- Email: [email protected]
ACUTE OSTEOMYELITIS TREATED WITH METHICILLIN
945
guided by the findings. If there is a discharge of ductpapilloma type which can be localised to one area of the breast
the surgeon may lay open the affected duct until the tumour is displayed. Local resection is the treatment of choice in younger women where histological evidence of aberration or invasion is absent; mutilating mastectomy should be avoided unless widespread involvement of the duct system is suspected.
discharge cannot be localised, the possibility of mammary-duct ectasia should be considered, and repeated cytological examination of the discharge should When the
be undertaken. If neither red blood-cells nor unaltered epithelial cells can be detected in several specimens, and no mass can be felt, then mastectomy does not seem
iustified. University Pathology Department, Western Infirmary, Glasgow.
A. T. SANDISON.
ACUTE OSTEOMYELITIS TREATED WITH METHICILLIN SIR,-We have had 2 interesting cases of acute osteo-
myelitis recently. CASE l.-A lad of 15 became semicomatose, with muttering a high fever. There were bilateral effusions into the knee-joints. He did not complain of bone pain. The diagnosis remained in doubt until blood-culture yielded Staphylococcus aureus. Because he was obviously gravely ill methicillin (’Celbenin’) was given after initial treatment with penicillin, streptomycin, and sulphadiazine had been ineffective. He slowly responded, bilateral tibial abscesses were drained, and eventually he recovered completely. CASE 2.-A man of 33 was admitted irrational and semicomatose, with a pyrexia of 103°F. Again the diagnosis was in doubt until blood-culture yielded Staph. aureus; and chloramphenicol was prescribed. In this case though methicillin was recommended it could not be given until three days after admission. His temperature then fell, but he remained irrational, and did not recover. At necropsy osteomyelitis of the right humerus, septic infarcts of the brain, acute endocarditis, and abscesses of the kidney were observed.
delirium and
,
significant that in both cases the organism subsequently proved sensitive in vitro to penicillin, tetracyline, erythromycin, and chloramphenicol; but in vivo neither penicillin in case 1 nor chloramphenicol in case 2 had any appreciable effect. It seems that methicillin should be given at once in overwhelming infection when Staph. aureus is isolated on blood-culture. The importance of blood-culture is obvious; and the medical bacteriologist should give prompt advice as soon as he It may be
has the necessary information. My thanks
are
due to my clinical
colleagues for
access to
the
case-
notes.
Hospital, Wolverhampton.
C. H. L. HOWELLS.
EXTERNAL CARDIAC MASSAGE
SIR,-It seems to me that referring to two quite distinct
and was reasonably well, in sinus rhythm, but with low bloodpressure (80/60). At 3 P.M. he suddenly collapsed, and I saw him about two minutes later. He was then pale and livid, and apnoeic, and no heart-sounds were audible. I sent sister for a scalpel, and at that moment Mr. Molloy’s original letter (Jan. 7) came to my mind. I gave the patient 3 rapid, light, but incisive blows to the precordium with my fist. Faint and irregular heart-sounds immediately became audible, and conventional artificial respiration was started. After three minutes an attempt was made to insert an airway. He started to gag and vomited a few ounces of clear fluid, and almost immediately regained consciousness, though he was confused. An electrocardiograph, taken thirty minutes from the onset, was similar to the original tracing, apart from the presence of definite sinus tachycardia. Next day he developed the susurrus of pericardial friction (possibly iatrogenic), and paroxysmal atrial fibrillation, which was rectified with quinidine. One week later his condition was
satisfactory.
In retrospect I
can certainly say that the blows were not to enough heavy depress the thoracic cage sufficiently to empty
the heart. Bulawayo,
your
correspondents
are
and different procedures. The first is the true " external cardiac massage " combined with artificial respiration, as described by Rainer and Bullough,l and modified by Kouwenhoven et al.2 The second procedure is probably analogous to the " gentle flick " to the misbehaving heart, mentioned by Mr. Weale (Jan. 21), and it appears probable, despite the implied vigour of Dr. Healy’s blow to the epigastrium (March 4), that his patient was subjected to this method. 1. Rainer, E. H., Bullough, J. Brit. med. J. 1957, ii, 1024. 2. Kouwenhoven, W. B., June, J. R., Knickerbocker, G. G. J. Amer. med. Ass. 1960, 173, 1064.
J. CHARLES SHEE.
Southern Rhodesia.
MYOGLOBINURIA
SiR,-Yet another group of patients might be added to those you described in your leading article (April 1) with Haff disease, obvious muscle trauma, or idiopathic
paroxysmal myoglobinuria. As first noted
et al.,! acute, debilitating, and myoglobinuria, and renal failure may accompany alcoholic excess and fatty liver. We have recently studied a patient with this syndrome. Since muscle weakness, oliguria, and dark urine are common findings in patients with the fatty cirrhotic liver of alcoholism, only a careful history and examination of the urine will lead to the proper diagnosis. Unfortunately, the relationship between alcoholism, liverdisease, and myoglobinuria remains obscure. even
by Fahlgren
fatal myonecrosis,
Massachusetts General Hospital, Boston.
WILLIAM A. TISDALE.
ESSENTIAL-FATTY-ACID CONTENT OF HENS’ EGGS et SiR,-Coppock al. (Jan. 14) recently drew attention to the similarity in essential-fatty-acid (E.F.A.) content of eggs from free-ranging and battery housed hens. Gresham
and Howard (Feb. claimed for E.F.A. in But Dr. Sinclair
Department of Pathology, The Royal
A recent case of mine would also appear to fall into the latter category. A man of 56 had sustained a major anterior cardiac infarction at 3 A.M. He was comfortably installed in hospital,
4) later doubted the importance preventing arterial disease. (Jan. 28 and Feb. 11) continues to prefer
free-range to battery eggs in his diet on the ground of supposed differences in their atherogenic properties. He quotes (Jan. 28) an experiment in support of this preference in which sudanophilic material was found in the aorta: of day-old chicks hatched from eggs of battery hens, but not in those hatched from those of free-range hens. Unfortunately no details were given of the number of chicks or of the staining technique used. We have felt it desirable to repeat Dr. Sinclair’s experiment in an attempt to assess the differences between these two types of aorta. In fact our experihave failed to disclose any differences whatsoever. Twenty-four fertile eggs from artificially inseminated battery birds (Rhode Island Red x Light Sussex, from Houghton Poultry Research Station, Huntingdon) and a similar sample of fertile eggs of free-range birds (pure Light Sussex-birds on grass at a local farm) were incubated separately in two ’Curfew’ electric observation incubators. ments
1. Fahlgren, H., Hed, R., Lundmark, C. Acta med. scand. 1957, 158, 405.
guided by the findings. If there is a discharge of ductpapilloma type which can be localised to one area of the breast
the surgeon may lay open the affected duct until the tumour is displayed. Local resection is the treatment of choice in younger women where histological evidence of aberration or invasion is absent; mutilating mastectomy should be avoided unless widespread involvement of the duct system is suspected.
discharge cannot be localised, the possibility of mammary-duct ectasia should be considered, and repeated cytological examination of the discharge should When the
be undertaken. If neither red blood-cells nor unaltered epithelial cells can be detected in several specimens, and no mass can be felt, then mastectomy does not seem
iustified. University Pathology Department, Western Infirmary, Glasgow.
A. T. SANDISON.
ACUTE OSTEOMYELITIS TREATED WITH METHICILLIN SIR,-We have had 2 interesting cases of acute osteo-
myelitis recently. CASE l.-A lad of 15 became semicomatose, with muttering a high fever. There were bilateral effusions into the knee-joints. He did not complain of bone pain. The diagnosis remained in doubt until blood-culture yielded Staphylococcus aureus. Because he was obviously gravely ill methicillin (’Celbenin’) was given after initial treatment with penicillin, streptomycin, and sulphadiazine had been ineffective. He slowly responded, bilateral tibial abscesses were drained, and eventually he recovered completely. CASE 2.-A man of 33 was admitted irrational and semicomatose, with a pyrexia of 103°F. Again the diagnosis was in doubt until blood-culture yielded Staph. aureus; and chloramphenicol was prescribed. In this case though methicillin was recommended it could not be given until three days after admission. His temperature then fell, but he remained irrational, and did not recover. At necropsy osteomyelitis of the right humerus, septic infarcts of the brain, acute endocarditis, and abscesses of the kidney were observed.
delirium and
,
significant that in both cases the organism subsequently proved sensitive in vitro to penicillin, tetracyline, erythromycin, and chloramphenicol; but in vivo neither penicillin in case 1 nor chloramphenicol in case 2 had any appreciable effect. It seems that methicillin should be given at once in overwhelming infection when Staph. aureus is isolated on blood-culture. The importance of blood-culture is obvious; and the medical bacteriologist should give prompt advice as soon as he It may be
has the necessary information. My thanks
are
due to my clinical
colleagues for
access to
the
case-
notes.
Hospital, Wolverhampton.
C. H. L. HOWELLS.
EXTERNAL CARDIAC MASSAGE
SIR,-It seems to me that referring to two quite distinct
and was reasonably well, in sinus rhythm, but with low bloodpressure (80/60). At 3 P.M. he suddenly collapsed, and I saw him about two minutes later. He was then pale and livid, and apnoeic, and no heart-sounds were audible. I sent sister for a scalpel, and at that moment Mr. Molloy’s original letter (Jan. 7) came to my mind. I gave the patient 3 rapid, light, but incisive blows to the precordium with my fist. Faint and irregular heart-sounds immediately became audible, and conventional artificial respiration was started. After three minutes an attempt was made to insert an airway. He started to gag and vomited a few ounces of clear fluid, and almost immediately regained consciousness, though he was confused. An electrocardiograph, taken thirty minutes from the onset, was similar to the original tracing, apart from the presence of definite sinus tachycardia. Next day he developed the susurrus of pericardial friction (possibly iatrogenic), and paroxysmal atrial fibrillation, which was rectified with quinidine. One week later his condition was
satisfactory.
In retrospect I
can certainly say that the blows were not to enough heavy depress the thoracic cage sufficiently to empty
the heart. Bulawayo,
your
correspondents
are
and different procedures. The first is the true " external cardiac massage " combined with artificial respiration, as described by Rainer and Bullough,l and modified by Kouwenhoven et al.2 The second procedure is probably analogous to the " gentle flick " to the misbehaving heart, mentioned by Mr. Weale (Jan. 21), and it appears probable, despite the implied vigour of Dr. Healy’s blow to the epigastrium (March 4), that his patient was subjected to this method. 1. Rainer, E. H., Bullough, J. Brit. med. J. 1957, ii, 1024. 2. Kouwenhoven, W. B., June, J. R., Knickerbocker, G. G. J. Amer. med. Ass. 1960, 173, 1064.
J. CHARLES SHEE.
Southern Rhodesia.
MYOGLOBINURIA
SiR,-Yet another group of patients might be added to those you described in your leading article (April 1) with Haff disease, obvious muscle trauma, or idiopathic
paroxysmal myoglobinuria. As first noted
et al.,! acute, debilitating, and myoglobinuria, and renal failure may accompany alcoholic excess and fatty liver. We have recently studied a patient with this syndrome. Since muscle weakness, oliguria, and dark urine are common findings in patients with the fatty cirrhotic liver of alcoholism, only a careful history and examination of the urine will lead to the proper diagnosis. Unfortunately, the relationship between alcoholism, liverdisease, and myoglobinuria remains obscure. even
by Fahlgren
fatal myonecrosis,
Massachusetts General Hospital, Boston.
WILLIAM A. TISDALE.
ESSENTIAL-FATTY-ACID CONTENT OF HENS’ EGGS et SiR,-Coppock al. (Jan. 14) recently drew attention to the similarity in essential-fatty-acid (E.F.A.) content of eggs from free-ranging and battery housed hens. Gresham
and Howard (Feb. claimed for E.F.A. in But Dr. Sinclair
Department of Pathology, The Royal
A recent case of mine would also appear to fall into the latter category. A man of 56 had sustained a major anterior cardiac infarction at 3 A.M. He was comfortably installed in hospital,
4) later doubted the importance preventing arterial disease. (Jan. 28 and Feb. 11) continues to prefer
free-range to battery eggs in his diet on the ground of supposed differences in their atherogenic properties. He quotes (Jan. 28) an experiment in support of this preference in which sudanophilic material was found in the aorta: of day-old chicks hatched from eggs of battery hens, but not in those hatched from those of free-range hens. Unfortunately no details were given of the number of chicks or of the staining technique used. We have felt it desirable to repeat Dr. Sinclair’s experiment in an attempt to assess the differences between these two types of aorta. In fact our experihave failed to disclose any differences whatsoever. Twenty-four fertile eggs from artificially inseminated battery birds (Rhode Island Red x Light Sussex, from Houghton Poultry Research Station, Huntingdon) and a similar sample of fertile eggs of free-range birds (pure Light Sussex-birds on grass at a local farm) were incubated separately in two ’Curfew’ electric observation incubators. ments
1. Fahlgren, H., Hed, R., Lundmark, C. Acta med. scand. 1957, 158, 405.