CORRESPONDENCE T o THE EDITOR: The article Endomyocardial Fibrosis: A Surgical Approach, by Dr. Denvard Lepley and associates (Ann Thorac Surg 18:626, 1974) was very interesting to me and my colleagues in Nigeria who have been concerned about this disease for many years. Until now, endomyocardial fibrosis (EMF) has been considered endemic to Africa and other subtropical countries and has been regarded as a nonsurgical cardiac disease, perhaps because of the lack of facilities for open-heart operations where this disease is prevalent. The surgical success of Dr. Lepley’s group definitely opens up new dimensions in the treatment armamentarium for EMF. Their speculations about the infectious etiology in their patient and her incidental association with a diseased primate raise an important question on the role of a secondary host in its pathogenesis. The presence of heartworms and other parasitic cardiac zoonoses in African children lends support to the infection theory and deserves further investigation. Pathologists dealing with EMF in Nigeria have reportedly found large clots in the ventricles of children who died during its early stages even before fibrosis had developed in the endomyocardium. Why these children develop ventricular clots remains an enigma. As Dr. Lepley and associates pointed out, it is ironic and unfortunate that the population most severely affected by this disease live in countries where openheart operations are not readily available. It is hoped that future development will offer these facilities which have been so badly needed. A. ADEBONOJO, M.D. SAMUEL

Lecturer-Consultant Department of Thoracic Surgery University of Ibadan Ibadan, Nigeria

To THE EDITOR: In a recent editorial, Sealy [ 13 reviewed the clinical landmarks leading to the present application of mediastinoscopy for evaluation of patients with suspected or proved bronchogenic carcinoma. His comments were timely, with emphasis on the importance of appropriate selection of procedures to achieve optimum results. In a review of diagnostic surgical procedures applicable to patients with pulmonary diseases, we presented a rationale for the selection of mediastinoscopy based on well-defined clinical and roentgenographic findings [2]. We endorse the philosophy espoused by Dr. Sealy that the selection of diagnostic surgical procedures should be determined by individualized patient evaluation, and we oppose categorical use of any procedure, including mediastinoscopy, except as a necessary clinical investigation. Conservative indications for mediastinoscopy have evolved in our practice 728

THE ANNALS OF THORACIC SURGERY