- Email: [email protected]
RETALIATION BY MENINGOCOCCI
436
define the outcome ? Inclusion of comprehensive of intellectual functions administered before and at fixed intervals after operation, carefully equated controls, and standardised operative procedures would at least provide additional evidence of the incidence, nature, and degree of intellectual impairment.5 can
tests
Neuropsychology Laboratory,
Nebraska Psychiatric Institute, Omaha, Nebraska, U.S.A.
AARON SMITH.
*** Dr. Smith’s own paper refers to 31 failed leucotomies in deteriorated schizophrenics. Not everyone would advise operation in such cases; and despite Dr. Smith’s opinion to the contrary, we could not distinguish between the long-term effects of operation in these patients and the mental deterioration in chronic psychotic inpatients, since he gives no details of the cases he describes as control patients.-ED. L. RETALIATION BY MENINGOCOCCI
SIR; Your annotation lead
me to
6
and Dr. Lamb’s
response7
write.
of meningococcal resistance to sulphonamides should it be considered to be limited to " American meningococci ".7 It is also misleading to employ the term meningococci in a generic sense. There are four varieties of these organisms, identified serologically as groups A, B, C, and D, of which the last is relatively rare. The great pandemics, apparently, were caused by group A organisms, and it is on these that the early work on sulphadiazine was conducted in the first half of the 1940s. Groups B and C have produced less extensive flurries of cases in intervening periods. Now, we are at a time when B is dominant, followed by C. There is evidence that, some years ago, B and C were not as sensitive to sulphadiazine as was A. Recently we examined several strains from Dr. Branham’s old collection (by courtesy of Dr. Margaret Pittman): two B strains which were isolated in 1936 (when it was most unlikely that they would have been exposed to any sulphonamide in the United States) were found to be resistant to sulphadiazine in a concentration of 0.1 mg. %. We have labelled such strains " partially resistant ", and those able to grow in 1 mg. % or more " resistant". These two partially resistant strains were made resistant to 5 mg. % by a few laboratory passages. During the past year or so over 500 strains of meningococci have been examined. These were obtained from both civilian and military sources in the continental United States, Western Europe, and Africa: resistance was detected among B strains and, to a lesser extent, among C strains submitted from both here and Europe. No strain was found to be resistant to any of the common antibiotics, especially penicillin G. It has, therefore, been recommended that the drug of first choice in the treatment of meningococcal infections should be penicillin G in massive dosage. If sulphonamides are used, I agree with Dr. Lamb that they should be secondary rather than the primary drug. While ampicillin may turn out to be a good drug for the treatment of meningococcal meningitis, there is certainly no great clinical evidence available to support it. Sensitivity testing can be accomplished satisfactorily in Mueller-Hinton agar which contains almost no sulphonamide inhibitors. Resistance should not be estimated by the disc method for this is notoriously inefficient with sulphonamides. Furthermore, one should be cautious about using " large inocula of the infecting organism "because sulphonamide testing is affected significantly by the inoculum. A standardised inoculum containing a reasonable number of organisms should The
is
problem
not new, nor
be used.
The capacity of group B and C organisms to resist the action of sulphonamides is not a recently acquired characteristic, but is inherent in many strains; when 5. 6. 7.
Smith, A. J. Neurol. Psychiat. 1964, 27, Lancet, 1964, ii, 1056. Lamb, R. ibid. p 1179.
511.
the proper epidemiological setting, emerge as the dominant ones in a given area.
given
Department of Preventive Medicine, College of Medicine, State University of New York, Syracuse, New York 13210.
they
may
HARRY A. FELDMAN.
ABDOMINAL PAIN OF SPINAL ORIGIN
SIR,-Referring to the letter by Mr. Daintree Johnson (Feb. 6), I should like to report an apparently unrecognised syndrome, which I call " thoracomarginal chondrodynia ". I have seen 15 cases characterised by acute or dull pain in the region of the costal arch (left or right) with localised tenderness over the end of a fluctuating rib cartilage (10th or llth). The cause is apparently a local irritation, probably due to compression-sometimes by bowed posture. Anxiety seems to contribute. I have used local anaesthetics or common analgesics together with reassurance as to the non-malignancy of the condition, which has then subsided after some time. Since some of these patients have been referred to me by colleagues as abdominal cases of obscure origin, I think it may be useful to keep this condition in mind. Centrallasarettet, S.-G. S. G. SJÖBERG. SJÖBERG. Eskilstuna, Sweden. S.-G. SIR,-In my opinion Mr. Daintree Johnson is right. I see many cases of subcostal and intercostal pain which in my opinion are due to protrusions of thoracic intervertebral disc substance. My treatment is aimed at reducing the protrusion by manipulation without anaesthesia, or by spinal traction. If the reduction is not stable, I inject a dextrose sclerosantinto the supporting ligaments of the joint on three occasions. The results are very satisfactory in some, but the stability in others is unsatisfactory. It is a treatment well worth trying. R. C. B. BARBOR. London, W.l. INAPPROPRIATE SECRETION OF VASOPRESSIN SIR,-Dr. Lee and his colleaguesreported a case of carcinoma of the lung with inappropriate secretion of
vasopressin (Schwartz-Bartter syndrome). Since January, 1964, we have studied five similar patients with bronchogenic oat-cell carcinoma. In the urine of the first patient,2 Dr. N. A. Thorn (Copenhagen) found high antidiuretic activity (1-8 LU. of vasopressin per 24 hours), at a time when plasma-osmolality was very low (245 mosmoles per kg. water). In the second patient,3 extracts of the tumour and its metastases were made, using the technique described by Amatruda et awl.and relatively high antidiuretic activity was found. A bronchogenic carcinoma of the malpighian type in a patient showing no clinical evidence of Schwartz-Bartter’s syndrome served as a control: no antidiuretic activity was found in this tumour. The substance present in the first tumour had the following activities, expressed as milliunits per mg. of acetone powder: antidiuretic activity in the rat, 7; vasopressor effect in the rat, 56; milk-ejecting potency in the rabbit, 1-3. These activities, which were all suppressed by treatment with thioglycollate, are in the ratio 100/80/19. The activity-ratio for argininevasopressin in the same tests is 100/100/18. These results suggest that vasopressin (or another peptide with a very similar pharmacological profile), but not oxytocin,s was present in the tumour. 1. Lee, J., Jones, J. J., Barraclough, M. A. Lancet, 1964, ii, 792. 2. de Sousa, R. C., Delaere, J., Thaon, A., Rudler, J. C., Mach, R. S. Schweiz. med. Wschr. 1964, 94, 1805. 3. Delaere, J., de Sousa, R. C., Rudler, J. C., Mach, R. S. Pr. méd. 1965,
73, 109. 4. Amatruda, T. T., Jr., Mulrow, P. J., Gallagher, J. C., New Engl. J. Med. 1963, 269, 544. 5. de Sousa, R. C- Berde, B., Mach, R. S. Unpublished.
Sawyer,
W. H.
define the outcome ? Inclusion of comprehensive of intellectual functions administered before and at fixed intervals after operation, carefully equated controls, and standardised operative procedures would at least provide additional evidence of the incidence, nature, and degree of intellectual impairment.5 can
tests
Neuropsychology Laboratory,
Nebraska Psychiatric Institute, Omaha, Nebraska, U.S.A.
AARON SMITH.
*** Dr. Smith’s own paper refers to 31 failed leucotomies in deteriorated schizophrenics. Not everyone would advise operation in such cases; and despite Dr. Smith’s opinion to the contrary, we could not distinguish between the long-term effects of operation in these patients and the mental deterioration in chronic psychotic inpatients, since he gives no details of the cases he describes as control patients.-ED. L. RETALIATION BY MENINGOCOCCI
SIR; Your annotation lead
me to
6
and Dr. Lamb’s
response7
write.
of meningococcal resistance to sulphonamides should it be considered to be limited to " American meningococci ".7 It is also misleading to employ the term meningococci in a generic sense. There are four varieties of these organisms, identified serologically as groups A, B, C, and D, of which the last is relatively rare. The great pandemics, apparently, were caused by group A organisms, and it is on these that the early work on sulphadiazine was conducted in the first half of the 1940s. Groups B and C have produced less extensive flurries of cases in intervening periods. Now, we are at a time when B is dominant, followed by C. There is evidence that, some years ago, B and C were not as sensitive to sulphadiazine as was A. Recently we examined several strains from Dr. Branham’s old collection (by courtesy of Dr. Margaret Pittman): two B strains which were isolated in 1936 (when it was most unlikely that they would have been exposed to any sulphonamide in the United States) were found to be resistant to sulphadiazine in a concentration of 0.1 mg. %. We have labelled such strains " partially resistant ", and those able to grow in 1 mg. % or more " resistant". These two partially resistant strains were made resistant to 5 mg. % by a few laboratory passages. During the past year or so over 500 strains of meningococci have been examined. These were obtained from both civilian and military sources in the continental United States, Western Europe, and Africa: resistance was detected among B strains and, to a lesser extent, among C strains submitted from both here and Europe. No strain was found to be resistant to any of the common antibiotics, especially penicillin G. It has, therefore, been recommended that the drug of first choice in the treatment of meningococcal infections should be penicillin G in massive dosage. If sulphonamides are used, I agree with Dr. Lamb that they should be secondary rather than the primary drug. While ampicillin may turn out to be a good drug for the treatment of meningococcal meningitis, there is certainly no great clinical evidence available to support it. Sensitivity testing can be accomplished satisfactorily in Mueller-Hinton agar which contains almost no sulphonamide inhibitors. Resistance should not be estimated by the disc method for this is notoriously inefficient with sulphonamides. Furthermore, one should be cautious about using " large inocula of the infecting organism "because sulphonamide testing is affected significantly by the inoculum. A standardised inoculum containing a reasonable number of organisms should The
is
problem
not new, nor
be used.
The capacity of group B and C organisms to resist the action of sulphonamides is not a recently acquired characteristic, but is inherent in many strains; when 5. 6. 7.
Smith, A. J. Neurol. Psychiat. 1964, 27, Lancet, 1964, ii, 1056. Lamb, R. ibid. p 1179.
511.
the proper epidemiological setting, emerge as the dominant ones in a given area.
given
Department of Preventive Medicine, College of Medicine, State University of New York, Syracuse, New York 13210.
they
may
HARRY A. FELDMAN.
ABDOMINAL PAIN OF SPINAL ORIGIN
SIR,-Referring to the letter by Mr. Daintree Johnson (Feb. 6), I should like to report an apparently unrecognised syndrome, which I call " thoracomarginal chondrodynia ". I have seen 15 cases characterised by acute or dull pain in the region of the costal arch (left or right) with localised tenderness over the end of a fluctuating rib cartilage (10th or llth). The cause is apparently a local irritation, probably due to compression-sometimes by bowed posture. Anxiety seems to contribute. I have used local anaesthetics or common analgesics together with reassurance as to the non-malignancy of the condition, which has then subsided after some time. Since some of these patients have been referred to me by colleagues as abdominal cases of obscure origin, I think it may be useful to keep this condition in mind. Centrallasarettet, S.-G. S. G. SJÖBERG. SJÖBERG. Eskilstuna, Sweden. S.-G. SIR,-In my opinion Mr. Daintree Johnson is right. I see many cases of subcostal and intercostal pain which in my opinion are due to protrusions of thoracic intervertebral disc substance. My treatment is aimed at reducing the protrusion by manipulation without anaesthesia, or by spinal traction. If the reduction is not stable, I inject a dextrose sclerosantinto the supporting ligaments of the joint on three occasions. The results are very satisfactory in some, but the stability in others is unsatisfactory. It is a treatment well worth trying. R. C. B. BARBOR. London, W.l. INAPPROPRIATE SECRETION OF VASOPRESSIN SIR,-Dr. Lee and his colleaguesreported a case of carcinoma of the lung with inappropriate secretion of
vasopressin (Schwartz-Bartter syndrome). Since January, 1964, we have studied five similar patients with bronchogenic oat-cell carcinoma. In the urine of the first patient,2 Dr. N. A. Thorn (Copenhagen) found high antidiuretic activity (1-8 LU. of vasopressin per 24 hours), at a time when plasma-osmolality was very low (245 mosmoles per kg. water). In the second patient,3 extracts of the tumour and its metastases were made, using the technique described by Amatruda et awl.and relatively high antidiuretic activity was found. A bronchogenic carcinoma of the malpighian type in a patient showing no clinical evidence of Schwartz-Bartter’s syndrome served as a control: no antidiuretic activity was found in this tumour. The substance present in the first tumour had the following activities, expressed as milliunits per mg. of acetone powder: antidiuretic activity in the rat, 7; vasopressor effect in the rat, 56; milk-ejecting potency in the rabbit, 1-3. These activities, which were all suppressed by treatment with thioglycollate, are in the ratio 100/80/19. The activity-ratio for argininevasopressin in the same tests is 100/100/18. These results suggest that vasopressin (or another peptide with a very similar pharmacological profile), but not oxytocin,s was present in the tumour. 1. Lee, J., Jones, J. J., Barraclough, M. A. Lancet, 1964, ii, 792. 2. de Sousa, R. C., Delaere, J., Thaon, A., Rudler, J. C., Mach, R. S. Schweiz. med. Wschr. 1964, 94, 1805. 3. Delaere, J., de Sousa, R. C., Rudler, J. C., Mach, R. S. Pr. méd. 1965,
73, 109. 4. Amatruda, T. T., Jr., Mulrow, P. J., Gallagher, J. C., New Engl. J. Med. 1963, 269, 544. 5. de Sousa, R. C- Berde, B., Mach, R. S. Unpublished.
Sawyer,
W. H.