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SANATORIA
203 GENITO-URINARY TUBERCULOSIS SiR,-Tuberculosis, it has been said (? erroneously), does not affect both the genital and the urinary F4ymtenis Published as frequently in the female its in the male. data supporting this are hard to find. Search of lnrlxlications on genito-urinary tuberculosis is quite often disappointing, because they do not mention female genital lesions which may occur before or after the urinary lesion is diagnosed. It would be interesting to know the incidence of genital lesions among the female patients in the series of 240 cases of genito-urinary tuberculosis treated by Air. Cosbie Ross and his colleagues and described in last week’s issue. Department
of
Pathology,
Chelsea Hospital for Women, London, S.W.3.
MAGNUS HAINES.
SULPHONAMIDE SENSITIVITY
SIR,—The following
case
has unusual features.
of
sulphonamide sensitivity
The patient was a married woman of 33, with no significant past illnesses or family history. Sho had had no previous skin trouble except for an attack in February, 1954, of subocular and facial cedema : this lasted four days, and cleared with anti-histamines. No cause for it was discovered. On Aug. 13, 1954, she went on holiday to Eastbourne. Because of recent " flu and nasal catarrh she was supplied with some sulphadimidine tablets, and told to take 1 g. every eight hours. On Aug. 18 she returned from Eastbourne feeling very unwell. Her temperature was 101-8 F, her pulse was rapid, and a papular-bullous erythema was present on all exposed areas, with " butterfly distribution on the face. All affected areas were cedematous. The eruption, which worsened rapidly, was thought to be a sulphonanude-sensitivity rash, so the sulphadimidine was stopped and treatment was begun with promethazine hydrochloride 25 mg. three times "
"
a day.
Three days later, on Aug. 21, she was admitted to hospital, since her temperature was still 101°-102°F, the rash was worse, and she had a severe cough. The differential diagnosis at this time was : (a) sulphonamide-sensitivity rash ; (b) lupus erythematosus ; or (c) bullous erythema multiforrne. X-ray examination of the chest and blood-count on Sept. 10 were normal, and the Q-fever cephalin-flocculation test was negative; the erythrocyte-sedimentation rate (t:.s.R.), however, was 125 mm. in one hour (Westergren). An evening pyrexia (up to 100°-101"F) persisted until Sept. 14. On Sept. 15 the E.S.R. was 57 mm. in one hour ; and serumproteins were 9-4 g. per 100 ml. On Sept. 20, when the E.S.R. was 42 mm. in one hour and the albumin/globulin ratio was 1-14, the patient was discharged from hospital. By this time the rash had clisappeared, but there was residual staining of the lesions. Marrow-films examined on Oct. 11 for lupus-erythematosus. cells were negative. Tests for cold agglutinins were also negative. By Nov. 2 the E.s.R. had fallen to 9 mm. in one hour and the patient felt quite well, although she complained of her hair lalling out. A month later there was still some loss of hair, and still slight pigmentation at the sites of the original lesions. The troublesome cough persisted.
Sulphonamide sensitivity following
exposure to
light
? common. This case is of interest in view of the following points : (1) The sulphonamide used (sulphadimidine) is the least toxic of all sulphonamides, and moreover it was used here in h1!lall doses-1 g. eight-hourly for five days (total 15 g.). (2) The E.S.R. was exceedingly high at the onset of the illness (125 mm. in
one
hour),
and it did not return to normal until
seven weeks later.
(3) For
one
month there
was an
evening pyrexia (up
101’F), which was accompanied by a cough. That,
to
in associa-
tion with the high
E.s.R. and the character of the rash, was highly suspicious of lupus erythematosus ; this diagnosis, however, was excluded by the marrow smear on Oct. 11. A similar rash may be found in acute disseminated lupus erythematosus or erythema multiforme.
Falling hair is common after sulphonamide sensitivity,
but the ultimate prognosis is good.
Marked residual
at the site of the lesions often till three months after the onset of the illness.
pigmentation
persists
My thanlzs aro due to Dr. Quntin Evans and Dr. H. A. Treble for permission to publish this case, which was under their care in the Kent and Canterbury Hospital. EDWARD D. FOX. Faversham, Kent. SANATORIA
SIR,— Never at. any time have there been sufficient beds available for the treatment of pulmonary tuberculosis in this country. The result has been that one of two policies was adopted : either patients were kept in sanatoria for long periods in order that quiescence might be reached with or without surgery ; or patients were given shorter periods of treatment and discharged nonquiescent, so that other patients could be admitted. In the latter case the butter, as it were, was spread thinly over as many slices of bread as possible. The experience of institutions adopting the other alternative shows that patients can be successfully treated, given time and determination by the patient and his advisers. It is my belief that bed rest, like Christianity, is often said to have failed when in reality the answer is that it has seldom been tried. The present comparative plethora of beds offers us an’ opportunity to tackle in earnest for the first time the problem of the chronic case, which has so far proved insoluble, except in institutions where the interests of the individual case were paramount and the shortening of a waiting-list a secondary consideration. D. OSBORNE HUGHES. Liverpool.
a
-
VENEREOLOGY AND DERMATOLOGY
SIR,—It is surprising that Dr. Nicol (Jan. 15) criticised my letter (Jan. 8) without knowing the local conditions in East Kent, and that he did so with so many incorrect statements. I did not
plead :
advantages of
a
I commented
the possibility and the venereology and dermatoVenereology was an independent on
combined post in
logy in that particular area. specialty long before the National Health Service became effective in 1948 ; it never has been entirely separate, although that is the agreed policy. There is no evidence that our aciminiatrators have considered the problem solved, and their poliey is still to staff the clinics with experienced conIn America, however, the Journal of Venereal sultants. Diseases has ceased publication, and at least one famous venereaologist has decided to extend his interests and style himself specialist in chronic diseases. A dermatologist recently appointed in East Anglia replaced a venereologist, but Dr. Nicol does not say that the retiring venereologist was also a dermatologist and that the advertisement stated that an extension of the dermatological services was envisaged. Anyhow, why did these venereologists in East Anglia and East Kent elect to transfer to bigger towns ? ’Perhaps it supports my view that there is not enough work to hold the interest of a venereologist in some areas. I did not say : " It is a bad thing to have too much spee ialisation." I said there was still room for the general surgeon and the consultant physician, and that the broader view was sometimes of value. I did not say a senior registrar in venereology could become competent in dermatology by working in both departments for three years : I said there were many consultants competent in both specialties ; and, as Mr. King and Dr. Russell (Jan. 1) said that registrars appointed to one of the specialties had no opportunity of acquiring specialist knowledge of the other, I cited one registrar who is working in both departments ; there are several others. My registrar will appreciate Dr. Nicol’s congratulations but he knows that East Kent offers insufficient scope for him in venereology. With regard to local conditions, Dr. Nicol will be pleased to hear that the clinics are adequate, and they are well sited at the hub of transport radiations ; they are probably unsurpassed for accessibility in any part of the country. The only major seaport in the area is Dover, and that does not have busy clinics. The liaison with other parts of the hospitals was
of
Pathology,
Chelsea Hospital for Women, London, S.W.3.
MAGNUS HAINES.
SULPHONAMIDE SENSITIVITY
SIR,—The following
case
has unusual features.
of
sulphonamide sensitivity
The patient was a married woman of 33, with no significant past illnesses or family history. Sho had had no previous skin trouble except for an attack in February, 1954, of subocular and facial cedema : this lasted four days, and cleared with anti-histamines. No cause for it was discovered. On Aug. 13, 1954, she went on holiday to Eastbourne. Because of recent " flu and nasal catarrh she was supplied with some sulphadimidine tablets, and told to take 1 g. every eight hours. On Aug. 18 she returned from Eastbourne feeling very unwell. Her temperature was 101-8 F, her pulse was rapid, and a papular-bullous erythema was present on all exposed areas, with " butterfly distribution on the face. All affected areas were cedematous. The eruption, which worsened rapidly, was thought to be a sulphonanude-sensitivity rash, so the sulphadimidine was stopped and treatment was begun with promethazine hydrochloride 25 mg. three times "
"
a day.
Three days later, on Aug. 21, she was admitted to hospital, since her temperature was still 101°-102°F, the rash was worse, and she had a severe cough. The differential diagnosis at this time was : (a) sulphonamide-sensitivity rash ; (b) lupus erythematosus ; or (c) bullous erythema multiforrne. X-ray examination of the chest and blood-count on Sept. 10 were normal, and the Q-fever cephalin-flocculation test was negative; the erythrocyte-sedimentation rate (t:.s.R.), however, was 125 mm. in one hour (Westergren). An evening pyrexia (up to 100°-101"F) persisted until Sept. 14. On Sept. 15 the E.S.R. was 57 mm. in one hour ; and serumproteins were 9-4 g. per 100 ml. On Sept. 20, when the E.S.R. was 42 mm. in one hour and the albumin/globulin ratio was 1-14, the patient was discharged from hospital. By this time the rash had clisappeared, but there was residual staining of the lesions. Marrow-films examined on Oct. 11 for lupus-erythematosus. cells were negative. Tests for cold agglutinins were also negative. By Nov. 2 the E.s.R. had fallen to 9 mm. in one hour and the patient felt quite well, although she complained of her hair lalling out. A month later there was still some loss of hair, and still slight pigmentation at the sites of the original lesions. The troublesome cough persisted.
Sulphonamide sensitivity following
exposure to
light
? common. This case is of interest in view of the following points : (1) The sulphonamide used (sulphadimidine) is the least toxic of all sulphonamides, and moreover it was used here in h1!lall doses-1 g. eight-hourly for five days (total 15 g.). (2) The E.S.R. was exceedingly high at the onset of the illness (125 mm. in
one
hour),
and it did not return to normal until
seven weeks later.
(3) For
one
month there
was an
evening pyrexia (up
101’F), which was accompanied by a cough. That,
to
in associa-
tion with the high
E.s.R. and the character of the rash, was highly suspicious of lupus erythematosus ; this diagnosis, however, was excluded by the marrow smear on Oct. 11. A similar rash may be found in acute disseminated lupus erythematosus or erythema multiforme.
Falling hair is common after sulphonamide sensitivity,
but the ultimate prognosis is good.
Marked residual
at the site of the lesions often till three months after the onset of the illness.
pigmentation
persists
My thanlzs aro due to Dr. Quntin Evans and Dr. H. A. Treble for permission to publish this case, which was under their care in the Kent and Canterbury Hospital. EDWARD D. FOX. Faversham, Kent. SANATORIA
SIR,— Never at. any time have there been sufficient beds available for the treatment of pulmonary tuberculosis in this country. The result has been that one of two policies was adopted : either patients were kept in sanatoria for long periods in order that quiescence might be reached with or without surgery ; or patients were given shorter periods of treatment and discharged nonquiescent, so that other patients could be admitted. In the latter case the butter, as it were, was spread thinly over as many slices of bread as possible. The experience of institutions adopting the other alternative shows that patients can be successfully treated, given time and determination by the patient and his advisers. It is my belief that bed rest, like Christianity, is often said to have failed when in reality the answer is that it has seldom been tried. The present comparative plethora of beds offers us an’ opportunity to tackle in earnest for the first time the problem of the chronic case, which has so far proved insoluble, except in institutions where the interests of the individual case were paramount and the shortening of a waiting-list a secondary consideration. D. OSBORNE HUGHES. Liverpool.
a
-
VENEREOLOGY AND DERMATOLOGY
SIR,—It is surprising that Dr. Nicol (Jan. 15) criticised my letter (Jan. 8) without knowing the local conditions in East Kent, and that he did so with so many incorrect statements. I did not
plead :
advantages of
a
I commented
the possibility and the venereology and dermatoVenereology was an independent on
combined post in
logy in that particular area. specialty long before the National Health Service became effective in 1948 ; it never has been entirely separate, although that is the agreed policy. There is no evidence that our aciminiatrators have considered the problem solved, and their poliey is still to staff the clinics with experienced conIn America, however, the Journal of Venereal sultants. Diseases has ceased publication, and at least one famous venereaologist has decided to extend his interests and style himself specialist in chronic diseases. A dermatologist recently appointed in East Anglia replaced a venereologist, but Dr. Nicol does not say that the retiring venereologist was also a dermatologist and that the advertisement stated that an extension of the dermatological services was envisaged. Anyhow, why did these venereologists in East Anglia and East Kent elect to transfer to bigger towns ? ’Perhaps it supports my view that there is not enough work to hold the interest of a venereologist in some areas. I did not say : " It is a bad thing to have too much spee ialisation." I said there was still room for the general surgeon and the consultant physician, and that the broader view was sometimes of value. I did not say a senior registrar in venereology could become competent in dermatology by working in both departments for three years : I said there were many consultants competent in both specialties ; and, as Mr. King and Dr. Russell (Jan. 1) said that registrars appointed to one of the specialties had no opportunity of acquiring specialist knowledge of the other, I cited one registrar who is working in both departments ; there are several others. My registrar will appreciate Dr. Nicol’s congratulations but he knows that East Kent offers insufficient scope for him in venereology. With regard to local conditions, Dr. Nicol will be pleased to hear that the clinics are adequate, and they are well sited at the hub of transport radiations ; they are probably unsurpassed for accessibility in any part of the country. The only major seaport in the area is Dover, and that does not have busy clinics. The liaison with other parts of the hospitals was