- Email: [email protected]
SEROLOGICAL DIAGNOSIS OF ANTHRAX
430
practitioner tincture of cannabis, which he mainlined, giving him a beautiful buzz ". There are, of course, many other drugs bought and sold on the black market-many drug-addicts now are using anything they can get hold of. Apart from the ones mentioned so far, there are the stimulantsRitalin’ (methylphenidate) and amphetamine powder; and apparently also many’Physeptone(methaddone) ampoules are also bought and sold daily on Piccadilly. (Incidentally, the black-market price of all these drugs is much higher at weekends.) Apparently, many people have gone off L.S.D. because they are afraid of its dangers. Obviously problems such as drug-addiction will not be solved by just clamping down on prescribing of certain
from yet another
"
Research into the factors causing addiction is vital. However, reducing the availability of known highly dangerous drugs is still very important as a prophylactic step, despite the risk of their replacement by substitutes. Therefore, one should not wait again-as in the case of heroin and cocaine and methylamphetamine in the pastfor Law and Authority to step in. Doctors should certainly reduce the availability of the barbiturates by more judicious and moderate prescribing. Medical practitioners have become possibly the greatest danger on the British drug scene, having formerly constituted an often under-estimated menace for the middle-aged.4 St. Bernard’s Hospital, M. M. GLATT. Southall, Middlesex.
is the case in individuals with no past history of exposure; thus retrospective confirmation is still possible. In conclusion we should like to stress the fact that although the incidence of anthrax amongst workers in the wool and hide industries is decreasing 10 as a result of disinfection and vaccination programmes, infection-rates outside these trades-e.g., in gardening enthusiasts-has remained steady. Whilst it is not suggested that vaccination should be extended beyond those industries primarily at risk, at least a method now exists whereby a positive diagnosis can be made in patients who have been given antibiotics before the true nature of the condition is
suspected. Research Establishment, Porton Down, Wilts.
Microbiological
drugs.
SEROLOGICAL DIAGNOSIS OF ANTHRAX SIR,-It is not always possible to isolate the anthrax bacillus from patients with a clinical diagnosis of cutaneous anthrax.56 Frequently such patients start antibiotic therapy before swabs are taken, and the lesion rapidly becomes sterile, despite progressive extension of necrosis and oedema caused by residual toxin. There are obvious reasons why laboratory confirmation of diagnosis is desirable, however, and we here report a case in which, for the first time to our knowledge, this was achieved by detecting the presence of toxin-neutralising antibodies in the serum. The patient, a 47-year-old female operative in a fertiliser factory, developed a lesion beneath the left angle of the jaw. Despite massive treatment with penicillin and tetracycline the lesion progressed to gross oedema of the face, neck, and mantle, necessitating tracheostomy, and, ultimately, skin-grafting of the central necrotic area. Repeated cultures of the primary lesion, satellite vesicles, and blood were negative. Serum was submitted for investigation 18 days after the appearance of the lesion, and toxin-neutralising antibody was demonstrated to a titre of 1 in 2 by the in-vitro method of Thorne and Beltonand by the in-vivo method of Darlow et al.A sample taken six months later was also positive, but subsequent samples have remained negative. In the experience of one of us (H. M. D.), antibodies are rare in treated, uncomplicated cases of cutaneous anthrax, though a very similar case to the above, exhibiting much oedema and necrosis, was recently investigated with positive findings (titre 1 in 8). Probably the presence of antibody in these two cases was attributable to an excess of toxin factor i (oedema factor), which was shown by Stanley and Smith9 to enhance the activity of factor n, the principal immunogenic component of anthrax toxin. Uncomplicated cases, however, tend to develop antibodies after a single subsequent dose of vaccine, instead of after three doses, as 4. Glatt, M. M. Bull. Narcot. 1962, 14, 20. 5. Evans, N. A. P. Lancet, 1967, ii, 716. 6. Taylor, L., Carslaw, R. W. ibid, 1967, i, 1214. 7. Thorne, C. B., Belton, F. C. J. gen. Microbiol. 1957, 17, 504. 8. Darlow, H. M., Belton, F. C., Henderson, D. W. Lancet, 1956, 476. 9. Stanley, J. L., Smith, H. J. gen. Microbiol. 1962, 31, 329.
ii,
Royal Postgraduate Medical School London W12.
H. M. DARLOW.
N. B. PRIDE.
CLONIDINE FOR MIGRAINE SIR,-Professor Zaimis and Dr. Hanington (Aug. 9, p. 298) have drawn attention to the possible use of ’ST 155’ (clonidine, ’Catapres ’) in the treatment of migraine. We have been using ST 155 in the migraine clinic at the Elizabeth Garrett Anderson Hospital since February, 1969, and we have now treated 31 patients. 9 were admitted to hospital so that frequent blood-pressure recordings could be made both before and for at least five days after treatment was started. All our patients were normotensive, and no significant blood-pressure alterations were noted with the dose of ST 155 used, which was approximately 1 g. per kg body-weight daily. Our maximum dosage has been 150 g. daily. The ages of the patients ranged from 17
to 78 years. Of the 31 patients treated, 20
improved substantially,
1 improved slightly, 7 were unchanged, and 3 were worse. The longest time any patient has been on ST 155 is five months and the shortest time four weeks.
The patients on treatment who improved reported that their headaches, if they occurred, were less frequent, less severe, and more amenable to their usual " attack " therapy -e.g., analgesics or ergotamine preparations. Several of the patients said that their head felt " clearer ", and less "
"
muzzy
or
"
woolly ".
The patients selected for treatment with ST 155 were those who complained of frequent severe headaches which had proved unresponsive to other forms of therapy. Thus, in this preliminary assessment, ST 155 appears to have provided encouraging results as a treatment for migraine. A full-scale clinical trial is planned, and it is hoped that this will confirm these early results, although it must be remembered that in a condition such as migraine any new treatment is likely to give good results at first. Elizabeth Garrett Anderson Hospital, MARCIA WILKINSON. London N.W.1.
DECLOTTING SCRIBNER SHUNTS SIR,-The article by Dr. Gaan and his colleagues (July 12, p. 77) and the subsequent correspondence, seem to indicate that injection of saline into the arterial limb is a common practice in declotting Quinton-Scribner shunts. Apart from the well-recognised danger of cerebrovascular complications, we have found that the upward dislodgement of even a small length of clot through the tapered vessel tip often produces a " ball-valve " thrombus which cannot be aspirated. We believe that there is no place for the forcible injection of saline into arterial cannulae used for dialysis. Experience suggests that the traditional shunt with its U-loop and step can be superseded bv the straight can10. H.M. Chief Inspector of Factories. Annual H.M. Stationery Office.
Report for 1967; p. 93.
practitioner tincture of cannabis, which he mainlined, giving him a beautiful buzz ". There are, of course, many other drugs bought and sold on the black market-many drug-addicts now are using anything they can get hold of. Apart from the ones mentioned so far, there are the stimulantsRitalin’ (methylphenidate) and amphetamine powder; and apparently also many’Physeptone(methaddone) ampoules are also bought and sold daily on Piccadilly. (Incidentally, the black-market price of all these drugs is much higher at weekends.) Apparently, many people have gone off L.S.D. because they are afraid of its dangers. Obviously problems such as drug-addiction will not be solved by just clamping down on prescribing of certain
from yet another
"
Research into the factors causing addiction is vital. However, reducing the availability of known highly dangerous drugs is still very important as a prophylactic step, despite the risk of their replacement by substitutes. Therefore, one should not wait again-as in the case of heroin and cocaine and methylamphetamine in the pastfor Law and Authority to step in. Doctors should certainly reduce the availability of the barbiturates by more judicious and moderate prescribing. Medical practitioners have become possibly the greatest danger on the British drug scene, having formerly constituted an often under-estimated menace for the middle-aged.4 St. Bernard’s Hospital, M. M. GLATT. Southall, Middlesex.
is the case in individuals with no past history of exposure; thus retrospective confirmation is still possible. In conclusion we should like to stress the fact that although the incidence of anthrax amongst workers in the wool and hide industries is decreasing 10 as a result of disinfection and vaccination programmes, infection-rates outside these trades-e.g., in gardening enthusiasts-has remained steady. Whilst it is not suggested that vaccination should be extended beyond those industries primarily at risk, at least a method now exists whereby a positive diagnosis can be made in patients who have been given antibiotics before the true nature of the condition is
suspected. Research Establishment, Porton Down, Wilts.
Microbiological
drugs.
SEROLOGICAL DIAGNOSIS OF ANTHRAX SIR,-It is not always possible to isolate the anthrax bacillus from patients with a clinical diagnosis of cutaneous anthrax.56 Frequently such patients start antibiotic therapy before swabs are taken, and the lesion rapidly becomes sterile, despite progressive extension of necrosis and oedema caused by residual toxin. There are obvious reasons why laboratory confirmation of diagnosis is desirable, however, and we here report a case in which, for the first time to our knowledge, this was achieved by detecting the presence of toxin-neutralising antibodies in the serum. The patient, a 47-year-old female operative in a fertiliser factory, developed a lesion beneath the left angle of the jaw. Despite massive treatment with penicillin and tetracycline the lesion progressed to gross oedema of the face, neck, and mantle, necessitating tracheostomy, and, ultimately, skin-grafting of the central necrotic area. Repeated cultures of the primary lesion, satellite vesicles, and blood were negative. Serum was submitted for investigation 18 days after the appearance of the lesion, and toxin-neutralising antibody was demonstrated to a titre of 1 in 2 by the in-vitro method of Thorne and Beltonand by the in-vivo method of Darlow et al.A sample taken six months later was also positive, but subsequent samples have remained negative. In the experience of one of us (H. M. D.), antibodies are rare in treated, uncomplicated cases of cutaneous anthrax, though a very similar case to the above, exhibiting much oedema and necrosis, was recently investigated with positive findings (titre 1 in 8). Probably the presence of antibody in these two cases was attributable to an excess of toxin factor i (oedema factor), which was shown by Stanley and Smith9 to enhance the activity of factor n, the principal immunogenic component of anthrax toxin. Uncomplicated cases, however, tend to develop antibodies after a single subsequent dose of vaccine, instead of after three doses, as 4. Glatt, M. M. Bull. Narcot. 1962, 14, 20. 5. Evans, N. A. P. Lancet, 1967, ii, 716. 6. Taylor, L., Carslaw, R. W. ibid, 1967, i, 1214. 7. Thorne, C. B., Belton, F. C. J. gen. Microbiol. 1957, 17, 504. 8. Darlow, H. M., Belton, F. C., Henderson, D. W. Lancet, 1956, 476. 9. Stanley, J. L., Smith, H. J. gen. Microbiol. 1962, 31, 329.
ii,
Royal Postgraduate Medical School London W12.
H. M. DARLOW.
N. B. PRIDE.
CLONIDINE FOR MIGRAINE SIR,-Professor Zaimis and Dr. Hanington (Aug. 9, p. 298) have drawn attention to the possible use of ’ST 155’ (clonidine, ’Catapres ’) in the treatment of migraine. We have been using ST 155 in the migraine clinic at the Elizabeth Garrett Anderson Hospital since February, 1969, and we have now treated 31 patients. 9 were admitted to hospital so that frequent blood-pressure recordings could be made both before and for at least five days after treatment was started. All our patients were normotensive, and no significant blood-pressure alterations were noted with the dose of ST 155 used, which was approximately 1 g. per kg body-weight daily. Our maximum dosage has been 150 g. daily. The ages of the patients ranged from 17
to 78 years. Of the 31 patients treated, 20
improved substantially,
1 improved slightly, 7 were unchanged, and 3 were worse. The longest time any patient has been on ST 155 is five months and the shortest time four weeks.
The patients on treatment who improved reported that their headaches, if they occurred, were less frequent, less severe, and more amenable to their usual " attack " therapy -e.g., analgesics or ergotamine preparations. Several of the patients said that their head felt " clearer ", and less "
"
muzzy
or
"
woolly ".
The patients selected for treatment with ST 155 were those who complained of frequent severe headaches which had proved unresponsive to other forms of therapy. Thus, in this preliminary assessment, ST 155 appears to have provided encouraging results as a treatment for migraine. A full-scale clinical trial is planned, and it is hoped that this will confirm these early results, although it must be remembered that in a condition such as migraine any new treatment is likely to give good results at first. Elizabeth Garrett Anderson Hospital, MARCIA WILKINSON. London N.W.1.
DECLOTTING SCRIBNER SHUNTS SIR,-The article by Dr. Gaan and his colleagues (July 12, p. 77) and the subsequent correspondence, seem to indicate that injection of saline into the arterial limb is a common practice in declotting Quinton-Scribner shunts. Apart from the well-recognised danger of cerebrovascular complications, we have found that the upward dislodgement of even a small length of clot through the tapered vessel tip often produces a " ball-valve " thrombus which cannot be aspirated. We believe that there is no place for the forcible injection of saline into arterial cannulae used for dialysis. Experience suggests that the traditional shunt with its U-loop and step can be superseded bv the straight can10. H.M. Chief Inspector of Factories. Annual H.M. Stationery Office.
Report for 1967; p. 93.