584
Proc. roy. Soc. Med. Volume 70 August 1977
might increase free fatty acid mobilization, this would be expected to result, if anything, in a hyperlipidwemia in which increased triglyceride levels would be most prominent, rather than in hypercholesterolhmia. Underlying causes should always be sought in patients with substantial hypercholesterolkmia, and a treatable cause such as hypothyroidism should not be missed. But the status of premyxcedema as a common entity is highly questionable on the basis of existing cross-sectional data. Yours sincerely B LEWIS
30 May 1977
Dr Isenberg's list of cases). A definite preceding incident of dental treatment is mentioned in only 5 cases and care must be taken to avoid the assumption that the mere presence of dental caries can lead to bacteremia. Nevertheless, this is a remarkably high proportion. It is surprising that these relatively common oral micro-organisms have seldom been identified as constituents of postextraction bacterxmia. The explanation may well lie in the fastidious culture requirements which, as Isenberg and others have suggested, help to make the isolation of lactobacilli in blood cultures from patients with infective endocarditis such a rare event. Yours faithfully D A MCGOWAN
24 May 1977
Lactobacilius Infective Endocarditis From Professor D A McGowan Department of Dental Surgery, University of Glasgow, Glasgow G2 3JZ Dear Sir, Dr David Isenberg's addition to the published cases of lactobacillus endocarditis (April Proceedings, p 278) was of particular interest to me as I have recently been looking at the infectivity of this species in the rabbit experimental endocarditis model (Durack D T & Beeson P B, 1972, British Journal ofExperimental Pathology 53, 44 49). The experiments were part of a study (supported by a British Heart Foundation grant) using a variety of oral isolates, and the initiation of infection with Lactobacillus casei occurred as readily as with streptococcal species. Chains of lactobacilli were seen arising from the surface in a scanning electron microscope preparation of a vegetation from one infected animal (Fig 1). A possible oral source of infection is mentioned in 9 of the 14 published cases of lactobacillus endocarditis (adding the cases of Berger et al. (1976, Deutsche medizinische Wochenschrift 101, 1349) and Fritsche et al. (1973, Deutsche medizinische Wochenschrift 98, 2239-2242) to
S4 Fig 1 Chains of lactobacilli arising from the surface ofan infected vegetation. E= erythrocyte
Cavernous Sinus Thrombosis Revisited From Dr M Robson Parsons Consultant Neurologist, General Infirmary, Leeds, LSI 3EX Dear Sir, Professor Yarington, in his interesting paper on cavernous sinus thrombosis (July, p 456), has surveyed the subject in great detail, but I am sure he would agree that the most important section is the one on management. The idea that the progress of medicine has been emulated in the treatment of the disease could be extended, for the management (or mismanagement) of the condition is a minature of the way in which bacterial infections of the nervous system are treated. As Professor Yarington says, it is tragic that clinicians, faced for once with a neurological disorder that can be cured, should so often allow disasters to occur because they procrastinate or prescribe treatment which is inadequate in quality or quantity. The precepts that treatment must start at once, and that the possibility of agranulocytosis in ten years time is no threat to a man destined to die within ten days, cannot be overemphasized. Similarly, those accustomed to prescribing a few thousand units of penicillin two or three times a day may need to be reminded that 'large doses' means at least two million units intravenously every two hours. One point which Professor Yarington does not discuss is the length of time for which treatment should be given. Relapses and death due to latent abscesses have often been reported and some advocate the giving of antibiotics for as long as three months. It may be that computerized axial tomography will prove to be of value in identifying patients likely to need such prolonged treatment. Where other drugs are concerned I share Professor Yarington's view that streptokinase and allied substances should only be used by experts, for their value does not seem to have been established and some are difficult to manage. It is harder
Letters to the Editor to comment on the use of anticoagulants. Personally I have always been reluctant to use them in patients with septicwmia or newly developed infarcts, but there is no denying that this policy might result in two avoidable strokes for every iatrogenic disaster it prevents. However, by comparison with really effective antibiotic treatment these drugs are of very little importance. To complete the survey of management it is perhaps worth mentioning the importance of anticonvulsants, for as might be expected fits may occur in febrile children and patients with cortical venous thrombosis. It would also be interesting to know if there are any reports of cavernous sinus thrombosis apparently caused by oral contraceptives. Yours faithfully
585
has made an appropriate contribution towards achieving this aim. Yours sincerely C R COID
27 May 1977
Early Postoperative Abdominal Complications and Reoperations after Gallbladder, Colonic and Gastric Surgery From Mr Ian P Todd Harley Street, London WI Dear Sir, I have read with interest Mr WardMcQuaid's excellent and honest Presidential Address (June Proceedings, pp 384-387). In these days when postoperative problems are far fewer than in yesteryear, it is good that such a review is M ROBSON PARSONS undertaken. All of us hear people say that they do not see any 3 June 1977 of their anastomoses leaking, that they do not ever drain a gallbladder bed or put in a T-tube, and all The Value of Comparative Pathology of us know that these statements are untrue and From Dr C R Coid indicate lack of criticism on our part. Self-audit is Division of Comparative Medicine, becoming the watch-word in America, and it is important that we should be on our guard against Clinical Research Centre, Harrow, personal complacency. Middlesex, HA] 3UJ Mr Ward-McQuaid suggests quite correctly that Dear Sir, Last year was the centenary anniversary of the Cruelty to Animals Act 1876 which regulates the patients treated at St Mark's are a selected the carrying out of experiments on living animals. series, and I would agree that this is so, particularly The Act is of significant public interest and it is not where treatment of the acute obstructive case, in surprising that during 1976 a considerable amount whom the mortality rate is so high, is concerned. of discussion took place between scientists and However, many of the referrals are sent there other groups about the value and ethics concerning because they present difficult problems which the study of pathological conditions that are another surgeon may feel unwilling to tackle, and I experimentally induced in animals. It is timely, believe that one should aim to match the results therefore, that Professor Scott in his address to the obtained at a specialist hospital. One might anaSection of Pathology (June Proceedings, p 373) lyse, too, why the results at specialist hospitals are should remind us that investigations into naturally better than elsewhere, and surely this is related not occurring diseases of animals, their similarities and only to the primary surgery but to the after-care. sometimes their differences, are entirely relevant to How much of this is related to nursing? It is the study of comparable problems in man. generally admitted that the standard of nursing has Unlike other aspects of medical research where fallen in this country and elsewhere, but there animals are used for comparative purposes, the seems to be no attempt to analyse why this is so, study of naturally occurring animal models of nor to remedy it. human disease does not seem to have attracted the Yours faithfully attention of biologists to the same extent. This is a IAN TODD pity. Comparative pathology is a field which could 2 June 1977 be exploited more, particularly though not exclusively, by medical and veterinary pathologists with benefits not only for man but for animal Children's Feet science as well. To pursue research of this kind From Professor Robert Roaf would possibly require some redeployment, addi- Liverpool tional personnel and perhaps an increase of exist- Dear Sir, I have read with great pleasure the ing resources. However, the greatest need at the editorial by Mr Lloyd-Roberts (June Proceedings, present time is for pathologists and other scientists p 375) based on his Presidential Address. With his to be aware of the interest and dividends which long experience and customary insight he says would accrue from undertaking studies in this field many wise things. of comparative medicine. Professor Scott's ediAlthough nearly everyone nowadays would agree torial on 'The Value of Comparative Pathology' that mobile flat feet in children seldom, if ever,
Proc. roy. Soc. Med. Volume 70 August 1977
might increase free fatty acid mobilization, this would be expected to result, if anything, in a hyperlipidwemia in which increased triglyceride levels would be most prominent, rather than in hypercholesterolhmia. Underlying causes should always be sought in patients with substantial hypercholesterolkmia, and a treatable cause such as hypothyroidism should not be missed. But the status of premyxcedema as a common entity is highly questionable on the basis of existing cross-sectional data. Yours sincerely B LEWIS
30 May 1977
Dr Isenberg's list of cases). A definite preceding incident of dental treatment is mentioned in only 5 cases and care must be taken to avoid the assumption that the mere presence of dental caries can lead to bacteremia. Nevertheless, this is a remarkably high proportion. It is surprising that these relatively common oral micro-organisms have seldom been identified as constituents of postextraction bacterxmia. The explanation may well lie in the fastidious culture requirements which, as Isenberg and others have suggested, help to make the isolation of lactobacilli in blood cultures from patients with infective endocarditis such a rare event. Yours faithfully D A MCGOWAN
24 May 1977
Lactobacilius Infective Endocarditis From Professor D A McGowan Department of Dental Surgery, University of Glasgow, Glasgow G2 3JZ Dear Sir, Dr David Isenberg's addition to the published cases of lactobacillus endocarditis (April Proceedings, p 278) was of particular interest to me as I have recently been looking at the infectivity of this species in the rabbit experimental endocarditis model (Durack D T & Beeson P B, 1972, British Journal ofExperimental Pathology 53, 44 49). The experiments were part of a study (supported by a British Heart Foundation grant) using a variety of oral isolates, and the initiation of infection with Lactobacillus casei occurred as readily as with streptococcal species. Chains of lactobacilli were seen arising from the surface in a scanning electron microscope preparation of a vegetation from one infected animal (Fig 1). A possible oral source of infection is mentioned in 9 of the 14 published cases of lactobacillus endocarditis (adding the cases of Berger et al. (1976, Deutsche medizinische Wochenschrift 101, 1349) and Fritsche et al. (1973, Deutsche medizinische Wochenschrift 98, 2239-2242) to
S4 Fig 1 Chains of lactobacilli arising from the surface ofan infected vegetation. E= erythrocyte
Cavernous Sinus Thrombosis Revisited From Dr M Robson Parsons Consultant Neurologist, General Infirmary, Leeds, LSI 3EX Dear Sir, Professor Yarington, in his interesting paper on cavernous sinus thrombosis (July, p 456), has surveyed the subject in great detail, but I am sure he would agree that the most important section is the one on management. The idea that the progress of medicine has been emulated in the treatment of the disease could be extended, for the management (or mismanagement) of the condition is a minature of the way in which bacterial infections of the nervous system are treated. As Professor Yarington says, it is tragic that clinicians, faced for once with a neurological disorder that can be cured, should so often allow disasters to occur because they procrastinate or prescribe treatment which is inadequate in quality or quantity. The precepts that treatment must start at once, and that the possibility of agranulocytosis in ten years time is no threat to a man destined to die within ten days, cannot be overemphasized. Similarly, those accustomed to prescribing a few thousand units of penicillin two or three times a day may need to be reminded that 'large doses' means at least two million units intravenously every two hours. One point which Professor Yarington does not discuss is the length of time for which treatment should be given. Relapses and death due to latent abscesses have often been reported and some advocate the giving of antibiotics for as long as three months. It may be that computerized axial tomography will prove to be of value in identifying patients likely to need such prolonged treatment. Where other drugs are concerned I share Professor Yarington's view that streptokinase and allied substances should only be used by experts, for their value does not seem to have been established and some are difficult to manage. It is harder
Letters to the Editor to comment on the use of anticoagulants. Personally I have always been reluctant to use them in patients with septicwmia or newly developed infarcts, but there is no denying that this policy might result in two avoidable strokes for every iatrogenic disaster it prevents. However, by comparison with really effective antibiotic treatment these drugs are of very little importance. To complete the survey of management it is perhaps worth mentioning the importance of anticonvulsants, for as might be expected fits may occur in febrile children and patients with cortical venous thrombosis. It would also be interesting to know if there are any reports of cavernous sinus thrombosis apparently caused by oral contraceptives. Yours faithfully
585
has made an appropriate contribution towards achieving this aim. Yours sincerely C R COID
27 May 1977
Early Postoperative Abdominal Complications and Reoperations after Gallbladder, Colonic and Gastric Surgery From Mr Ian P Todd Harley Street, London WI Dear Sir, I have read with interest Mr WardMcQuaid's excellent and honest Presidential Address (June Proceedings, pp 384-387). In these days when postoperative problems are far fewer than in yesteryear, it is good that such a review is M ROBSON PARSONS undertaken. All of us hear people say that they do not see any 3 June 1977 of their anastomoses leaking, that they do not ever drain a gallbladder bed or put in a T-tube, and all The Value of Comparative Pathology of us know that these statements are untrue and From Dr C R Coid indicate lack of criticism on our part. Self-audit is Division of Comparative Medicine, becoming the watch-word in America, and it is important that we should be on our guard against Clinical Research Centre, Harrow, personal complacency. Middlesex, HA] 3UJ Mr Ward-McQuaid suggests quite correctly that Dear Sir, Last year was the centenary anniversary of the Cruelty to Animals Act 1876 which regulates the patients treated at St Mark's are a selected the carrying out of experiments on living animals. series, and I would agree that this is so, particularly The Act is of significant public interest and it is not where treatment of the acute obstructive case, in surprising that during 1976 a considerable amount whom the mortality rate is so high, is concerned. of discussion took place between scientists and However, many of the referrals are sent there other groups about the value and ethics concerning because they present difficult problems which the study of pathological conditions that are another surgeon may feel unwilling to tackle, and I experimentally induced in animals. It is timely, believe that one should aim to match the results therefore, that Professor Scott in his address to the obtained at a specialist hospital. One might anaSection of Pathology (June Proceedings, p 373) lyse, too, why the results at specialist hospitals are should remind us that investigations into naturally better than elsewhere, and surely this is related not occurring diseases of animals, their similarities and only to the primary surgery but to the after-care. sometimes their differences, are entirely relevant to How much of this is related to nursing? It is the study of comparable problems in man. generally admitted that the standard of nursing has Unlike other aspects of medical research where fallen in this country and elsewhere, but there animals are used for comparative purposes, the seems to be no attempt to analyse why this is so, study of naturally occurring animal models of nor to remedy it. human disease does not seem to have attracted the Yours faithfully attention of biologists to the same extent. This is a IAN TODD pity. Comparative pathology is a field which could 2 June 1977 be exploited more, particularly though not exclusively, by medical and veterinary pathologists with benefits not only for man but for animal Children's Feet science as well. To pursue research of this kind From Professor Robert Roaf would possibly require some redeployment, addi- Liverpool tional personnel and perhaps an increase of exist- Dear Sir, I have read with great pleasure the ing resources. However, the greatest need at the editorial by Mr Lloyd-Roberts (June Proceedings, present time is for pathologists and other scientists p 375) based on his Presidential Address. With his to be aware of the interest and dividends which long experience and customary insight he says would accrue from undertaking studies in this field many wise things. of comparative medicine. Professor Scott's ediAlthough nearly everyone nowadays would agree torial on 'The Value of Comparative Pathology' that mobile flat feet in children seldom, if ever,
