454
CORRESPONDENCE
teaching hospital consisting of 2,000 beds over a LO-year period (SEEDAT et al., 1974; ANC~RN & SEEDAT, 1976). We are unable to offer an explanation for the rarity of primary hyperparathyroidism since the stimulus for parathyroid secretion, namely, hypocalcaemia is present (RASMUSSEN & REIFENSTEIN, 1962). The mean serum calcium in the African in South Africa is about 0.25 mmol/litre less than in Europeans or Americans. This level is 2.4 mmol/litre. The dietary calcium intake of the African in South Africa is 0.4 to 0.6 g daily, about a third to half of that taken by most Europeans or Americans (WALKER & ARVIDSSON, 1954). The rarity of hyperparathyroidism in the African is a minor reason for the uncommonness of renal calculi in the African. EPSTEIN (1971) states that hyperparathyroidism is variously estimated to account for less than one to more than 10% of all cases of nephrolithiasis. However, the main reason for the rarity of renal calculi in the African is probably the saturation of Na/Ca excretion in the urine, since in the African MODLIN (1967) found that the Na excretion is raised and the Ca excretion is low. Thus the Na/Ca saturation ratio is high in the African comnared to Whites and those patients who form renal calculi. Bony changes in chronic renal failure among Africans in Durban is uncommon (SEEDAT.1975). It is possible that the low phosphorus content in our African population prevents the bony changes in uraemia. The low serum phosphorus levels, by inversely producing a raised serum calcium level, may prevent parathyroid hyperactivity which has an osteoclastic activity upon bones. Similar studies in Israel (BERLYNEef al., 1973) and Italy (MASCHIOet al., 1974) have shown that bony changes due to chronic renal failure are uncommon in population groups on a low protein, low phosphorus diet. Thus we have found that both primary and secondary hyperparathyroidism is rare in the African in Durban. Whilst a lower serum phosphorus level, by producing an inversely raised serum calcium level, may protect patients with chronic renal failure from secondary hyperparathyroidism we are unable to explain the rarity of primary hyperparathyroidism in the African since the stimulus of hyperparathyroidism, namely, hypocalcaemia is present. This work was supported by the South African Medical We are, etc., Research Council. Y. K. SEEDAT I. B. ANGORN Department of Medicine and Surgery, University of Natal and King Edward VIII Hospital Durban 4000, South Africa. References Albright, F., Aub, J. C. & Bauer, W. H. (1934). Hyperparathyroidism: a common and polymorphic condition as illustrated by seventeen proved cases from one clinic. Journal of the American. Medical Association, 102, 1276-1287. Angorn, I. B. & Seedat, Y. K. (1976). Primary hyperparathyroidism in Black South Africans. South African Medical Journal, 50, 1246-1248. Berlyne, G. M., Ben-Arie, J., Epstein, N., Booth, E. M. & Yagil, R. (1973). Rarity of renal osteodystrophy in Israel due to low phosphorus intake. Nephron, 10, 141-156. Boonstra, C. E. & Jackson, C. E. (1965). Hyperparathyroidism detected by routine serum calcium analysis. Prevalence in a clinic population. Annals of Internal Medicine, 63, 468474.
Epstein, F. H. (1971). In: Diseases ofthe Kidney, Strauss, M. B. & Welt. L. G. (Editors). Boston. D. 921. Maschio, G., Bonucci, ‘E., Mioni, G., ‘D’Angelo, A., Ossi, E., Valvo, E. & Lupo, A. (1974). Biochemical and morphological aspects of bone tissue in chronic renal failure. Neuhron. 12. 437-448. Mehta, A., Bhan{,.P. & Briers, R. 0. (1972). Primary hyperparathyrotdtsm in an African patient. East African Medical Journal, 49,219-225. Modlin, M. (1967). The aetiology of renal stone: a new concept arising from studies on a stone-free population. Annals of the Royal College of Surgeons of England, 40,155-178. Purnell, D. C., Smith, L. H., Scholz, D. A., Elveback, L. R. & Arnand, C. D. (1971). Primary hyperparathyroidism: a prospective clinical study. American Journal of Medicine, 50, 670-678. Rasmussen, H. & Reifenstein, E. C. (1962). In: Textbook of endocrinology, Williams, R. H. (Editor). Philadelphia, p. 767. Seedat, Y. K. (1975). A study of bony changes in chronic renal failure among the South African Indian and African racial group. VIth Znternational Congress on Nephrology, June &12th, 1975, Firenze, Italy, Abstract No. 732. Seedat, Y. K., Angorn, I. B. & Pillay, N. (1974). Hyperparathyroidism associated with rickets. South African Medical Journal, 48,2267-2269. Tucker. R. B.. Rubenstein. A. H.. Levin. N.. Jackson. R. A., Levin, B. & Du Plessis,.D. J. (1965). Primary hyperparathyroidism: the clmtcal and biochemical aspects in 15 patients. South African Medical Journal, 39, 901-909. Walker, A. R. P. & Arvidsson, U. B. (1954). The significance of low serum calcium values in the South African Bantu. South A,frican Medical Journal, 28, 48-51. Accepted for publication 31st July, 1977. Antibacterial activity of emetine SIR-A successful trial of emetine therapy has been accepted as a means of differentiating pyogenic from amoebic liver abscesses (GRANT et al., 1969), 98.4% of which have been shown to be bacteriologicaIly sterile (LOPEZ et al., 1970). Metronidazole, originally an amoebicide, is active against a wide variety of anaerobic bacteria (SUTTER, 1977) and so cannot be used in a discriminatory therapeutic trial (KANE et al., 1976). We wondered whether emetine is active against anaerobic bacteria, but were unable to find any in vitro susceptibility data. We tested 27 stock strains of anaerobic bacteria using a standard agar dilution technique with supplemented brucella agar (THORNSBERRY,1977), incorporating emetine HCL in concentrations up to 50 micrograms/ml. 50 mcg/ml was chosen based on the highest achievable level in liver tissue of a dog experimental model (GIMBIC et al., 1948) given a therapeutic dose of emetine. The anaerobic strains tested included five strains of Bacteroides fragilis ss. fragilis, two Bacteroides mefaninogenicus, four Clostridia perfringens, four Peptococcus sp., two Peptostreptococcus sp. and two Fusobacterium nucleatum. All 27 strains were resistant to 50 mcg/ml of emetine. We conclude from our testing that emetine has no in vitro activity against anaerobic bacteria and, unlike
CORRESPONDENCE
metronidazole, may be clinically useful in a therapeutic trial to discriminate pyogenic from amoebic liver abscesses. We are, etc. MICHAEL SANDS JAIME TORRES, Center,
Louisiana State University Medical Department of Medicine, 1542 Tulane Avenue, New Orleans, Louisiana 70112, U.S.A.
of the American
Medical
Whilst it is obvious that this monster is not a parasitic worm it is difficult to decide what it could be. It is probably a blood plasma clot such as is frequently found when performing an autopsy on a body some few days dead. I am sure that some of your readers will have other explanations for the origin of this monster. I am, etc., D.A. DENHAM London School of Hygiene and Tropical Medicine, heppel Street (Gower Street), London WCIE 7HT.
References Gimbic, A., Clarke, D. & Smith, P. (1948). Disposition of emetine in tissue. Journal of Pharmacology, 94, 431-436. Grant, R., Morgan, L. & Cohen, A. (1969). Hepatic abscesses.American Journal of Surgery. 118, 15-20. Kane, J., Kossieck, B. & Parker, R. (1976). Metronidazole and hepatic abscess: a false positive response. Journal
455
Association,
Accepied for publication
3lst July, 1977.
236,
2653-2654. Lopez, G., Escobedo, A., Onchoa, E. & Bautista, J. (1970). Estudio bacteriologico en el absceso hypatico en pacientes y en hamsters. Archives de Investigation Medica, 1, S21-S26. Sutter, V. (1977). In vitro susceptibility of anaerobes. Comparison of clindamicin and other antimicrobial aaents. Journal of Znfectious Diseases. 135, S7-S12. Th&nsberry, C. - (1977). Techniques for anaerobic susceptibility testing. Journal of Infectious Diseases, 135, S4-S6. Accepted for publication
25th July, 1977.
“A most certaine and true relation of a strange monster or serpent found in the left ventricle of the heart of John -Pennant, gentleman, of the age of 21 years.” SIR-The above is the title of a namuhlet bv Edward May published in 1639 in London. It is-quoted in the IndexCatalogue of Medical and Veterinary Zoology, Part 10, and your readers, if they were to come across it, might, as I did, become excited and think they had found the first reference to Dirojilaria immitis infection of man. I was able to consult Dr. May’s work in the Wellcome Library where I was quickly disabused of my expectations. The “monster” is shown in the figure kindly redrawn by Dr. Pakeer Oothuman. The original drawing is 32 cm long and was full sized. The heart of Mr. John Pennant was ‘
CORRESPONDENCE
teaching hospital consisting of 2,000 beds over a LO-year period (SEEDAT et al., 1974; ANC~RN & SEEDAT, 1976). We are unable to offer an explanation for the rarity of primary hyperparathyroidism since the stimulus for parathyroid secretion, namely, hypocalcaemia is present (RASMUSSEN & REIFENSTEIN, 1962). The mean serum calcium in the African in South Africa is about 0.25 mmol/litre less than in Europeans or Americans. This level is 2.4 mmol/litre. The dietary calcium intake of the African in South Africa is 0.4 to 0.6 g daily, about a third to half of that taken by most Europeans or Americans (WALKER & ARVIDSSON, 1954). The rarity of hyperparathyroidism in the African is a minor reason for the uncommonness of renal calculi in the African. EPSTEIN (1971) states that hyperparathyroidism is variously estimated to account for less than one to more than 10% of all cases of nephrolithiasis. However, the main reason for the rarity of renal calculi in the African is probably the saturation of Na/Ca excretion in the urine, since in the African MODLIN (1967) found that the Na excretion is raised and the Ca excretion is low. Thus the Na/Ca saturation ratio is high in the African comnared to Whites and those patients who form renal calculi. Bony changes in chronic renal failure among Africans in Durban is uncommon (SEEDAT.1975). It is possible that the low phosphorus content in our African population prevents the bony changes in uraemia. The low serum phosphorus levels, by inversely producing a raised serum calcium level, may prevent parathyroid hyperactivity which has an osteoclastic activity upon bones. Similar studies in Israel (BERLYNEef al., 1973) and Italy (MASCHIOet al., 1974) have shown that bony changes due to chronic renal failure are uncommon in population groups on a low protein, low phosphorus diet. Thus we have found that both primary and secondary hyperparathyroidism is rare in the African in Durban. Whilst a lower serum phosphorus level, by producing an inversely raised serum calcium level, may protect patients with chronic renal failure from secondary hyperparathyroidism we are unable to explain the rarity of primary hyperparathyroidism in the African since the stimulus of hyperparathyroidism, namely, hypocalcaemia is present. This work was supported by the South African Medical We are, etc., Research Council. Y. K. SEEDAT I. B. ANGORN Department of Medicine and Surgery, University of Natal and King Edward VIII Hospital Durban 4000, South Africa. References Albright, F., Aub, J. C. & Bauer, W. H. (1934). Hyperparathyroidism: a common and polymorphic condition as illustrated by seventeen proved cases from one clinic. Journal of the American. Medical Association, 102, 1276-1287. Angorn, I. B. & Seedat, Y. K. (1976). Primary hyperparathyroidism in Black South Africans. South African Medical Journal, 50, 1246-1248. Berlyne, G. M., Ben-Arie, J., Epstein, N., Booth, E. M. & Yagil, R. (1973). Rarity of renal osteodystrophy in Israel due to low phosphorus intake. Nephron, 10, 141-156. Boonstra, C. E. & Jackson, C. E. (1965). Hyperparathyroidism detected by routine serum calcium analysis. Prevalence in a clinic population. Annals of Internal Medicine, 63, 468474.
Epstein, F. H. (1971). In: Diseases ofthe Kidney, Strauss, M. B. & Welt. L. G. (Editors). Boston. D. 921. Maschio, G., Bonucci, ‘E., Mioni, G., ‘D’Angelo, A., Ossi, E., Valvo, E. & Lupo, A. (1974). Biochemical and morphological aspects of bone tissue in chronic renal failure. Neuhron. 12. 437-448. Mehta, A., Bhan{,.P. & Briers, R. 0. (1972). Primary hyperparathyrotdtsm in an African patient. East African Medical Journal, 49,219-225. Modlin, M. (1967). The aetiology of renal stone: a new concept arising from studies on a stone-free population. Annals of the Royal College of Surgeons of England, 40,155-178. Purnell, D. C., Smith, L. H., Scholz, D. A., Elveback, L. R. & Arnand, C. D. (1971). Primary hyperparathyroidism: a prospective clinical study. American Journal of Medicine, 50, 670-678. Rasmussen, H. & Reifenstein, E. C. (1962). In: Textbook of endocrinology, Williams, R. H. (Editor). Philadelphia, p. 767. Seedat, Y. K. (1975). A study of bony changes in chronic renal failure among the South African Indian and African racial group. VIth Znternational Congress on Nephrology, June &12th, 1975, Firenze, Italy, Abstract No. 732. Seedat, Y. K., Angorn, I. B. & Pillay, N. (1974). Hyperparathyroidism associated with rickets. South African Medical Journal, 48,2267-2269. Tucker. R. B.. Rubenstein. A. H.. Levin. N.. Jackson. R. A., Levin, B. & Du Plessis,.D. J. (1965). Primary hyperparathyroidism: the clmtcal and biochemical aspects in 15 patients. South African Medical Journal, 39, 901-909. Walker, A. R. P. & Arvidsson, U. B. (1954). The significance of low serum calcium values in the South African Bantu. South A,frican Medical Journal, 28, 48-51. Accepted for publication 31st July, 1977. Antibacterial activity of emetine SIR-A successful trial of emetine therapy has been accepted as a means of differentiating pyogenic from amoebic liver abscesses (GRANT et al., 1969), 98.4% of which have been shown to be bacteriologicaIly sterile (LOPEZ et al., 1970). Metronidazole, originally an amoebicide, is active against a wide variety of anaerobic bacteria (SUTTER, 1977) and so cannot be used in a discriminatory therapeutic trial (KANE et al., 1976). We wondered whether emetine is active against anaerobic bacteria, but were unable to find any in vitro susceptibility data. We tested 27 stock strains of anaerobic bacteria using a standard agar dilution technique with supplemented brucella agar (THORNSBERRY,1977), incorporating emetine HCL in concentrations up to 50 micrograms/ml. 50 mcg/ml was chosen based on the highest achievable level in liver tissue of a dog experimental model (GIMBIC et al., 1948) given a therapeutic dose of emetine. The anaerobic strains tested included five strains of Bacteroides fragilis ss. fragilis, two Bacteroides mefaninogenicus, four Clostridia perfringens, four Peptococcus sp., two Peptostreptococcus sp. and two Fusobacterium nucleatum. All 27 strains were resistant to 50 mcg/ml of emetine. We conclude from our testing that emetine has no in vitro activity against anaerobic bacteria and, unlike
CORRESPONDENCE
metronidazole, may be clinically useful in a therapeutic trial to discriminate pyogenic from amoebic liver abscesses. We are, etc. MICHAEL SANDS JAIME TORRES, Center,
Louisiana State University Medical Department of Medicine, 1542 Tulane Avenue, New Orleans, Louisiana 70112, U.S.A.
of the American
Medical
Whilst it is obvious that this monster is not a parasitic worm it is difficult to decide what it could be. It is probably a blood plasma clot such as is frequently found when performing an autopsy on a body some few days dead. I am sure that some of your readers will have other explanations for the origin of this monster. I am, etc., D.A. DENHAM London School of Hygiene and Tropical Medicine, heppel Street (Gower Street), London WCIE 7HT.
References Gimbic, A., Clarke, D. & Smith, P. (1948). Disposition of emetine in tissue. Journal of Pharmacology, 94, 431-436. Grant, R., Morgan, L. & Cohen, A. (1969). Hepatic abscesses.American Journal of Surgery. 118, 15-20. Kane, J., Kossieck, B. & Parker, R. (1976). Metronidazole and hepatic abscess: a false positive response. Journal
455
Association,
Accepied for publication
3lst July, 1977.
236,
2653-2654. Lopez, G., Escobedo, A., Onchoa, E. & Bautista, J. (1970). Estudio bacteriologico en el absceso hypatico en pacientes y en hamsters. Archives de Investigation Medica, 1, S21-S26. Sutter, V. (1977). In vitro susceptibility of anaerobes. Comparison of clindamicin and other antimicrobial aaents. Journal of Znfectious Diseases. 135, S7-S12. Th&nsberry, C. - (1977). Techniques for anaerobic susceptibility testing. Journal of Infectious Diseases, 135, S4-S6. Accepted for publication
25th July, 1977.
“A most certaine and true relation of a strange monster or serpent found in the left ventricle of the heart of John -Pennant, gentleman, of the age of 21 years.” SIR-The above is the title of a namuhlet bv Edward May published in 1639 in London. It is-quoted in the IndexCatalogue of Medical and Veterinary Zoology, Part 10, and your readers, if they were to come across it, might, as I did, become excited and think they had found the first reference to Dirojilaria immitis infection of man. I was able to consult Dr. May’s work in the Wellcome Library where I was quickly disabused of my expectations. The “monster” is shown in the figure kindly redrawn by Dr. Pakeer Oothuman. The original drawing is 32 cm long and was full sized. The heart of Mr. John Pennant was ‘
