Br Med J: first published as 10.1136/bmj.3.5560.255 on 29 July 1967. Downloaded from

BRITISH MED I CAL JOURNAL LONDON SATURDAY 29 JULY 1967 Pointers Subarachnoid Haemorrhage: Psychiatric mor- bidity high in 261 cases studied by Dr. P. B. Storey (p. 261). Vitamin-B12 and Psychiatric Symptoms: Only Changed Character of Osteomyelitis memory impairment seemed related to the deficiency in Dr. Ralph Shulman's series of 27 In the last 25 years the clinical picture of haematogenous osteomyelitis patients (p. 266). has changed dramatically for the better. As this period corresponds Cerebral Infarction: Dr. S. K. Battacharji and with the development and wider use of antibiotics, much of the credit colleagues find no support for stenosis alone has been given to them. Though some critics fear that the old cycle of playing a decisive part in pathogenesis (p. 270). fulminating septicaemic disease will begin again once there are sufficient Another Smoking Hazard: Bronchoconstriction antibiotic-resistant organisms circulating in the antibiotics due to irritant action of smoke particles, prob- world,' at ably mediated through the vagus, according to present are the most potent weapon in the treatment of osteomyelitis, and Dr. G M. Sterling (p. 275). their benefit has been enormous. The appropriate antibiotic will sterilize Humidifying Oxygen: Dr. B. J. Freedman the bone abscess, thus reducing the local thrombosis in the bone and the found Woulfe's bottle method adequate (p. 277). size of the sequestra. As the small-sequestra left after treatment may Heparin and Anginal Pain: Intravenous admini- be absorbed, open sinuses and mixed infections have become rare. stration produced same effects as placebo in Dr. C. Bulfitt Massive sequestra are uncommon, and multiple recurrences of infection patients studied by J. (p. 279). are now rare. The two conditions leading to a persistent sinus are a Calcium Infusion Test: Dr. J. V. Lever and colleagues found that calcium retention is not mixed bacterial infection in a cavity whose walls cannot collapse. conclusive evidence of osteomalacia (p 281). Whether antibiotics are responsible for all the present success of treat- Sickling and Haematuria: Dr. 0. 0. Akinkugbe ment is questionable, for whether in Europeans, Indians, or East Africans2 from Ibadan in Nigeria reports four cases show- the disease has changed to a less dramatic form. It is reasonable to

ing radiological evidence of renal papillary http://www.bmj.com/ necrosis assume that at least in advanced societies an improvement in the general (p. 283). health and hygiene of Case Reports: Association of Guillain-Barr6 the community, particularly in infants and syndrome with chronic lymphatic leukaemia (p. adolescents, has reduced the number of primary foci from which haemato- 286). Gas in portal vein (p. 288). genous osteomyelitis might spring. Minor infections are better treated, Rubella: Serological method for demonstrating impetigo is rare, dental and tonsillar care is better. But these improve- recent infection described by Dr. J. E. Banatvala ments alone do not suffice to explain the diminished severity of the disease and his colleagues (p. 286). in poorer populations. Clearly there are other factors at work, and they A Case for Cannabis ? Leading article (p. 258). are not easy to explain. on 28 September 2021 by guest. Protected copyright. Clinicopathological Conference: Diarrhoea and While the more easily diagnosed form Goitre-Case Demonstration at the Royal Post- septicaemic accompanied by graduate Medical School (p. 293). multiple foci of bone infection and positive blood culture has become New Appliances: Mr. H. B. Eckstein describes rare, osteomyelitis in its modem subacute and benign form has become a new urinary diversion appliance (p. 297). a trap for the unwary. Infantile osteomyeitis, though less common, may Coronary Care Unit: Dr. B. L. Pentecost and remain true to its old form. It is more often due to streptococcal infec- colleagues describe the organization of a unit in tion than is adolescent osteomyelitis. Systemic disturbances are often a general hospital (p. 298). less than the local physical signs would suggest, the disease being charac- Annual Scientific Meeting: Final report of terized by massive oedema of part of a limb and rapid separation of a scientific proceedings (p. 300). large sequestrum, sometimes of the whole metaphysis of a long bone. Pertinax: Without Prejudice (p. 304). This tragedy may have occurred before adequate antibiotic therapy has Post-concussional Sequelae: Letter from Dr. J. had time to act. A broad-spectrum antibiotic must be given at once in Schorstein (p. 305). suspected cases without waiting to establish the correct one by laboratory Abortion Bill: Lords Debate (p. 316). studies. Overseas Conference of B.MA.: Report, Supplement, p. 101. In adolescence, still the most common age at which osteomyelitis develops, a subacute form of the disease is now more often seen than General Medical Council: Meeting of Disci- plinary Committee (Supplement, p. 104). formerly. As before, the epiphysis remains the site of infection, the lower Doctors and Clergy: Annual meeting (Supple- femoral epiphysis being most frequently attacked, and a history of trauma ment, p. 107). is still obtained in about half the cases. The onset is gradual. The Bristol Annual Meeting: Annual Dinner of patient is reluctant to use the limb, so that the physician may confuse B.M.A. (Supplement, p. 108). the disease with early poliomyelitis or juvenile rheumatism. As the most

© British Medical Yournal, 1967. All reproduction rights reserved. No. 5560, page 2755 256 29 July 1967 Leading Articles serious error in the treatment of osteomyelitis is delay in lying bone; the medulla has become decompressed already.

the administration of an antibiotic, treatment should not A specimen of pus should be taken in order to establish the Br Med J: first published as 10.1136/bmj.3.5560.255 on 29 July 1967. Downloaded from await resolution of the doubt about the diagnosis. Better appropriate antibiotic. The edges of the wound may be a cured child with an undiagnosed disease than a sick lightly drawn together, and after some delay it will usually child with osteomyelitis. Radiology is of no value in estab- heal with the minimum of scarring. Continuation of anti- lishing the diagnosis early, changes not usually being visible biotic therapy to avoid mixed infection and to prevent a until between the seventh and tenth day. The important recurrence of inflammation is necessary. Therapy should features are tenderness in the vicinity of an epiphysial line, continue for a minimum period of four weeks after the onset local evidence of inflammation, especially oedema, and a of the disease. raised erythrocyte sedimentation rate. The rise in the white Osteomyelitis in the adult from a cause other than injury cell count may be slight and delayed. True, an increase in is extremely rare, but it may be encountered in debilitating the neutrophil/lymphocyte ratio may be more important as diseases, among which diabetes is well recognized. As a diagnostic sign in the early stages, but it later returns to L. R. I. Baker and his colleagues recently reported,3 other normal. Blood culture is negative in most cases. Estimation debilitating diseases such as neutropenia secondary to systemic of the antibody titre is of little value. corticosteroid therapy may be rare precipitating causes, as Suspected cases must be given adequate doses of a broad- also may hypogammaglobulinaemia. spectrum antibiotic and put at rest with local immobilization Much remains obscure in the epidemiology of osteomyelitis, of the affected part. It is possible in some cases to abort the and further studies of its incidence in this and other countries disease so effectively that the radiological evidence may be are needed. While antibiotics have drawn its sting, their use doubtful and merely consist of local rarefaction on the meta- does not wholly explain the changed pattern of the disease. physial side of the epiphysial plate. If the systemic mani- They do need to be given early. Treated within the first festations of infection continue, it may be wise to change the three days, osteomyelitis may remain a benign disease. antibiotic, but this will usually mean that pus has formed. Usually subperiosteal, it is indicated by an increase in the I Winters, J. L., and Cahan, I., 7. Bone 7t Surg., 1960, 42A, 691. local oedema, and demands surgical incision. If sub- 2 Harris, N H., and Kirkaldy, W. H., ibid., 1965, 47B, 526. ' Baker, L. R. I., Brain, M. C., Miller, J. K., and Raphael, M. J., Brit. periosteal pus is found, there is no need to drill the under- med. 7., 1967, 1, 722. http://www.bmj.com/

Thyrocalcitonin Thus much is known of the physiology of this hormone from experimental work. It is known too that human thyroid Thyrocalcitonin, or simply calcitonin, is a hormone that lowers contains thyrocalcitonin.10 11 Nevertheless, the role of thyro- the concentration of calcium in the plasma. Though it was calcitonin in disease in man and its possible usefulness in discovered four years ago,' its significance in clinical practice therapeutics have not yet been defined. G. A. Williams and remains uncertain. However, its source is now clearly recog- colleagues,"2 studying totally thyroidectomized patients main- on 28 September 2021 by guest. Protected copyright. nized to be in the thyroid gland. tained on exogenous thyroxine, found them to have normal In a number of species, including man, two distinct types resting levels of calcium but an impaired ability to restore the of thyroid cell can be recognized. The thyroxine-producing calcium level to normal after an infusion of calcium gluconate. *epithelial cells, arranged in acini or follicles, are familiar, but This suggests that calcitonin is more necessary for the in addition there are cells of a different histological and control of hypercalcaemia than for the maintenance of a nor- histochemical type lying adjacent to the follicles but within mal level of calcium. The place, if any, of calcitonin the basement membrane. These have been variously known in the disturbances of calcium metabolism in thyrotoxicosis is as " light cells," " parafollicular cells," " mitochondrion-rich not known, but there is evidence to suggest that the occasional cells," and " C cells." From studies using histochemical2 and hypercalcaemia seen in this disease is not due to impaired immunofluorescentO techniques there seems little doubt that secretion of calcitonin.1' In the report of the Clinicopatho- these cells are the site of production of calcitonin. The logical Conference this week at page 293 a remarkable case is mode of action of the hormone has also been determined. described in which a medullary carcinoma of the thyroid was Experiments in vitro4 5 and in vivoi 7 indicate that associated with persistent diarrhoea. The functions of the calcitonin lowers the calcium level in the plasma by a direct C cells and their possible relationship to this syndrome are action on bone, inhibiting bone resorption. The hormone the subject of expert discussion by Professor A. G. E. Pearse, also lowers the inorganic phosphate level in plasma and Dr. E. D. Williams, and Professor I. McIntyre. causes phosphaturia.8 Hypercalcaemia is the stimulus for Syndromes of hypersecretion of thyrocalcitonin might be secretion of the hormone, and hypocalcaemia inhibits secre- expected to occur, but so far only isolated cases have been tion. It would appear, therefore, that secretion of calcitonin reported in which the findings were consistent with that possi- is controlled by a feedback mechanism operating through bility. In one" the patient presented with tetany and a the plasma calcium level9 in a manner similar to that for the diffuse non-toxic goitre. The serum calcium was 8.1 mg./ control of the secretion of parathyroid hormone, but in the 100 ml. and biopsy of the thyroid showed an increase in the reverse direction. " parafollicular " cells. Extraction of the biopsy material