septic joint. These changes
were
not
present on x-ray films obtained from
hospital where she was seen initially. On the day following a joint aspiration, multiple lesions appeared over her body. These were erythematous and maculopapular, with ve¬ the
sicular heads in their centers. Several of these lesions eventually progressed to small purpuric lesions 0.5 to 1.0 cm in diameter. As the investigation continued, we began to suspect the diagnosis of gonococcal arthritis with secondary osteomyelitis. Further questioning revealed a positive history for sexual intercourse, which she had denied
previously.
In
addition, although
three blood cultures and the material from the joint aspiration were nega¬ tive, a cervical culture was positive for N gonorrhoeae, and Gram-nega¬ tive diplococci were found on a smear from a vaginal discharge and from the scrapings of one of the skin le¬
sions.
Consequently, the patient was given penicillin parenterally, 100,000 units/kg/day in six divided doses, with rapid clinical improvement. There
much debate in our hos¬ pital concerning whether gonococcus was capable of causing such rapid and destructive bone changes. Many expe¬ rienced staff members had never en¬ countered such an instance. In addi¬ tion, many of the articles and books I read on the subject did not mention such a complication of gonococcal in¬ fection. However, I did find several articles, especially from the preantibiotic era, which did describe such cases
was
vividly.
It struck
me how little everyone knew about this complication of gon¬ orrhea, especially since the advent of penicillin has made it almost non¬
existent.
Gregory Magee Senior Medical Student University of Cincinnati School of Medicine Cincinnati
plasty or reconstruction of the breast after mastectomy is, in reality, a cosmetic procedure, frequently including a prosthesis that attempts, often with indifferent results, to develop (not to
create or reconstruct or augment) a breast-appearing mass, together with a pseudonipple. Bernard Notes, MD Washington, DC
Acute Hypotension From Thioridazine
not
To the Editor.\p=m-\Inthe QUESTIONS AND section (233:823, 1975), the question arises, "when is augmentation mammoplasty after mastectomy feasible?" The questioner and answerer speak of "augmentation mammoplasty" and "reconstruction of the breast after mastectomy." Such fallacious terminology does not, in my opinion, meet the usual standards of the prestigious JAMA as used in connection with the statement "mastectomy after carcinoma of the left breast 18 months ago." This so-called augmentation mammo-
erative. This would then include all of the possible subcategories under his first three classifications. To use the term "mass or destructive lesions" leaves certain possible causes of coma unlisted.
Physical Medicine
B. B. Kumar, MD Center for Human Mt Pleasant, Mich
Development
Size of Mammary Lumps To the Editor.\p=m-\Iwould agree with everything in the recent MEDICOLEGAL
ROUNDS article concerning treatment of mammary lumps (233:559,1975) except the opinion that a lump the size of a pullet egg is a small breast lump. A pullet egg might be small when compared to Grade A Large, but it certainly is of substantial size when found in a breast. Also, why in this day and age do we continue to describe all lumps in comparison with some food item instead of giving an accurate estimate of size? J. W.
and
Rehabilitation To the Editor.\p=m-\Ithink
George
the treatment of noncontact sports injuries. I think part of the problem is that too few patients are referred to physicians in my specialty of physical medicine and rehabilitation to use all the modalities available to physicians, as well as to work closely with the physical therapist in providing a therapeutic physical therapy program. Margaret S. Filante, MD
Greenbrae, Calif
The Smile Test To the Editor.\p=m-\I wish to call attention to a simple but valuable psychological diagnostic procedure well known to many nonpsychiatrist physicians. It is known as the "smile test," and the procedure, as the name implies, is carried out by smiling at people and observing the response. Some have even cautiously suggested therapeutic implications, but this has not been validated by doubleblind randomized studies. Consideration that both the stimulus and the response in this test
bal prompts letter.
me
are nonver-
to terminate this C. Z. Cohen, MD Staten Island, NY
Hardy, MD
AT&T Long Lines Kansas City, Mo
The Comatose Patient To the Editor.\p=m-\Itwas with great interest that the article by Posner was perused (233:1313, 1975). Dr Posner's
classification of "coma" pathophysiologically into the four categories is excellent. It would be enlightening if instead of using the terms "supratentorial mass lesions" and "infratentorial mass" or "destructive lesions," the terms "supratentorial lesions" or "infratentorial lesions" were used, and if, in the subclassification of each of
A.
Sheehan, MD (232:1127,1975) makes a good point in indicating the lack of use of physical therapy modalities in
common.
Terminology ANSWERS
tal, traumatic, infectious, neoplastic and then toxic, metabolic, and degen-
Irwin Perlmutter, MD Coral Gables, Fla
To the Editor.\p=m-\A 57-year-old man received 100 mg of thioridazine orally on two different occasions for maladaptive behavior. Within two hours of the administration of this drug, he was noted to have transitory unconsciousness associated with hypotension. The patient made an uneventful recovery with simple supportive measures. The laboratory studies were unremarkable. The patient was not receiving any other drugs at this time. Hypotension from thioridazine is mentioned in the manufacturer's literature, but occurrence of the reaction with such relatively low doses is
probably
the first three groups, the usual diagnostic classifications of varieties of diseases were used, namely, congeni-
Wrong Structural Formula. \p=m-\Inthe USAN COUNCIL
New Names List No.
149, published in the Aug 25 issue (233:909-910, 1975), the structural formula of xanoxate sodium was incorrect (p 909). The correct formula is printed here. o
Il
o
II
(CH3)sCH0v^í\>';\^>xX0Na
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/19/2015
were
not
present on x-ray films obtained from
hospital where she was seen initially. On the day following a joint aspiration, multiple lesions appeared over her body. These were erythematous and maculopapular, with ve¬ the
sicular heads in their centers. Several of these lesions eventually progressed to small purpuric lesions 0.5 to 1.0 cm in diameter. As the investigation continued, we began to suspect the diagnosis of gonococcal arthritis with secondary osteomyelitis. Further questioning revealed a positive history for sexual intercourse, which she had denied
previously.
In
addition, although
three blood cultures and the material from the joint aspiration were nega¬ tive, a cervical culture was positive for N gonorrhoeae, and Gram-nega¬ tive diplococci were found on a smear from a vaginal discharge and from the scrapings of one of the skin le¬
sions.
Consequently, the patient was given penicillin parenterally, 100,000 units/kg/day in six divided doses, with rapid clinical improvement. There
much debate in our hos¬ pital concerning whether gonococcus was capable of causing such rapid and destructive bone changes. Many expe¬ rienced staff members had never en¬ countered such an instance. In addi¬ tion, many of the articles and books I read on the subject did not mention such a complication of gonococcal in¬ fection. However, I did find several articles, especially from the preantibiotic era, which did describe such cases
was
vividly.
It struck
me how little everyone knew about this complication of gon¬ orrhea, especially since the advent of penicillin has made it almost non¬
existent.
Gregory Magee Senior Medical Student University of Cincinnati School of Medicine Cincinnati
plasty or reconstruction of the breast after mastectomy is, in reality, a cosmetic procedure, frequently including a prosthesis that attempts, often with indifferent results, to develop (not to
create or reconstruct or augment) a breast-appearing mass, together with a pseudonipple. Bernard Notes, MD Washington, DC
Acute Hypotension From Thioridazine
not
To the Editor.\p=m-\Inthe QUESTIONS AND section (233:823, 1975), the question arises, "when is augmentation mammoplasty after mastectomy feasible?" The questioner and answerer speak of "augmentation mammoplasty" and "reconstruction of the breast after mastectomy." Such fallacious terminology does not, in my opinion, meet the usual standards of the prestigious JAMA as used in connection with the statement "mastectomy after carcinoma of the left breast 18 months ago." This so-called augmentation mammo-
erative. This would then include all of the possible subcategories under his first three classifications. To use the term "mass or destructive lesions" leaves certain possible causes of coma unlisted.
Physical Medicine
B. B. Kumar, MD Center for Human Mt Pleasant, Mich
Development
Size of Mammary Lumps To the Editor.\p=m-\Iwould agree with everything in the recent MEDICOLEGAL
ROUNDS article concerning treatment of mammary lumps (233:559,1975) except the opinion that a lump the size of a pullet egg is a small breast lump. A pullet egg might be small when compared to Grade A Large, but it certainly is of substantial size when found in a breast. Also, why in this day and age do we continue to describe all lumps in comparison with some food item instead of giving an accurate estimate of size? J. W.
and
Rehabilitation To the Editor.\p=m-\Ithink
George
the treatment of noncontact sports injuries. I think part of the problem is that too few patients are referred to physicians in my specialty of physical medicine and rehabilitation to use all the modalities available to physicians, as well as to work closely with the physical therapist in providing a therapeutic physical therapy program. Margaret S. Filante, MD
Greenbrae, Calif
The Smile Test To the Editor.\p=m-\I wish to call attention to a simple but valuable psychological diagnostic procedure well known to many nonpsychiatrist physicians. It is known as the "smile test," and the procedure, as the name implies, is carried out by smiling at people and observing the response. Some have even cautiously suggested therapeutic implications, but this has not been validated by doubleblind randomized studies. Consideration that both the stimulus and the response in this test
bal prompts letter.
me
are nonver-
to terminate this C. Z. Cohen, MD Staten Island, NY
Hardy, MD
AT&T Long Lines Kansas City, Mo
The Comatose Patient To the Editor.\p=m-\Itwas with great interest that the article by Posner was perused (233:1313, 1975). Dr Posner's
classification of "coma" pathophysiologically into the four categories is excellent. It would be enlightening if instead of using the terms "supratentorial mass lesions" and "infratentorial mass" or "destructive lesions," the terms "supratentorial lesions" or "infratentorial lesions" were used, and if, in the subclassification of each of
A.
Sheehan, MD (232:1127,1975) makes a good point in indicating the lack of use of physical therapy modalities in
common.
Terminology ANSWERS
tal, traumatic, infectious, neoplastic and then toxic, metabolic, and degen-
Irwin Perlmutter, MD Coral Gables, Fla
To the Editor.\p=m-\A 57-year-old man received 100 mg of thioridazine orally on two different occasions for maladaptive behavior. Within two hours of the administration of this drug, he was noted to have transitory unconsciousness associated with hypotension. The patient made an uneventful recovery with simple supportive measures. The laboratory studies were unremarkable. The patient was not receiving any other drugs at this time. Hypotension from thioridazine is mentioned in the manufacturer's literature, but occurrence of the reaction with such relatively low doses is
probably
the first three groups, the usual diagnostic classifications of varieties of diseases were used, namely, congeni-
Wrong Structural Formula. \p=m-\Inthe USAN COUNCIL
New Names List No.
149, published in the Aug 25 issue (233:909-910, 1975), the structural formula of xanoxate sodium was incorrect (p 909). The correct formula is printed here. o
Il
o
II
(CH3)sCH0v^í\>';\^>xX0Na
Downloaded From: http://jama.jamanetwork.com/ by a Florida International University Medical Library User on 06/19/2015
