135

TROPICAL IMMERSION FOOT

PSITTACOSIS
p.

SIR,-Have Dr Allen and Mr Taplin (Nov. 24,

1185)

considered the possibility that cercariae from avian or mammalian species of blood-flukes may play some part in the condition under discussion ? Schistosomal cercarial dermatitis is often extremely itchy-not a feature described by Allen and Taplin in their subjects-but the pattern of reactivity could be altered by prolonged immersion. It would be interesting to know if the Vietnam patients developed blood eosinophilia or other evidence of possible trematode infestation.
P.O. Box 1907,

Bulawayo,
Rhodesia.

J. CHARLES SHEE.

INTRAVENOUS FEEDING

SIR,-Iwas sorry to learn that Mr Wright (Dec. 8, p. 1335) has had such difficulties with insulin and glucose and that he warns against its use in seriously ill and cachectic patients. This was the very group for which we introduced it and in which we found striking biochemical and clinical improvement. I can only suppose that he is not using it in the same way or that he is giving something else, such as excessive water, to produce undesirable effects. If, of course, one allows the bloodsugar to rise to the very high levels that are seen in hyperosmolar diabetic coma, and then brings the blood-sugar down fast with insulin, precisely the sort of disequilibrium syndrome which he describes is produced. The hypophosphataemia of which he writes and which was also mentioned in your editorial (Nov. 24, p. 1179) is wellrecognised. I do not think anyone familiar with intravenous feeding techniques would now fail to add phosphate unless the regimen also included a phosphate-containing preparation, such as Intralipid or Aminosol . I find Mr Wrights theoretical discussion puzzling. Firstly, he cites cellular overhydration in his patients without producing evidence for it and then he suggests that raising the blood-sugar or giving insulin are responsible for this. If the free glucose within the cell rises concomitantly with the plasma-glucose then the changes in extracellular and intracellular osmolality will cancel each other out and no water will pass into the cell. Apart from the " disequilibrium syndrome ", which is easy enough to avoid, I cannot see how insulin could make the matter

SiR,-Dr McKendrick and his colleaguespublished the C.F.T. serum titres which we obtained using a psittacosis group antigen commonly employed in this country. Though a 4-fold rise in antibody was demonstrated in 5 out of 6 patients the titres were so low that we might have missed the laboratory diagnosis if we had not been aware beforehand of the firm clinical and epidemiological diagnosis. The antigen was used at the recommended strength, but was slightly anti-compleraentary and could not be used satisfactorily at higher concentration. Later we prepared an ether-extracted psittacosis group antigen, which was not anti-complementary, and performed chessboard titrations on the serum samples from the outbreak. It became apparent that the first antigen we had used had been at suboptimal strength for the detection of antibody in early convalescent serum. The titres we obtained using the ether-extracted antigen were as follows:

The second serum specimens gave titres about 16-fold higher with the ether-extracted antigen than with the suboptimal antigen originally used.
School of Pathology, Middlesex Hospital Medical School, London W1P 7LD.

D. S. DANE J. R. PATTISON.

VACCINATION AGAINST CYTOMEGALOVIRUS ?

worse-certainly not by causing glucose to pass against a concentration gradient as Mr Wright suggests. Indeed, since insulin enhances phosphorylation in most tissues and causes synthesis of large molecules from small, it should have the effect of lowering intracellular osmolality. Flear 4 has produced good evidence that changes in cellular hydration do occur after injury and that these are related to alterations of membrane permeability and to changes in the concentration of intermediary metabolites other than glucose. Evidence has also been produced that insulin
may, in
2 fact, improve this situation.2 There are many factors, as well as insulin, involved in the glucose intolerance after injury. In view of the variable insulin resistance after injury I am not surprised that your correspondent found a lack of correlation between glucose utilisation and plasma-insulin levels. General Hospital, S. P. ALLISON. Nottingham NG1 6HA.

SIR,-Professor Elek and Professor Stem (Jan. 5, p. 1) adthe eventual vaccination of all adolescent girls with a live tissue-culture-adapted strain of cytomegalovirus. It is surprising to find the possible cancer hazard of such a procedure dismissed so lightly, since it is now clear that many members of the herpesvirus group are oncogenic. Mareks disease of the domestic fowl,2 renal adenocarcinoma of the frog,3 lymphocytic leukxmia of the guineapig 4 are all naturally occurring malignancies associated with herpesviruses. Experimentally herpesviruses saimiriand ateles6 cause lymphomas and leukxmia in primates. EpsteinBarr virus transforms human lymphocytes in culture and
vocate

there is African

close association between this virus and both

lymphomaand nasopharyngeal carcinoma.8 Seroepidemiological studies show a correlation between herpesvirus simplex type 2 and carcinoma of the cervix,
one case at least, a fragment of viral D.N.A. has been found covalently linked to cell D.N.A.10 An association between herpesvirus simplex type 1 and carcinoma of the lip has also been claimed. 11 Both of these latter viruses

and, in

1.
2.

Hinton, P., Allison, S. P., Littlejohn, S., Lloyd, J. Lancet, 1971, i,

767.

Hinton, P., Allison, S. P., Littlejohn, S., Lloyd, J. ibid. 1973, ii,

218. 3. Allison, S. P. in Parenteral Nutrition (edited by A. W. Edinburgh, 1972. 4. Flear, C. T. G. J. clin. Path. 1970, 23, suppl. 4, 16.

Wilkinson).

McKendrick, G. D. W., Davies, J., Dutta, T. Lancet, 1973, ii, 1255. Churchill, A. E., Biggs, P. M. Nature, 1967, 215, 528. Granoff, A. in Oncogenesis and Herpesviruses; p. 171. Lyons, 1972. Hsiung, G. D., Kaplow, L. S. J. Virol. 1969, 3, 355. Melendez, L. V., Daniel, M. D., Hunt, R. D., Frazer, C. E. O., Garcia, F. G., King, N. W., Williamson, M. E. J. natn. Cancer Inst. 1970, 44, 1175. 6. Melendez, L. V., Hunt, R. D., Daniel, M. D., Frazer, C. E. O., Barahona, H. H., Garcia, F. G., King, N. W. in Oncogenesis and Herpesviruses; p. 451, Lyons 1972. 7. Zur Hausen, H., Diehl, V., Wolf, H., Schulte-Holthausen H., Schneider, U. Nature New Biology, 1972, 237, 189. 8. Wolf, H., Zur Hausen, H., Becker, V. ibid. 1973, 244, 245. 9. Rawls, W. E., Iwamoto, K., Adam, E., Melnick, J. L., Green, G. H. Lancet, 1970, ii, 1142. 10. Roizman, B., Frenkel, N. Cancer Res. 1973, 33, 1402. 11. Wyburn-Mason, R. Br. med. J. 1957, ii, 615.
1. 2. 3. 4. 5.