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ANTIBODY-ANTIGEN REACTIONS OBSERVEDBY FLUORESCENCE
A. MACDONALD.Department of Bacteriology,University of Aberdeen.
BRUCE CRUICKSHANK.Department of Pathology,
Royal Infirmary,Glasgow.
SIR,-Your annotation of May 31 gives the impressionthat the Coons technique has scarcely been tried in thiscountry. This is far from the truth: the localisation of
tissue antigens in the kidney and the relation betweenautoantibodies and Hashimoto’s disease 2 are but two ofthe recent studies using the method. Your hope that" simpler techniques will no doubt be introduced"
ignores the important contribution recently published inyour own crolumns.3 This is carrying modesty a bit far.
SiR,—Your annotation reviews a very limited amount ofthe information which has been obtained by this technique.Studies of viruses, plasma-proteins, and tissue antigensand of antibody production have each produced morepapers during the present decade than the study of bac-teria or their products. Even in the field you select fordetailed review, several contributions have been over-looked. 4-8 It is regrettable, too, that reference to Britishwork is so scanty. The technique has been used in at leastnine laboratories and papers from at least six of thesehave appeared during the last year 9-16; Weiler’s work,also, was done and published in this country;17 Themodification described by Chadwick et a1.14 has simplifiedthe technique, introduced a reliable alternative fluoro-chrome, and reduced the incidence of non-specificstaining. Kaplan 18 has recently described a furthermodification which eliminates non-specific staining withfluorescein-labelled sera.
1. Hill, A. G. S., Cruickshank, B. Brit. J. exp. Path. 1953, 34, 27.2. White, R. G. Proc. R. Soc. Med. 1957, 50, 953.3. Chadwick, C. S., McEntegart, M. G., Nairn, R. C. Lancet, 1958, i, 412.4. Hill, A. G. S., Deane, H. W., Coons, A. H. J. exp. Med. 1950, 92, 35.5. Schmidt, W. C. ibid, 1952, 95, 105.6. Sheldon, W. H. Proc. Soc. exp. Biol., N.Y. 1953, 84, 165.7. Deacon, W. E., Falcone, V. H., Harris, A. ibid. 1957, 96, 477.8. Poetschke, G., Killisch, L., Uehleke, H. Z. Immunitätsf. 1957, 114, 406.9. Beale, G. H., Kacser, H. J. gen. Microbiol. 1957, 17, 68.
10. Holborow, E. J., Weir, D. M., Johnson, G. D. Brit. med. J. 1957, ii, 732.11. Scott, D. G. Brit. J. exp. Path. 1957, 38, 178.12. Sharp, A. A., Bidwell, E. Lancet, 1957, ii, 359.13. White, R. G. Proc. R. Soc. Med. 1957, 50, 953.14. Chadwick, C. S., McEntegart, M. G., Nairn, R. C. Lancet, 1958, i, 412.15. Cruickshank, B., Currie, A. R. Immunology, 1958, 1, 13.16. McEntegart, M. G., Chadwick, C. S., Nairn, R. C. Brit. J. vener. Dis.
1958, 34, 1.17. Weiler, E. Brit. J. Cancer, 1956, 10, 560.18. Kaplan, M. H. J. Immunol. 1958, 80, 254.
THE RUSSIAN VACCINE
D. STARK MURRAY.Kingston Hospital
Pathological Laboratory,Kingston-upon-Thames, Surrey.
SIR,-The letter of Dr. Liversedge last week was a
very fair summary of the position that arises from thepublicity given to the Russian vaccine for multiplesclerosis. During the recent visit of the Socialist MedicalAssociation delegation to the Soviet Union, we endeav-oured to get some information about this vaccine. Un-fortunately we were not able to get in touch with ProfessorShubladze, but we had a long conversation with Dr.Zhdanov, a deputy Minister of Health and himself avirologist. We did not gather from him that the vaccineis being widely used in the Soviet Union, and indeedwe have been much surprised to find how much of itappears to have been made available for export. He toldus that they were very well aware of what had been saidabout the vaccine in other countries and implied - thatit had been put back on an experimental basis and wasnow the subject of further extensive laboratory investiga-tion. This is something, he concluded, which clearly
needs testing, and when the results are available they willbe published in the scientific press at once.
In these circumstances we have been answering themany queries we have had in a very cautious way, andhave advised doctors and patients not to be optimisticabout it and not to spend large amounts of money onit until more information is available. We agree, however,with Dr. Liversedge that the attitude taken by the
Ministry of Health on this is far too negative a one andif the material is to be imported it should be the subjectof real scientific test and report.
1. Sneddon, I. B. Brit. med. J. 1955, i, 1448.2. Sneddon, I. B. Postgrad. med. J. 1958, 34, 262.3. Jordan J. W. Darke, C. S. Thorax, 1958, 13, 69.
ZIRCONIUM GRANULOMAS
I. B. SNEDDON.
SIR,-Your annotation (May 31), in reviewing theadmirable work of Shelley and Hurley on zirconiumgranulomas, supported their claim to be the first to
demonstrate a granulomatous reaction in the skin byexperimental means. In so doing you overlooked thework on beryllium that has been carried out in this
country. In 1955 I reported the production of a sarcoid-like granuloma after a positive epidermal reaction to avery dilute solution of beryllium sulphate in a case ofberyllium disease. This observation has been confirmedin a second case of my own reported recently,2 and byJordan and Darke.3
In all these cases the epithelioid reaction has followedthe application of very dilute solutions to the skin so thatno question of a foreign-body reaction can be entertained.It would appear to be a type of delayed allergic responseto minute amounts of beryllium, very comparable withthe reaction to zirconium.
STOKES-ADAMS ATTACKS TREATED WITH
CORTICOTROPHIN
SIR,- The paper by Dr. Litchfield and his colleaguesin your issue of May 3 prompts us to record the followingcase.
A man aged 68 was admitted to this hospital on April 26with a history of syncopal attacks for six months. Immediatelybefore admission they were occurring, on average, four or fivetimes daily. An attack was observed shortly after admission.There was the classical pallor, followed by flushing on recovery,of Stokes-Adams syncope. Although, on that occasion, actualcardiac standstill was not confirmed by his pulse or by ausculta-tion, this has been observed in subsequent episodes. The onlysignificant findings were moderate cardiomegaly, free aorticreflux, and a blood-pressure of 200/65 mm. Hg. The electro-cardiogram showed a P-R interval of 0-24 seconds and a rightbundle-branch block. There was no aortic calcification and theWassermann reaction was negative.On the first few hospital days he averaged four to five attacks
daily with, however, a number of minor episodes of transientfaintness without loss of consciousness. Ephedrine (gr. 1/q.d.s.) and Hyperduric ’ adrenaline (2 ml.) 12-hourly had noeffect on the frequency of attacks; so, stimulated by theexperiences of Dr. Litchfield and his colleagues, we stoppedother drugs on May 6 and substituted prednisilone 20 mg. q.d.s.On May 7 he had forty attacks, the next day three, and he hasnow remained free for twelve days. His last cardiogram showsa normal P-R interval (02 sec.). The right bundle-branch blockis unchanged. We are now gradually reducing the steroid.
It is, as Litchfield et al. point out, a matter of commonexperience that Stokes-Adams attacks vary in frequency
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in an unpredictable manner without any specific treat-ment. We feel, however, that this patient’s clinical coursejustifies this interim letter, and we await with interest bothfuture developments in our patient and the experienceof others in similar circumstances.
M. J. TEMPLERWAVERLEY.Prospect Park Hospital,
Reading.
1. Ann. R. Coll. Surg. Engl. 1954, 15, 300; Ann. Surg. 1954, 139, 129.
THE TOURNIQUET
CHARLES A. PANNETT.
SIR,-Your leader of May 31 put the case for andagainst the tourniquet with clarity and balanced judg-ment, but I think does not answer effectively two pointsI made in my letter of March 15: infection is likely toestablish itself more easily; and damaging effects canfollow the sometimes very great oedema.Your erudite leader says there is no clear evidence on the
increased liability to infection. But the case for this is self-evident. Whilst the tourniquet is on, the life processes of thecells, the reaction to infection, the responses to trauma are inabeyance. It is on to these defenceless cells that staphylococcifall, a perfect culture medium. And we must remember thatthey divide every half hour. But when the constrictor isremoved conditions still remain favourable, for the inability ofthe lymphatics to absorb the oedema, which may be very greatand last for days, denotes severe damage to the mechanism ofabsorption, the permeability of the endothelium of the lym-phatics and the ability of the muscles to assist mechanically.Thus not only is there stagnant plasma in the tissue-spaces butalso no fresh plasma containing immune bodies can exudeinto them. The conditions are ideal for infection. There is noneed of experiments to prove this contention, for the factsstand out and only observation and a little thought are neededto recognise the situation.
Paralysis of the hand and infection in a limb are seriousrisks and I doubt if these limbs are ever restored com-
pletely to normal. It is small consolation to a patientsuffering paralysis or a long drawn-out infection to betold that his predicament is rare and only exceptionallypermanent when he knows that it could have beenavoided altogether had the surgeon adopted anothermethod of operating.
DISPLAYING AXILLARY LYMPHATICS
J. B. KINMONTH.St. Thomas’s Hospital Medical School,
London. S.E.1.
SIR,-Mr. Heanley asks (May 31, p. 1181) whetheranyone has published data on axillary lymphatics usingpatent-blue dye to visualise them. He will find referencesto it in a Hunterian lecture and in other papers on the
lymphatic system by Mr. G. W. Taylor and myselfdescribing work done at St. Bartholomew’s and St.Thomas’s Hospitals during the past decade.We found, like Mr. Heanley, that the lymphatic path-
ways from the arm could be readily identified in theaxilla during the operation of radical mastectomy. It
appeared to us that preservation of the lymphatic path-ways from the arm was incompatible with the clearanceof the axilla which is part of Halsted’s radical mastectomy,because they were so intermingled with the pathwaysdraining the breast. Mr. R. S. Murley also studied someof his patients in the same way and came to the sameconclusion. We have not pursued the problem further,because we abandoned the radical operation for otherreasons some years ago. It may well be that Mr. Heanleymay find by careful dissection that the two pathways canbe separated and it will be interesting to hear of his resultsin the future.
TREATMENT OF OBESITY
JOHN N. BADHAM.Harperbury Hospital,
near St. Albans.
SIR,-Dr. Jacoby (May 31) suggests that weight reduc-tion by conventional methods, or by the hydrophilic-colloid method, is not enduring. In the case of the colloidmethod my experience is that after six to eight weeks’treatment the patient has become " reconditioned
" to
eating sensibly and continues on the right path for a
variable period thereafter. This may vary from weeksor months to an indefinite period, and in any case if thepatient’s dietetic habits relapse this can be easily remediedby another course of treatment, which is inexpensive,non-toxic, and needs the minimum of the doctor’s time.
In the criteria I suggested for weight-reducing treatments(April 26) I omitted to include " economy of doctor’s time ".This is most desirable, but I note Dr. Jacoby recommendspsychotherapy as an alternative-and though I agree thatpsychological factors exist in some cases, the obese are manyand the psychiatrists few. For this reason psychotherapyseems impractical for the masses, quite apart from the factthat the professional-time factor would make the cost veryhigh.
I am grateful to another physician who, in a personal com-munication, pointed out that, setiologically, it is not so muchovereating as incorrect selection of food which is important.Of course he is right,
" incorrect eating " is a much more aptterm than " overeating ". In giving instructions to patientswho are about to reduce I do not give a definite diet, becauseof the efficacy of the method, this is unnecessary, but the
patient receives a written explanation of the principles of cor-rect food selection. My correspondent relied on re-educatinghis patients to better dietary habits, but I feel that withoutsome effective aid to bring about the " reconditioning " itmust be hard going for the doctor and hard on the patient.
SIR,-Dr. Jacoby (May 31) appears to have misunder-stood my letter of April 5, for he accuses me of extollingthe very type of treatment that my letter criticised.
" It is easy ", he states, " to put a patient on a diet, giveappetite-reducing pills, and get considerable reduction in
weight." This seems doubtful. A recent examination of therecords of 150 patients (average overweight 56 lb.) treated forobesity along these lines showed that only 8 of them reachednormal weight.
" This weight is regained almost invariably once super-vision is discontinued." This is borne out by work done bothhere and elsewhere. 114 patients treated for severe obesitywith satisfactory weight loss one to’eight years previously were
recalled to hospital. Their average weight was only 1 lb. lessthan before treatment began. Only 3 had reached normalweight.
Because of the poor results of previous treatment, an obesityclinic was started in this hospital. The therapeutic regimen isvery different from that which Dr. Jacoby implies we are using.He states that my letter " completely ignores the psycho-somatic aspects of obesity ". Yet the letter said, " time has beenspent in discovering the background of each patient’s obesityand the special difficulties in treating it ".The patients attend the clinic frequently (usually at intervals
of two or four weeks for the first months) and see the samedoctor at each visit. All but a small proportion have hadprevious medical treatment which failed. Yet most of themfind that the personal interest taken in them and the oppor-tunity to discuss their problems enables them to reach normalweight, often without the use of drugs. 105 patients haveattended regularly until discharge over the past two years. 102of them reached normal weight. These have all been followedup, and none has so far relapsed.The psychological background of obesity, described by Dr.
Jacoby, has been known for many years. In some patients it isobvious. In many it is undetectable, either by patient or doctor;
