- Email: [email protected]
SALMONELLA OSTEOMYELITIS
966
patient’s
bed-table. We have found that used to this and sleep is not disturbed.
patients
soon
get
We have placed further emphasis on these established methods in the hope that they may assist others in the differential diagnosis of thyrotoxicosis and anxiety states. We suggest that serum-creatine levels can be estimated on such patients during their first outpatient attendance. Those with raised serum-creatine levels can then be admitted to hospital for a few nights so that an accurate recording of the sleeping pulse-rate can be made. Further confirmation of overactivity of the thyroid gland will be provided if a definite fall in serum-creatine levels and sleeping pulse-rate occurs after the administration of Lugol’s iodine for three weeks. A. G. FREEMAN. Bristol Royal Infirmary. The Middlesex
Hospital, London, W.1.
SIR,-The article by Dr. White and Dr. Meynell (April 7), in which they describe a case of paratyphoid-C osteomyelitis, prompts us to comment on a particular aspect of salmonella osteomyelitis which has so far not been adequately considered. They state that their patient is a Jamaican, which, to our mind, means that he is, to some degree, of Negro descent. If this is true, it is a pity that the patient has not been examined for the presence of
one of the varieties of sickle-cell disease. All observers have stressed the utmost rarity of salmonella infections of the bones. This is less true in countries where sickle-cell anaemia is prominent. At the native hospital of Leopoldville we have observed in less than two years 5 cases of salmonella osteitis, all occurring in infants suffering from sickle-cell anxmia.1 This is not a pure coincidence : in the available literature we found 8 further cases of this association and recently we came across a 9th published case.2 In one of these the existence of sickle-cell disease was publications, not the but the hsematoauthor, suspected by apparently the data of could fit with this better patient hardly logical
diagnosis.3 One of us,4reviewing the epidemiology of salmonellosis in the Belgian Congo, referred to 14 salmonella cultures, all isolated from osteomyelitis in Negroes with sickle-cell anaemia. These facts seem to suggest that the pathogenetic relationship between the two conditions is very close, and any description of salmonella osteomyelitis in a Negro is incomplete when it gives no information on the presence or absence of sickle cells. In the data given by Dr. White and Dr. Meynell, the patient’s haemoglobin value is too high for the diagnosis of homozygous sickle-cell anaemia ; it is however perfectly compatible with sic.kle-cell/hemoglobinC disease, a haemoglobinopathy which is known for its ability to provoke bone changes. Recently, we reported a case of this disease, with long-standing suppuration of one hip.5 Unhappily, the pus was not examined bacterio-
logicallv. Luluaburg, Belgian Congo. Institut de Médecine Tropicale Princesse Astrid, Leopoldville, Belgian Congo.
2.
3. 4. 5.
Jamaica.
LOUIS S. GRANT.
USE OF VITAMIN K IN THE NEWBORN
SIR,-We would like to draw attention to the possible dangers of overdosage with water-soluble vitamin.]K analogues, when adminstered parenterally, especially in premature babies. Until recently, it had been thought that vitamin K was entirely non-toxic and might safely be given repeatedly in doses of 10 mg. ; but recent investigations’ suggest that in premature babies these doses may lead to the development of kernicterus. There is good evidence that an intramuscular injection of 0.5-1 mg. (e.g., menaphthone B.P.C.) is more than adequate for the prophylaxis of haemorrhagic disease of the newborn, due to hypoprothrombinaemia.2 In cases of established haemorrhagic disease of the newborn due to this
cause a
dose of 1-2 mg. should suffice to restore the to normal levels. N. B. CAPON V. M. CROSSE W. GAISFORD R. LIGHTWOOD F. W. MILLER.
plasma-prothrombin
PHENYLBUTAZONE IN THE TREATMENT OF PROLAPSED INTERVERTEBRAL DISC
SIR,-I should like to draw attention to the remark. able effect of phenylbutazone in cases of herniated intervertebral disc. In starting this treatment rather over a year ago, I thought that the drug might have an anti-inflammatory action at the nerve-root, and so diminish the pain of the condition, but so constant has its effect proved in relieving the pain and reducing the physical signs (e.g., straight-leg raising and areas of altered cutaneous sensitivity) that I now believe that it exerts a direct action on the disc itself, possibly by altering its fluid content differentiallv as between the annulus fibrosus and the nucleus pulposus. In fact, I believe that it performs a medical manipulation." Now that I have treated well over 50 cases of disc hernia (cervical, thoracic, and lumbar) with an estimated 90% success-rate, I feel the time has come to make known the method so that someone better qualified than "
can produce a properly controlled series, with research into the mode of action of this extraordinary drug. I have been able to find only one report of its successful use in this condition.3 The dosage I employ is 200 mg. three times a day for two days, and then twice a day for two days, making a total of 2 g. There is no point in prolonging the administration of this potentially dangerous drug beyond that, since, if it is going to work, it produces dramatic relief in the first thirty-six to forty hours, but it has very little effect on the lesser discomfort and stiffness of the healing phase. If the condition is not cured in
myself
some
J. VANDEPITTE.
E. VAN OYE.
SIR,-The article by Dr. White and Dr. Meynell was very interesting to us here. I wish, however, to draw attention to some inaccuracies. 1.
Pathology Department, University College of the West Indies,
D. MATTINGLY.
SALMONELLA OSTEOMYELITIS
Provincial Laboratory,
Dr. White and Dr. Meynell reported that "in theWest by far the commonest type of salmonella, infootion is paratyphoid C " ; actually, paratyphoid’C is rare and the commonest type of salmonella infection is S. typhi. They also state that 584 cases of paratyphoid were notified in Jamaica in 1952. The W.H.O. report to which they refer gives this figure under the headirig " typhoid and paratyphoid fevers cases " ; in actual fact, all 584 cases were typhoid fever, and none were paratyphoid. Only a few months ago we diagnosed our first case of paratyphoid C in Jamaica, and this has attracted so much interest that we are publishing the case shortly.
Indies
Vandepitte, J., Colaert, J., Lambotte-Legrand, J., LambotteLegrand, C., Périn, F. Ann. Soc. belge Méd. trop. 1953, 33, 511. Ellenbogen, N. C., Rain, J., Grosamann, L. Amer. J. Dis. Child. 1955, 90, 275. Carrington, G., Davison, W. Bull. Johns Hopk. Hosp. 1925. 36, 428. van Oye, E. Ann. Soc. belge Med. trop. 1955, 35, 229. Vandepitte, J., Colaert, J. Ibid, p. 457.
1. See Lancet, 1955, i, 669, 819 ; Arch. Dis. Childh. 2. Hardwicke, S. H. J. Pediat. 1944, 24, 259. 3. Brunelli, G. Min. Med. Torino. 1954, 45, 1819.
1956, 30, 501.
patient’s
bed-table. We have found that used to this and sleep is not disturbed.
patients
soon
get
We have placed further emphasis on these established methods in the hope that they may assist others in the differential diagnosis of thyrotoxicosis and anxiety states. We suggest that serum-creatine levels can be estimated on such patients during their first outpatient attendance. Those with raised serum-creatine levels can then be admitted to hospital for a few nights so that an accurate recording of the sleeping pulse-rate can be made. Further confirmation of overactivity of the thyroid gland will be provided if a definite fall in serum-creatine levels and sleeping pulse-rate occurs after the administration of Lugol’s iodine for three weeks. A. G. FREEMAN. Bristol Royal Infirmary. The Middlesex
Hospital, London, W.1.
SIR,-The article by Dr. White and Dr. Meynell (April 7), in which they describe a case of paratyphoid-C osteomyelitis, prompts us to comment on a particular aspect of salmonella osteomyelitis which has so far not been adequately considered. They state that their patient is a Jamaican, which, to our mind, means that he is, to some degree, of Negro descent. If this is true, it is a pity that the patient has not been examined for the presence of
one of the varieties of sickle-cell disease. All observers have stressed the utmost rarity of salmonella infections of the bones. This is less true in countries where sickle-cell anaemia is prominent. At the native hospital of Leopoldville we have observed in less than two years 5 cases of salmonella osteitis, all occurring in infants suffering from sickle-cell anxmia.1 This is not a pure coincidence : in the available literature we found 8 further cases of this association and recently we came across a 9th published case.2 In one of these the existence of sickle-cell disease was publications, not the but the hsematoauthor, suspected by apparently the data of could fit with this better patient hardly logical
diagnosis.3 One of us,4reviewing the epidemiology of salmonellosis in the Belgian Congo, referred to 14 salmonella cultures, all isolated from osteomyelitis in Negroes with sickle-cell anaemia. These facts seem to suggest that the pathogenetic relationship between the two conditions is very close, and any description of salmonella osteomyelitis in a Negro is incomplete when it gives no information on the presence or absence of sickle cells. In the data given by Dr. White and Dr. Meynell, the patient’s haemoglobin value is too high for the diagnosis of homozygous sickle-cell anaemia ; it is however perfectly compatible with sic.kle-cell/hemoglobinC disease, a haemoglobinopathy which is known for its ability to provoke bone changes. Recently, we reported a case of this disease, with long-standing suppuration of one hip.5 Unhappily, the pus was not examined bacterio-
logicallv. Luluaburg, Belgian Congo. Institut de Médecine Tropicale Princesse Astrid, Leopoldville, Belgian Congo.
2.
3. 4. 5.
Jamaica.
LOUIS S. GRANT.
USE OF VITAMIN K IN THE NEWBORN
SIR,-We would like to draw attention to the possible dangers of overdosage with water-soluble vitamin.]K analogues, when adminstered parenterally, especially in premature babies. Until recently, it had been thought that vitamin K was entirely non-toxic and might safely be given repeatedly in doses of 10 mg. ; but recent investigations’ suggest that in premature babies these doses may lead to the development of kernicterus. There is good evidence that an intramuscular injection of 0.5-1 mg. (e.g., menaphthone B.P.C.) is more than adequate for the prophylaxis of haemorrhagic disease of the newborn, due to hypoprothrombinaemia.2 In cases of established haemorrhagic disease of the newborn due to this
cause a
dose of 1-2 mg. should suffice to restore the to normal levels. N. B. CAPON V. M. CROSSE W. GAISFORD R. LIGHTWOOD F. W. MILLER.
plasma-prothrombin
PHENYLBUTAZONE IN THE TREATMENT OF PROLAPSED INTERVERTEBRAL DISC
SIR,-I should like to draw attention to the remark. able effect of phenylbutazone in cases of herniated intervertebral disc. In starting this treatment rather over a year ago, I thought that the drug might have an anti-inflammatory action at the nerve-root, and so diminish the pain of the condition, but so constant has its effect proved in relieving the pain and reducing the physical signs (e.g., straight-leg raising and areas of altered cutaneous sensitivity) that I now believe that it exerts a direct action on the disc itself, possibly by altering its fluid content differentiallv as between the annulus fibrosus and the nucleus pulposus. In fact, I believe that it performs a medical manipulation." Now that I have treated well over 50 cases of disc hernia (cervical, thoracic, and lumbar) with an estimated 90% success-rate, I feel the time has come to make known the method so that someone better qualified than "
can produce a properly controlled series, with research into the mode of action of this extraordinary drug. I have been able to find only one report of its successful use in this condition.3 The dosage I employ is 200 mg. three times a day for two days, and then twice a day for two days, making a total of 2 g. There is no point in prolonging the administration of this potentially dangerous drug beyond that, since, if it is going to work, it produces dramatic relief in the first thirty-six to forty hours, but it has very little effect on the lesser discomfort and stiffness of the healing phase. If the condition is not cured in
myself
some
J. VANDEPITTE.
E. VAN OYE.
SIR,-The article by Dr. White and Dr. Meynell was very interesting to us here. I wish, however, to draw attention to some inaccuracies. 1.
Pathology Department, University College of the West Indies,
D. MATTINGLY.
SALMONELLA OSTEOMYELITIS
Provincial Laboratory,
Dr. White and Dr. Meynell reported that "in theWest by far the commonest type of salmonella, infootion is paratyphoid C " ; actually, paratyphoid’C is rare and the commonest type of salmonella infection is S. typhi. They also state that 584 cases of paratyphoid were notified in Jamaica in 1952. The W.H.O. report to which they refer gives this figure under the headirig " typhoid and paratyphoid fevers cases " ; in actual fact, all 584 cases were typhoid fever, and none were paratyphoid. Only a few months ago we diagnosed our first case of paratyphoid C in Jamaica, and this has attracted so much interest that we are publishing the case shortly.
Indies
Vandepitte, J., Colaert, J., Lambotte-Legrand, J., LambotteLegrand, C., Périn, F. Ann. Soc. belge Méd. trop. 1953, 33, 511. Ellenbogen, N. C., Rain, J., Grosamann, L. Amer. J. Dis. Child. 1955, 90, 275. Carrington, G., Davison, W. Bull. Johns Hopk. Hosp. 1925. 36, 428. van Oye, E. Ann. Soc. belge Med. trop. 1955, 35, 229. Vandepitte, J., Colaert, J. Ibid, p. 457.
1. See Lancet, 1955, i, 669, 819 ; Arch. Dis. Childh. 2. Hardwicke, S. H. J. Pediat. 1944, 24, 259. 3. Brunelli, G. Min. Med. Torino. 1954, 45, 1819.
1956, 30, 501.