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THE STAPHYLOCOCCI
445
clearly had episodes of generalised cerebral ischsmia, the cause of which was, as is common, cardiac dysrhythmia. In the remaining two cases the patient had both general and focal ischaemic episodes; but the presence of the generalised ischaemic spells would or should have alerted the examiner to the possibility that these were syncope or presyncope type spells. " The possibility of a cardiac cause for a T.I.A. needs to be appreciated more widely ", they The issue is state. But this is not the important issue. that these are two separate conditions and the diagnosis can be made on the basis of the history; this is what should be more widely appreciated and understood. cases
Department of Neurology, Mayo Clinic, Rochester, Minnesota 55901, U.S.A.
SIR,-We would
R. G. SIEKERT.
agree with Professor Siekert about the
from focal cerebral ischsemia, and that syncope is a manifestation of the former, but would challenge his use of the term syncope in some instances. In his article 1-which we regret we had not seen before submission of our paper-he describes syncope as a manifestation of generalised cerebral ischxmia occurring in elderly men two or three times a day without warning, lasting less than a minute, and without postsyncopal confusion. In syncope, as we understand it, the patient experiences a feeling of faintness and of darkening or greying of vision before he loses consciousness, he usually remains unconscious for something more than a minute and comes round gradually, still feeling weak and faint. The sudden loss and resumption of consciousness Professor Siekert describes we would regard as due to focal ischaemia of the reticular formation in the brainstem. Similarly he accepts vertigo as evidence of focal ischsemia only when it is accompanied by another symptom. We fully appreciate the difficulty of always being certain what a patient means when he speaks of giddiness or dizziness, but in some instances it is possible to be satisfied that it is a vestibular disturbance he is describing and not a preof
distinguishing generalised
syncopal feeling. In our view the patients we described did have episodes of focal ischoemia. We would also have been prepared to diagnose focal ischxmia in some of the patients in whom Professor Siekert made a diagnosis of generalised ischxmia. University Department Clinical Neurology, National Hospital, Queen Square, London WC1N 3BG.
of
JOHN MARSHALL P. M. MCALLEN.
THE STAPHYLOCOCCI
SiR,—Iwant to thank you for the mostly favourable review (July 28, p. 187) of the book which I edited, The Staphylococci. I was a bit chagrined when the reviewer noted that on p. 205 we referred to Prof. Mary Barber as I want to assure your " Barber and his colleagues ". readers that both Dr Carl Abramson and myself remember Mary Barber. Dr Abramson wrote by far the longest chapter in the book, one containing several hundred references, and I can imagine that in the still of the night when quoting the Barber et al. paper, he was momentarily unaware that it was Mary Barber he was quoting. She had her hand in many things relating to staphylococci. Many journals today refer only to the initials of the 1. Reed, R. L., 223, 893.
even
someone
Center for Disease Control, Atlanta, Georgia 30333, U.S.A.
JAY O. COHEN.
THE PHYSIOLOGY AND PATHOPHYSIOLOGY OF THE SKIN
SIR,-Your criticism (Aug. 11, p. 302) that only a limited subjects were covered in a work entitled the Physiology and Pathophysiology of the Skin is valid. However, it should be mentioned that about eight or nine other contributors have agreed to write sections on other aspects of skin physiology, including the dermis, the dendritic cell populations of the epidermis, the sebaceous glands, photobiology of the skin, the mucous membranes, the hair follicle, and the sweat glands. The publishers are understandably reticent about publicising material which is not actually in the jaws of their press. It is hoped that vol. III, dealing with
number of
* ** We showed Professor Siekert’s letter to Professor Marshall and Dr McAllen, whose reply follows.-ED. L.
importance
in the original publication. I believe that interested in Women’s Lib should look into this practice, as under these circumstances the faux pas referred to is easy to fall into.
authors,
Siekert, R. G., Merideth, J. J. Am. med. Ass. 1973,
the dermis and the dendritic cell populations of the epidermis, will be handed to the publishers later this year for publication in the first half of 1974. Other volumes will follow as typescript is received. I trust this will allay your justified misgivings. Dermatology Department, University College Hospital Medical School, University Street, London WC1E 6JJ.
A. JARRETT.
VITAMIN C AND THE COMMON COLD
SIR,-Wilson and Loh,’ reporting
some success in the of the common cold by administration of ascorbic acid, have renewed interest in the controversy on this subject. Pauling has repeatedly drawn attention to the many favourable claims, 2,3 but negative results have also been recordedand a further critical review has just appeared.5 I hesitate to comment without offering any new data, but I should like to suggest that the reluctance to accept the possible " anti-cold " effect of ascorbic acid is perhaps based on an unproved assumption-namely, that this effect is similar in character to its known anti-scorbutic action. It may well be that these two actions are distinct and unrelated. This indeed seems probable when we consider the very different dosages recommended for the prevention of scurvy (about 50 mg. per day) and for the treatment of colds (500 mg. to several grammes per day).,The smaller dose is certainly effective in scurvy, and it is therefore " misleading to speak of a requirement " for these higher unless indeed the common cold is regarded as a dosages, disease. it deficiency Surely is more likely that the higher dosages have some pharmacological action which requires further study. Incidentally, the concept of the daily requirement may well have played a part in limiting the choice of dosage in some cold trials to inadequate levels, since a figure of four times the anti-scorbutic dose must have appeared more than sufficient on conventional vitamin theory. However, this dosage (200 mg. per day) probably has little effect on colds, a point stressed by Pauling and accepted by Wilson and Loh, who suggest 2 g. per day as the optimum dosage. Wilson and Loh consider that the action is on the
prophylaxis and
treatment
1. Wilson, C. W. M., Loh, H. S. Lancet, 1973, i, 638. 2. Pauling, L. Vitamin C and the Common Cold. San Francisco, 1970. 3. Pauling, L. Scott. med. J. 1973, 18, 1. 4. Nutr. Rev. 1967, 25, 228. 5. Br. med. J. Aug. 11, 1973, p. 311.
clearly had episodes of generalised cerebral ischsmia, the cause of which was, as is common, cardiac dysrhythmia. In the remaining two cases the patient had both general and focal ischaemic episodes; but the presence of the generalised ischaemic spells would or should have alerted the examiner to the possibility that these were syncope or presyncope type spells. " The possibility of a cardiac cause for a T.I.A. needs to be appreciated more widely ", they The issue is state. But this is not the important issue. that these are two separate conditions and the diagnosis can be made on the basis of the history; this is what should be more widely appreciated and understood. cases
Department of Neurology, Mayo Clinic, Rochester, Minnesota 55901, U.S.A.
SIR,-We would
R. G. SIEKERT.
agree with Professor Siekert about the
from focal cerebral ischsemia, and that syncope is a manifestation of the former, but would challenge his use of the term syncope in some instances. In his article 1-which we regret we had not seen before submission of our paper-he describes syncope as a manifestation of generalised cerebral ischxmia occurring in elderly men two or three times a day without warning, lasting less than a minute, and without postsyncopal confusion. In syncope, as we understand it, the patient experiences a feeling of faintness and of darkening or greying of vision before he loses consciousness, he usually remains unconscious for something more than a minute and comes round gradually, still feeling weak and faint. The sudden loss and resumption of consciousness Professor Siekert describes we would regard as due to focal ischaemia of the reticular formation in the brainstem. Similarly he accepts vertigo as evidence of focal ischsemia only when it is accompanied by another symptom. We fully appreciate the difficulty of always being certain what a patient means when he speaks of giddiness or dizziness, but in some instances it is possible to be satisfied that it is a vestibular disturbance he is describing and not a preof
distinguishing generalised
syncopal feeling. In our view the patients we described did have episodes of focal ischoemia. We would also have been prepared to diagnose focal ischxmia in some of the patients in whom Professor Siekert made a diagnosis of generalised ischxmia. University Department Clinical Neurology, National Hospital, Queen Square, London WC1N 3BG.
of
JOHN MARSHALL P. M. MCALLEN.
THE STAPHYLOCOCCI
SiR,—Iwant to thank you for the mostly favourable review (July 28, p. 187) of the book which I edited, The Staphylococci. I was a bit chagrined when the reviewer noted that on p. 205 we referred to Prof. Mary Barber as I want to assure your " Barber and his colleagues ". readers that both Dr Carl Abramson and myself remember Mary Barber. Dr Abramson wrote by far the longest chapter in the book, one containing several hundred references, and I can imagine that in the still of the night when quoting the Barber et al. paper, he was momentarily unaware that it was Mary Barber he was quoting. She had her hand in many things relating to staphylococci. Many journals today refer only to the initials of the 1. Reed, R. L., 223, 893.
even
someone
Center for Disease Control, Atlanta, Georgia 30333, U.S.A.
JAY O. COHEN.
THE PHYSIOLOGY AND PATHOPHYSIOLOGY OF THE SKIN
SIR,-Your criticism (Aug. 11, p. 302) that only a limited subjects were covered in a work entitled the Physiology and Pathophysiology of the Skin is valid. However, it should be mentioned that about eight or nine other contributors have agreed to write sections on other aspects of skin physiology, including the dermis, the dendritic cell populations of the epidermis, the sebaceous glands, photobiology of the skin, the mucous membranes, the hair follicle, and the sweat glands. The publishers are understandably reticent about publicising material which is not actually in the jaws of their press. It is hoped that vol. III, dealing with
number of
* ** We showed Professor Siekert’s letter to Professor Marshall and Dr McAllen, whose reply follows.-ED. L.
importance
in the original publication. I believe that interested in Women’s Lib should look into this practice, as under these circumstances the faux pas referred to is easy to fall into.
authors,
Siekert, R. G., Merideth, J. J. Am. med. Ass. 1973,
the dermis and the dendritic cell populations of the epidermis, will be handed to the publishers later this year for publication in the first half of 1974. Other volumes will follow as typescript is received. I trust this will allay your justified misgivings. Dermatology Department, University College Hospital Medical School, University Street, London WC1E 6JJ.
A. JARRETT.
VITAMIN C AND THE COMMON COLD
SIR,-Wilson and Loh,’ reporting
some success in the of the common cold by administration of ascorbic acid, have renewed interest in the controversy on this subject. Pauling has repeatedly drawn attention to the many favourable claims, 2,3 but negative results have also been recordedand a further critical review has just appeared.5 I hesitate to comment without offering any new data, but I should like to suggest that the reluctance to accept the possible " anti-cold " effect of ascorbic acid is perhaps based on an unproved assumption-namely, that this effect is similar in character to its known anti-scorbutic action. It may well be that these two actions are distinct and unrelated. This indeed seems probable when we consider the very different dosages recommended for the prevention of scurvy (about 50 mg. per day) and for the treatment of colds (500 mg. to several grammes per day).,The smaller dose is certainly effective in scurvy, and it is therefore " misleading to speak of a requirement " for these higher unless indeed the common cold is regarded as a dosages, disease. it deficiency Surely is more likely that the higher dosages have some pharmacological action which requires further study. Incidentally, the concept of the daily requirement may well have played a part in limiting the choice of dosage in some cold trials to inadequate levels, since a figure of four times the anti-scorbutic dose must have appeared more than sufficient on conventional vitamin theory. However, this dosage (200 mg. per day) probably has little effect on colds, a point stressed by Pauling and accepted by Wilson and Loh, who suggest 2 g. per day as the optimum dosage. Wilson and Loh consider that the action is on the
prophylaxis and
treatment
1. Wilson, C. W. M., Loh, H. S. Lancet, 1973, i, 638. 2. Pauling, L. Vitamin C and the Common Cold. San Francisco, 1970. 3. Pauling, L. Scott. med. J. 1973, 18, 1. 4. Nutr. Rev. 1967, 25, 228. 5. Br. med. J. Aug. 11, 1973, p. 311.