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PURPURA WITH HYPOGAMMAGLOBULINÆMIA
141 in hypersensitivity states. It can be assumed that the allergen in this patient was not a contaminant of the vaccination, but the tubercle bacillus itself (or a part of it), and that as long as it was present the steroids were able to exert some effect on the existing lesions, but not to prevent relapses. Probably it was the specific action of P.A.s. and isoniazid on the bacillus itself which prevented the reappearance of the rash. I. MACHTEY Second Medical Department, M. BANDMANN Beilinson Medical Centre, A. PALANT. Petah-Tiqva, Israel.
X-RAY INACTIVATION OF HISTAMINE SIR,-In 19581described the suppression of an allergic skin rash by a dose of radiotherapy (1500r in 5 treatments). This inhibition occurred immediately after treatment-that is, before the normal skin reaction had time to appear. The explanation I hoped for from your readers has now been given by Dr. Sturde and Dr. Heitmann (Dec. 23, p. 1362), who show that radiotherapy inibits histamine, presumably while that substance is still within the secreting cells. In general, radiotherapy for allergic conditions is out of fashion. Perhaps Dr. Sturde and Dr. Heitmann’s work will arouse further
interest. Saint Luke’s Hospital, Rathgar, Dublin.
GASTROENTERITIS DUE TO ESCHERICHIA COLI SIR,-In your annotation (Jan. 6, p. 32) you seem to imply that nowadays the prevention of spread of Escherichia coli in an infant’s ward may be virtually impossible. My colleagues and I do not think this defeatist attitude is justified. Over the past 9 years a system of strict barrier nursing evolved in Brighton has proved to be effective in limiting the spread of these organisms.I-3 As a result of experience with epidemics such as the recent one on Tees-side we were prompted, in collaboration with the Public Health Laboratory, Brighton, to carry out a long-term study of the problem of cross-infection with E. coli, which is still continuing.4 You are, of course, correct in suggesting that the vehicle of enteropathogens may be the nurse or the doctor, although one must not lose sight of the possibility that air-borne bacteria may be carried between cubicles on cross-draughts. Because of the human factor precautions in our infants’ and gastroenteritis units are strictly applied throughout the 24 hours; everyone entering a cubicle is expected to observe the routine - not only parents, cleaners, housemen, consultants, and administrative and junior nursing staff, but also the occasional visitor, such as the clinical photographer. Royal Alexandra Hospital for Sick Children, TREVOR P. MANN. Brighton 1.
J. B. HEALY. BACTERIOLOGY IN THE SURGERY
SIR,PURPURA WITH HYPOGAMMAGLOBULINÆMIA SIR,—We describe here a patient with anaphylactoid purpura with hypogammaglobulinæmia without liver dysfunction or gastrointestinal symptoms. The patient, a 53-year-old man, was admitted here on Jan. 17, 1967, with pyrexia of unknown origin. He said that he had been in good health until he developed a rash on the legs, pyrexia, weakness, and painfully swollen joints 7 months before. He was then 23 days in hospital, where idiopathic purpura was diagnosed, and his condition remained unchanged : some days after his discharge a private physician prescribed for the first time steroids (prednisolone, 15 mg. per day) which he took for 5 months until 10 days before admission here for further investigation. The patient appeared acutely ill with a typical rash of anaphylactoid purpura on the legs and buttocks and a temperature of 1014°F (385°C). The liver and spleen were palpable. The laboratory findings were as follows: hxmatological examination showed hypochromic anaemia, serum-iron 35 µg. per 100 ml., hasmatocrit 32%, Hb 10-6 g. per 100 ml., white blood-cells 7000 with normal differential count, platelets plentiful, no abnormality in bone-marrow aspirate; bloodurea 55 mg., sugar 95 mg., and cholesterol 290 mg., per 100 ml., serum-glutamic-oxaloacetic-transaminase 64 units, serum-glutamic-pyruvic-transaminase 40 units, liver-function normal by all tests, Wassermann reaction and Kahn test negative, occult-blood test many times negative; urine showed specific gravity 1023-1025, daily output 500-800 ml., protein + +, few red cells, no calciuria. A week after admission urea clearance was abnormal. The blood-urea level increased and the urine output diminished. Electrolyte-levels were found to be normal many times. Sigmoidoscopy was normal. No L.E. cells were found, and liver biopsy showed no abnormality. Repeated bloodcultures were negative. Serum electrophoresis showed intense hypogammaglobulinxmia. 3 days’ fascal fat estimation was normal. We immediately started treatment with high daily doses of y-globulin and with antibiotics and vitamins. The temperature gradually returned to normal and the patient improved. He was discharged on Feb. 23 feeling well. P. POUGGOURAS National Medical Service, A. SIMOS Hippocration Hospital, A. PAPAZACHARIAS. Athens. 1.
Healy, J. B. Lancet, 1958, ii, 267.
"... multiple resistance should once again be a warning against prescribing antibiotics to children with diarrhoea without identifying the cause.... We suspect that these drugs are vastly overprescribed for patients of all ages with diarrhœa (annotation, Lancet, Jan. 6, p. 32). " ... logistic problems are the main reasons why the family doctor uses the hospital or public health laboratory less often than he would wish (annotation, Lancet, Dec. 30, p. 1405). "
"
These were precisely the considerations leading us to undertake "bacteriology in the surgery ", despite our working in a city where diagnostic facilities for the family doctor compare favourably with those of any other part of the country. Earlier diagnosis and prompter specific treatment can limit spread of infection and speed return to work, in the best "I’m backing Britain" spirit! A man aged 28. Oct. 23, 1 P.M. Seen at home complaining of " flu
"
and mild diarrhoea. Rectal swab plated at surgery: simultanesent through routine channels to routine Lab. A.
ously, specimen
Patient started on mist. kaolin et morph. Oct. 24. Surgery culture grows non-lactose fermenter, and slide agglutination at nearby Lab. B shows it is Shigella sonnei. 10 A.M. Patient revisited specially, and treatment changed to neomycin. Oct. 25. Patient much improved Oct. 26. 2 P.M. Lab. A phones " provisional Sonne isolated". Oct. 28. Written confirmation received from Lab A.
0. and M. should indeed look at the matter, as you suggest, but until the efficiency of laboratory services for family doctors is greatly increased, "bacteriology in the surgery" is more than just the "game" your annotation implies. JAMES D. E. KNOX A. R. LAURENCE G. MACNAUGHTAN A. A. ROBERTSON. Edinburgh. Gibson, M., Mann, T. P. Nursing Times, Sept. 24, 1965, p. 1309; ibid. Oct. 1, p. 1334. 2. See Lancet, 1966, i, 700. 3. See Br. med. J. 1966, i, 876. 4. Jameson, J. E., Mann, T. P., Rothfield, N. J. Lancet, 1954, ii, 459. 1.
X-RAY INACTIVATION OF HISTAMINE SIR,-In 19581described the suppression of an allergic skin rash by a dose of radiotherapy (1500r in 5 treatments). This inhibition occurred immediately after treatment-that is, before the normal skin reaction had time to appear. The explanation I hoped for from your readers has now been given by Dr. Sturde and Dr. Heitmann (Dec. 23, p. 1362), who show that radiotherapy inibits histamine, presumably while that substance is still within the secreting cells. In general, radiotherapy for allergic conditions is out of fashion. Perhaps Dr. Sturde and Dr. Heitmann’s work will arouse further
interest. Saint Luke’s Hospital, Rathgar, Dublin.
GASTROENTERITIS DUE TO ESCHERICHIA COLI SIR,-In your annotation (Jan. 6, p. 32) you seem to imply that nowadays the prevention of spread of Escherichia coli in an infant’s ward may be virtually impossible. My colleagues and I do not think this defeatist attitude is justified. Over the past 9 years a system of strict barrier nursing evolved in Brighton has proved to be effective in limiting the spread of these organisms.I-3 As a result of experience with epidemics such as the recent one on Tees-side we were prompted, in collaboration with the Public Health Laboratory, Brighton, to carry out a long-term study of the problem of cross-infection with E. coli, which is still continuing.4 You are, of course, correct in suggesting that the vehicle of enteropathogens may be the nurse or the doctor, although one must not lose sight of the possibility that air-borne bacteria may be carried between cubicles on cross-draughts. Because of the human factor precautions in our infants’ and gastroenteritis units are strictly applied throughout the 24 hours; everyone entering a cubicle is expected to observe the routine - not only parents, cleaners, housemen, consultants, and administrative and junior nursing staff, but also the occasional visitor, such as the clinical photographer. Royal Alexandra Hospital for Sick Children, TREVOR P. MANN. Brighton 1.
J. B. HEALY. BACTERIOLOGY IN THE SURGERY
SIR,PURPURA WITH HYPOGAMMAGLOBULINÆMIA SIR,—We describe here a patient with anaphylactoid purpura with hypogammaglobulinæmia without liver dysfunction or gastrointestinal symptoms. The patient, a 53-year-old man, was admitted here on Jan. 17, 1967, with pyrexia of unknown origin. He said that he had been in good health until he developed a rash on the legs, pyrexia, weakness, and painfully swollen joints 7 months before. He was then 23 days in hospital, where idiopathic purpura was diagnosed, and his condition remained unchanged : some days after his discharge a private physician prescribed for the first time steroids (prednisolone, 15 mg. per day) which he took for 5 months until 10 days before admission here for further investigation. The patient appeared acutely ill with a typical rash of anaphylactoid purpura on the legs and buttocks and a temperature of 1014°F (385°C). The liver and spleen were palpable. The laboratory findings were as follows: hxmatological examination showed hypochromic anaemia, serum-iron 35 µg. per 100 ml., hasmatocrit 32%, Hb 10-6 g. per 100 ml., white blood-cells 7000 with normal differential count, platelets plentiful, no abnormality in bone-marrow aspirate; bloodurea 55 mg., sugar 95 mg., and cholesterol 290 mg., per 100 ml., serum-glutamic-oxaloacetic-transaminase 64 units, serum-glutamic-pyruvic-transaminase 40 units, liver-function normal by all tests, Wassermann reaction and Kahn test negative, occult-blood test many times negative; urine showed specific gravity 1023-1025, daily output 500-800 ml., protein + +, few red cells, no calciuria. A week after admission urea clearance was abnormal. The blood-urea level increased and the urine output diminished. Electrolyte-levels were found to be normal many times. Sigmoidoscopy was normal. No L.E. cells were found, and liver biopsy showed no abnormality. Repeated bloodcultures were negative. Serum electrophoresis showed intense hypogammaglobulinxmia. 3 days’ fascal fat estimation was normal. We immediately started treatment with high daily doses of y-globulin and with antibiotics and vitamins. The temperature gradually returned to normal and the patient improved. He was discharged on Feb. 23 feeling well. P. POUGGOURAS National Medical Service, A. SIMOS Hippocration Hospital, A. PAPAZACHARIAS. Athens. 1.
Healy, J. B. Lancet, 1958, ii, 267.
"... multiple resistance should once again be a warning against prescribing antibiotics to children with diarrhoea without identifying the cause.... We suspect that these drugs are vastly overprescribed for patients of all ages with diarrhœa (annotation, Lancet, Jan. 6, p. 32). " ... logistic problems are the main reasons why the family doctor uses the hospital or public health laboratory less often than he would wish (annotation, Lancet, Dec. 30, p. 1405). "
"
These were precisely the considerations leading us to undertake "bacteriology in the surgery ", despite our working in a city where diagnostic facilities for the family doctor compare favourably with those of any other part of the country. Earlier diagnosis and prompter specific treatment can limit spread of infection and speed return to work, in the best "I’m backing Britain" spirit! A man aged 28. Oct. 23, 1 P.M. Seen at home complaining of " flu
"
and mild diarrhoea. Rectal swab plated at surgery: simultanesent through routine channels to routine Lab. A.
ously, specimen
Patient started on mist. kaolin et morph. Oct. 24. Surgery culture grows non-lactose fermenter, and slide agglutination at nearby Lab. B shows it is Shigella sonnei. 10 A.M. Patient revisited specially, and treatment changed to neomycin. Oct. 25. Patient much improved Oct. 26. 2 P.M. Lab. A phones " provisional Sonne isolated". Oct. 28. Written confirmation received from Lab A.
0. and M. should indeed look at the matter, as you suggest, but until the efficiency of laboratory services for family doctors is greatly increased, "bacteriology in the surgery" is more than just the "game" your annotation implies. JAMES D. E. KNOX A. R. LAURENCE G. MACNAUGHTAN A. A. ROBERTSON. Edinburgh. Gibson, M., Mann, T. P. Nursing Times, Sept. 24, 1965, p. 1309; ibid. Oct. 1, p. 1334. 2. See Lancet, 1966, i, 700. 3. See Br. med. J. 1966, i, 876. 4. Jameson, J. E., Mann, T. P., Rothfield, N. J. Lancet, 1954, ii, 459. 1.