SIR,-Chloramphenicol and ampicillin are the drugs of choice irt the treatment of Salmonella typhimurium infection 12 but resistance to both drugs has been reported. 3-6 A 66-year-old patient was admitted to our department with severe diarrhoea, which had lasted for 12 days, complicated by acute renal failure. Despite optimal doses of ampicillin and later chloramphenicol, diarrhoea continued and renal failure progressed. Faecal and urine cultures grew S. typhimurium resistant to chloramphenicol, ampicillin, tetracycline, and carbenicillin, but sensitive to co-thmoxazole, streptomycin, cephalosporins, and nitrofurazone. The patient was treated with co-trimoxazole and responded well. Among 17 S. typhimurium strains isolated in our hospital during 1977 15 (88%) were resistant to both chloramphenicol and ampicillin. Of 305 S. typhimurium strains isolated in Northern Israel during the same year 160 (52%) were resistant to both drugs, and only 3 (1%) were resistant to co-trimoxazole. We believe that co-trimoxazole should be the antibiotic of choice for S. typhimurium infections in Israel. Because of the growing resistance of S. typhimurium to chloramphenicol and ampicillin in the world36 the possibility of treating S. typhimurium salmonellosis with co-trimoxazole deserves worldwide consideration. We thank the bacteriological laboratory, W. Hirsch Central Laboratory, Kupat Holim, Haifa; the bacteriological laboratory at the Rothschild Hospital in Haifa; and the public health laboratory, Haifa, for supplying us with their data.

Departments of Medicine and Microbiology, Rambam Medical Centre and Aba Khoushy School of Medicine,

Technion, Israel



SIR,-High-density-lipoprotein (H.D.L.) cholesterol estimaon 200 diabetics attending our clinic failed to demonstrate a significant correlation between H.D.L. cholesterol and total glycosylated haemoglobin A as proposed by Dr Calvert and colleagues (July 8, p. 66). Although a reciprocal relationship exists in a subpopulation (female insulin-dependent diabetics, aged 15-40 years) it is lost when the whole population is considered because other factors, particularly type of treatment, seem far more important than degree of control of hyperglycxmia in’influencing H.D.L. cholesterol levels indiations

betics. Like those of Calvert et al., our diabetics on insulin have higher H.D.L. cholesterol levels than patients matched for age and sex on diet and/or oral hypoglycaemics (see table). This difference is reduced by obesity and smoking, which are associated with lower H.D.L. cholesterol levels in our population. There is no difference between H.D.L. cholesterol levels in our patients treated by diet alone, and those on diet plus oral hypoglycæmics, suggesting the insulin augments H.D.L. rather than that oral hypoglycaemics have a special effect. We are now testing this hypothesis with a prospective study. I have also looked at the association between plasma-lipids, including H.D.L. cholesterol, and vascular disease. Although Gardner, P., Provine, H. T. Manual of Acute Bacterial Infections. p. 82. Boston, 1975. 2. Grossman, M., Jawetz E. in Current Medical Diagnosis and Treatment 1977 (edited by M. A. Krupp and M. U. Chatton); p. 815. Los Altos, 1977. 3. Mohadjer, S., Badalian, K., Mehrabian, S.J. trop. Med. Hyg. 1973, 76, 265. 4. Anderson, E. S. W.H.O. Weekly Epidem. Rec 1974, 8, 65. 5. McHuge G. L., Moellering, R. C., Hopkins, C. C., Swartz, M. N. Lancet, 1975, i, 235. 6. Grant, R. B., Bannatyne, R. M., Shapiey, A. J. J. infect. Dis. 1976, 134,




patients with cardiac disease have marginally higher total cholesterols and triglyceride and lower H.D.L. cholesterol (see table) the results are less impressive than those obtained by others with non-diabetics. Only by studying H.D.L. in more detail prospectively will we ascertain whether changes in H.D.L. cholesterol are of the same significance in the diabetic as in the non-diabetic. Diabetic Unit. Royal Perth Hospital, Perth, Western Australia



SIR,—Dengue hæmorrhagic



is characterised

by increased vascular permeability, thrombocytopenia, and haemorrhagic diathesis.’ Immune complexes may play a role in the pathogenesis of D.H.F. as indicated by serum-complement changes,2 the presence of curculating immune complexes detectable by the Raji-cell technique,3 and by platelet-aggre-

gation.4 Plasma from 21 D.H.F. cases was collected on days 2-11 of the fever, stored at -20°C for up to 4 months, and tested for immune complexes by platelet aggregation. All the patients had primary or secondary dengue infection according to Winter5 (serology done at S.E.A.T.O. medical research laboratory in Bangkok). Platelet-aggregation tests were done with fresh platelets at pH 7.6and 6.5.6 A glutaraldehyde-preserved platelet suspension at pH 7.6was also used. An increased platelet-aggregation titre with fresh platelets was found in 10 cases comprising all four grades of disease. At pH 6.5 the titre was increased in 1 of 18 cases while preserved platelets revealed an increased titre in 1 of 11 cases. Most of the increases at pH 7.6 were small to moderate. The titres were 1:16 in 4 cases, 1:32 in 4 cases, 1:64 in 1 case, and 1:256 in 1 case. Normal controls had a titre of 1:2-1:4, and rarely reached 1:8. There was no association between the presence of

immune complexes, the grade of disease, or the haemagglutination inhibition titres. The platelet-aggregation test results suggested that dengue plasma contained immune complexes. Complexes are poorly reactive with fresh platelets at pH 6.56 and do not react with preserved platelets.4 The circulating complexes could increase vascular permeability by binding complement and induce platelet destruction, both of which fit the clinical’picture of D.H.F. Low levels of circulating complexes were found in 47.6% of D.H.F. cases in all grades of diseases. With the Raji-cell technique complexes were detected at all grades of disease in 62% of cases of D.H.F.3 The absence of an association between the presence of com-



1. Russel, P. K. in Progress in Immunology, p. 831. London, 1971. 2. Bull. Wld Hlth Org. 1973, 48, 117. 3. Theofilopoulos, A. N., Wilson, C. B., Dixon, F J. J. clin Invest. 1976, 57, 169. 4. Myllaya, C. Scand. J. Hœmat. Suppl 1973, 19. 5. Winter, P. E., Yuill, T. M., Udomsakdi, S., Gould, D., Nontapanich, S., Russel, P. K. Am J. trop. Med. Hyg. 1968, 17, 590. 6. Hedford, E , Norberg, R. Clin. exp Immun. 1974, 16, 493.


plexes and clinical findings may be because specimens were collected on different days of fever. The role of immune complexes in the pathogenesis of dengue fever is still unknown. Dr Natth

Bhamarapravati, chairman, department of pathology, and

director, W.H.O. Collaborating Centre for Dengue Haemorrhagic Fever, supported this study. Mrs Vina Churdboonchart supplied specimens

and clinical and serological data.

Department of Pathology, Ramathibodi Hospital,

Bangkok 4, Thailand


countries. Yet, as stressed,8 its maximum benefit to health cannot be achieved until there are improvements in all spheres where good hygiene practices count-in the provision of water for washing and bathing as well as for drinking, and in education about food preparation, toilet practices, and refuse dis-

posal. M.R.C Human Biochemistry Research Unit, South African Institute for Medical Research, Johannesburg, South Africa



SIR,-In its January issue Tropical Doctor stated "Water is the key to health". The context was schistosomiasis control. While this statement is indisputable, few appreciate how lengthy the interval may be between water improvement and beneficial effects. We have often found only small differences in health status between populations with and without pure water


In several areas we have determined mortality-rates of African infants. Rates in 1970 and 1976 were only slightly higher in rural compared with urban populations with their far more satisfactory water supplies.’ Moreover, unexpectedly, the prosame, portion of deaths from gastroenteritis was much the about a quarter, in both country and town populations.2 We have also compared the health status of several groups of African Tswana and Zulu schoolchildren. Only slight differences were found whether the principal source of water was shallow wells, bore holes, intermittently flowing river water, swiftly and perennially flowing river water, mountain streams, ‘ and town water supply. In the different areas, rates of growth and records of school absenteeism did not differ significantly.3 In Eastern Transvaal in the Crocodile Valley African schoolchildren from different villages had much the same prevalences of schistosomiasis whether their particular village had a piped water supply or not, simply because virtually all children, no matter how threatened, played in the heavily infected river nearbv.4 The most unexpected observations concerned prevalences of salmonellae and shigellse in fsces of African schoolchildren. Workers at this Institute found that frequencies of infections from serial studies in pre-puberty pupils were 72% at a village were the water source was shallow wells at times contaminated by cattle, 28 at the same village after bore-hole water became available, but 45 in Soweto, Johannesburg, where potable water is fully available.5 An intriguing outcome of the change in the water source in the village mentioned was that fluorosis, previously absent in pupils’ teeth, became manifest within three years. This unwished for change is analogous to one reported from Nigeria, when a change from impure river water to well water was associated with the appearance of endemic

goitre.6 Also scabetic lesions in schoolchildren






slightly less prevalent in town compared with country.’ Interestingly, studies in Nigeria suggest that quantity of water available may be more important than its quality.8 Provision of adequate pure water must always be accorded very high priority by public-health authorities in developing 1 Richardson, B. D. Trans. R. Soc. trop. Med. Hyg. 1970, 64, 921 2. Spencer, I W F., Coster, M. E. E. S. Afr med.J. 1969, 43,

1391, 1438,

1466. 3. Walker, A. R P, Walker, B. F., Richardson, B. D.J. trop. Med. Hyg. 1978, 2. 81, 4. Walker, A. R.

P, Walker, B. F., Richardson, B. D. Am.J. trop. Med. Hyg. 1970, 19, 792 5. Richardson, N. J, Koornhof, H. J., Hayden-Smith, S. J. Hyg. 1976, 64, 245. 6. van Amelsvoort, V. Trop geogr. Med. 1971, 23, 304 7

Richardson, B D. Lancet, 1972, i, 839. 8. Tomkins, A. M, Drasar, B. S., Bradley, A. K., Williamson, R. Soc trop. Med. Hyg. 1978, 72, 239.

W. A. Trans.

SiR,—Ienjoyed the duelling, in your columns (Aug, 12, p. 378) arising from the Dundee group’s paperl. In the concluding sentence of their letter, Bateson et al. wonder "whether the anomaly does not reflect the relative inaccuracy of attempting to document gallstone size radiologically". If that is a worry, who did the documenting? In their paper, cholecystograms were "ordered" (rather like one’s supper) from "a radiologist" who then reported the films "unaware of the nature of the treatment". This key figure in the study is not an author, and he is neither



thanked. What


odd busi-


Department of Radiology, Addenbrooke’s Hospital, Cambridge CB2 2QQ 1.


Bateson, M. C., Ross, P. E., Munson, J., Bouchier, I. A. D. Lancet, 1978, i, 1111.

Commentary from Westminster From



Parliamentary Correspondent

of the Mental Health Act

LEGISLATION to amend the 1959 Mental Health Act is proposed by the Government in its long-awaited whitepaper reviewing the present law. As expected, the document published last Tuesday admits that although on the whole the Act has worked well there are areas where its powers are being abused and misused and that the time has come for some improvements. In general the proposed changes stem from the need to strengthen the rights and safeguard the liberties of the mentally disordered while at the same time retaining a proper regard for the rights and safety of the public and National Health Service staff. The review has taken much longer than anticipated, largely because of disagreement between the four Government Departments involved. As a result the end product is likely to prove too cautious and conservative for those who wanted to see radical changes in the law. The overall effect of the proposals would be to retain most of the 1959 Act, but tighten up monitoring and admission procedures. Since 95% of patients resident in mental-illness and mental-handicap hospitals are voluntary patients, the white-paper concentrates largely on the remaining 5% who are compulsorily admitted and detained. Section 29 of the Act has now become the most widely used form of compulsory admission: 12 000 people were admitted in this way in 1976. It provides for admission for observation, but, according to the whitepaper, it is being invoked more frequently than was orig-

Circulating immune complexes in dengue haemorrhagic fever.

638 TREATMENT OF SALMONELLA TYPHIMURIUM SALMONELLOSIS SIR,-Chloramphenicol and ampicillin are the drugs of choice irt the treatment of Salmonella typ...
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