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To the Editor.— In a recent review, Schreiber wrote that the Coombs test can detect as few as 1,500 molecules of IgG per erythrocyte but that about 2,000 molecules of IgG per erythrocyte were necessary to augment the clearance of IgG-coated RBCs (1982; 248:1380). He concluded that "the antiglobulin test is a sensitive, albeit crude, method for the detection of antibody on the erythrocyte surface." However, approximately 2% to 5% of all patients with autoimmune hemolytic anemia (AHA) will have a negative Coombs test result, 1 and a recent edition of a hematology textbook states that "the greatest shortcoming of the antiglobulin test is its relative insensitivity." 2 As reported by Mollison and Hughes-Jones, 3 as few as ten anti-Rh antibodies can shorten the RBC survival substantially. However, at least 500 molecules of antibodies per erythrocyte must be present to give a positive reaction by the Coombs reagent. 1 Thus

Bacterial endocarditis is an infection with substantial morbidity and mortality. Since only about 15% of all cases of endocarditis can be associated with previous dental, medical, or surgical manipulation, the recommendations for antibiotic prophylaxis against endocarditis have been surrounded by controversy and uncertainty. 1 Controlled clinical investigation of prophylaxis against endocarditis is no longer possible due to both ethical considerations and the prohibitively large patient number necessary to achieve significant results. In the absence of hard data, recommendations for antibiotic prophylaxis must be deduced from knowledge that bacteremia accompanies certain surgical procedures and that certain cardiac lesions predispose to bacterial endocarditis. Prophylaxis against endocarditis is generally recommended in patients at high risk for dental, urologic, gastrointestinal tract, gynecologic, throat, and intracardiac surgery because of, for the most part, lesions involving manipulation or incision of mucosal surfaces. Scant attention has been given to the issue of antibiotic prophylaxis for bacterial endocarditis

The Leser-Trelat sign is characterized by the sudden appearance and rapid increase in both the size and number of seborrheic keratoses. This paraneoplastic syndrome is most frequently associated with adenocarcinoma (67%), with the gastrointestinal (GI) tract being the most common primary tumor site (72%). However, in 22% of cases, the syndrome has been associated with lymphoproliferative malignant neoplasms. We describe herein a patient with the Leser-Trelat sign who had a lymphocytic lymphoma and later was found to have an adenocarcinoma of the large bowel. Report of a Case An obese, 59-year-old woman had a recent history of easy fatigability and malaise. Two months before, she had noticed the sudden appearance of many "warts" on her face and neck. On physical examination, multiple, 2- to 6-mm, seborrheic keratoses and numerous pigmented filariform papillomas were present on the neck and malar regions (Figure). Examination of the abdomen disclosed moderate hepatosplenomegaly. Findings from

In Reply.— Although Dr Lycka does not question the use of antibiotic prophylaxis for procedures such as oral, gastrointestinal, or genitourinary surgery, he avoids the fact that there have never been controlled clinical trials that prove that antibiotic prophylaxis will decrease the risk for bacterial endocarditis associated with these procedures. In fact, it is not likely that such a study will ever be conducted. 1 Thus, the decision to administer antibiotic prophylaxis against possible bacterial endocarditis is a medical judgment that rests on the specific risk-to-benefit ratio. It is our opinion that patients at high risk for bacterial endocarditis who undergo dermatologic surgery should receive appropriate antibiotic prophylaxis. 2 Fine et al 3 have recently reported significant bacteremia following the incision and drainage of abscesses and have advised for appropriate bacterial endocarditis prophylaxis. Kaye 4 has also recommended antibiotic prophylaxis against bacterial endocarditis for the surgical management of abscesses in

To the Editor.— Ferguson Smith 1 did not realize that he had discovered an autosomal-dominant trait when he reported a single case of multiple self-healing squamous carcinomas (MSHSC) in 1934. 2 It is now recognized that both familial and sporadic types of MSHSC exist. Both entities are now included in the designation of multiple Ferguson-Smith keratoacanthomas. The MSHSC are occasionally known for an extremely mutilating course and fatal outcome. The patient initially described by Ferguson Smith was again cited 14 years later for extensive nasal destruction that required a prosthesis. 3 Charteris 4 described a patient with MSHSC who died as a result of an extensive recurrent anal lesion. We report a patient with sporadic MSHSC who experienced extensive recurrent perineural invasion of the right supratrochlear nerve. This observation suggests that perineural invasion by keratoacanthoma should not be regarded as an entirely benign condition. Report of a Case.— A 44-year-old

THE BONE age, as measured by the number of ossification centers which are calcified, has become an index of the stage of development of the growing child. The disturbances in the appearance of these ossification centers associated with endocrine dysfunction are clearly defined. But there are many instances of abnormal ossification in which the causative factors are not understood. The purpose of this paper is to describe a small group of patients, some with retarded and others with precipitated development of ossification centers, who did not have other evidence of endocrine dysfunctions, and the occurrence of nonrachitic craniotabes in the latter group. REPORT OF CASES The first six cases are examples of retarded osseous development (Table 1). Five of these children were short in stature, and none of the six revealed any sign of the endocrine disorders which are characterized by delayed skeletal maturation. The next seven cases (Table 2)

Ectodermal dysplasia is a rare condition characterized by complete or partial anodontia and by defects in other ectodermal structures. Thoma, 1 in his textbook "Oral Pathology," has given a collective review of 18 cases reported in the literature from 1883 to 1941, and Brodie and Sarnat 2 contributed another case in 1942. REPORT OF A CASE History .—V. M., a girl born April 7, 1941, came under observation at the children's endocrine clinic on Jan. 28, 1944 at the age of 2 years and 8 months, having been referred from the children's clinic of the Boston Dispensary because of the peculiar behavior of her teeth and nails. The mother stated that neither finger nails nor toe nails ever grew; hence they were never cut. The patient neither complained of excessive heat nor suffered from spells of fever or syncope on exposure to the summer sun. She had never been sick