HOMOEOPATHIC TREATMENT OF OSTEOARTHRITIS

304

Use of suboptimum doses of antibiotics is the main reason for the emergence of resistant gonococcal strains worldwide.4 An institutional way of giving suboptimum therapy is the single-dose treatment regimen, for which the failure rate lies between 307o and 7%, not so far from the 10% failure rate Brown et al. consider

COPING WITH THE RESISTANT GONOCOCCUS

SIR,-Dr Brown and colleagues’ report (Dec. 18, p. 1366) of decreased sensitivity of both penicillinase-producing Neisseria gonorrhoeae (PPNG) and non-PPNG to a range of commonly used antibiotics is worrying. We agree that their findings necessitate the evaluation of combination therapies for gonorrhoea, although higher doses of single agents may be equally effective, as Dr Barlow and colleagues note (Jan. 15, p. 125). We have studied 42 PPNG and 46 non-PPNG strains isolated from patients attending the sexually transmitted disease clinic at St Mary’s Hospital, London. Our non-PPNG were, however, very much more sensitive to penicillin than those reported from Bangkok; only one isolate had a minimum inhibitory concentration (MIC) of more than 0-55 mg/l. The MICs of spectinomycin, erythromycin, tetracycline, cefuroxime, and sulphamethoxazole were significantly higher for PPNG than for non-PPNG. This is in direct contrast to the findings of Brown et al. that the MICs of the cephalosporines were higher for non-PPNG and that there was no significant difference between the sensitivity of PPNG and nonPPNG to the other antimicrobial agents. Sng et al. found similar results with cefotaxime among gonococci isolated in Singapore; they thought that this sensitivity pattern might be a result of the antibiotic pressure caused by the prophylactic use of cephalosporins by prostitutes in Singapore. One reason for this discrepancy may be related to the difference in sensitivity to penicillin of our non-PPNG isolated in London and the non-PPNG found in the Far East. Non-PPNG penicillin resistance of the degree found in Bangkok has been ascribed to the combination of series of chromosomal mutations.2Furthermore some of these mutations have been linked with increased resistance to other antibiotics, such as tetracycline, spectinomycin and chloramphenicol.2 It is possible that chromosomal resistance to beta-lactamase stable cephalosporins could occur in non-PPNG. Since no beta-lactamase would be involved cefuroxime and cefoxitin would have no particular advantage. There has to date been no good reason to look for chromosomal beta-lactam resistance in PPNG.

non-PPNG, being penicillin sensitive, would be

less likely to have this type of linked chromosomal resistance to other agents. Most of the PPNG which we isolated between 1979 and early 1981 were acquired abroad, many from the Far East. This group of organisms were probably epidemiologically quite distinct from the non-PPNG which we studied and indeed more closely related to the PPNG studied by Brown and his colleagues.

Our

own

Most PPNG which we now isolate are indigenous and it would be to see if these indigenous PPNG are more sensitive to non-beta-lactam antibiotics that those acquired from abroad.

interesting

CH. HERZOG* C. A. ISON C. S. F. EASMON

Department of Bacteriology, St Mary’s Hospital Medical School, London W2 1PG

*Present addressSwitzerland.

Department of Internal Medicine, University Hospital, Basel,

awl.

on the antimicrobial isolated in Bangkok is is an understatement. A new treatment for gonorrhoea is needed but to confine the solution to combination therapies is too restrictive. A more important question is-is single-drug or single-dose treatment passé?

SIR,-The report of Brown

et

susceptibility of Neisseria gonorrhoeae alarming: nevertheless, their conclusion

unacceptable. Single-dose treatment,

with its ease of prescription, discourages the formulation of a proper policy for gonorrhoea because it minimises the importance of the infection. The choice of antibiotic and treatment regimen for gonorrhoea may not yet be a real problem in Europe and North America but the absence ofa control policy for sexually transmitted disease may lead to a situation as disturbing as that described for Bangkok. Laboratory of Microbiology, C H.U. Bretonneau, 37044 Tours, France

SIR,-Dr Brown and co-workers suggest that, in an area like Bangkok, where there is a high incidence of both penicillinaseproducing Neisseria gonorrhoeae (PPNG) and non-PPNG with high penicillin minimum inhibitory concentrations (MICs), combination antibiotic therapy for gonorrhoea should be evaluated. Dr Barlow and his colleagues (Jan. 15, p. 125) disagree and suggest that increased doses of currently used agents should be tried first. One agent, not mentioned in either communication, provides a compromise between these two views-namely, the amoxycillinl clavulanic-acid formulation ‘augmentin’. In theory at least, and if used in high doses, the amoxycillin component should be active against the high penicillin MIC, non-PPNG strains while the clavulanic acid should protect the amoxycillin from inactivation by the enzymes produced by the PPNG strains. In Sapporo, where resistant gonococci are less common than they are in Bangkok, standard courses of augmentin (375 mg 6-hourly for 7 days) produced bacteriological cure in 289 cases of gonorrhoea.1 A trial of high-dose augmentin in Bangkok might prove worthwhile. Regional Public Health Laboratory; University Hospital of Wales, Cardiff CF4 4XW

Yeo KL Susceptibility of Neisseria gonorrhoeae to cefotaxime and ceftizoxime. Br J Vener Dis 1981, 57: 162-64. 2. Sparling PF, Guyman L, Biswas G Antibiotic resistance in the gonococcus. In: Schlesinger D, ed. Microbiology 1976, Washington, DC: American Society for Microbiology, 1976: 494-500. 3. Brown S, Warnnissorn T, Biddle J, Panikabutra K, Traisupa A. Antimicrobial resistance of Neisseria gonorrhoeae in Bangkok Is single-drug treatment passé? Lancet 1982; ii: 1366-68.

Sng EH, Rajan VS, Pang R,

C. D. RIBEIR0

HOMOEOPATHIC TREATMENT OF OSTEOARTHRITIS

SIR,-I read with mixed feelings the study in The Lancet ofJ an. 15 (p. 97). A doctor’s prime concern is the care of his patients. Doctors from King’s College Hospital, London, and the Kent and Sussex Hospital, where orthodox medicine is practised, proved this, by collaborating with doctors from homoeopathic hospitals to see if a homoeopathic remedy (Rhus tox.) would relieve the sufferings of patients with osteoarthritis. Unfortunately, this study did not confirm the claims made by homoeopathic practitioners. Advances in medical knowledge have led to effective preventive measures so that many diseases are now of only historical importance, and drugs, improved medical, nursing, and ancillary care, and advanced surgery have saved many lives. All the same

many patients and doctors, realising the limitations of allopathy, have turned to homoeopathy, a complementary medicine, and do not regret the move. Doctors who consider homoeopathic medicine as unscientific find it difficult to comprehend the principle of "like cures like" (simiha 4. 5.

1.

G. PINON R. QUENTIN R. VARGUES

6

Johnston NA, Kolator B, Seth AD A survey of beta-lactamase-producing gonococcal isolates reported in the United Kingdom 1979-80. Lancet 1981, i. 263-64. Thabaut A, Durosoir JL, Saliou P, et al. ’La sensibilité actuelle de Neisseria gonorrhoeae en region parisienne.’ Résultats d’un essai thérapeutique comparé. Bull Soc Path Exp 1980; 73: 353-63. Jaffe HW, Biddle JW, Johnson SR, Weisner PJ. Infections due to penicillinaseproducing Neisseria gonorrhoeae in the United States 1976-1980. J Infect Dis 1981, 144: 191-97. on BRL 25000 (Augmentin) treatment of gonorrhoeal infections. In: Leigh DA, Robinson OPW, eds. Augmentin: Proceedings of the Second Symposium Amsterdam: Excerpta Medica, 1982

1. Kumamoto Y. Basic and clinical studies

204-21.

305 similibus curentur), the fact that there is no trace of the parent substance in homoeopathic remedies, and the notion of a constitutional remedy specific for a particular person being prescribed irrespective of the disease. In determining the efficacy of homoeopathic remedies, controlled trials should first focus on remedies prescribed for acute conditions. For example, trials of Arnica in accidental or surgical trauma could evaluate pain relief, wound healing, postoperative complications such as thrombophlebitis and pulmonary embolism, and duration of convalescence and hospital stay; burns units can evaluate Cantharis; and Chelidonium can be assessed in patients with infective

hepatitis. In chronic diseases, constitutional remedies are invariably indicated, and homoeopathic treatment is needed for at least a year. As the clinical features change the patient may need different remedies. Thus in chronic conditions, a particular homoeopathic remedy alone cannot be evaluated; in osteoarthritis, for example, controlled trials should be of one system of treatment against another and should be of long duration. Mersey Regional Department of Homoeopathic Medicine, Mossley Hill Hospital, Liverpool L 18 8BU

if a large scale investigation of Pertussin is justified. The disadvantage of the homoeopathic prophylactic is that it is likely to be short-lasting. Nonetheless, even if it were shown to have only see

modest efficacy it would still be valuable for children for whom the orthodox vaccine was contraindicated and for contacts under 3 months of age. Clinical research-workers must get their designs right. Homoeopathy is based on a careful matching of the patient’s symptoms with those of the drug picture: anything less is not in accord with homoeopathic theory. The trial reported by Dr Shipley and colleagues takes no account of the patient’s total symptom picture and might therefore have been expected to fail. I regret this, especially since it encourages those prejudiced against homoeopathy to conclude that because this trial is negative, the method as a whole stands condemned. It is not, to adapt the title of your editorial, homoeopathy which is on trial, but simply a micropotency of Rhus tox. in the treatment of osteoarthritis. 44 The

Drive, Northwood, Middlesex

JOHN M. ENGLISH

A. GHOSH DELTA INFECTION IN THE U.K.

SIR,-Dr Shipley and colleagues state that "Only two previous ,controlled trials comparing homoeopathic remedies and conventional treatment have been reported". If they were referring in rheumatology conditions and if "conventional drugs they may be right. However, a controlled homoeopathic remedies with conventional management was published from this hospital in 19771 and was followed by a further report a year later in the same journal. Our trials, like Shipley’s, revealed no measurable advantage of homoeopathic remedies over conventional management. It seems extraordinary that properly controlled trials of homoeopathic remedies are only now being carried out 150 years after homoeopathy was proposed as an alternative therapeutic system. Perhaps the highly individualised therapeutic regimens used in homoeopathy make a conventional controlled trial virtually to controlled trials

treatment" means trial comparing

SIR,-Dr Tedder and colleagues (Oct. 2, p. 764) suggest that delta antigen has been introduced amongst U.K. drug addicts only recently since they were unable to find anti-6 in the serum of patients referred before 1982. Using fluorescein labelled anti-o antibody (kindly donated by Dr M. Rizzetto) in a direct immunofluorescence technique, we have found 6-antigen in the liver tissue of seven out of fifteen HBsAg positive drug addicts referred to the liver unit, King’s College Hospital, between 1976 and 1981. In none of the seven positive cases could hepatocyte nuclei be stained with a fluorescein conjugated high titre anti-HBc/anti-HBe serum, excluding crossreaction with this system. One of these patients, White and British, who died with decompensated cirrhosis in 1977, had liver biopsies in 1971, 1972, and 1973. 6-antigen was present in the liver cell nuclei on all occasions (see figure). Our findings show that 6-antigen

impossible to organise. Trinity Hospital, Taunton, Somerset

PETER F. ROE

SIR,-In our Jan. 15 paper on the use of Rhus tox. in osteoarthritis the description of the method may need some clarification. In this double-blind, double-dummy placebo controlled crossover.trial the patients took both capsules and drops every day. The three treatments referred to are those combinations of: (1) placebo capsules and placebo drops, (2) fenoprofen capsules and placebo drops, and (3) placebo capsules and Rhus tox. drops.

’, ’

Department of Rheumatology, Middlesex Hospital, London W1P 9PG

MICHAEL SHIPLEY

StR,-As homoeopathically oriented physician I wholeheartedly agree with your editorial about the need to establish the validity of homoeopathy on a scientific basis. The Midland Homoeopathic Research Group, was founded for this purpose in 1977, at the instigation of Dr R. Pinsent, late research adviser to the Royal College of General Practitioners. On the group’s behalf, I am attempting to undertake just such a study on Pertussin. The difficulties should not be underestimated. Despite a generation’s opportunity and enormous numbers of children available for investigation, there is still a 20% difference between different authorities’ estimates of the efficacy of orthodox pertussis vaccine. It is taking time to acquire sufficient cases even for a pilot study to a

Roe PF A double blind trial to assess the benefit of Arnica Montana stroke illness Br Homoeopath J 1977, 66: 207-20.

1 Savage RH, acute

in

Staining of liver cell nuclei using a fluorescein conjugated anti-a antibody in liver biopsy from a drug addict, obtained in 1971 (about 480). present in North European drug addicts as early as 1971-73, confirming the observation of Hansonn et al. who found serological evidence of ó-infection in 1973 in Sweden.

was

Departments of Immunology and Child Health and Liver

King’s College Hospital and Medical School, London SE5 8RX

Unit,

DIEGO VERGANI GIORGINA MIELI-VERGANI MUNTHER JAFAR HUSSAIN BERNARD PORTMANN ROGER WILLIAMS

BG, Moestrup T, Widell A, Mordenfelt E Infection with delta agent Sweden Introduction ofa new hepatitis agent J Infect Dis 1982, 146: 472-78

1 Hansonn

in