BRITISH MEDICAL JOURNAL
6 OCTOBER 1979
871
NEWS AND NOTES
V"iews Minerva sometimes wonders how and why research workers embark on their projects. Why, for example, did two Boston surgeons decide to study the incidence of bacteraemia after defecation (Archives of Surgery, 1979, 114, 937) ? They collected 82 volunteers and took blood cultures five minutes before and 15 minutes after defecation. Only two of the 328 cultures grew micro-organisms, and in both cases it was a skin commensal.
However self-interested the advice from the British Small Animal Veterinary Association that the elderly should be encouraged to keep pets, the reasoning seems sound. Apart from companionship, pet ownership encourages old people to go shopping for food and to keep at least one room reasonably warm. Meanwhile the anti-dog campaigners can point to the rising numbers of reports of toxocariasis. The Center for Disease Control in Atlanta has recently reported the prevalence in the American population of seropositivity to Toxocara antigens as varying from 0O() to 130), with highest values in black children from the southern states. A report in the Journal of the American Medical Association (1979, 242, 1343) quotes two New York vets (and vets are normally reassuring propagandists) who are concerned not only about loss of eyes but also about deaths from larval-induced encephalitis or myocarditis. Horse riding for the disabled is not, it seems, a peculiarly British concept: it is catching on fast in North America too. An article in the "Canadian Medical Association Journal" (1979, 121, 631) credits the great eighteenth century physician Boerhaave with the popularisation of horse riding for invalids and claims that Aesculapius
and Galen were also enthusiasts.
Infant mortality in London in the eighteenth century was over 600,, and much of this must have been due to gastrointestinal infections (American J7ournal of Diseases of Children, 1979, 133, 779). When glass feeding bottles were introduced in the 1840s their transparency made plain the difficulties of keeping them clean. No wonder so.many babies had died from use of casually rinsed pottery, pewter, or silver pap boats and nursing bottles. The crucial advance came in 1884 when Ferdinand Hueppe devised an apparatus for sterilising milk and bottles in a steam bath. But how many third-world mothers today have adequate facilities ?
Despite having introduced compulsory vaccination of all infants with oral polio vaccine in 1965, the Egyptian health authorities have not yet managed to control the disease. Last year, says the WHO Weekly Epidemiological Record (No 37), there was an increase in cases over 1977, with nearly 1000 patients seen at the Imbada poliomyelitis institute. Vaccination histories showed that most affected children had not been reached by the "compulsory" programmeo.
Dogs have been shown to be more likely to survive heatstroke if they have first been treated with antibiotics (Aviation, Space, and Environmental Medicine, 1979, 50, 816). The explanation seems to be that one of the complications of heatstroke is endotoxaemia, and that this can be prevented by prior reduction of the intestinal bacterial population. The most common late cause of death after injury to the spinal cord is still chronic renal failure, says D G Thomas in his review in the "Practitioner" (1979, 223, 339). Obsessional concern with urological problems remains the key to long-term survival of these patients.
generation.
Changes in affect are well-recognised features of multiple sclerosis, but presentation of the disease as an acute psychosis is less familiar (7ournal of Neurology, Neurosurgery, and Psychiatry, 1979, 42, 859). Three young women seen recently in Oxford had developed bizarre mental and physical behaviour thought at first to be due to schizophrenia (two cases) or hypomania. In each case recovery was complete and only with the recurrence of symptoms did the diagnosis of multiple sclerosis become obvious.
Forensic scientists at the Home Office Central Research Establishment are looking at ways of sexing bloodstains and the timing of last intercourse from vaginal swabs. These examples from the establishment's annual report show that whatever dents may have appeared in the reputation of British criminal justice the boffins are determined to maintain their top ranking in the international league.
In patients with low back pain a raised protein concentration in the cerebrospinal fluid may be a pointer to a disc lesion. But a study in Finland reported in "Acta Neurologica Scandinavica" (1979, 60, 93) found that only 6 out of 28 patients with acute lumbar disc prolapse had clearly abnormal protein values, so the exclusion value of the test seems nil. MINERVA
An American family with 10 members who have suffered from renal-cell carcinoma turns out to have a chromosome aberration-a balanced translocation between chromosomes 3 and 8 evidently conferring a high risk of the cancer (New England Journal of Medicine, 1979, 301, 592 and 606). This is the first example of a dominantly inherited aberration associated with a particular cancer, and with prenatal diagnosis it will clearly enable the carcinoma to be prevented in the next
BRITISH MEDICAL JOURNAL
872
6 OCTOBER 1979
EPIDEMIOLOGY Leptospirosis in man, British Isles, 1978 J
D COGHLAN
Sixty-five cases of leptospirosis were confirmed in 1978 by the Leptospira Reference Laboratory of the Public Health Laboratory Service. Sixty-one of these were probably acquired in the British Isles-42 in England, two in Wales, 10 in Scotland, and seven in Eire. Cases were reported in all age groups but were most common in the working population. The preponderance of men over women is due to the occupations mainly affected (table).
the British Isles. During recent years in Britain the Hebdomadis serogroup has accounted for more human cases of leptospirosis than any other.
Hebdomadis serogroup This serogroup contains at least 27 serotypes, subdivided on the basis of antigenic
Occupational group or likely source of infection and ser Occupational group or likely source Miners Farmers, unspecified .. (farm workers) .. Pig farmers Dairy and cattle farmers .. Abattoir workers .. Meat inspector.. .. .. Veterinarian Contact with sewage .. Immersion in or contact with polluted water .. .. Contact rats (direct) .. .. Contact dog .. Acquired abroad Trader (street market) .. .. Not known Total
Hebdomadis sejro6 hebdomadis 7
17 2 1
Serogroup Icterohaemorrhagiae
Canicola
Australis
1
1
6 3 1
13 3 18 2 1 1 3
1 2
1
4
4
2
2
1
2 4 1 10
1
65
2 2
1 1 4
2
2
26
5
4 31
The table also shows the results of serological tests on the patients; the infecting strains belonged to four of the 16 recognised leptospiral serogroups-namely, hebdomadis icterohaemorrhagiae (40°0%), (50 8%), canicola (7-70o), and australis (15%o).
Classification of leptospira On the recommendation of the subcommittee on the taxonomy of leptospira at its meeting in Munich in 1978 (to be published), two species have been recognised within the genus Leptospira-L biflexa, which includes the saprophytic serotypes (serovars) commonly found in water, and L interrogans, which comprises the parasitic and potentially pathogenic serotypes that cause leptospirosis of animals and man. Within the species L interrogans over 160 different serotypes have been identified. These are indistinguishable morphologically, culturally, and physiologically but may be differentiated by agglutination and agglutinin-absorption tests or by antigenic factor analysis.' Serological studies have shown antigenic relationships among the serotypes that allow them to be grouped together into serogroups. There are at least 16 such serogroups of pathogenic leptospires.' Strains representing nine of these serogroups have been isolated from man or wild and domestic animals in Leptospira Reference Laboratory, Public Health Laboratory Service, Colindale J D COGHLAN, PHD, director
Total
analysis, as suggested by Dikken and Kmety,3 into three or more groups. Hebdomadis contains nine serotypes closely related to the reference strain hebdomadis of serotype hebdomadis. Sejroe contains at least 12 serotypes, of which sejrod, saxkoebing, and hardjo have been isolated in the British Isles; and mini has six representative serotypes allied to mini, a serotype named after the Italian worker Mino.4 The first outbreak in Britain of human leptospirosis due to strains of the hebdomadis serogroup was reported by Saluka and Moore.5 They investigated four cases of anicteric febrile illness in cowmen who worked in two dairy farms in Surrey. The infections had apparently originated from infected cattle. Since then many cases of human leptospirosis of this nature have been diagnosed serologically in various parts of the country; all of them appeared to be infections of the sejroe subgroup of the hebdomadis serogroup, and were probably acquired from infected cattle. Thus Johnston et al5 reported on an outbreak of leptospirosis with meningeal symptoms in farm staff on two farms in the south-west of Scotland, where high antibody titres against the hebdomadis serogroup were demonstrated in cattle as well as in patients' sera. In 1978 strains of this serogroup accounted for just over half of the total number diagnosed in the British Isles. All of these strains, with the exception of two from imported cases, were of subserogroup sejroe. Most patients were farmers or abattoir workers. The main clinical features of the disease were its abrupt onset with fever and myalgia, temporary improvement after two to three days, relapse
after one to two days with more severe symptoms suggestive of meningitis, sometimes renal and (less often) hepatic disturbances, and prolonged convalescence. The cases of hebdomadis infection occurred sporadically over most of the country from Scotland to the south of England. Outbreaks of two or three cases occurred on individual farms in the north of England, where serological evidence of infection by strains of the same subserogroup was found in a high percentage of cows tested. Transmission of infection from cows to dairy workers probably occurs during the milking process, either through skin contact with infected cows' urine or milk or through inhalation of infectious droplets of urine or milk in the confines of the milking shed. We do not yet know what proportion of the population at risk through working with infected animals become infected, or whether infection invariably causes illness or may remain subclinical. Leptospires belonging to the hebdomadis serogroup have not yet been isolated from human patients in the British Isles, and diagnosis has had to be made on the basis of serological tests, which often fail to identify the serotype of the infecting strain. To confirm that the human and cattle strains are identical it will be necessary to obtain human isolates by culturing the blood of suspected cases during the leptospiraemic phase in the first weeks of illness. The human and animal isolates could then be compared by agglutininabsorption tests with rabbit hyperimmune sera or by antigenic factor analysis. Serological tests reported by Michna, Ellis and Michna,' and Ellis et ala have shown that many cattle in Scotland and Northern Ireland have been infected by strains of the hebdomadis serogroup, and Scott Orr and Little'9 reported that 42 20o of 187 sera of cattle taken at a local abattoir in England had significantly high levels of antibodies to serotype hardjo. Clinical illness in cows in England manifested by mastitis and transient fever was reported by Howell et all" in cows that were serologically positive in tests for the hebdomadis serogroup. Ellis et al" were the first to report the successful isolation of leptospires belonging to that serogroup from the milk and blood of cows in a herd where 70 of the 140 animals had clinical mastitis. The first successful isolation of leptospires from the aqueous humour of an aborted bovine fetus was also reported by Ellis et al.9 The strain was found to belong to the hebdomadis serogroup and to be closely related to serotype
harjdo. Scott Orr and Little'0 report the successful isolation of 13 strains of leptospira from 200 bovine kidneys collected from apparently normal animals in an abattoir in England. All strains appeared to be identical and one of them was identified as serotype hardjo by antigenic factor analysis carried out by Kmety at the Institute of Epidemiology, Komensky University, Bratislava, Czechoslavakia. Strains of the hebdomadis (sejroe)
BRITISH MEDICAL JOURNAL
have been isolated from small wild mammals, voles, field mice, and hedgehogs in Britain and shown to belong to serotypes sejrod, hardjo, and saxkoebing.5 It is not clear whether cattle become infected through grazing in fields contaminated by the urine of these reservoir hosts, or whether the cattle are the principal carriers of the infection. Cattle isolates have usually been identified as belonging to serotype hardjo.
serogroup
Icterohaemorrhagiae
873
6 OCTOBER 1979
serogroup
canicola infection acquired it from contact with dogs, though only two of them are known to have had such contact.
BMA NOTICES Central Meetings
Australis
OCTOBER
serogroup
Leptospires of the australis serogroup are carried by hedgehogs and field mice in Britain, but the one human case that was diagnosed in 1978 was in a 27-year-old man who acquired the infection while on safari in the Sudan.
Hospital Junior Staff Committee, 10 am. Scottish Joint Consultants Committee (7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.15 am. 10 Wed BMA Council Executive, 10 am. 10 Wed Rheumatology and Rehabilitation Group Committee, 2 pm. 11 Thurs Scottish General Medical Services Committee (7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.30 am. 12 Fri Board of Science and Education, 10.30 am. 16 Tues Joint Consultants Committee (BMA House, Tavistock Square, London WC1H 9JP), 9.30 am. 17 Wed Negotiating Subcommittee (CCHMS), 10 9 Tues 9 Tues
Twenty-six cases of icterohaemorrhagiae infection were confirmed in the British Isles References am. during 1978, seven of which occurred in the Scottish Council (7 Drumsheugh Gardens, Kmety, E, Thesis, Factor analysis of Leptospires of 17 Wed Republic of Ireland. Ten (380 ) were in EH3 7QP), 10.45 am. Edinburgh the Icterohaemorrhagiae and certain related sero- 17 Wed Membership and Communications Subfarmers, three of whom were pig farmers. groups. Bratislava, Slovak Academy of Sciences, committee (CCHMS), pm. 1967. Those three infections were probably derived 2 World 18 Thurs General Medical Committee, 10 am. Health Organisation, World Health Organisa- 18 Thurs General PurposesServices Subcommittee (CCHMS), from rats rather than the pigs since no illness tion Technical Report Series, 1967, no 380, p 7. 10 am. 3 Dikken, H, and Kmety, E, in Methods in Microin the pigs was reported. Six of the patients 18 Thurs 10.15 am. Organisation Committee, biology, vol 11, ed T Bergan and J R Norris, p 268. had probably acquired infection through New York, Academic Press, 1978. 4 Mino, P, Mi*nchener Medizinische Wochenschrift, contact with contaminated water or through Division Meetings 1941, 88, 96. swimrriing or accidental immersion in water 6 Saluka, A, and Moore, W, British Medical journal, Members proposing to attend meetings marked * are asked 1969, 1, 226. recently contaminated with rats' urine. Two 6 Johnston, W G, Orr, J P, and Wright, C L, Veterinary to notify in advance the honorary secretary concerned. others were thought to be due to direct 7 Record, 1978, 102, 267. Blackburn-At Montague Health Centre, Tuesday, Michna, S W, Veterinary Record, 1971, 88, 384. contact with rats. Ellis, W A, and Michna, S W, Veterinary Record, 9 October, 8 pm, general meeting. 1
1976, 99, 387. Ellis, W A, et al, Veterinary Record, 1976, 99, 458. Scott Orr, H, and Little, T W A, in press. Howell, D, et al, Veterinary Record, 1969, 84, 122. "Ellis, W A, et al, Veterinary Record, 1976, 99, 368. 13 Twigg, G I, Hughes, D M, and McDiarmid, A, Veterinary Record, 1972, 90, 598. 10
Canicola
serogroup
Probably all five patients who suffered from
MEDICAL NEWS
ness
Anglo-French medical exchange bursaries
SOCIETIES AND LECTURES
University Department of Medical Biophysics, BlackLaboratory, Dundee DD1 4HN. (Tel Dundee ext 503.)
23181
attending lctures marked a fee is charged or a ticket Applications are invited before 31 October For is required. Applications should be made first to the institutions concerned. for bursaries to be awarded in 1980 to young British clinical research workers under an Monday, 8 October exchange scheme between the Institut National ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, Mr G Keen: Operative surgery of benign and malignant de la Sante et de la Recherche Medicale in oesophageal lesions.* Paris and the Ciba Foundation in London. The value of the grant is 3960 NF a month, Tuesday, 9 October tax free (less about 225 NF for insurance), INSrITUTE OF CHILD HEALTH-5.30 pm, Alex Simpson Smith lecture by Mr V A J Swain: Children's surgery and they will be awarded for one to four months -a glimpse into the past. for clinical experience or research in France. RoYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, Sir Stanford Cade memorial lecture by Mr G J Hadfield: Preference will normally be given to candidates Carcinoma of the breast. who hold teaching posts or are in positions where they can pass on the experience they Wednesday, 10 October OF NEUROLOGY-Sandoz Foundation have acquired. Application forms may be INSTITUTE advanced lectures, 6 pm, Professor Sir Andrew Huxley, FRS: Activation and contraction in striated obtained from the foundation, 41 Portland muscle. 7 pm, Professor J A Simpson: Muscle Place, London WlN 4BN (01-636 9456). disorders after infancy. *
COMING EVENTS International Symposium on Gastrointestinal Hormones-15-18 September, Cambridge. Details from Dr S R Bloom and Dr Julia M Polak, Royal Postgraduate Medical School, Ducane Road, London W12 OHS. Closing date for receipt of abstracts 31 March 1980. National Association for the Welfare of Children in Hospital-Annual conference, "Up to 1 year old in the inner city," 30 October, London. Details from the association, 7 Exton Street, London SE1 8UE. (Closing date for applications 12 October.) British Association for PsychopharmacologySymposium "The psychopharmacology of alcohol," 22-23 November, London. Details from Dr David Wheatley, 325 Staines Road, Twickenham TW2 5AX. (Tel 01-894 2722.) National Association for Mental Health-Conference "Mental health and meditation," 1 December, London. Details from Charles Patmore, MIND, 22 Harley Street, London WIN 2ED. (Tel 01-637 0741.) Society for Radiological Protection-Details of two meetings, "Hazard control and planning in the working environment," 22 January 1980, London; and "Emergency arrangements-planning and practice," 22 April 1980, London, are available from Professor J H Martin,
Third
INSTITUTE OF ORTHOPAEDICS-6 pm, Dr Doreen Browne: Systemic effects of major injury-lung. 7 pm, Professor B McKibbin: Pathology of fracture healing. NORTHWICK PARK LECTURES IN CLINICAL SCIENCE4.30 pm, Professor W S Peart, FRS: Hormones and the kidney. ROYAL COLLEGE OF SURGEONS OF EDINBURGH-4.30 pm, Mr I T Macphee: The enigma of periodontology. ROYAL COLLEGE OF SURGEONS OF ENGLAND-5.15 pm, Mr I M Hill: Principles of heart surgery.* 6.30 pm, Professor J P Mitchell: Trauma of the urinary tract.*
Thursday, 11 October ROYAL COLLEGE OF PHYSICIANS OF LONDON-5 pm, Teale lecture by Professor J A Davis: The aftereffects of birth asphyxia. ROYAL COLLEGE OF SURGEONS OF ENGLAND-6.30 pm, Professor M Hobsley: Salivary gland swellings.* WEST OF SCOTLAND COMMITTEE FOR POSTGRADUATE MEDICAL EDUCATION CENTRE FOR MEDICAL WOMEN9.30 am, Professor F I Caird: The future of geriatrics. Friday, 12 October INSTITUTE OF LARYNGOLOGY AND OTOLOGY-4.30 pm, annual address, Sir Frank Hartley: Interdisciplinary influences-stimulus or distraction ? ROYAL COLLEGE OF PHYSICIANS OF LoNDON-4 pm, Charles West lecture by Professor C E Stroud: Sickle-cell anaemia: a growing problem. ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, Mr P Bewes: Surgery in the tropics.*
Bromley-At Farnborough Hospital Postgraduate Centre, on Friday, 19 October, 7.45 pm, wine tasting evening for members and guests.* Burton upon Trent and District-At Bretby Golf Club, Wednesday, 24 October, 1 pm, golf tournament followed by meal at Stanhope Arms Hotel at 7 pm.* Coventry-At Rolls-Royce Ltd, Parkside, Tuesday, 9 October, 7.30 pm, sherry, buffet supper, film show, and tour of factory.* (Husbands/wives invited.) Dartford, Gravesend, and Medway-At St Bartholomew's Hospital, Rochester, Tuesday, 6 November, 8.30 pm, agm. Doncaster-At Doncaster Royal Infirmary, Wednesday, 17 October, 7.30 for 8 pm, dinner meeting, speaker Mr John Randall: "Pensions and superannuation."6 East Yorkshire-At Holy Trinity Church, Hull, Thursday, 18 October, 12.30 pm, commemorative service, St Luke's Day. Fife-At Station Hotel, Kirkcaldy, Tuesday, 9 October, 7 for 7.30 pm, dinner/lecture, speaker Professor J D E Knox: "On moving house-general practice and the health centre."` Redbridge and Stratford-At King George Hospital, Ilford, Wednesday, 10 October, AGM. St Marylebone and North-east Westminster and Paddington-At BMA House, Thursday, 11 October, 6 for 7 pm, AGM, followed by buffet dinner.* Trent North Hospital Junior Staff Committee-
At Hallamshire Hospital, Wednesday, 10 October,
5.30 pm, agm. Wakefield-At Milford Hall Country Club, Friday, 12 October, 7.30 for 8 pm, annual dinner dance.* (Guests are invited.) Walsall-At Three Crowns Inn, Sutton Road, Walsall, Wednesday, 10 October, 7.30 for 8 pm, Mr P A Lapworth, vice-principal, West Midlands College, Walsall, on education.* (Hot buffet provided.) Guests
invited.* West Herts-At the Rose and Crown, 60 High Street, Kings Langley, Herts, Tuesday, 16 October, 8 pm, agm. Mr Norman Ellis, the BMA's senior
are
industrial relations officer will attend. Worcester and Bromsgrove-At Ronkswood Hospital, Saturday, 13 October, 2.15 pm, symposium "The clinical and economic problems of chronic renal
failure."*
UNIVERSITIES AND COLLEGES LONDON Dr Wallace Fox has had the title of professor of community therapeutics conferred on him in respect of his post at the Cardiothoracic Institute.
CONSULTANT APPOINTMENTS BIRMINGHAM AHA(T)-Dr I
J
F
Morle, Dr E B Rolfe
(radiologists). HAMPSHIRE AHA-Mr P B Ashcroft (ENT and research
otology). WESSEx RHA-Dr P R W Lanham (anaesthetist).
tD
British Medical Journal 1979
All Rights Reserved. No part of this publication may be
reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the British Medical_Journal.
6 OCTOBER 1979
871
NEWS AND NOTES
V"iews Minerva sometimes wonders how and why research workers embark on their projects. Why, for example, did two Boston surgeons decide to study the incidence of bacteraemia after defecation (Archives of Surgery, 1979, 114, 937) ? They collected 82 volunteers and took blood cultures five minutes before and 15 minutes after defecation. Only two of the 328 cultures grew micro-organisms, and in both cases it was a skin commensal.
However self-interested the advice from the British Small Animal Veterinary Association that the elderly should be encouraged to keep pets, the reasoning seems sound. Apart from companionship, pet ownership encourages old people to go shopping for food and to keep at least one room reasonably warm. Meanwhile the anti-dog campaigners can point to the rising numbers of reports of toxocariasis. The Center for Disease Control in Atlanta has recently reported the prevalence in the American population of seropositivity to Toxocara antigens as varying from 0O() to 130), with highest values in black children from the southern states. A report in the Journal of the American Medical Association (1979, 242, 1343) quotes two New York vets (and vets are normally reassuring propagandists) who are concerned not only about loss of eyes but also about deaths from larval-induced encephalitis or myocarditis. Horse riding for the disabled is not, it seems, a peculiarly British concept: it is catching on fast in North America too. An article in the "Canadian Medical Association Journal" (1979, 121, 631) credits the great eighteenth century physician Boerhaave with the popularisation of horse riding for invalids and claims that Aesculapius
and Galen were also enthusiasts.
Infant mortality in London in the eighteenth century was over 600,, and much of this must have been due to gastrointestinal infections (American J7ournal of Diseases of Children, 1979, 133, 779). When glass feeding bottles were introduced in the 1840s their transparency made plain the difficulties of keeping them clean. No wonder so.many babies had died from use of casually rinsed pottery, pewter, or silver pap boats and nursing bottles. The crucial advance came in 1884 when Ferdinand Hueppe devised an apparatus for sterilising milk and bottles in a steam bath. But how many third-world mothers today have adequate facilities ?
Despite having introduced compulsory vaccination of all infants with oral polio vaccine in 1965, the Egyptian health authorities have not yet managed to control the disease. Last year, says the WHO Weekly Epidemiological Record (No 37), there was an increase in cases over 1977, with nearly 1000 patients seen at the Imbada poliomyelitis institute. Vaccination histories showed that most affected children had not been reached by the "compulsory" programmeo.
Dogs have been shown to be more likely to survive heatstroke if they have first been treated with antibiotics (Aviation, Space, and Environmental Medicine, 1979, 50, 816). The explanation seems to be that one of the complications of heatstroke is endotoxaemia, and that this can be prevented by prior reduction of the intestinal bacterial population. The most common late cause of death after injury to the spinal cord is still chronic renal failure, says D G Thomas in his review in the "Practitioner" (1979, 223, 339). Obsessional concern with urological problems remains the key to long-term survival of these patients.
generation.
Changes in affect are well-recognised features of multiple sclerosis, but presentation of the disease as an acute psychosis is less familiar (7ournal of Neurology, Neurosurgery, and Psychiatry, 1979, 42, 859). Three young women seen recently in Oxford had developed bizarre mental and physical behaviour thought at first to be due to schizophrenia (two cases) or hypomania. In each case recovery was complete and only with the recurrence of symptoms did the diagnosis of multiple sclerosis become obvious.
Forensic scientists at the Home Office Central Research Establishment are looking at ways of sexing bloodstains and the timing of last intercourse from vaginal swabs. These examples from the establishment's annual report show that whatever dents may have appeared in the reputation of British criminal justice the boffins are determined to maintain their top ranking in the international league.
In patients with low back pain a raised protein concentration in the cerebrospinal fluid may be a pointer to a disc lesion. But a study in Finland reported in "Acta Neurologica Scandinavica" (1979, 60, 93) found that only 6 out of 28 patients with acute lumbar disc prolapse had clearly abnormal protein values, so the exclusion value of the test seems nil. MINERVA
An American family with 10 members who have suffered from renal-cell carcinoma turns out to have a chromosome aberration-a balanced translocation between chromosomes 3 and 8 evidently conferring a high risk of the cancer (New England Journal of Medicine, 1979, 301, 592 and 606). This is the first example of a dominantly inherited aberration associated with a particular cancer, and with prenatal diagnosis it will clearly enable the carcinoma to be prevented in the next
BRITISH MEDICAL JOURNAL
872
6 OCTOBER 1979
EPIDEMIOLOGY Leptospirosis in man, British Isles, 1978 J
D COGHLAN
Sixty-five cases of leptospirosis were confirmed in 1978 by the Leptospira Reference Laboratory of the Public Health Laboratory Service. Sixty-one of these were probably acquired in the British Isles-42 in England, two in Wales, 10 in Scotland, and seven in Eire. Cases were reported in all age groups but were most common in the working population. The preponderance of men over women is due to the occupations mainly affected (table).
the British Isles. During recent years in Britain the Hebdomadis serogroup has accounted for more human cases of leptospirosis than any other.
Hebdomadis serogroup This serogroup contains at least 27 serotypes, subdivided on the basis of antigenic
Occupational group or likely source of infection and ser Occupational group or likely source Miners Farmers, unspecified .. (farm workers) .. Pig farmers Dairy and cattle farmers .. Abattoir workers .. Meat inspector.. .. .. Veterinarian Contact with sewage .. Immersion in or contact with polluted water .. .. Contact rats (direct) .. .. Contact dog .. Acquired abroad Trader (street market) .. .. Not known Total
Hebdomadis sejro6 hebdomadis 7
17 2 1
Serogroup Icterohaemorrhagiae
Canicola
Australis
1
1
6 3 1
13 3 18 2 1 1 3
1 2
1
4
4
2
2
1
2 4 1 10
1
65
2 2
1 1 4
2
2
26
5
4 31
The table also shows the results of serological tests on the patients; the infecting strains belonged to four of the 16 recognised leptospiral serogroups-namely, hebdomadis icterohaemorrhagiae (40°0%), (50 8%), canicola (7-70o), and australis (15%o).
Classification of leptospira On the recommendation of the subcommittee on the taxonomy of leptospira at its meeting in Munich in 1978 (to be published), two species have been recognised within the genus Leptospira-L biflexa, which includes the saprophytic serotypes (serovars) commonly found in water, and L interrogans, which comprises the parasitic and potentially pathogenic serotypes that cause leptospirosis of animals and man. Within the species L interrogans over 160 different serotypes have been identified. These are indistinguishable morphologically, culturally, and physiologically but may be differentiated by agglutination and agglutinin-absorption tests or by antigenic factor analysis.' Serological studies have shown antigenic relationships among the serotypes that allow them to be grouped together into serogroups. There are at least 16 such serogroups of pathogenic leptospires.' Strains representing nine of these serogroups have been isolated from man or wild and domestic animals in Leptospira Reference Laboratory, Public Health Laboratory Service, Colindale J D COGHLAN, PHD, director
Total
analysis, as suggested by Dikken and Kmety,3 into three or more groups. Hebdomadis contains nine serotypes closely related to the reference strain hebdomadis of serotype hebdomadis. Sejroe contains at least 12 serotypes, of which sejrod, saxkoebing, and hardjo have been isolated in the British Isles; and mini has six representative serotypes allied to mini, a serotype named after the Italian worker Mino.4 The first outbreak in Britain of human leptospirosis due to strains of the hebdomadis serogroup was reported by Saluka and Moore.5 They investigated four cases of anicteric febrile illness in cowmen who worked in two dairy farms in Surrey. The infections had apparently originated from infected cattle. Since then many cases of human leptospirosis of this nature have been diagnosed serologically in various parts of the country; all of them appeared to be infections of the sejroe subgroup of the hebdomadis serogroup, and were probably acquired from infected cattle. Thus Johnston et al5 reported on an outbreak of leptospirosis with meningeal symptoms in farm staff on two farms in the south-west of Scotland, where high antibody titres against the hebdomadis serogroup were demonstrated in cattle as well as in patients' sera. In 1978 strains of this serogroup accounted for just over half of the total number diagnosed in the British Isles. All of these strains, with the exception of two from imported cases, were of subserogroup sejroe. Most patients were farmers or abattoir workers. The main clinical features of the disease were its abrupt onset with fever and myalgia, temporary improvement after two to three days, relapse
after one to two days with more severe symptoms suggestive of meningitis, sometimes renal and (less often) hepatic disturbances, and prolonged convalescence. The cases of hebdomadis infection occurred sporadically over most of the country from Scotland to the south of England. Outbreaks of two or three cases occurred on individual farms in the north of England, where serological evidence of infection by strains of the same subserogroup was found in a high percentage of cows tested. Transmission of infection from cows to dairy workers probably occurs during the milking process, either through skin contact with infected cows' urine or milk or through inhalation of infectious droplets of urine or milk in the confines of the milking shed. We do not yet know what proportion of the population at risk through working with infected animals become infected, or whether infection invariably causes illness or may remain subclinical. Leptospires belonging to the hebdomadis serogroup have not yet been isolated from human patients in the British Isles, and diagnosis has had to be made on the basis of serological tests, which often fail to identify the serotype of the infecting strain. To confirm that the human and cattle strains are identical it will be necessary to obtain human isolates by culturing the blood of suspected cases during the leptospiraemic phase in the first weeks of illness. The human and animal isolates could then be compared by agglutininabsorption tests with rabbit hyperimmune sera or by antigenic factor analysis. Serological tests reported by Michna, Ellis and Michna,' and Ellis et ala have shown that many cattle in Scotland and Northern Ireland have been infected by strains of the hebdomadis serogroup, and Scott Orr and Little'9 reported that 42 20o of 187 sera of cattle taken at a local abattoir in England had significantly high levels of antibodies to serotype hardjo. Clinical illness in cows in England manifested by mastitis and transient fever was reported by Howell et all" in cows that were serologically positive in tests for the hebdomadis serogroup. Ellis et al" were the first to report the successful isolation of leptospires belonging to that serogroup from the milk and blood of cows in a herd where 70 of the 140 animals had clinical mastitis. The first successful isolation of leptospires from the aqueous humour of an aborted bovine fetus was also reported by Ellis et al.9 The strain was found to belong to the hebdomadis serogroup and to be closely related to serotype
harjdo. Scott Orr and Little'0 report the successful isolation of 13 strains of leptospira from 200 bovine kidneys collected from apparently normal animals in an abattoir in England. All strains appeared to be identical and one of them was identified as serotype hardjo by antigenic factor analysis carried out by Kmety at the Institute of Epidemiology, Komensky University, Bratislava, Czechoslavakia. Strains of the hebdomadis (sejroe)
BRITISH MEDICAL JOURNAL
have been isolated from small wild mammals, voles, field mice, and hedgehogs in Britain and shown to belong to serotypes sejrod, hardjo, and saxkoebing.5 It is not clear whether cattle become infected through grazing in fields contaminated by the urine of these reservoir hosts, or whether the cattle are the principal carriers of the infection. Cattle isolates have usually been identified as belonging to serotype hardjo.
serogroup
Icterohaemorrhagiae
873
6 OCTOBER 1979
serogroup
canicola infection acquired it from contact with dogs, though only two of them are known to have had such contact.
BMA NOTICES Central Meetings
Australis
OCTOBER
serogroup
Leptospires of the australis serogroup are carried by hedgehogs and field mice in Britain, but the one human case that was diagnosed in 1978 was in a 27-year-old man who acquired the infection while on safari in the Sudan.
Hospital Junior Staff Committee, 10 am. Scottish Joint Consultants Committee (7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.15 am. 10 Wed BMA Council Executive, 10 am. 10 Wed Rheumatology and Rehabilitation Group Committee, 2 pm. 11 Thurs Scottish General Medical Services Committee (7 Drumsheugh Gardens, Edinburgh EH3 7QP), 10.30 am. 12 Fri Board of Science and Education, 10.30 am. 16 Tues Joint Consultants Committee (BMA House, Tavistock Square, London WC1H 9JP), 9.30 am. 17 Wed Negotiating Subcommittee (CCHMS), 10 9 Tues 9 Tues
Twenty-six cases of icterohaemorrhagiae infection were confirmed in the British Isles References am. during 1978, seven of which occurred in the Scottish Council (7 Drumsheugh Gardens, Kmety, E, Thesis, Factor analysis of Leptospires of 17 Wed Republic of Ireland. Ten (380 ) were in EH3 7QP), 10.45 am. Edinburgh the Icterohaemorrhagiae and certain related sero- 17 Wed Membership and Communications Subfarmers, three of whom were pig farmers. groups. Bratislava, Slovak Academy of Sciences, committee (CCHMS), pm. 1967. Those three infections were probably derived 2 World 18 Thurs General Medical Committee, 10 am. Health Organisation, World Health Organisa- 18 Thurs General PurposesServices Subcommittee (CCHMS), from rats rather than the pigs since no illness tion Technical Report Series, 1967, no 380, p 7. 10 am. 3 Dikken, H, and Kmety, E, in Methods in Microin the pigs was reported. Six of the patients 18 Thurs 10.15 am. Organisation Committee, biology, vol 11, ed T Bergan and J R Norris, p 268. had probably acquired infection through New York, Academic Press, 1978. 4 Mino, P, Mi*nchener Medizinische Wochenschrift, contact with contaminated water or through Division Meetings 1941, 88, 96. swimrriing or accidental immersion in water 6 Saluka, A, and Moore, W, British Medical journal, Members proposing to attend meetings marked * are asked 1969, 1, 226. recently contaminated with rats' urine. Two 6 Johnston, W G, Orr, J P, and Wright, C L, Veterinary to notify in advance the honorary secretary concerned. others were thought to be due to direct 7 Record, 1978, 102, 267. Blackburn-At Montague Health Centre, Tuesday, Michna, S W, Veterinary Record, 1971, 88, 384. contact with rats. Ellis, W A, and Michna, S W, Veterinary Record, 9 October, 8 pm, general meeting. 1
1976, 99, 387. Ellis, W A, et al, Veterinary Record, 1976, 99, 458. Scott Orr, H, and Little, T W A, in press. Howell, D, et al, Veterinary Record, 1969, 84, 122. "Ellis, W A, et al, Veterinary Record, 1976, 99, 368. 13 Twigg, G I, Hughes, D M, and McDiarmid, A, Veterinary Record, 1972, 90, 598. 10
Canicola
serogroup
Probably all five patients who suffered from
MEDICAL NEWS
ness
Anglo-French medical exchange bursaries
SOCIETIES AND LECTURES
University Department of Medical Biophysics, BlackLaboratory, Dundee DD1 4HN. (Tel Dundee ext 503.)
23181
attending lctures marked a fee is charged or a ticket Applications are invited before 31 October For is required. Applications should be made first to the institutions concerned. for bursaries to be awarded in 1980 to young British clinical research workers under an Monday, 8 October exchange scheme between the Institut National ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, Mr G Keen: Operative surgery of benign and malignant de la Sante et de la Recherche Medicale in oesophageal lesions.* Paris and the Ciba Foundation in London. The value of the grant is 3960 NF a month, Tuesday, 9 October tax free (less about 225 NF for insurance), INSrITUTE OF CHILD HEALTH-5.30 pm, Alex Simpson Smith lecture by Mr V A J Swain: Children's surgery and they will be awarded for one to four months -a glimpse into the past. for clinical experience or research in France. RoYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, Sir Stanford Cade memorial lecture by Mr G J Hadfield: Preference will normally be given to candidates Carcinoma of the breast. who hold teaching posts or are in positions where they can pass on the experience they Wednesday, 10 October OF NEUROLOGY-Sandoz Foundation have acquired. Application forms may be INSTITUTE advanced lectures, 6 pm, Professor Sir Andrew Huxley, FRS: Activation and contraction in striated obtained from the foundation, 41 Portland muscle. 7 pm, Professor J A Simpson: Muscle Place, London WlN 4BN (01-636 9456). disorders after infancy. *
COMING EVENTS International Symposium on Gastrointestinal Hormones-15-18 September, Cambridge. Details from Dr S R Bloom and Dr Julia M Polak, Royal Postgraduate Medical School, Ducane Road, London W12 OHS. Closing date for receipt of abstracts 31 March 1980. National Association for the Welfare of Children in Hospital-Annual conference, "Up to 1 year old in the inner city," 30 October, London. Details from the association, 7 Exton Street, London SE1 8UE. (Closing date for applications 12 October.) British Association for PsychopharmacologySymposium "The psychopharmacology of alcohol," 22-23 November, London. Details from Dr David Wheatley, 325 Staines Road, Twickenham TW2 5AX. (Tel 01-894 2722.) National Association for Mental Health-Conference "Mental health and meditation," 1 December, London. Details from Charles Patmore, MIND, 22 Harley Street, London WIN 2ED. (Tel 01-637 0741.) Society for Radiological Protection-Details of two meetings, "Hazard control and planning in the working environment," 22 January 1980, London; and "Emergency arrangements-planning and practice," 22 April 1980, London, are available from Professor J H Martin,
Third
INSTITUTE OF ORTHOPAEDICS-6 pm, Dr Doreen Browne: Systemic effects of major injury-lung. 7 pm, Professor B McKibbin: Pathology of fracture healing. NORTHWICK PARK LECTURES IN CLINICAL SCIENCE4.30 pm, Professor W S Peart, FRS: Hormones and the kidney. ROYAL COLLEGE OF SURGEONS OF EDINBURGH-4.30 pm, Mr I T Macphee: The enigma of periodontology. ROYAL COLLEGE OF SURGEONS OF ENGLAND-5.15 pm, Mr I M Hill: Principles of heart surgery.* 6.30 pm, Professor J P Mitchell: Trauma of the urinary tract.*
Thursday, 11 October ROYAL COLLEGE OF PHYSICIANS OF LONDON-5 pm, Teale lecture by Professor J A Davis: The aftereffects of birth asphyxia. ROYAL COLLEGE OF SURGEONS OF ENGLAND-6.30 pm, Professor M Hobsley: Salivary gland swellings.* WEST OF SCOTLAND COMMITTEE FOR POSTGRADUATE MEDICAL EDUCATION CENTRE FOR MEDICAL WOMEN9.30 am, Professor F I Caird: The future of geriatrics. Friday, 12 October INSTITUTE OF LARYNGOLOGY AND OTOLOGY-4.30 pm, annual address, Sir Frank Hartley: Interdisciplinary influences-stimulus or distraction ? ROYAL COLLEGE OF PHYSICIANS OF LoNDON-4 pm, Charles West lecture by Professor C E Stroud: Sickle-cell anaemia: a growing problem. ROYAL COLLEGE OF SURGEONS OF ENGLAND-6 pm, Mr P Bewes: Surgery in the tropics.*
Bromley-At Farnborough Hospital Postgraduate Centre, on Friday, 19 October, 7.45 pm, wine tasting evening for members and guests.* Burton upon Trent and District-At Bretby Golf Club, Wednesday, 24 October, 1 pm, golf tournament followed by meal at Stanhope Arms Hotel at 7 pm.* Coventry-At Rolls-Royce Ltd, Parkside, Tuesday, 9 October, 7.30 pm, sherry, buffet supper, film show, and tour of factory.* (Husbands/wives invited.) Dartford, Gravesend, and Medway-At St Bartholomew's Hospital, Rochester, Tuesday, 6 November, 8.30 pm, agm. Doncaster-At Doncaster Royal Infirmary, Wednesday, 17 October, 7.30 for 8 pm, dinner meeting, speaker Mr John Randall: "Pensions and superannuation."6 East Yorkshire-At Holy Trinity Church, Hull, Thursday, 18 October, 12.30 pm, commemorative service, St Luke's Day. Fife-At Station Hotel, Kirkcaldy, Tuesday, 9 October, 7 for 7.30 pm, dinner/lecture, speaker Professor J D E Knox: "On moving house-general practice and the health centre."` Redbridge and Stratford-At King George Hospital, Ilford, Wednesday, 10 October, AGM. St Marylebone and North-east Westminster and Paddington-At BMA House, Thursday, 11 October, 6 for 7 pm, AGM, followed by buffet dinner.* Trent North Hospital Junior Staff Committee-
At Hallamshire Hospital, Wednesday, 10 October,
5.30 pm, agm. Wakefield-At Milford Hall Country Club, Friday, 12 October, 7.30 for 8 pm, annual dinner dance.* (Guests are invited.) Walsall-At Three Crowns Inn, Sutton Road, Walsall, Wednesday, 10 October, 7.30 for 8 pm, Mr P A Lapworth, vice-principal, West Midlands College, Walsall, on education.* (Hot buffet provided.) Guests
invited.* West Herts-At the Rose and Crown, 60 High Street, Kings Langley, Herts, Tuesday, 16 October, 8 pm, agm. Mr Norman Ellis, the BMA's senior
are
industrial relations officer will attend. Worcester and Bromsgrove-At Ronkswood Hospital, Saturday, 13 October, 2.15 pm, symposium "The clinical and economic problems of chronic renal
failure."*
UNIVERSITIES AND COLLEGES LONDON Dr Wallace Fox has had the title of professor of community therapeutics conferred on him in respect of his post at the Cardiothoracic Institute.
CONSULTANT APPOINTMENTS BIRMINGHAM AHA(T)-Dr I
J
F
Morle, Dr E B Rolfe
(radiologists). HAMPSHIRE AHA-Mr P B Ashcroft (ENT and research
otology). WESSEx RHA-Dr P R W Lanham (anaesthetist).
tD
British Medical Journal 1979
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