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TREATMENT OF PULMONARY TUBERCULOSIS

D. ADLER.Ilford Chest Clinic.

SIR,-I have long been convinced that routine sana-torium treatment for pulmonary tuberculosis is outdated,and the Madras results as communicated by Dr. WallaceFox (Sept. 1) should leave no room for further doubt.Over the past few years, approximately 150 cases of pul-

monary tuberculosis under my care have had domiciliarychemotherapy. Many of these continued full-time work

throughout the course of treatment. The type of case variedfrom minimal disease with negative sputum to cavitatingdisease with positive sputum. The results fully satisfy thethree critical questions posed by Dr. Fox-namely, that theresponse to treatment, relapse-rate, and risks to contacts werenot adversely affected. In my view, sanatorium treatmenthas no advantages over domiciliary chemotherapy. On thecontrary, the disadvantages are obvious.In undertaking domiciliary treatment in this country, initial

treatment should include the three main anti-tuberculousdrugs until the results of drug sensitivity tests are known. Iftwo drugs are to be used streptomycin and isoniazid should bethe drugs of choice for the first three months. Patients shouldbe given a " lecture " stressing the dangers of omitting drugsand the importance of reporting as soon as possible anyuntoward drug reaction, particularly dizziness. In this way,serious drug reactions will be avoided even in elderly patients.In fact, the only cases of permanent ataxia known to meoccurred in patients treated in hospital, presumably becausethe routine and outmoded regimen of bed rest masks the

symptom.No disease is more hidebound with outmoded tradition than

pulmonary tuberculosis. This is particularly true of sanatoriumtreatment with its regimen of gradual up-grading which hashardly changed since pre-chemotherapy days. It is to be hopedthat the convincing results of the Madras work will stimulatea new approach to the management of pulmonary tuberculosis.In my view, domiciliary chemotherapy is the treatment ofchoice. Most tuberculosis beds now in use could as a resultbe put to better purpose.

REACTION TO PETHIDINE

IN PATIENTS ON PHENELZINE

SIR,-On several occasions attention has been drawn tountoward effects occurring when vasopressors, certain

analgesics, and imipramine have been administered to apatient receiving treatment with monoamine-oxidaseinhibitors. In the most recent instance recorded by Dr.Taylor (Aug. 25), pethidine was given to patients takingphenelzine (’Nardil ’).As long ago as February, 1961, we have mentioned in

our comprehensive literature that phenelzine potentiatesthe action of certain drugs, that others were to be used withcaution, and that imipramine (’ Tofranil ’) and phenelzineshould not be used together. Since it is obvious fromrecent reports that doctors are still unaware of the poten-tial danger involved, may we draw attention to our

current recommendations on the subject. Our literaturenow states:

" Pethidine or Morphine. Palmer 1 reports one death hebelieved to be due to the potentiation of pethidine by Nardil,and Reid and Jones 2 report another. In view of the possibleneed for pethidine during labour, Nardil should not thereforebe administered after the 38th week of pregnancy. The sameprecaution applies with regard to morphine. Pethidine andmorphine must be avoided, not only while Nardil is beingadministered, but also for at least a fortnight after its discon-tinuance." "

In addition, we list the drugs that must not be admini-1. Palmer, H. Brit. med. J. 1960, ii, 944.2. Reid, N. C. R. W., Jones, D. ibid. 1962, i, 408.

stered with phenelzine, those that are potentiated byphenelzine, and those that appear not to be potentiatedby phenelzine.

D. D. H. CRAIG.Department of Clinical Investigation,

William R. Warner & Co. Ltd.,Eastleigh, Hampshire.

EFFICIENCY OF CARDIAC MASSAGE

J. W. PEARSON.Baltimore City Hospitals,

Maryland, U.S.A.

SIR,-May I intervene in the debate on the relativeefficacy of internal and external cardiac massage (July28) ? Meaningful facts and figures to demonstrate thesuperiority of one or the other technique are almost

impossible to obtain in humans: and the interpretationof results of animal experiments must always be equi-vocal. 1 The fact remains that there are reasons whyexternal cardiac massage, as a first-aid measure, is

superior to internal cardiac massage: (1) no special equip-ment is needed; (2) external massage is less tiring toperform for long periods; and (3) there is less mentalhesitation in starting external massage, especially outsidea hospital, ’.

I feel that the superiority of external over internalmassage on the top of a double-decker bus in PiccadillyCircus should not need experimental proof.

ISOZYME NOMENCLATURE

SIR, The identification of isozymes was again thesubject of discussion at the 10th Colloquium of Protides ofthe Biologic Fluids in Bruges.

Inasmuch as the European representatives outnumberedthose from the New World, the method of nomenclaturefavoured by them-namely, numbering from the fastestanodic (1) to cathodic (5)-was most popular.They pointed out that this followed the classical electro-

phoretic method of nomenclature.This classical method of nomenclature, however, has not

been without criticism. It was introduced when only threeglobulin components were recognised. With the developmentof more elegant means of separation it was necessary to employsub-designations, such as: oc-1, (x-2, p-1, p-2, &c. We arenow faced with deciding whether one worker’s p-2 is the sameas another’s fast y on immunoelectrophoresis; and such termsas fast <x-2 and slow a-2 are in common use in starch-gelelectrophoresis.

Since lactic-acid-dehydrogenase isozymes have been moststudied, I think there is a tendency to use this as a prototype.It has 5 principal components and can conveniently benumbered 1 to 5 from the anode. But the system universallyadopted will have to apply to many other enzymes as well,and many have more than 5 migrating components. It wouldbe regrettable if a system were based on the coincidence thatL.D.H. has 5 components.A non-specific esterase stain on starch gels shows 7 com-

ponents. As many as 13 have been described in alkaline-phosphatase stains of tissue extracts. One of two choices canbe made: either to number each component from cathodic toanodic with each enzyme or, as we have recently suggested, tonumber them with reference to some standard-e.g., proteinstain on starch-gel electrophoresis. The latter has the dis-advantage of showing more than one component per fractionin many cases, but it would lead to more uniformity amongthe various zymograms. The use of starch gel as a referenceseems preferable to various other media-paper electro-

phoresis, chromatography-because it is relatively reproducibleand gives a more discrete separation.

I should like also to call attention to another componentthat is almost universally present-namely, the enzymatic

1. Redding, J. S., Cozine, R. A. Anesthesiology, 1961, 22, 280.2. Weale, F. E., Rothwell-Jackson, R. L. Lancet, 1962, i, 990.3. Lawrence, S. H., Eisenberg, R. M. Unpublished.