584

MethodsThe technique used to determine the total serum-cholesterol

was essentially that described by Hobson et al. (1953).Results

Because the total serum-cholesterol increases with age, andbecause the values for females are significantly higher thanthose for males in the same age-group (Hobson et al. 1953),the results have been broken down by age-groups showing thesexes separately.There were very few patients aged over seventy and these

showed scattered results which have been omitted. Therewere 234 women aged from thirteen to sixty-nine, and 209men aged from fifteen to sixty-nine.The mean values, together with the standard error of the

means for psoriatics and controls, for each of three age-groups of each sex were:

The figures in parentheses indicate the number of cases in each cell.These results show no significant difference between

psoriatics and controls.The results were also scrutinised for any correlation

between serum-cholesterol and body-weight. The caseswere divided into three ranges of less than 90%, 90-109%,

and over 110% of the normal body-weight for the sameage-ranges as before, and for each sex. The normalvalues were taken from Joslin’s Treatment of DiabetesMellitus (1959). !These investigations showed no constant relationship

between serum-cholesterol and body-weight in either

sex, nor any clear distinction between psoriatics andcontrols.

SummaryThe serum-cholesterol of 176 patients with psoriasis,

aged from thirteen to sixty-nine years shows no significantvariation from a normal control group matched for age,sex, and body build.

’

We are grateful to Dr. Arthur Jordan for advice.

REFERENCES

Castro-Mendoza, H. J., Gomez Orbaneja, J. (1946) Rev. clin. esp. 21, 296.Dodds, E. C., MacCormac, H., Robertson, J. D. (1942) Brit. J. Derm. 54,

212.Dogliotti, M. (1953) Hautarzt, 4, 17.Grutz, O. (1938) Arch. Derm. Syph., Berlin, 177, 246.

— Burger, M. (1933) Klin. Wschr. 12, 373.Hobson, W., Jordan, A., Roseman, C. (1953) Lancet, ii, 961.Joslin, E. P., Root, H. F., White, P., Marble, A. (1959) The Treatment of

Diabetes Mellitus; p. 830. London.Lea, W. A., Cornish, H. H., Block, W. D. (1958) J. invest. Derm. 30, 181.Levy-Franckel, A., Breant, P. (1948) Ann. Derm. Syph., Paris, 8, 109.Radl, J., Kraus, Z., Toussek, M. (1957) Derm. Wschr. 64, 275.Rosen, I., Rosenfeld, H., Krasnow, F. (1937) Arch. Derm. Syph., Chicago,

35, 1093.Shapiro, E. M., Knox, J. M., Grundy, S. (1958) J. invest. Derm. 30, 181.Tickner, A., Mier, P. D. (1960) Brit. J. Derm. 72, 131.

Preliminary Communications

EFFECT OF HUMAN GROWTH HORMONE ON

THE METABOLIC RESPONSE TOSURGICAL TRAUMA

TRAUMA of any kind is followed by a period of proteincatabolism during which nitrogen appears in excess in theurine, and a state of negative nitrogen balance exists. Theexcessive nitrogen loss is to some extent due to a

diminished intake, but it is mainly obligatory and a funda-mental part of the body’s response to injury.1The role of growth hormone in the metabolic changes

which follow injury is unknown. Large doses of bovinegrowth hormone given after severe burns have no effect onthe excretion of urinary nitrogen.2 The concept of speciesspecificity of growth hormone confuses the interpretationof these results.

Preliminary studies show a low content of growthhormone in the pituitary glands of patients dying within aday or two of operation.3 Plasma-growth-hormone levels,measured by a bioassay technique, are raised within five tosix days of a surgical operation, and the administration ofhuman growth hormone five to six days after injuryreduces the urinary excretion of nitrogen. 3 Human

growth hormone has been regarded as an anabolic agent ofconsiderable potency because its administration to normalsubjects and patients with hypopituitarism reduces theexcretion of nitrogen,.4-6

It seemed of interest to investigate the anabolic proper-ties of administered human growth hormone during aperiod of postoperative catabolism, and to compare the1. Kinney, J. M. Ciba Symposium on Protein Metabolism; p. 275.

Berlin, 1962.2. Soroff, H. S., Rearson, E., Green, N. L., Artz, C. P. Surg. Gynec.

Obstet. 1960, 111, 259.3. Gemzell, C. A. Ciba Symposium on Protein Metabolism; p. 297.

Berlin, 1962.4. Bradshaw, J. S., Abbott, W. E., Levey, S. Amer. J. Surg. 1960, 99, 600.5. Bergenstal, D. M., Lubs, H. A., Hallman, L. F., Patten, J., Levine, H. J.,

Li, C. H. J. Lab. clin. Med. 1957, 50, 791.6. Ikkos, D., Luft, R., Gemzell, C. A. Lancet, 1958, i, 720.

results with those obtained when other known anabolicagents, such as anabolic steroids, are given under similarconditions. Human growth hormone was therefore givento healthy male patients for the first five days after inguinalherniorrhaphy. The metabolic balances of nitrogen,sodium, potassium, and calcium were measured.

THE STUDY

Eight male patients, aged 25-50, who required unilateral

inguinal herniorrhaphy, were selected. The patients were

studied in pairs. One of each pair received human growthhormone, the other acted as control and was given injections ofdistilled water. Pairs of bottles of dissolved growth hormoneand distilled water were prepared in the laboratory, and neitherpatient, nurses, nor surgeon knew which bottle -contained thegrowth hormone until after the investigation.

Metabolic balance studies were started twenty-four hoursbefore operation and continued for five days afterwards. Theintake of food and fluids was measured by the staff of themetabolic diet kitchen, and the nitrogen, sodium, potassium,and calcium contents were calculated from tables. The dailyurinary output of nitrogen was measured by the Kjeldhalmethod. Fxcal nitrogen was not measured, but 10% of the oralintake was added to the output in calculating the balance. Theurinary sodium and potassium outputs were estimated with theflame photometer. Urinary calcium was measured by thesodium-edetate method.Human growth hormone, prepared by Dr. A. E. Wilhelmi,

was given to us by the endocrinology study section of theNational Institutes of Health. Sufficient powdered hormonefor 5 daily injections was dissolved in 10 ml. of distilled waterand sterilised by Seitz filtration. The solution was kept at 4’Cuntil injection. The first injection was given within an hour ofoperation and a further 5 injections were given at twenty-four-hour intervals. Two patients had 2-5 mg. per day, one had5 mg., and the other had 10 mg. per day respectively. Thesedoses are reported by Ikkos et al. to cause nitrogen retentionin resting subjects.The potency of the human growth-hormone preparation was

tested by measuring its effect on the serum-triglyceride con-centration in a normal subject under fasting conditions Thetriglyceride (as fatty acids) rose from 0-05 mEq. per litre before7. Henneman, P. H., Forbes, A. P., Holdawer, M., Dempsey, E. F.,

Carroll, E. L. J. clin. Invest. 1960, 39, 1223.

585

injection to 1-9 mEq. per litre four hours after an intramuscularinjection of 6 mg. of the preparation.

RESULTS

The daily nitrogen balance for each patient is shown in thefigure. The intake has been plotted upwards from zero and theoutput downwards from the intake. A positive balance there-fore appears as a shaded area above the zero line, and a negativebalance appears below. All the patients in the study show theusual period of negative nitrogen balance after operation, andgrowth hormone did not alter the normal pattern. The treatedpatient in the first pair studied shows a slight reduction in thenegative nitrogen balance when compared with the control. Theintake of nitrogen in the last pair was high, and this explains theearly swing to a positive balance in these two patients; but evenunder these conditions there was no retention of nitrogen when

growth hormonewas given.The total intake,

output, and balanceof sodium, potas-sium, and calciumfor each patient,calculated for thefive days of the

study, is shown intable I. There wasno difference in the

pattern or in themean daily excre-

tion of these elec-

trolytes in either

group. Three ofthe control patientsand three of thetreated groupshowed a postopera-tive retention ofsodium. All the

patients had a mildnegative balance ofpotassium afteroperation, and theywere all in positivebalance at the endof the study. Therewas no difference inthe level of calciumexcretion in thetreated and un-treated patients.

DISCUSSION

The results ofthese studies indi-cate that theanabolic proper-ties of human

growth hormonecannot be detectedwhen it is givenin the dose-rangeof 2-5-10 mg.daily after surgicaloperation. The

precise mode ofaction of growthhormone on pro-tein metabolism isstill undeter-mined. It hasbeen suggested

The effect of human growth hormone onnitrogen balance during five days afteringuinal herniorrhaphy.

TABLE I-THE EFFECT OF HUMAN GROWTH HORMONE ON THE CUMULATIVE

5-DAY POSTOPERATIVE BALANCES OF SODIUM, POTASSIUM, AND

CALCIUM

Statistical analysis of potassium output, controls versus growth hormone:t=0’74; D.F.=6; 0’4>p>0’5.

that the anabolic effects of growth hormone are due to anincrease in the rate of protein synthesis rather than to anydecrease in the rate of protein catabolism or breakdown.The stimulus for catabolism after trauma may be greaterthan the stimulus for anabolism provided by growthhormone, and catabolism thus continues unabated. Thisconcept is of interest when the effects of growth hormoneand anabolic steroids are compared. In another study inthis department an anabolic steroid (methandienone) wasgiven immediately after herniorrhaphy, and there was asignificant reduction in the excretion of nitrogen in thefive days of the study (table 11). Anabolic steroids in con-trast to growth hormone have the property of decreasingprotein catabolism as well as increasing the synthesis ofnew protein. This difference in the properties of the twosubstances may explain the results obtained.

TABLE II-THE EFFECT OF METHANDIENONE AND HUMAN GROWTH

HORMONE ON THE MEAN 5-DAY NITROGEN BALANCE AFTER INGUINALHERNIORRHAPHY IN MEN

Statistical analysis of nitrogen output, methandienone versus growth hor-mone : t = 3-27; D.F.=8; 0’01>p>0’001.

Metabolic balance studies after hypophysectomy or

after surgical operations in patients who have had previoushypophysectomy are, provided cortisone is given, similarto those in patients with intact pituitary glands. 8 Itappears therefore that the metabolic response to trauma is

independent of any changes in the secretion of growthhormone. But it is possible that growth hormone may actlater in convalescence during the period of anabolismwhen protein is reaccumulating, repair is progressing, andthe patient is in a positive nitrogen balance. The presentstudies are limited to the catabolic phase, but it would beof interest to continue giving growth hormone untilanabolism was well established. It may be that extra

growth hormone at this period would accelerate theanabolism of protein. It should be noted that the reportednitrogen-retaining effects of human growth hormone occurin the second five days after injury.

Further assays of circulating growth-hormone levels arenecessary before and after surgical operation before any

8. Johnston, I. D. A., Welbourn, R. B. Unpublished data.

586

conclusions can be reached about the role of endogenousgrowth hormone in postoperative anabolism.

SUMMARY

Daily injections of human growth hormone (2-5-10 mg.per day) had no effect on the catabolism of protein immedi-ately after inguinal herniorrhaphy.The post-operative urinary excretion of sodium,

potassium, and calcium was unaltered by growth hormone.We wish to record our thanks to the endocrinology study section of

the National Institutes of Health for supplies of human growthhormone.We also wish to thank Prof. R. B. Welbourn for his help and

encouragement; Miss M. Pountain and Miss M. Martin for laboratoryassistance; and Staff-nurse J. Duff and the dietetic department of theRoyal Victoria Hospital for help with the metabolic balance studies.

IVAN D. A. JOHNSTONM.CH. Belf., F.R.C.S.

Senior Tutor in SurgeryDAVID R. HADDENM.B. Belf., M.R.C.P.

Clinical Research Fellow

Department of Surgery,Queen’s University,

BelfastThe Sir George E. Clark

Metabolic Clinic,Royal Victoria Hospital,

Belfast

THE BOWIE AND DICK AUTOCLAVE

TAPE TEST*

* A report to the Medical Research Council Working Party onSteam Pressure Sterilisers.

AT a recent symposium one of us (J. H. B.) describeda standard package for testing high-vacuum sterilisers.There was also a reference to a simpler form of the testdeveloped by Mr. J. Dick in which thermocouples werereplaced by heat-sensitive indicator tape. This test hassince proved so convenient and so reliable that we con-sider that it should be more widely known. There is

urgent need to check the performance of new sterilisers.2The test we now describe should be within the capabilitiesof any hospital and should permit information to be

quickly collected over a wide area.TEST AS ORIGINALLY DESCRIBED

29 huckaback towels were washed and folded intofour along their length and then doubled across to give

1. Recent Developments in the Sterilization of Surgical Materials: Reportof a Symposium organised by the Pharmaceutical Society of GreatBritain and Smith & Nephew Research Ltd. London, 1961.

2. See Lancet, 1962, i, 628.

Fig. 1-General arrangement of original test, showing towels andtape before sterilisation.

Fig. 2--a, satisfactory run (uniform colour change); b, unsatisfac-tory run (colour change incomplete at centre).

eight thicknesses of cloth. The folded towels were stackedin alignment one above the other and placed in a rectangu-lar dressing-casket. Two 12-in. lengths of autoclave

tape were inserted at various levels in a pack stuck totowels in the form of a St. Andrew’s cross (fig. 1). Thebox was then subjected to a sterilising cycle. After a

satisfactory run there was a uniform colour changethroughout the tape (fig. 2a). An unsatisfactory run wasindicated by a central area of incomplete colour change(fig. 2b). If the tapes at several levels were examined an

egg-shaped bubble of residual air, which was responsiblefor the failure in steam penetration, was clearly defined.Examination and Definition of Technical Details

Towels.-Huckaback towels complying with B.s. 1781 TL5,having a minimum size 36 x 24 in. before laundering, shouldbe used. They must be laundered at least once before beingused and should be unfolded and aired for at least an hourbefore each test. They should be relaundered when soiled ordiscoloured.Tape.-Our experience has shown that the only suitable

tape at present available is "

type 1222 " made by the Minne-

sota Mining and Manufacturing Company. Other tapes havebeen tried but have proved to be unstable in storage, sensitiveto dry heat, or oversensitive to steam. It is convenient toapply the tape to 10 x 8 in. sheets of unglazed paper whichcan then be placed between the towels. It may be of interestto use several such sheets at various levels in order to plot theresidual air space, but a single sheet at the centre of the stackis sufficient to indicate a satisfactory or unsatisfactory run.

Packaging and number of towels used.-It does not seem tomatter whether the towels are packed in a dressing casket

complying with B.s. 3281 or in a similar-sized box of metal orcardboard (so long as it is not airtight), or are wrapped infabric. The exact number of towels to be used is not easy to

specify. When new, 29 towels can be packed into the standardcasket only with difficulty; after being washed many times theywill occupy perhaps three-quarters of the space. It is prob-ably simplest to use as many towels as will, when folded intoeight layers, form a stack 10-11 in. high.

Interpretation of TestThe original test agreed with thermocouple readings

to within about 2°C. The tape then used is no longermanufactured, but the 1222 tape recommended has beenchecked against thermocouples, Browne’s tubes, and ther-mophilic spores. There was sufficient agreement to war-rant the tape test being proposed for rapid screeningpurposes.

This test is essentially a test of steam penetration andnot of time-at-temperature. A uniform colour changemay be obtained without adequate initial air removal ifthe holding time is artificially extended. Such a uniformcolour change should not be accepted if the sterilisation-holding time as recorded from the chamber drain exceeds31/2 minutes at 134°C or 12 minutes at 126°C. Wehave no experience of using this test at 121°C, or at

temperatures above 134°C.If penetration is shown by this test to be virtually

instantaneous, the time and temperature relationship onthe recorder chart can be accepted-provided that the

accuracy of the recorder is assured.In most high-vacuum sterilisers installed in this country,

the sterilisation process consists in the four-stage sequence:pre-vacuum, steaming, drying, and breaking vacuum. In thesesterilisers a satisfactory test result indicates both adequate airremoval and the absence of significant air leakage into thechamber. In some sterilisers, steam is admitted during thepre-vacuum period and before the steaming period proper.If enough steam is admitted, penetration will occur and theload temperature will consequently rise before the end of the