1278 weeks and methicillin for one week. After this, repeated blood-cultures (venous and arterial) were sterile but all the clinical signs continued. The cardiac murmurs had increased in intensity. On Sept. 3, eight weeks after admission to hospital and sixteen weeks after the presumed start of the illness, treatment was started with fusidic acid (3 g. per day, reducing after three days to 1-5 g.) in combination with novobiocin (1 g. per day). The patient’s temperature returned to normal after three days and remained so. There were no further clinical signs of microemboli and the spleen became impalpable. Fusidic acid and novobiocin were continued in this dosage for five weeks and the patient was observed during a further week in hospital. During this period, repeated blood-cultures were sterile and there was no clinical evidence of relapse. This has also been the case during a further two weeks of observation as an outpatient, after his discharge from hospital on Oct. 16.
Cusackhas recently reported a success with fusidic acid in a highly resistant case of staphylococcal septicaemia, and Scowen and Garrod2 have shown that a combination of fusidic acid with penicillin exhibits synergism. In the present case, however, serum levels of penicillin which were well above the in-vitro bactericidal level produced no clinical improvement and it was felt that a combination of fusidic acid with some other antibiotic than penicillin was desirable. Recent " invitro " evidence3 has shown that a combination of fusidic acid with novobiocin exhibits marked synergism, and the present case indicates the value of this in the treatment of penicillin-resistant staphylococcal septicaemia. I am indebted to Prof. C. H. Stuart-Harris for permission to report this case; and to Dr. Austin Darragh and the staff of Leo, Ireland, Ltd., for their interest and a supply of ’Fucidin ’. The Royal Hospital, ROBERT PENMAN. Sheffield.
could offer. I would be very glad readers who might like to help. 217, Balham High Road, London, S.W.17. (Tel: BALham 3657/8)
hear from any of your
J. B. C. SWINNEY Probation Officer.
LACTIC-DEHYDROGENASE ISOENZYMES SIR,-May I add a few words to the discussion on the assay of lactic-dehydrogenase isoenzymes, which has been taking place n your journal during the past few months? If one elevates the pH of the substrate media to pH. 9,0-9,55 it is possible to eliminate sodium cyanide as used by van der Helm et aland still get comparable patterns. I used a buffer consisting of 10-0 g. tris and 1-2 g. glycine per litre, which gives a pH of approximately 9-3. Roughly following the procedure of Nachlas et al.Iused the following reagents in these proportions: 01 M lithium lactate in buffer, 2-0 mI.; N.A.D. (D.P.N.) 1 mg. per ml. in buffer, 2-0 ml.; 0-1% gelatin, 1-0 ml.; tetrazolium salt 1 mg.
DETECTION OF GLAUCOMA
SiR,—The Ministry of Health pamphlet on The Prevention and Alleviation of Blindness rightly states that simple glaucoma may be accompanied by no clamant symptoms ", but any doctor and certainly any ophthalmic medical practitioner should be able to suspect simple glaucoma from the appearance of the discs. The outstanding omission in the pamphlet is that there is no recommendation that all patients over forty years of age "
medical eye examination.
A WEST-END CLINIC FOR TREATMENT OF
ALCOHOLISM of my work as a probation officer result SiR,-As in Pentonville Prison, I was recidivist alcoholics among able to get opened in July, 1961, a hostel for alcoholics in South London. This hostel is now well established, and I am anxious to open in the West End of London a clinic for the outpatient treatment of alcoholics. a
This clinic will deal with what I call the "
alcoholic, for whom a great deal can be done with the support of the family. Premises have already been obtained in the West End where the clinic would operate for two evenings a week. A number of social workers, recruited from psychiatric social workers and probation officers, are prepared to help, and we have secured the services of a doctor for one of the two evenings. We need another doctor’s help on one evening a week for some three hours. The ideal solution might be a retired doctor living not too far from the West End; but a younger doctor might well be interested in the clinic and the valuable experience it 1. 2. 3.
Cusack, P. B. ibid. 1962, ii, 403. Scowen, E. F., Garrod, L. P. Lancet, 1962, i, 933. Darragh, A. Personal communication.
1, left-hand side of each tracing is fastest anodic fraction. Tetrazolium salts used. Top tracings: N.B.T. Middle tracings: I.N.T. Bottom tracings: M.T.T. Left-hand triplet of tracings on cancer patient. Note elevation OfL.D.5 in tracings on right-hand side. This patient had liver damage of unknown cause. L.D.
ml., 1-0 ml.; phenazine methosulfate, 9-1
ml., 1-0 mt.
Colour development takes place in 60 to 90 minutes at 37°C in the dark. The gelatin maintains a colloidal suspension of the nonspecifically reduced tetrazolium salt. If one places the slide upsidedown as in van der Helm’s procedure, it is possible to eliminate the gelatin with little or no loss of sensitivity. The tetrazolium salts I have used are 2-p-iodophenyl, 3-p-nitro phenyl, 5-phenyl tetrazolium (I.N.T.), nitro-blue tetrazolium (N.B.T.) and thiazolyl tetrazolium (M.T.T.). These salts are roughly equivalent in sensitivity. Two examples of the relative results are shown in the
In normal serums I have been able to consistently observe L.D.4 and L.D.5 in small amounts. L.D.5 may occasionally be observed as a trace but L.D.4 has always been evaluated. The patterns illustrated were developed using 0-2% agar gel. I have had little observable difficulty with the problems of diffusion which may be one objection to using agar at this low concentration. In view of the results of Conklin et al. showing that lactic dehydrogenase is associated with lipids and/or lipoproteins in tissues and the results of Pearse and Hess 4 showing substantial differences in the substantivity of the above tetrazolium salts for lipids and/or lipoproteins, one would expect consistent differences in the isoenzyme patterns found in serum, depending on the tetrazolium salt used. So far I have der Helm, H. J., Zondag, H. A., Hartog, H. A. Ph., Van der Kooi, M. W. Clin. Chem. Acta, 1962, 7, 540. 2. Nachlas, M. M., Margulies, S. I., Goldberg, J. D., Seligman, A. M. Anal. Biochem. 1960, 1, 317. 3. Conklin, J. L., Dewey, M. M., May, B. J. Histochem. Cytochem. 1962, 1.
10, 365. Pearse, A. G. E., Hess,
Experentia, 1961, 17,
1279 been able to observe any consistent differences. The differences I have observed are such that I am unable to explain them. Further studies will be needed to elucidate this factor in lactic-dehydrogenase isoenzyme studies. I wish to express my sincere appreciation to Dr. T. J. Hanlon not
inspiring investigation. for his
consultations and enthusiastic support of this
Veterans Administration Hospital, Muskogee, Oklahoma.
CHARLES F. MATSON Chief,
in the first study period was greater than in the Jamaican in spite of a much smaller weight deficit. It is therefore probable that the turnover-rate is also influenced by the protein intake at the time of the test. rate
It seemed worth drawing attention to this point in the hope that future studies of turnover-rates in malnutrition will be designed in such a way that the effects of these two factors-level of protein intake and degree of depletioncan be separately assessed.
TREATMENT OF HIATUS HERNIA
SiR,—Iwas very interested in the letter by Dr. Fox (Nov. 24), particularly when he was discussing his sleeping experience. I have been fortunate in having experience of two types of bed, one in London and the other in a cottage in the country. The former is so designed that when sitting in bed, simply by pulling a lever the buttocks descend and the back and the knees rise. In principle I find this entirely satisfactory, and the only disadvantage is that the distance provided from the buttocks to the knee is rather too long. In this bed I find little or no tendency to sag. The other bed is hinged about half-way, and can be raised at the foot and the head to the desired position. I find that if the head is raised about 10-12 in. and the foot 2-3 in. it is entirely satisfactory, and again I have little tendency to sag. JACK PRITCHARD. London, N.W.3. PROTEIN MALNUTRITION AND ALBUMIN BREAKDOWN has SiR,—It recently been shown that in infants with malnutrition the breakdown-rate of plasma protein albumin is greatly reduced, so that the half-life is approximately doubled. Two groups working independentlyone in Jamaica,! the other in Cape Town 2-have obtained almost identical results. This reduced rate of breakdown may perhaps be interpreted as a compensatory reaction to shortage of protein supplies. The important question arises: is this a response to the level of protein intake at the time of the test, or to the state of protein depletion at the time of the test ?These are obviously separate variables. The results of animal experiments have generally been interpreted as showing that the operative factor in altering the rate of albumin catabolism is the actual protein intake. These two studies on human infants suggest, however, that both factors are important. Cohen and Hansen2 kept their patients on a low protein intake during the initial test in order to achieve a steady state, whereas Picou and Waterlow1 gave the babies as much food as they would take. The results may be compared and summarised as follows:
Medical Research Council
Tropical Metabolism Research Unit, c/o Department of Chemical Pathology, St. Mary’s Hospital, London, W.2.
J. C. WATERLOW.
BLOOD-GROUPS IN BENIGN AND MALIGNANT PROSTATIC HYPERTROPHY SIR,-People of blood-group A have been shown to
an increased susceptibility to carcinoma of the stomach,l uterine carcinoma,2 salivary-gland tumours,3 and carcinoma of the pancreas.4 It was decided to investigate myoadenoma and carcinoma of the prostate with respect to ABO and rhesus blood-grouping. The myoadenoma series was composed of 325 consecutive patients for the years 1958-61, and the carcinoma series was composed of 336 patients from the years 1948-61. Histological diagnosis was made from material obtained at operation, biopsy, or necropsy. In 5-4% of patients a hard prostate, raised serum-acid-phosphatase, and/or radiological signs of
metastasis was accepted as evidence for carcinoma in the absence of adequate histological proof. 11-0% of the carcinoma series which did not satisfy these criteria were excluded. In 16-6% of myoadenoma patients and 22-6% of carcinoma patients the blood-grouping was not recorded. In all patients the age of diagnosis was recorded. The frequency of bloodgroups in London based on a series of 10,0005 was used as the control series. The frequency of blood-groups in the myoadenoma, carcinoma, and control series is shown in table I. The relative TABLE
OF A, B, 0 AND RHESUS BLOOD-GROUPS IN THE MYOADENOMA, CARCINOMA, AND CONTROL SERIES (%)
TABLE II-RELATIVE FREQUENCY OF BENIGN AND MALIGNANT PROSTATIC HYPERTROPHY IN PERSONS OF GROUP A COMPARED WITH A FREQUENCY OF ONE IN GROUP 0
and carcinoma of the prostate in as compared with that in bloodgroup 0 is shown in table II. No significant association between myoadenoma and any blood-group was found, but there was a definite preponderance of blood-group A in patients with carThere was no significant cinoma of the prostate (P<0-01). association of rhesus-grouping with either myoadenoma or carcinoma of the prostate. Any bias in these results can be excluded since the myoadenoma series follows the normal London distribution for blood-groups, and both the myoadenoma and carcinoma patients are drawn from the same
frequency of myoadenoma patients of blood-group A
The Jamaican babies were more underweight, and therefore presumably more protein-depleted, than the Cape Town ones. In the Jamaican study the protein intake was roughly the same over the two periods of measurement, so that this is eliminated as a
If the results of the initial and final
plotted against bodyis significant (r=0-71;
weight, a correlation is found which P=0 01). This shows the influence of the degree of malnutrition. In the Cape Town study the reduction in turnover1. 2.
Picou, D., Waterlow, J. C. Clin. Sci. 1962, 22, Cohen, S. Hansen, J. D. L. ibid. 1962, 23, 351.
population. Aird, I., Bentall, H. H., Fraser Roberts, J. A., Brit. med. J. 1953, i, 799. Helmbold, W. 7th Congress of the International Society of Bloodtransfusion; p. 34. Rome, 1958. 3. Cameron, J. M. Lancet, 1958, i, 239. 4. Aird, I., Lee, J. A. H., Fraser Roberts, J. A. Brit. med. J. 1960, i, 1163. 5. Discombe, H., Meyer, H. Amer. J. clin. Path. 1952, 22, 543. 1. 2.