drs. Hamman
and Rich have extended to them the pre-
liminary courtesy of reading their original and
important contributions. By all means let
us, if we wish, refer to a case with combina-
tion of symptoms and signs and of histo-
pathological changes in the lungs similar to
those described by them as an example of the
Hamman-Rich disease. But to say that a
patient with a different and more chronic sort
of illness and with histopathological changes
similar in only some respects is suffering from
the same syndrome or disease is meaningless
unless it is intended to imply that his illness
has some close aetiological or pathogenetic
relationship with that of the four patients
described by Hamman and Rich. While this
may be true, it is surely undesirable to imply
a priori by the unreflecting use of words a
proposition which should be submitted to
objective study.
The term " chronic diffuse interstitial
fibrosis " which in the past I myself have
used for the more chronic cases' suffers from
the defect that it refers to an end result. To
be restricted to the use of this term is as if
" pleural thickening " were the only term by
which we could refer to pleurisy. We need a
term appropriate to an evolving histopatho-
logical process. The essential feature of this
process, in general terms, is inflammatory
thickening of alveolar walls with progressive
reticulin proliferation and formation of
fibrous tissue ; it may be added that any
cellular exudate present in the alveolar spaces
is predominantly of macrophages, though
variable in amount. The problem is to find
a name which, after an acceptably restrictive
definition, can be applied with clarity to a
process having these characteristics. If
" interstitial fibrosis of the lung " is to be
applied to such a process, some such epithet
as " progressive " must be added to indicate
reference to an active process, and the mean-
ing of the term " interstitial " must be re-
stricted in a very curious way to exclude the
perivascular and peribronchial spaces, which
are the most extensive " interstitia " in the
lung. As the process is an inflammatory one
page 686
Treatment of Thyroid Disorders
in the lung, etymology would permit it to be
called a pneumonia. But this would not have
the sanction of usage, for, by a generally
accepted convention, " pneumonia " is re-
stricted to inflammations of the lung
characterized predominantly by exudate into
the alveolar spaces. I had been thinking over
this problem of nomenclature for some time,
when in March 1963, during an informal dis-
cussion at a colloquy on pulmonary insuffi-
ciency at the University of Oklahoma, Dr.
A. L. Fishman suggested to me the possibility
of adopting the term " alveolitis." And, after
reflection, I have concluded that the term
" fibrosing alveolitis " is as acceptable as any
we are likely to devise to refer to the whole
gamut of histopathological changes from the
acute type described by Hamman and Rich
to the much more frequent chronic type.
Of course, in a broad sense, a pneumonia
is also a pulmonary alveolitis ; but if we
accept the conventionally restricted definition
of " pneumonia " suggested above, and adopt
the complementary convention that the term
" alveolitis " shall refer to an inflammatory
change predominantly in the alveolar walls,
the distinction between the usages of the
words " pneumonia " and " alveolitis " be-
comes evident. The fibrosis consequent upon
non-resolution of a pneumonia results from
organization of alveolar exudate, is custo-
marily and without confusion called an
organizing pneumonia, and is quite distinct
from the progressive fibrosis predominantly
in alveolar walls, leading in severely affected
parts to obliteration of alveolar spaces in con-
fluent tracts of fibrous tissue, which
characterizes fibrosing alveolitis.
The adoption of " fibrosing alveolitis"
offers other advantages besides the ability to
indicate, with a not too arbitrary restriction
of meaning, the essentials of the histopatho-
logical changes which characterize the group
of cases to which we wish to refer. It also
directs attention to the part of the lung where
the functional defect is to be found, for in
patients whose lungs are affected in this way
it is disturbance of the orderly encounter be-
tween gas in the alveoli and blood in the
alveolar capillaries that is the earliest and
principal cause of disability. If a clinician
uses the term fibrosing alveolitis, he is com-
mitting himself to nothing beyond a state-
ment of belief that histopathological changes
of a certain broad type are present in the
lungs. The freedom of this term from aetio-
logical implications facilitates discussion both
of causation and of the interrelationships
between acute and chronic forms and between
cases in which the lung changes present as a
lone phenomenon and those in which they
accompany such diseases as rheumatoid
arthritis.-I am, etc.,
London S.W.3. J. G. SCADDING.
REFERENCE
I Livingstone, J. L., Lewis, J. G., Reid, L., and
Jefferson. K. E., Quart. 7. Med., 1964. 33, 71.
2 Hamman, L., and Rich, A. R., Bull. Johns Hopk.
Hosp., 1944, 74, 177.
3 Scadding, J. G., Brit. med. 7., 1960, 1, 443.
SIR,-I read with interest the article on
treatment of thyroid disorders (22 August,
p. 493) which records the discussion
on the subject by a panel consisting of
Sir Edward Wayne, Mr. Guy Blackburn,
and Dr. R. H. Davis. It was refreshing to
see how ready they all were to see each other's
point of view, and the upshot of their dis-
cussion would, I feel, be generally acceptable
at present.
I would like to underline the point made
by Sir Edward Wayne that all the thio com-
pounds used as antithyroid drugs act in the
same way, and point out that methylthiouracil
is far cheaper than the proprietary prepara-
tions for which great superiority is unjusti-
fiably claimed. I was disappointed that in
the discussion no mention of the dosage of
that class of drug was made, because I fear
many people still use too much for too long.
I do not know what Sir Edward Wayne means
by his advocacy of a big dose at the
beginning, but I do not find any need to
use more than 50 mg. of methylthiouracil
four times a day to start with and think that,
as with potassium perchlorate, this level
suitably tailored later is far safer than the
high doses originally employed. Also, with
due respect to Sir Edward Wayne and Mr.
Blackburn, who are both enthusiastic about
the value of pre-operative preparation with
anti-thyroid drugs, mainly because of their
fear of post-operative thyroid crisis, I doubt
whether there is any advantage these days in
such a course. Few patients now reach the
surgeon in a severely thyrotoxic state which
has been allowed to run on to the point of
grave emaciation and uncontrolled auricular
fibrillation with heart failure, and I find that
my patients do uniformly well with modern
anaesthesia after 10 days' rest, iodine, and
sedation.-I am, etc.,
Selly Oak Hospital, A. M. NusSEY.
Birmingham.
Toxaemia of Pregnancy
SIR,-We would like to make some
comments on your leading article entitled
"New Look at Toxaemia of Pregnancy"
(22 August, p. 459) in which you refer to
the possible role of renin in the pathogenesis
of toxaemia.
In the literature there is considerable con-
fusion concerning the use of the term renin,
since this enzyme has not so far been
obtained in pure form. In some instances
the term renin is used to refer to the enzyme
which converts plasma angiotensinogen to
angiotensin, whereas in others it is loosely
applied to renal extract which has been puri-
fied to a varying degree and which contains
the enzyme renin. Used in the latter context
we cannot agree with your statement " nor
is there any pharmacological reason why
renin should produce proteinuria, oedema, or
epileptiform seizures." It has been known
for some time that injection of renin (purified
renal extract) produces proteinuria in experi-
mental animals,`-3 and it has also been shown
that both renin and angiotensin increase the
rate of disappearance of Evans blue-protein