METHOTREXATE AND SMALLPOX VACCINATION

1250 METHOTREXATE AND SMALLPOX VACCINATION SiR,-On Oct. 4, 1968, a woman, aged 58, was seen with a severely infected, primary vaccinial lesion 2 in. in diameter on the left upper arm. There was an acutely tender mass of glands, the size of a tennis ball, in the left axilla. She was ill with a temperature of 101°F. Primary vaccination had been performed three weeks earlier. By the tenth day a large vaccinial pustule had developed at the site of inoculation and since then had continued to extend. By Oct. 1 she had begun to feel extremely unwell. She sweated, shivered, and noticed that " blisters were developing on the body ". These were in fact seven characteristic vaccinial pustules distributed on the trunk and extremities. They occurred on normal skin and were not related to the guttate psoriasis of the trunk which was also present. Inquiry revealed that this was being treated by a dermatologist with methotrexate. She had been vaccinated by another doctor who was apparently unaware either of this or of its significance. The patient was treated with tetracycline 250 mg. 6-hourly and y-globulin 5 ml. intramuscularly. Hyperimmune antivaccinial y-globulin did not become available until Oct. 7, when she was given 14 ml. intramuscularly. On this date, despite the continued fever and sepsis, her white-blood-cell count was 6500 per c.mm. (polymorphs 60%, lymphocytes 35%, monocytes 5%). On Oct. 10 she developed an acute lymphangitis in the left forearm originating in a vaccinial lesion on the thenar eminence. Ampicillin was substituted for tetracycline, and this rapidly came under control. Thereafter improvement continued and she was fit to return to the United States a few days later. This patient had been having up to 50 mg. of methotrexate by mouth once a month earlier in the year. She was lucky that at the time of her primary vaccination she had herself reduced the dose to 15 mg. because of earlier experiences of nausea after taking the drug. The importance of proper communication between doctors collaborating in the treatment of patients is emphasised by this case. The very important dangers of the use of immunosuppressive drugs in the management of much less important disease is quite clear. London W.l. JOHN ALLISON.

EMOTIONAL PROBLEMS IN A CHRONIC HÆMODIALYSIS UNIT should like to thank Professor de Wardener for his SIR,-I letter (Nov. 23, p. 1141), but it seems that we did not succeed in making clear the purpose and conclusions of our paper (Nov. 9, p. 987). We had not the slightest intention to denigrate, with or without psychiatric gloss, the medical team. On the contrary, because the team is extremely hard-working, devoted, and skilled (as was clearly stated in the paper), we thought that its reactions and interactions with patients should be studied. Further I should like to stress that none of the physicians has transferred his interest to transplantation-and certainly not Dr. Czaczkes, who is very actively in charge of the unit. Professor de Wardener lauds the nurses’ tendency to regard the patients as their own. I should like to state another opinion: the patients ’are sick people who have to receive the best of medical care; but they are adults who do not " belong to "

mechanics of chronic haemodialysis. However, two evenings a week for two years seems to be quite enough time to develop contact.

Department of Psychiatry and Renal Unit, Hadassah University Hospital and Medical School, Jerusalem, Israel.

A. KAPLAN DE-NOUR.

ABSENCE OF FINGERPRINTS IN FOUR GENERATIONS

SIR,-Complete absence of dermatoglyphics (finger, palm, prints) in more than one member of a family has been described only once previously.1 At that time 13 affected members in a kindred of 24 (three generations) showed bilateral partial flexion contractures of the fingers and toes, bilateral webbing of the toes, and transient congenital milia. Since 1964, toe, and sole

1 of 2

siblings in the fourth generation (see accompanying has shown similar signs. In addition 2 new members of the third generation (111-8 and ill-14) are affected. The genealogical table shows the distribution of features in 16 of 28 members in four generations. The widespread use of fingerprints for identification makes it likely that the congenital absence of dermal ridges (fingerprint patterns) would be remarked upon whenever it was observed. To date similar kindreds have not been reported. St. Christopher’s Hospital for Children, HENRY W. BAIRD. Philadelphia, Pennsylvania 19133.

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DIGITAL DERMATOGLYPHICS AND BLOOD-GROUPS

SIR,-In a population sample consisting of 300 White individuals of both sexes (200 male, 100 female) we have determined the frequency of digital patterns (whorls [w.], radial-loops [R.L.], ulnar loops [u.L.], and arches [A.]) in relation to the ABO and Rh blood-types. We found an increase of whorls and a decrease of loops in the people with 0 bloodtype. This difference was statistically highly significant (we used X2 figures obtained from contingency tables). The results were as follows:

anyone. I certainly agree

that, as the number of patients increases, the emotional problems of the staff diminish. This, in my opinion, should not be attributed to a decrease in the " desire of a professional to protect ’her ’ patients from a succession of ’ meddling amateurs ’ ", but to the lesser emotional involvement, and lesser possessiveness, as often happens with overprotective mothers with an increasing number of children. I also cannot agree with Professor de Wardener’s remarks on our having little contact with dialysis. He is right to assume that I, as a psychiatrist, do not understand much of the

We explain these results by either a pure genetic association (pleiotropic action of agglutinogens or their precursors during 1.

Baird, H. W. J. Pediat. 1964, 64, 621.