721
Q fever, typhus fever, and psittacosis. Indirect fluorescent antibody test was also negative for R.M.S.F. and typhus. Serum was
injected intraperitoneally into meadow voles (Microtus pennyslvanius), and the spleen and tunica vaginalis exhibited no rickettsia when the animals were killed at six days. Other animals had no antibodies to rickettsia twenty-one days after injection. Leptospirosis, therefore, seemed more likely. A battery of 22 leptospirosis antigens was then run against paired sera from all three cases by the Leptospirosis Reference Laboratory at the National Communicable Disease Center. None were positive. In case 3 dark-field examination of acute blood and urine specimens was negative. Culture of blood and urine by the method of Sulzer and Jonesl2 was also negative. Patients 1 and 2 received antibiotics, but the third patient had received no antibiotics which might have interfered with recovery of leptospira or inhibited antibody-titre rises. We cannot explain these raised Weil-Felix titres. A positive reaction was noted in five of twenty-four cases tested in Japan.s No definitive conclusions can be drawn from this small series regarding leptospirosis as a cause of M.L.N.S. We agree that the similarities between leptospirosis and M.L.N.s. are noteworthy, but further studies on any possible relationship of M.L.N.S. to rickettsia and leptospirosis are needed. We thank Dr Willy Burgdorfer and Dr Robert N. Philip at the Rocky Mountain Laboratory for the special rickettsial studies. of Pediatrics, Good Samaritan Hospital, Phoenix, Arizona 85006, U.S.A.
Department
Pediatrics Luke Air Force Base Hospital Arizona
P. S. BERGESON S. P. SERLIN
Department of
L. I. CORMAN
METRONIDAZOLE RESISTANCE AMONG BACTEROIDES FRAGILIS
Sm,—Dr Ingham and colleagues (Jan. 28, p. 214) reported that long-term metronidazole therapy in a patient with Crohn’s disease produced marked resistance in a strain of Bacteroides fragilis. They kindly sent us this strain, and we have confirmed their in-vitro findings. Their patient took more than 2 kg of metronidazole over 3tyears of continuous therapy, so the emergence of resistance is not surprising. For acute anaerobic infections, both for prophylaxis and treatment, the maximum recommended dosages for metronidazole lie between 6-6g and 18-0 g given over periods of 3-7 days. We rarely find it necessary to use more than 10 g in a complete course of therapy. Because of the impression gained by Eykyn and Phillips’ that similar conventional therapy might lead to an increased resistance among faecal anaerobes, we have begun a prospective study. The thirty-three patients and four healthy volunteers so far studied have received full therapeutic courses of metronidazole, and there has been no evidence of resistance among faecal isolates of B. fragilis. Moreover, the minimum inhibitory concentrations of metronidazole for these isolates are not higher than those of isolates obtained in parallel from the fseces of a hundred healthy untreated adults. Despite these early findings it is clearly important to test all anaerobic isolates for their metronidazole sensitivity, thus monitoring for the possible development of resistance. However, despite the widespread yet specific use of metronidazole over two decades for trichomoniasis, resistance among the obligate anaerobes of the vaginal and colonic flora of women has never been reported. Since metronidazole is a narrow-spectrum antimicrobial agent for which there are clearly defined and restricted indica12.
Sulzer, C. R., Jones, W. L., Leptospirosis: Methods in Laboratory Diagnosis, C D.S Atlanta publication no. 76-8275. U.S. Department of Health, Education, and Welfare.
1.
Eykyn, S. J., Phillips, I. Br. med. J. 1976, ii, 1418.
tions (Crohn’s disease per se is not one of them) its use in clinical practice should continue to be limited. Unlike the widely used and relatively broad-spectrum drugs such as tetracycline and ampicillin, metronidazole is unlikely to be needed by individual patients more frequently than once or twice in a lifetime, and on those occasions effective courses of treatment should rarely exceed 7 days. A. T. WILLIS P. H. JONES K. D. PHILLIPS GILLIAN GOTTOBED
Public Health Laboratory, Luton and Dunstable Hospital, Luton LU4 0DZ
REVIEWING THE MENTAL HEALTH ACT
SiR,-Mr Philip Bean’s article in The Times of Jan.3 was of anxiety to many people, and Dr Watt’s reasoned reply (March 11, p. 552) is welcome. The Mental Health Act 1959 might be viewed as the zenith of a movement which gave professionally qualified people in the health and social services wide discretionary powers in relation to the liberty of mentally ill patients. Watt is correct in saying that these powers are a cause
exercised with care and that misuse is uncommon. However, the climate of opinion outside the psychiatric services is very different from that prevailing in the 1950s when the Royal Commission reported and the Act became law. There are several factors in this, of which three may be cited here as important. First, there is the increase in concern in Europe and North America with human rights and with the use of psychiatry, in countries less scrupulous about the inviolability of individuals, for ends other than the good of the patient. Second, the U.S. Supreme Court has been concerned with the interpretation in the context of psychiatry of clauses in the fourteenth amendment to the Federal Constitution which provide that no person shall be deprived "of life, liberty or property without due process of law" and that each individual is entitled to "the equal protection of the law". (Most individual States have similar clauses in their Constitutions.’) American lawyers who have looked at the current English legislation tend to feel that, by this standard, it may not be adequate and that doctors and other health workers here may not always be careful in ensuring that the due process of the law as it stands has been observed. This seems to be the burden of Bean’s criticism. Third, the effect of the various official tribunals and inquiries into the tragic deaths of children from "non-accidental injury" is important. Many health and social workers now appreciate that it is possible that the careers and personal happiness of well-qualified, able, and experienced professional people may be placed in jeopardy, not merely by carelessness, but when a judgment made in difficult circumstances, after thought, in good faith, and in accord with accepted practice, proves wrong. In other words, the professional discretion that a worker is expected to exercise from day to day may be wider than society ultimately is prepared to accept. Many people in the U.K. believe that the administrative law, of which the Mental Health Act is one example and the law on tribunals is another, leans too heavily on the individual citizen. Some eminent men, of whom Lord Scarman is one, advocate a Bill of Rights which could cover mental patients.2 Short of this- radical solution it seems inevitable that new enactments will have more stringent legal safeguards in relation to individuals. Undoubtedly this would make aspects of
psychiatric practice more difficult, that medicine will be allowed movement? Department of Community Medicine, University of Manchester, Manchester M13 9PL
to
Watt says, but is it likely dissociate itself from this
as
HUW FRANCIS
1. Wing, K. M. The Law and the Public’s Health; p. 30. St. Louis, 1976. 2. Scarman. English Law: the New Dimension. London, 1974.
Q fever, typhus fever, and psittacosis. Indirect fluorescent antibody test was also negative for R.M.S.F. and typhus. Serum was
injected intraperitoneally into meadow voles (Microtus pennyslvanius), and the spleen and tunica vaginalis exhibited no rickettsia when the animals were killed at six days. Other animals had no antibodies to rickettsia twenty-one days after injection. Leptospirosis, therefore, seemed more likely. A battery of 22 leptospirosis antigens was then run against paired sera from all three cases by the Leptospirosis Reference Laboratory at the National Communicable Disease Center. None were positive. In case 3 dark-field examination of acute blood and urine specimens was negative. Culture of blood and urine by the method of Sulzer and Jonesl2 was also negative. Patients 1 and 2 received antibiotics, but the third patient had received no antibiotics which might have interfered with recovery of leptospira or inhibited antibody-titre rises. We cannot explain these raised Weil-Felix titres. A positive reaction was noted in five of twenty-four cases tested in Japan.s No definitive conclusions can be drawn from this small series regarding leptospirosis as a cause of M.L.N.S. We agree that the similarities between leptospirosis and M.L.N.s. are noteworthy, but further studies on any possible relationship of M.L.N.S. to rickettsia and leptospirosis are needed. We thank Dr Willy Burgdorfer and Dr Robert N. Philip at the Rocky Mountain Laboratory for the special rickettsial studies. of Pediatrics, Good Samaritan Hospital, Phoenix, Arizona 85006, U.S.A.
Department
Pediatrics Luke Air Force Base Hospital Arizona
P. S. BERGESON S. P. SERLIN
Department of
L. I. CORMAN
METRONIDAZOLE RESISTANCE AMONG BACTEROIDES FRAGILIS
Sm,—Dr Ingham and colleagues (Jan. 28, p. 214) reported that long-term metronidazole therapy in a patient with Crohn’s disease produced marked resistance in a strain of Bacteroides fragilis. They kindly sent us this strain, and we have confirmed their in-vitro findings. Their patient took more than 2 kg of metronidazole over 3tyears of continuous therapy, so the emergence of resistance is not surprising. For acute anaerobic infections, both for prophylaxis and treatment, the maximum recommended dosages for metronidazole lie between 6-6g and 18-0 g given over periods of 3-7 days. We rarely find it necessary to use more than 10 g in a complete course of therapy. Because of the impression gained by Eykyn and Phillips’ that similar conventional therapy might lead to an increased resistance among faecal anaerobes, we have begun a prospective study. The thirty-three patients and four healthy volunteers so far studied have received full therapeutic courses of metronidazole, and there has been no evidence of resistance among faecal isolates of B. fragilis. Moreover, the minimum inhibitory concentrations of metronidazole for these isolates are not higher than those of isolates obtained in parallel from the fseces of a hundred healthy untreated adults. Despite these early findings it is clearly important to test all anaerobic isolates for their metronidazole sensitivity, thus monitoring for the possible development of resistance. However, despite the widespread yet specific use of metronidazole over two decades for trichomoniasis, resistance among the obligate anaerobes of the vaginal and colonic flora of women has never been reported. Since metronidazole is a narrow-spectrum antimicrobial agent for which there are clearly defined and restricted indica12.
Sulzer, C. R., Jones, W. L., Leptospirosis: Methods in Laboratory Diagnosis, C D.S Atlanta publication no. 76-8275. U.S. Department of Health, Education, and Welfare.
1.
Eykyn, S. J., Phillips, I. Br. med. J. 1976, ii, 1418.
tions (Crohn’s disease per se is not one of them) its use in clinical practice should continue to be limited. Unlike the widely used and relatively broad-spectrum drugs such as tetracycline and ampicillin, metronidazole is unlikely to be needed by individual patients more frequently than once or twice in a lifetime, and on those occasions effective courses of treatment should rarely exceed 7 days. A. T. WILLIS P. H. JONES K. D. PHILLIPS GILLIAN GOTTOBED
Public Health Laboratory, Luton and Dunstable Hospital, Luton LU4 0DZ
REVIEWING THE MENTAL HEALTH ACT
SiR,-Mr Philip Bean’s article in The Times of Jan.3 was of anxiety to many people, and Dr Watt’s reasoned reply (March 11, p. 552) is welcome. The Mental Health Act 1959 might be viewed as the zenith of a movement which gave professionally qualified people in the health and social services wide discretionary powers in relation to the liberty of mentally ill patients. Watt is correct in saying that these powers are a cause
exercised with care and that misuse is uncommon. However, the climate of opinion outside the psychiatric services is very different from that prevailing in the 1950s when the Royal Commission reported and the Act became law. There are several factors in this, of which three may be cited here as important. First, there is the increase in concern in Europe and North America with human rights and with the use of psychiatry, in countries less scrupulous about the inviolability of individuals, for ends other than the good of the patient. Second, the U.S. Supreme Court has been concerned with the interpretation in the context of psychiatry of clauses in the fourteenth amendment to the Federal Constitution which provide that no person shall be deprived "of life, liberty or property without due process of law" and that each individual is entitled to "the equal protection of the law". (Most individual States have similar clauses in their Constitutions.’) American lawyers who have looked at the current English legislation tend to feel that, by this standard, it may not be adequate and that doctors and other health workers here may not always be careful in ensuring that the due process of the law as it stands has been observed. This seems to be the burden of Bean’s criticism. Third, the effect of the various official tribunals and inquiries into the tragic deaths of children from "non-accidental injury" is important. Many health and social workers now appreciate that it is possible that the careers and personal happiness of well-qualified, able, and experienced professional people may be placed in jeopardy, not merely by carelessness, but when a judgment made in difficult circumstances, after thought, in good faith, and in accord with accepted practice, proves wrong. In other words, the professional discretion that a worker is expected to exercise from day to day may be wider than society ultimately is prepared to accept. Many people in the U.K. believe that the administrative law, of which the Mental Health Act is one example and the law on tribunals is another, leans too heavily on the individual citizen. Some eminent men, of whom Lord Scarman is one, advocate a Bill of Rights which could cover mental patients.2 Short of this- radical solution it seems inevitable that new enactments will have more stringent legal safeguards in relation to individuals. Undoubtedly this would make aspects of
psychiatric practice more difficult, that medicine will be allowed movement? Department of Community Medicine, University of Manchester, Manchester M13 9PL
to
Watt says, but is it likely dissociate itself from this
as
HUW FRANCIS
1. Wing, K. M. The Law and the Public’s Health; p. 30. St. Louis, 1976. 2. Scarman. English Law: the New Dimension. London, 1974.
