- Email: [email protected]
DIAGNOSIS OF BRUCELLOSIS
390
importance of the general condition of the patient in determining the likelihood of development of pressure sores. We believe that this study will also allow a comparison to be made of the effectiveness of different nursing procedures in groups of patients with a variety of diseases. While it is possible that many of the traditional procedures, such as the application of spirit and powder and the rubbing in of soap, have little to commend them, the evidence so far submitted in favour of silicone creams is not conclusive. At the moment the widespread use of these expensive creams as a prophylactic measure for all patients who are nursed in bed either at home or in hospital is in our opinion unjustified. Large trials conducted by local health authorities and by medical and nursing teams in hospital are urgentlv required. Whittington Hospital, Highgate Wing, London, N.19.
A. N. EXTON-SMITH DOREEN NORTON.
DIAGNOSIS OF BRUCELLOSIS
SiR,ŇYour review (Jan. 30)
of my book agrees with me know little about this disease. It was for that reason that I wrote the book on brucellosis in England. I have evidently failed in my task, for your conclusion is that " many physicians will be unconvinced by the diagnosis in at least half the patients." The only reason you give for this extraordinary statement is that a rise in the titre of agglutinins after an injection of brucellin can be demonstrated in some apparently normal subjects. I took as my criteria of diagnosis those advised by Wilson and Miles in a standard textbook 1 of bacteriology and immunology. In not one of my cases was " therapeutic success " used as the diagnostic weapon you suggest. Every one was confirmed by either an initial agglutination titre of 1 in 80, or a positive skin test, or a fourfold rise in agglutination titre after the skin test if that was negative. Aside from this backing by eminent authorities I feel that your argument is a weak one. You might as well say that because many apparently normal persons have a positive reaction to the Mantoux test you do not believe that they have ever been infected with the tubercle bacillus. " Apparently normal " people may have a positive serum reaction for syphilis, toxoplasmosis, or other disease. Are we therefore to abandon the use of these tests and to ignore their results ? It is true that the clinical history is important in the diagnosis of brucellosis, and indeed it is often the crucial factor in deciding whether to " treat or not. Wilson and Miles say: The interpretation of the agglutination test is not always easy, and demands a knowledge of the clinical history and the occupation of the patient." They also give this criterion which is less stringent than mine: A titre of 1 in 20 to 1 in 80, in the presence of clinically undulant fever, may likewise be considered as practically diagnostic of this disease." You are also guilty of a misuse of words. You say that my conclusions are dogmatic. Dogmatic means based on a-priori assumptions which are incapable of proof. If you read the book again carefully you will see that all the conclusions were based on the work of other investigators or my own observations. They cannot therefore be called dogmatic. Everyone who has anything original or unusual to put forward must expect to be disbelieved. I know that the correct thing to do with an ill-informed review is to ignore it; but it is important for the sake of the patients to protest in this case. So long as this unfortunate attitude of disbelief is exhibited towards the mani-
that
we
"
1.
Wilson, G. S., Miles, A. A. Topley and Wilson’s Principles of Bacteriology Immunology. London, 1955.
and
festations of chronic brucellosis, so long will cases be missed and much suffering which could be prevented will continue. HUGH WALLIS. Bath.
*** Of Dr. Wallis’ 35 proven cases, we make it that were diagnosed by agglutination tests, 2 by skin tests alone, and 18 by a fourfold rise in agglutination titres after the injection of brucellin. We accept the evidence of the agglutination tests, with the proviso that no single test confirms a diagnosis beyond any possible doubt. 15
Of the skin test, Wilson and Miles
(p. 1911)
say:
" Generally speaking the reaction resembles the tuberculin reaction in denoting the occurrence of infection without giving any clear indication of its activity... ; it may then remain positive for months or years. Great discretion has to be exercised in interpreting the test. In some countries 20-30 per cent of the population may react positively to it. It may be of value in survey work, but its use in the diagnosis of chronic brucella infection in the complete absence of other supporting laboratory findings should generally be discouraged. It is well to remember that, particularly in persons who have been previously exposed to brucella infection the intradermal injection of the test antigen may be followed by the appearance of circulating antibodies."
The W.H.O. committee on brucellosis believe that the intradermal test should not stand alone as supporter of the diagnosis. As to the significance of a fourfold rise in titre after injection of brucellin, we have seen no convincing evidence to justify Dr. Wallis’ interpretation. Brucellin, like any other antigen, produces antibodies: the amount produced is-to judge by experience with such things as T.A.B.-very variable. If the patient has had a previous infection-i.e., has a positive brucellin reaction-the titre will rise even higher than it will in a virgin; and in the circumstances we feel that Dr. Wallis places too much reliance on this serological reaction in making a diagnosis. That was one reason why we described his conclusions as " dogmatic ".
the 35 case-histories in Dr. Wallis’ book, would say that half are probably brucella infections, and of the rest, some may be psychosomatic ailments and some P.u.o.s-and there are many causes of pyrexia in children about which we know little or nothing. Dr. Wallis’ view seems to be that once a child has had a brucella infection any future vague illness is the same thing.-ED. L.
Re-examining
we
HYPNOSIS AND UNREGISTERED PRACTITIONERS
Dr. A. A. MASON, secretary, British National Division, International Society for Clinical and Experimental Hypnosis, writes: . I have been approached by Dr. Ainslie Meares, the Aus"
tralian president of the society, and Dr. H. Grant-Whyte, a member of the South African Medical and Dental Council, both of whom are investigating the problem of lay hypnotists and the possible harmful effects which can be caused by the use of hypnosis by unqualified practitioners. Dr. Grant-Whyte has approached the Minister of Health in an attempt to get legislation in South Africa along the lines of the British Hypnotism Act, 1952, and also in an attempt to restrict the practice of unregistered and untrained persons. It would be of great assistance to both these doctors to have available all the details of harmful effects which have followed the use of hypnosis by unregistered practitioners, and indeed if sufficient evidence is present it could stimulate similar action in this country. I should be grateful, therefore, if any doctors who have evidence from their own practice of patients suffering harm following the use of hypnotism by unqualified practitioners could communicate the details of such cases to me at 24, Avenue Road, Regent’s Park, London, N.W.8. Of course, I need hardly assure the doctors and their patients that this matter will be treated in the strictest confidence."
importance of the general condition of the patient in determining the likelihood of development of pressure sores. We believe that this study will also allow a comparison to be made of the effectiveness of different nursing procedures in groups of patients with a variety of diseases. While it is possible that many of the traditional procedures, such as the application of spirit and powder and the rubbing in of soap, have little to commend them, the evidence so far submitted in favour of silicone creams is not conclusive. At the moment the widespread use of these expensive creams as a prophylactic measure for all patients who are nursed in bed either at home or in hospital is in our opinion unjustified. Large trials conducted by local health authorities and by medical and nursing teams in hospital are urgentlv required. Whittington Hospital, Highgate Wing, London, N.19.
A. N. EXTON-SMITH DOREEN NORTON.
DIAGNOSIS OF BRUCELLOSIS
SiR,ŇYour review (Jan. 30)
of my book agrees with me know little about this disease. It was for that reason that I wrote the book on brucellosis in England. I have evidently failed in my task, for your conclusion is that " many physicians will be unconvinced by the diagnosis in at least half the patients." The only reason you give for this extraordinary statement is that a rise in the titre of agglutinins after an injection of brucellin can be demonstrated in some apparently normal subjects. I took as my criteria of diagnosis those advised by Wilson and Miles in a standard textbook 1 of bacteriology and immunology. In not one of my cases was " therapeutic success " used as the diagnostic weapon you suggest. Every one was confirmed by either an initial agglutination titre of 1 in 80, or a positive skin test, or a fourfold rise in agglutination titre after the skin test if that was negative. Aside from this backing by eminent authorities I feel that your argument is a weak one. You might as well say that because many apparently normal persons have a positive reaction to the Mantoux test you do not believe that they have ever been infected with the tubercle bacillus. " Apparently normal " people may have a positive serum reaction for syphilis, toxoplasmosis, or other disease. Are we therefore to abandon the use of these tests and to ignore their results ? It is true that the clinical history is important in the diagnosis of brucellosis, and indeed it is often the crucial factor in deciding whether to " treat or not. Wilson and Miles say: The interpretation of the agglutination test is not always easy, and demands a knowledge of the clinical history and the occupation of the patient." They also give this criterion which is less stringent than mine: A titre of 1 in 20 to 1 in 80, in the presence of clinically undulant fever, may likewise be considered as practically diagnostic of this disease." You are also guilty of a misuse of words. You say that my conclusions are dogmatic. Dogmatic means based on a-priori assumptions which are incapable of proof. If you read the book again carefully you will see that all the conclusions were based on the work of other investigators or my own observations. They cannot therefore be called dogmatic. Everyone who has anything original or unusual to put forward must expect to be disbelieved. I know that the correct thing to do with an ill-informed review is to ignore it; but it is important for the sake of the patients to protest in this case. So long as this unfortunate attitude of disbelief is exhibited towards the mani-
that
we
"
1.
Wilson, G. S., Miles, A. A. Topley and Wilson’s Principles of Bacteriology Immunology. London, 1955.
and
festations of chronic brucellosis, so long will cases be missed and much suffering which could be prevented will continue. HUGH WALLIS. Bath.
*** Of Dr. Wallis’ 35 proven cases, we make it that were diagnosed by agglutination tests, 2 by skin tests alone, and 18 by a fourfold rise in agglutination titres after the injection of brucellin. We accept the evidence of the agglutination tests, with the proviso that no single test confirms a diagnosis beyond any possible doubt. 15
Of the skin test, Wilson and Miles
(p. 1911)
say:
" Generally speaking the reaction resembles the tuberculin reaction in denoting the occurrence of infection without giving any clear indication of its activity... ; it may then remain positive for months or years. Great discretion has to be exercised in interpreting the test. In some countries 20-30 per cent of the population may react positively to it. It may be of value in survey work, but its use in the diagnosis of chronic brucella infection in the complete absence of other supporting laboratory findings should generally be discouraged. It is well to remember that, particularly in persons who have been previously exposed to brucella infection the intradermal injection of the test antigen may be followed by the appearance of circulating antibodies."
The W.H.O. committee on brucellosis believe that the intradermal test should not stand alone as supporter of the diagnosis. As to the significance of a fourfold rise in titre after injection of brucellin, we have seen no convincing evidence to justify Dr. Wallis’ interpretation. Brucellin, like any other antigen, produces antibodies: the amount produced is-to judge by experience with such things as T.A.B.-very variable. If the patient has had a previous infection-i.e., has a positive brucellin reaction-the titre will rise even higher than it will in a virgin; and in the circumstances we feel that Dr. Wallis places too much reliance on this serological reaction in making a diagnosis. That was one reason why we described his conclusions as " dogmatic ".
the 35 case-histories in Dr. Wallis’ book, would say that half are probably brucella infections, and of the rest, some may be psychosomatic ailments and some P.u.o.s-and there are many causes of pyrexia in children about which we know little or nothing. Dr. Wallis’ view seems to be that once a child has had a brucella infection any future vague illness is the same thing.-ED. L.
Re-examining
we
HYPNOSIS AND UNREGISTERED PRACTITIONERS
Dr. A. A. MASON, secretary, British National Division, International Society for Clinical and Experimental Hypnosis, writes: . I have been approached by Dr. Ainslie Meares, the Aus"
tralian president of the society, and Dr. H. Grant-Whyte, a member of the South African Medical and Dental Council, both of whom are investigating the problem of lay hypnotists and the possible harmful effects which can be caused by the use of hypnosis by unqualified practitioners. Dr. Grant-Whyte has approached the Minister of Health in an attempt to get legislation in South Africa along the lines of the British Hypnotism Act, 1952, and also in an attempt to restrict the practice of unregistered and untrained persons. It would be of great assistance to both these doctors to have available all the details of harmful effects which have followed the use of hypnosis by unregistered practitioners, and indeed if sufficient evidence is present it could stimulate similar action in this country. I should be grateful, therefore, if any doctors who have evidence from their own practice of patients suffering harm following the use of hypnotism by unqualified practitioners could communicate the details of such cases to me at 24, Avenue Road, Regent’s Park, London, N.W.8. Of course, I need hardly assure the doctors and their patients that this matter will be treated in the strictest confidence."