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TREATMENT OF ENURESIS
511 TREATMENT OF ENURESIS
SiR,—Dr. Symonds draws attention (Feb. 26) to the spacing of children as a cause of neurotic illness. It is for this reason that I advise my patients to wait for 2-3 years before considering a second baby. It is after the age of 3 that the child begins to demand a brother or sister, and, though at first he notices the change in composition of the family picture where all viewing eyes are directed to a new centre, he soon takes on the role of little father. The younger child, bound up in his mother alone, cannot comprehend the reduced interest in his subordinate figure. A greater factor, however, in emotional illness is the patient’s position at the top of the family tree. Every general practitioner knows how often the mother and her first infant are on his doorstep. About her eagerly awaited firstborn she is unduly anxious and overprotective, and she lacks experience. The first child therefore receives a welter of care, and is the only one who will receive 100% of his mother’s affection, and so much anxiety. He it is who suffers from a situation less poignant for any aftercomer ; and in nine cases out of ten it is possible for the doctor to diagnose the primigeniture of his patient from a consideration of his
symptoms alone. R. N. C. SMITH.
Ilford.
B.C.G. VACCINATION
Sm,-Professor- Heaf (Feb. 12) says that " there is strong evidence that B.c.G. increases resistance against tuberculous infection, although statistical proof is difficult to obtain."
He admits
our ignorance of allergy and tuberculosis, but he also says " these immunity acknowledged advantages of the vaccine are sufficient to justify its use." Are these advantages so generally acknowledged 1 The fact that the vaccine is readily administered and cheap is not so very important : the fundamental question to which we do not know the answer is whether a positive skin reaction is really very important in immunity to tuberculosis. After all we have other diseases in which positive skin reactions occur, but I do not know that it has been suggested that they mean immunity. For example, does a positive Frei test indicate any immunity to lymphogranuloma inguinale, and does Casoni’s reaction indicate any immunity ?Are we really justified in asking parents to submit their children to injections which may, in a significant proportion of cases, produce unpleasant local reactions, and have a risk, however slight, of causing general disease, when we have really no sound knowledge of its good effects. Some of us in the older group are perhaps overanxious. We remember previous campaigns for the use of B.C.G.
in
We remember also the movement for immunisation against scarlet fever some 20 years ago, now I think
completely discarded, and we remember earlier attempts (with much enthusiasm) to use vaccines against whoopingcough whose value is now known to have been nil. I write because I want to be convinced.- If B.C.G. is a, all means let us use it; but I would like to know more about the " acknowledged advantages of the vaccine." We do know of the solid advantages of
good thing then by immunisation
against diphtheria and, therefore, some extremely hesitant about any procedure which might prejudice that immunisation. It is admitted that many authorities of high standing are sceptical about B.C.G. and that indeed in recent years the sceptics have of us
are
become more vocal. Is there an answer to this ?° It has been pointed out by Dr. McIntosh, senior chest physician in Dundee, that in that city there was a very considerable decline in tuberculosis mortality in 1947-51 and he points out that if B.c.G. had been used on a wide scale in 1947 there would have been a strong temptation to credit it with the good result. Can Professor Heaf convince those of us who hesitate on the brink ?
I am, of course, and not that of my
expressing a purely personal employing authority.
doubt
R. C. WEBSTER.
Accrmgton.
BEHÇET’S SYNDROME one has collected a series of cases of a disease it is a pardonable error to suppose that the condition must be commoner than is supposed and that others are missing the diagnosis. We are impelled to defend our dermatological colleagues from the charge of failing to diagnose Beheet’s syndrome. In their interesting paper (Feb. 19) Dr. Phillips and Dr. Scott give a useful account of aphthosis of the mouth and vulva with its other possible complications. The dermatologist, however, is only too familiar with the incomplete picture of aphthous stomatitis, the common occurrence of which should be emphasised as opposed to the extreme rarity of involvement of the vulva or the eyes.
SiR,-When
rare
The association of lesions of the mucosa and skin with various inflammatory reactions of the eyes has long puzzled Juvenile cataract with atopic eczema dermatologists. (Werner’s syndrome and Rothmund’s syndrome) is due to a combination of genetic defects,l but the eye lesions of sarcoidosis and Reiter’s syndrome have no obvious explanation. The pemphigus and erythema-multiforme groups, on the other hand, attack the mucosse and skin with equal severity ; and in these the graver the illness the more probable is involvement of the conjunctivse, mouth, and genitalia. But in bringing the erythema-multiforme group-which includes the Stevens-Johnson syndrome-into the differential diagnosis of Beheet’s syndrome, Phillips and Scott have made matters unduly difficult. Erythema multiforme, when it affects the mucous membranes, produces superficial sloughing of the whole mucosa, and true painful aphthous ulceration is never found in this condition. They are incorrect in stating that the Stevens-Johnson syndrome occurs as a single attack; recurrent, though admittedly not cyclical, attacks are not uncommon.
One disease, which they do not mention, that could be confused with Beheet’s syndrome is benign mucous-membrane pemphigus. We have tried to clarify the diagnostic criteria of this conditionwhich must sometimes be missed through the patients receiving only a specialised examination by the gynaecologist. Ocular pemphigus, as it is also called, produces chronic recurrent ulceration and scarring of the conjunctivse, mouth, and vulva ; and though there is no doubt in our minds that it is a distinct entity affecting the elderly, it resembles Beheet’s syndrome closely enough to be important in differential diagnosis.
Finally, we are a little mystified by the statement that Beheet’s syndrome may eventually be placed among the collagen diseases. The setiology of Beheet’s syndrome may be obscure, but one would require evidence of involvement of collagen in the disease-process before throwing it into this modish ragbag. Rupert Hallam Department of Dermatology, Royal Infirmary,
R. E. CHURCH
I. B. NEDDON. SNEDDON. S SheSeld. 1. I. Sheffield. B. SiR,-The extremely interesting article by Dr. Phillips and Dr. Scott prompts me to record the following case of Beheet’s syndrome. A married man, aged 35, had an inflammation of his left eye in August, 1952, which cleared up with penicillin eye-drops. The following month the inflammation recurred and later spread- to the other eye. He was then found to have a bilateral iritis. In October, 1952, he received a 10-day course of oral cortisone and his vision which had previously been blurred became normal. The iritis relapsed soon after treatment was stopped and was not improved by a course of local cortisone therapy. After that the condition of his eyes deteriorated until he became completely blind owing to a bilateral irido-
cyclitis. In November, 1952, he first had very painful ulcers inner aspects of his lips, buccal mucosa, tongue, and 1. 2.
on
the
palate,
Carleton, A. Brit. J. Derm. 1943, 55, 83. Church, R. E., Sneddon, I. B. Ibid, 1953, 65, 235.
SiR,—Dr. Symonds draws attention (Feb. 26) to the spacing of children as a cause of neurotic illness. It is for this reason that I advise my patients to wait for 2-3 years before considering a second baby. It is after the age of 3 that the child begins to demand a brother or sister, and, though at first he notices the change in composition of the family picture where all viewing eyes are directed to a new centre, he soon takes on the role of little father. The younger child, bound up in his mother alone, cannot comprehend the reduced interest in his subordinate figure. A greater factor, however, in emotional illness is the patient’s position at the top of the family tree. Every general practitioner knows how often the mother and her first infant are on his doorstep. About her eagerly awaited firstborn she is unduly anxious and overprotective, and she lacks experience. The first child therefore receives a welter of care, and is the only one who will receive 100% of his mother’s affection, and so much anxiety. He it is who suffers from a situation less poignant for any aftercomer ; and in nine cases out of ten it is possible for the doctor to diagnose the primigeniture of his patient from a consideration of his
symptoms alone. R. N. C. SMITH.
Ilford.
B.C.G. VACCINATION
Sm,-Professor- Heaf (Feb. 12) says that " there is strong evidence that B.c.G. increases resistance against tuberculous infection, although statistical proof is difficult to obtain."
He admits
our ignorance of allergy and tuberculosis, but he also says " these immunity acknowledged advantages of the vaccine are sufficient to justify its use." Are these advantages so generally acknowledged 1 The fact that the vaccine is readily administered and cheap is not so very important : the fundamental question to which we do not know the answer is whether a positive skin reaction is really very important in immunity to tuberculosis. After all we have other diseases in which positive skin reactions occur, but I do not know that it has been suggested that they mean immunity. For example, does a positive Frei test indicate any immunity to lymphogranuloma inguinale, and does Casoni’s reaction indicate any immunity ?Are we really justified in asking parents to submit their children to injections which may, in a significant proportion of cases, produce unpleasant local reactions, and have a risk, however slight, of causing general disease, when we have really no sound knowledge of its good effects. Some of us in the older group are perhaps overanxious. We remember previous campaigns for the use of B.C.G.
in
We remember also the movement for immunisation against scarlet fever some 20 years ago, now I think
completely discarded, and we remember earlier attempts (with much enthusiasm) to use vaccines against whoopingcough whose value is now known to have been nil. I write because I want to be convinced.- If B.C.G. is a, all means let us use it; but I would like to know more about the " acknowledged advantages of the vaccine." We do know of the solid advantages of
good thing then by immunisation
against diphtheria and, therefore, some extremely hesitant about any procedure which might prejudice that immunisation. It is admitted that many authorities of high standing are sceptical about B.C.G. and that indeed in recent years the sceptics have of us
are
become more vocal. Is there an answer to this ?° It has been pointed out by Dr. McIntosh, senior chest physician in Dundee, that in that city there was a very considerable decline in tuberculosis mortality in 1947-51 and he points out that if B.c.G. had been used on a wide scale in 1947 there would have been a strong temptation to credit it with the good result. Can Professor Heaf convince those of us who hesitate on the brink ?
I am, of course, and not that of my
expressing a purely personal employing authority.
doubt
R. C. WEBSTER.
Accrmgton.
BEHÇET’S SYNDROME one has collected a series of cases of a disease it is a pardonable error to suppose that the condition must be commoner than is supposed and that others are missing the diagnosis. We are impelled to defend our dermatological colleagues from the charge of failing to diagnose Beheet’s syndrome. In their interesting paper (Feb. 19) Dr. Phillips and Dr. Scott give a useful account of aphthosis of the mouth and vulva with its other possible complications. The dermatologist, however, is only too familiar with the incomplete picture of aphthous stomatitis, the common occurrence of which should be emphasised as opposed to the extreme rarity of involvement of the vulva or the eyes.
SiR,-When
rare
The association of lesions of the mucosa and skin with various inflammatory reactions of the eyes has long puzzled Juvenile cataract with atopic eczema dermatologists. (Werner’s syndrome and Rothmund’s syndrome) is due to a combination of genetic defects,l but the eye lesions of sarcoidosis and Reiter’s syndrome have no obvious explanation. The pemphigus and erythema-multiforme groups, on the other hand, attack the mucosse and skin with equal severity ; and in these the graver the illness the more probable is involvement of the conjunctivse, mouth, and genitalia. But in bringing the erythema-multiforme group-which includes the Stevens-Johnson syndrome-into the differential diagnosis of Beheet’s syndrome, Phillips and Scott have made matters unduly difficult. Erythema multiforme, when it affects the mucous membranes, produces superficial sloughing of the whole mucosa, and true painful aphthous ulceration is never found in this condition. They are incorrect in stating that the Stevens-Johnson syndrome occurs as a single attack; recurrent, though admittedly not cyclical, attacks are not uncommon.
One disease, which they do not mention, that could be confused with Beheet’s syndrome is benign mucous-membrane pemphigus. We have tried to clarify the diagnostic criteria of this conditionwhich must sometimes be missed through the patients receiving only a specialised examination by the gynaecologist. Ocular pemphigus, as it is also called, produces chronic recurrent ulceration and scarring of the conjunctivse, mouth, and vulva ; and though there is no doubt in our minds that it is a distinct entity affecting the elderly, it resembles Beheet’s syndrome closely enough to be important in differential diagnosis.
Finally, we are a little mystified by the statement that Beheet’s syndrome may eventually be placed among the collagen diseases. The setiology of Beheet’s syndrome may be obscure, but one would require evidence of involvement of collagen in the disease-process before throwing it into this modish ragbag. Rupert Hallam Department of Dermatology, Royal Infirmary,
R. E. CHURCH
I. B. NEDDON. SNEDDON. S SheSeld. 1. I. Sheffield. B. SiR,-The extremely interesting article by Dr. Phillips and Dr. Scott prompts me to record the following case of Beheet’s syndrome. A married man, aged 35, had an inflammation of his left eye in August, 1952, which cleared up with penicillin eye-drops. The following month the inflammation recurred and later spread- to the other eye. He was then found to have a bilateral iritis. In October, 1952, he received a 10-day course of oral cortisone and his vision which had previously been blurred became normal. The iritis relapsed soon after treatment was stopped and was not improved by a course of local cortisone therapy. After that the condition of his eyes deteriorated until he became completely blind owing to a bilateral irido-
cyclitis. In November, 1952, he first had very painful ulcers inner aspects of his lips, buccal mucosa, tongue, and 1. 2.
on
the
palate,
Carleton, A. Brit. J. Derm. 1943, 55, 83. Church, R. E., Sneddon, I. B. Ibid, 1953, 65, 235.