BRITISH MEDICAL JOURNAL
remarkably clear. Taking a second swab, I notified Dr Litt, who on examination found it difficult to believe that this had been a diphtheritic case. He let the child remain, pending the result of the second swab. It was negative. Precisely the same train of events occurred in three following cases-first swabs positive, follow-ups negative. Dr Litt, giving permission for the fourth child to remain in the home, remarked, "I suppose Dr Mitchell wants to prove the efficacy of his homoeopathy." Matron agreed, "Yes, I'm sure he does." G RUTHVEN MITCHELL Brighton, Sussex BN2 1GB
Mitchell, G R, British Homoeopathic journal, 1957, 46, 46.
Trichinosis SIR,-Dr P Bouree and others (21 April, p 1047) do not mention the large outbreak of trichinosis which occurred in England in late 1940 and early 1941, centred on Wolverhampton. This was reported by Sheldon.' At least 500 people appeared to have been affected. All had swelling of the eyelids, most had fever and muscular pains, and many had focal central nervous system manifestations. The incidence in women was four times greater than in men. There were no deaths. The source of the infection appeared to be uncooked sausage meat, and Sheldon discovered that a high proportion of working people in the Midlands, especially women, habitually ate sandwiches made with uncooked sausage. The very day before the Lancet containing Sheldon's paper appeared I was baffled by a young man in outpatients with swollen eyes and muscular pains; so I asked a colleague to see him, who was equally baffled. The following morning the colleague threw the Daily Mirror across the breakfast table to me and commented, "There's the diagnosis of that boy," for the paper contained an account of Sheldon's article. This was the first and only occasion in my life when reading the Daily Mirror-or any other newspaper enabled me to reach a diagnosis. JOHN W TODD Farnham, Surrey GU9 8DR I
1355
19 MAY 1979
Sheldon, J H, Lancet, 1941, 1, 203.
SIR,-In the paper on trichinosis (21 April, p 1047) the authors state, with reference to horse meat being incriminated, that "this pathogenetic mechanism is surprising since the horse is strictly herbivorous." I myself have seen horses eating sheep's offal in the Middle East. The source of the horse meat in the reported attack was "from an Eastern country." I also understand that during the 1914-8 war meat was fed to horses in the British cavalry regiments on the Western Front. G E FFRENCH Occupational Health Unit, Central Middlesex Hospital, London NW10 7NS
Pressure on the tracheal mucosa from cuffed tubes SIR,-The well-documented fact that it is easier to damage the trachea with small residue endotracheal-tube cuffs than large is reiterated by Drs J M Leigh and J P Maynard
(5 May, p 1173). It must be borne in mind, however, that even the Lanz cuff, for example, can result in damage if there is a malfunction of the valve mechanism of the over-pressure safety balloon. Moreover, I do not feel that the authors' data (which relate to their pressure measurements in two patients) justify the conclusion that Lanz-type tubes are mandatory in all intensive care units. Other large-residue cuffs can be used safely by monitoring the intracuff pressures. In the case of the spongefilled cuff (Kamen-Wilkinson) the size of the endotracheal or tracheostomy tube in relation to the size of the trachea is critical. Since this cuff functions like a spring a "large" tube in a "small" trachea results in high lateral pressure on the wall of the trachea. It has been my observation in clinical practice that when large-residue cuffs are correctly adjusted a gas leak past the cuff will often occur at the peak of inspiration, particularly when high inflation pressures are used. Therein lies their safety. Thus when small residue cuffs are used a tiny audible gas leak past the cuff at a peak inspiratory pressure of not more than 20 mm Hg ensures that the mean pressure bearing on the tracheal wall will not exceed the intratracheal pressure. No attempt to produce a completely airtight seal at this or higher airway pressure should be made. The situation is analogous to that of an infant or child intubated with an uncuffed tube of appropriate size during positivepressure ventilation. The final "seal" is effected by the mucous cushion secreted by the tracheal mucosa in response to the "foreign body." My clinical observations while using the traditional red rubber tubes in this fashion for many years without causing any significant tracheal damage have been supported by the histological findings of a controlled experimental study in dogs.' In the operating room setting at least, cuff management seems as important as cuff design. It seems neither prudent nor practical at present to replace all tubes with small-residue tubes endobronchial including cuffs, presumably, by those with large-residual cuffs of the Lanz type for routine anaesthetic practice. Hard evidence to the contrary would be required before considering such a change and it is lacking. JOHN HoMI Anaesthetic Unit, London El 1BB
London Hospital Medical College,
'Homi, J, et al, British Journal of Anaesthesia, 1978, 50, 434.
Remedy for excessive salivation SIR,-The distressing symptom of drooling (5 May, p 1200), whether due to poor neuromuscular development, as seen in some mentally defective children, or acquired when a patient has sustained a cerebrovascular accident, may be treated with the help of a simple intraoral appliance,' similar to a removable orthodontic appliance. The appliance, called a palatal training appliance, was designed originally to assist in soft-palate rehabilitation2 as an aid to speech therapy, and consists of a loop of wire extending into the soft palate region. Personal experience gained from treating over 200 patients with palatoglossal incoordination suggests that it also appears to improve oral sensitivity, which is generally reduced in this condition, as well as improving the co-
ordination between the tongue, soft palate, and pharynx, which is necessary for a normal swallowing action. The appliance has proved useful for the treatment of patients with drooling problems after a cerebrovascular accident, based on experience of over 100 patients. The normal pattern is for salivation to increase somewhat for a period of about three weeks, but afterwards a rapid improvement occurs. Most patients may have the loop of wire removed after a few weeks, but a few seem to need it for a long while and request to have it replaced. It causes no inconvenience unless normal sensations return. In the case of children, 45 of whom have been treated for drooling for a variety of reasons, the greatest success has been with the mentally subnormal group, and spastics have been the most difficult. I have not been able to determine which children have a good prognosis with this treatment, but because it is simple and easily reversible little is lost in trying, and some very pleasing results have been obtained. The palatal training appliance may be constructed by dental surgeons in any branch of the Health Service and will enable the speech therapist to treat these patients more effectively. To try to help patients with poor lip posture, a lip seal reminder3 has been developed recently by the medical physics group in the physics department of Exeter University, and it appears to be a valuable aid to encourage lip closure. It has been designed to develop a tactile awareness in addition to a reminder, particularly when the patient is concentrating on other things. The device is not triggered by excessive salivation and only when the lips open does it sound the alarm. W G SELLEY Dental Department, Royal Devon and Exeter Hospital (Heavitree), Exeter EX1 2ED I
2 3
Selley, W G, British Dental.Journal, 1977, 143, 12. Tudor, C, and Selley, W G, British Journal of Disorders of Communication, 1974, 9, 117. Available from Bio Instrumentations Limited, Holmcroft, School Road, Silverton, Exeter, Devon.
Heat stroke or hypothermia? SIR,-I thank Dr T J Bassler (20 January, p 197) for his comments on our work related to heat stroke and distance running.1-3 His points regarding the inaccuracies in reports of causes of death from ischaemic heart disease instead of heat stroke in distance running events are well taken. Perhaps the most inaccurate and paradoxical report, to my knowledge, was when cases of death due to hypothermia were attributed to hyperthermia. In a report entitled "Jogging in Tasmania"4 the author noted the death from "heat stroke" of a young man jogging in the streets of Massachusetts on a hot, humid, and polluted day. He compared this with two deaths in the "Go as You Please" race from Hobart to Mount Wellington in Tasmania in 1912, implying that the cause of death was again heat stroke, unusual in the temperate climate of Tasmania. When I reviewed these reports, I found that three people had died on Mount Wellington, two in 1903 and a third in 1970. However, conditions were unlike the hot, humid summer's day in Massachusetts, for these races were conducted in the northern hemisphere's summer but the southern hemisphere's winter,
1356
and on both occasions a blizzard prevailed. The Mercury, a Hobart newspaper, reported on 21 September 1903, "They had to face a snowstorm, with a strong south-westerly wind. Many of them were dressed only in singlets and light knickers, ... and the top sides of the mountain were covered with some feet of snow...." One of the participants noted some years later, "They were lying over logs, on the ground, and under trees, too exhausted to continue." Thus the deaths were a result-of hypothermia, the end result of exhaustion and inadequate or wet clothing in a cold, windy environment. It is clear that lightly clad runners are vulnerable to environmental conditions, both hot and cold, and the organisers of any community jogging events should realise that weather conditions can create a medical nightmare out of a "fun run." JOHN R SUTTON Department of Medicine, McMaster University,
Hamilton,
Ontario, Canada L8S 4J9
Sutton, J R, et al, Medical Journal of Australia, 1972, 2, 127. 2Sutton, J R, and Harrison, H C, Medical J'ournal of Australia, 1977, 1, 193. 3Hughson, R L, and Sutton, J R, British Medical J'ournal, 1978, 1, 1158. 4Robinson, C R R, New England Journal of Medicine, 1971, 285, 1267.
Canvasser's knuckle SIR,-We are all aware of such complaints as "housemaid's knee," clergyman's knee," "student's elbow," "miner's elbow," and "weaver's bottom"; but I would like to introduce another member of this family, which I have discovered recently-namely, "canvasser's knuckle." During the course of the recent election I knocked on dozens of doors and subsequently developed painful swelling and inflammation of the proximal interphalangeal joints of my right hand. At a conservative estimate I would say that 50 % of party workers who laboured hard during the last campaign suffered from "canvasser's knuckle" and that their discomfort could be relieved by a liberal application of cold hand cream. ADRIAN THOMPSON University Medical School, Leeds 2
Illness seen at menopause clinic
SIR,-The recent paper by Mr S Chakravarti and others (14 April, p 983) noted that a group of the patients presenting in a menopause clinic had symptoms which were not apparently attributable to the oestrogen deficiency of the climacteric. Of the first 40 patients referred to a menopause clinic in Newcastle, 19 were found to be suffering from conditions requiring treatment but unrelated to oestrogen deficiency (although this was judged to be present in at least nine of the 19 on the basis of characteristic symptoms and raised plasma concentrations of follicle-stimulating hormone). The range of diagnoses included hyperthyroidism, primary hyperparathyroidism, hypertension, cardiac failure, and alcoholism, as well as depressive illness. Undoubtedly there is a tendency for women aged around 50 to attribute any untoward
BRITISH MEDICAL JOURNAL
symptoms to the menopause and their doctors may sometimes accept this explanation too readily. A major function of a menopause clinic is a full diagnostic appraisal of the patient. I WANDLESS University Department of Medicine (Geriatrics), Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
Cervical cytology
SIR,-Since becoming a principal in general practice in 1973 I have been concerned about the accuracy of technicians' reports on cervical smears. In 1977 in Gloucestershire I and a partner were running a family planning clinic in a practice of 10 000 patients. We became worried when it seemed to us that there were too many reports of squamous cells only, requesting the smear to be repeated. We collected reports on smears done on our patients over a six-month period. These smears were taken by the doctors in the Family Planning Association clinic, the consultant gynaecologists, and the partners in our practice. We found that of the three technicians who reported, one requested a significantly higher number of repeats than the other two, and it did not seem that any one doctor was requested to repeat his smear more than another. We pointed this out to the pathology department and realised that a larger study was neededperhaps nationally-really to prove our point, formally and statistically, that there may be a vast amount of public expenditure wasted because of mistakes in cell typing. I am now in a smaller general practice in Yorkshire and again became worried because every single cervical smear I have taken is simply reported "no malignant cells." This is a complete contrast to my reports in Gloucestershire and I have not changed my technique. I therefore did two slides. One was of cells from my buccal cavity (statified squamous) and the other slide was prepared by my scraping the inside of my nose with a finger nail (mainly mucous cells, but the slide may have had some psuedostratified columnar ciliated cells or goblet cells). These were fixed and sent to Leeds as though they were smears. Each was reported as "normal smear, no malignant cells." The reporting aspect of the national cytology service should be investigated. I and some of my GP colleagues feel we may be wasting our time and that of the patient's as well as a lot of public money. R E G SLOAN Castleford, W Yorks WFlO 2QS
Pituitary suppression in chronic airways disease? SIR,-We were interested to read the paper entitled "Hypopituitarism in normal-pressure hydrocephalus" by Drs S G Barker and H Garvan (21 April, p 1039), having recently discovered some similar endocrine abnormalities among 16 male patients with chronic obstructive airways disease.' Serum tri-iodothyronine, thyroxine, cortisol, and oestradiol levels were normal in our patients but there was depression of serum testosterone, the degree of depression apparently being related to the degree of hypoxia and hypercapnia. Normal serum lutenising
19 mAY 1979
hormone and follicle stimulating hormone values suggested hypothalamic or pituitary suppression rather than testicular failure. Three of eight hypercapnic patients had high serum prolactin values not attributable to drug consumption. As hypoxia of altitude has been shown to cause depression of adrenal and gonadal function,2 3 we assumed hypoxia or hypercapnia to be the likely cause of the endocrine abnormalities in our patients. However, in view of the findings of Drs Barker and Garvan it seems possible that the raised intracranial pressure known to occur in hypercapnia, even to the extent of causing an eroded pituitary fossa on x-ray,4 may account for our findings. We are currently involved in further studies in this field. PETER d'A SEMPLE G H BEASTALL W S WATSON ROBERT HUME Medical Division, Southern General Hospital, Glasgow G51 4TF l Semple, P d'A, et al, Thorax, in press. 2 Pugh, L G C E, British 1962, 2, 621. 3 Guerra-Garcia, R, Velasquez, A, and Coyotupa, J, J'ournal of Clinical Endocrinology and Metabolism, 1969, 29, 179. Newton, D A G, Bone, I, and Bonsor, G, Thorax, 1978, 33, 684.
Medical3Journal,
Treatment of ulcerative colitis SIR,-I was interested to read of the use of thalidomide by Dr M F R Waters and his colleagues (24 March, p 792) for the treatment of chronic ulcerative colitis. Clofazimine is another drug used for treating leprosy and erythema nodosum leprosum and this agent has been claimed to be effective in cases of pyoderma gangrenosum.' Clofazimine has also been used in the treatment of Buruli ulcers, the necrotising skin lesions caused by Mycobacterium ulcerans, and I have heard anecdotally of the successful use of thalidomide in this condition. Buruli ulcers and pyoderma gangrenosum may resemble each other closely. If further studies are to be carried out using thalidomide in patients with ulcerative colitis, then it might be interesting to concentrate on those cases which are associated with pyoderma gangrenosum. KEVIN M DE COCK
Michaelsson, G, et al, Archives of Dermatology, 112, 344.
1976,
Drug eruption or psoriasis?
SIR,-In their article giving general principles for approaching the problem of a suspected drug eruption Drs R A Hardie and J A Savin (7 April, p 935) mention that antimalarials and lithium may worsen psoriasis. This association will usually be evident from the patient's history. We recently encountered a case in which a "toxic erythema" provoked by a sulphonamide evolved imperceptibly into erythrodermic psoriasis, presenting considerable diagnostic and therapeutic difficulties. The patient was a 20-year-old black male with no past or family history of skin disease. He developed ulcerative colitis in July 1978 and was initially treated with sulphasalazine. There was a favourable response, but in October 1978 he developed an itchy symmetrical erythematous and later scaling eruption associated with fever and generalised lymphadenopathy. This subsided after
remarkably clear. Taking a second swab, I notified Dr Litt, who on examination found it difficult to believe that this had been a diphtheritic case. He let the child remain, pending the result of the second swab. It was negative. Precisely the same train of events occurred in three following cases-first swabs positive, follow-ups negative. Dr Litt, giving permission for the fourth child to remain in the home, remarked, "I suppose Dr Mitchell wants to prove the efficacy of his homoeopathy." Matron agreed, "Yes, I'm sure he does." G RUTHVEN MITCHELL Brighton, Sussex BN2 1GB
Mitchell, G R, British Homoeopathic journal, 1957, 46, 46.
Trichinosis SIR,-Dr P Bouree and others (21 April, p 1047) do not mention the large outbreak of trichinosis which occurred in England in late 1940 and early 1941, centred on Wolverhampton. This was reported by Sheldon.' At least 500 people appeared to have been affected. All had swelling of the eyelids, most had fever and muscular pains, and many had focal central nervous system manifestations. The incidence in women was four times greater than in men. There were no deaths. The source of the infection appeared to be uncooked sausage meat, and Sheldon discovered that a high proportion of working people in the Midlands, especially women, habitually ate sandwiches made with uncooked sausage. The very day before the Lancet containing Sheldon's paper appeared I was baffled by a young man in outpatients with swollen eyes and muscular pains; so I asked a colleague to see him, who was equally baffled. The following morning the colleague threw the Daily Mirror across the breakfast table to me and commented, "There's the diagnosis of that boy," for the paper contained an account of Sheldon's article. This was the first and only occasion in my life when reading the Daily Mirror-or any other newspaper enabled me to reach a diagnosis. JOHN W TODD Farnham, Surrey GU9 8DR I
1355
19 MAY 1979
Sheldon, J H, Lancet, 1941, 1, 203.
SIR,-In the paper on trichinosis (21 April, p 1047) the authors state, with reference to horse meat being incriminated, that "this pathogenetic mechanism is surprising since the horse is strictly herbivorous." I myself have seen horses eating sheep's offal in the Middle East. The source of the horse meat in the reported attack was "from an Eastern country." I also understand that during the 1914-8 war meat was fed to horses in the British cavalry regiments on the Western Front. G E FFRENCH Occupational Health Unit, Central Middlesex Hospital, London NW10 7NS
Pressure on the tracheal mucosa from cuffed tubes SIR,-The well-documented fact that it is easier to damage the trachea with small residue endotracheal-tube cuffs than large is reiterated by Drs J M Leigh and J P Maynard
(5 May, p 1173). It must be borne in mind, however, that even the Lanz cuff, for example, can result in damage if there is a malfunction of the valve mechanism of the over-pressure safety balloon. Moreover, I do not feel that the authors' data (which relate to their pressure measurements in two patients) justify the conclusion that Lanz-type tubes are mandatory in all intensive care units. Other large-residue cuffs can be used safely by monitoring the intracuff pressures. In the case of the spongefilled cuff (Kamen-Wilkinson) the size of the endotracheal or tracheostomy tube in relation to the size of the trachea is critical. Since this cuff functions like a spring a "large" tube in a "small" trachea results in high lateral pressure on the wall of the trachea. It has been my observation in clinical practice that when large-residue cuffs are correctly adjusted a gas leak past the cuff will often occur at the peak of inspiration, particularly when high inflation pressures are used. Therein lies their safety. Thus when small residue cuffs are used a tiny audible gas leak past the cuff at a peak inspiratory pressure of not more than 20 mm Hg ensures that the mean pressure bearing on the tracheal wall will not exceed the intratracheal pressure. No attempt to produce a completely airtight seal at this or higher airway pressure should be made. The situation is analogous to that of an infant or child intubated with an uncuffed tube of appropriate size during positivepressure ventilation. The final "seal" is effected by the mucous cushion secreted by the tracheal mucosa in response to the "foreign body." My clinical observations while using the traditional red rubber tubes in this fashion for many years without causing any significant tracheal damage have been supported by the histological findings of a controlled experimental study in dogs.' In the operating room setting at least, cuff management seems as important as cuff design. It seems neither prudent nor practical at present to replace all tubes with small-residue tubes endobronchial including cuffs, presumably, by those with large-residual cuffs of the Lanz type for routine anaesthetic practice. Hard evidence to the contrary would be required before considering such a change and it is lacking. JOHN HoMI Anaesthetic Unit, London El 1BB
London Hospital Medical College,
'Homi, J, et al, British Journal of Anaesthesia, 1978, 50, 434.
Remedy for excessive salivation SIR,-The distressing symptom of drooling (5 May, p 1200), whether due to poor neuromuscular development, as seen in some mentally defective children, or acquired when a patient has sustained a cerebrovascular accident, may be treated with the help of a simple intraoral appliance,' similar to a removable orthodontic appliance. The appliance, called a palatal training appliance, was designed originally to assist in soft-palate rehabilitation2 as an aid to speech therapy, and consists of a loop of wire extending into the soft palate region. Personal experience gained from treating over 200 patients with palatoglossal incoordination suggests that it also appears to improve oral sensitivity, which is generally reduced in this condition, as well as improving the co-
ordination between the tongue, soft palate, and pharynx, which is necessary for a normal swallowing action. The appliance has proved useful for the treatment of patients with drooling problems after a cerebrovascular accident, based on experience of over 100 patients. The normal pattern is for salivation to increase somewhat for a period of about three weeks, but afterwards a rapid improvement occurs. Most patients may have the loop of wire removed after a few weeks, but a few seem to need it for a long while and request to have it replaced. It causes no inconvenience unless normal sensations return. In the case of children, 45 of whom have been treated for drooling for a variety of reasons, the greatest success has been with the mentally subnormal group, and spastics have been the most difficult. I have not been able to determine which children have a good prognosis with this treatment, but because it is simple and easily reversible little is lost in trying, and some very pleasing results have been obtained. The palatal training appliance may be constructed by dental surgeons in any branch of the Health Service and will enable the speech therapist to treat these patients more effectively. To try to help patients with poor lip posture, a lip seal reminder3 has been developed recently by the medical physics group in the physics department of Exeter University, and it appears to be a valuable aid to encourage lip closure. It has been designed to develop a tactile awareness in addition to a reminder, particularly when the patient is concentrating on other things. The device is not triggered by excessive salivation and only when the lips open does it sound the alarm. W G SELLEY Dental Department, Royal Devon and Exeter Hospital (Heavitree), Exeter EX1 2ED I
2 3
Selley, W G, British Dental.Journal, 1977, 143, 12. Tudor, C, and Selley, W G, British Journal of Disorders of Communication, 1974, 9, 117. Available from Bio Instrumentations Limited, Holmcroft, School Road, Silverton, Exeter, Devon.
Heat stroke or hypothermia? SIR,-I thank Dr T J Bassler (20 January, p 197) for his comments on our work related to heat stroke and distance running.1-3 His points regarding the inaccuracies in reports of causes of death from ischaemic heart disease instead of heat stroke in distance running events are well taken. Perhaps the most inaccurate and paradoxical report, to my knowledge, was when cases of death due to hypothermia were attributed to hyperthermia. In a report entitled "Jogging in Tasmania"4 the author noted the death from "heat stroke" of a young man jogging in the streets of Massachusetts on a hot, humid, and polluted day. He compared this with two deaths in the "Go as You Please" race from Hobart to Mount Wellington in Tasmania in 1912, implying that the cause of death was again heat stroke, unusual in the temperate climate of Tasmania. When I reviewed these reports, I found that three people had died on Mount Wellington, two in 1903 and a third in 1970. However, conditions were unlike the hot, humid summer's day in Massachusetts, for these races were conducted in the northern hemisphere's summer but the southern hemisphere's winter,
1356
and on both occasions a blizzard prevailed. The Mercury, a Hobart newspaper, reported on 21 September 1903, "They had to face a snowstorm, with a strong south-westerly wind. Many of them were dressed only in singlets and light knickers, ... and the top sides of the mountain were covered with some feet of snow...." One of the participants noted some years later, "They were lying over logs, on the ground, and under trees, too exhausted to continue." Thus the deaths were a result-of hypothermia, the end result of exhaustion and inadequate or wet clothing in a cold, windy environment. It is clear that lightly clad runners are vulnerable to environmental conditions, both hot and cold, and the organisers of any community jogging events should realise that weather conditions can create a medical nightmare out of a "fun run." JOHN R SUTTON Department of Medicine, McMaster University,
Hamilton,
Ontario, Canada L8S 4J9
Sutton, J R, et al, Medical Journal of Australia, 1972, 2, 127. 2Sutton, J R, and Harrison, H C, Medical J'ournal of Australia, 1977, 1, 193. 3Hughson, R L, and Sutton, J R, British Medical J'ournal, 1978, 1, 1158. 4Robinson, C R R, New England Journal of Medicine, 1971, 285, 1267.
Canvasser's knuckle SIR,-We are all aware of such complaints as "housemaid's knee," clergyman's knee," "student's elbow," "miner's elbow," and "weaver's bottom"; but I would like to introduce another member of this family, which I have discovered recently-namely, "canvasser's knuckle." During the course of the recent election I knocked on dozens of doors and subsequently developed painful swelling and inflammation of the proximal interphalangeal joints of my right hand. At a conservative estimate I would say that 50 % of party workers who laboured hard during the last campaign suffered from "canvasser's knuckle" and that their discomfort could be relieved by a liberal application of cold hand cream. ADRIAN THOMPSON University Medical School, Leeds 2
Illness seen at menopause clinic
SIR,-The recent paper by Mr S Chakravarti and others (14 April, p 983) noted that a group of the patients presenting in a menopause clinic had symptoms which were not apparently attributable to the oestrogen deficiency of the climacteric. Of the first 40 patients referred to a menopause clinic in Newcastle, 19 were found to be suffering from conditions requiring treatment but unrelated to oestrogen deficiency (although this was judged to be present in at least nine of the 19 on the basis of characteristic symptoms and raised plasma concentrations of follicle-stimulating hormone). The range of diagnoses included hyperthyroidism, primary hyperparathyroidism, hypertension, cardiac failure, and alcoholism, as well as depressive illness. Undoubtedly there is a tendency for women aged around 50 to attribute any untoward
BRITISH MEDICAL JOURNAL
symptoms to the menopause and their doctors may sometimes accept this explanation too readily. A major function of a menopause clinic is a full diagnostic appraisal of the patient. I WANDLESS University Department of Medicine (Geriatrics), Newcastle General Hospital, Newcastle upon Tyne NE4 6BE
Cervical cytology
SIR,-Since becoming a principal in general practice in 1973 I have been concerned about the accuracy of technicians' reports on cervical smears. In 1977 in Gloucestershire I and a partner were running a family planning clinic in a practice of 10 000 patients. We became worried when it seemed to us that there were too many reports of squamous cells only, requesting the smear to be repeated. We collected reports on smears done on our patients over a six-month period. These smears were taken by the doctors in the Family Planning Association clinic, the consultant gynaecologists, and the partners in our practice. We found that of the three technicians who reported, one requested a significantly higher number of repeats than the other two, and it did not seem that any one doctor was requested to repeat his smear more than another. We pointed this out to the pathology department and realised that a larger study was neededperhaps nationally-really to prove our point, formally and statistically, that there may be a vast amount of public expenditure wasted because of mistakes in cell typing. I am now in a smaller general practice in Yorkshire and again became worried because every single cervical smear I have taken is simply reported "no malignant cells." This is a complete contrast to my reports in Gloucestershire and I have not changed my technique. I therefore did two slides. One was of cells from my buccal cavity (statified squamous) and the other slide was prepared by my scraping the inside of my nose with a finger nail (mainly mucous cells, but the slide may have had some psuedostratified columnar ciliated cells or goblet cells). These were fixed and sent to Leeds as though they were smears. Each was reported as "normal smear, no malignant cells." The reporting aspect of the national cytology service should be investigated. I and some of my GP colleagues feel we may be wasting our time and that of the patient's as well as a lot of public money. R E G SLOAN Castleford, W Yorks WFlO 2QS
Pituitary suppression in chronic airways disease? SIR,-We were interested to read the paper entitled "Hypopituitarism in normal-pressure hydrocephalus" by Drs S G Barker and H Garvan (21 April, p 1039), having recently discovered some similar endocrine abnormalities among 16 male patients with chronic obstructive airways disease.' Serum tri-iodothyronine, thyroxine, cortisol, and oestradiol levels were normal in our patients but there was depression of serum testosterone, the degree of depression apparently being related to the degree of hypoxia and hypercapnia. Normal serum lutenising
19 mAY 1979
hormone and follicle stimulating hormone values suggested hypothalamic or pituitary suppression rather than testicular failure. Three of eight hypercapnic patients had high serum prolactin values not attributable to drug consumption. As hypoxia of altitude has been shown to cause depression of adrenal and gonadal function,2 3 we assumed hypoxia or hypercapnia to be the likely cause of the endocrine abnormalities in our patients. However, in view of the findings of Drs Barker and Garvan it seems possible that the raised intracranial pressure known to occur in hypercapnia, even to the extent of causing an eroded pituitary fossa on x-ray,4 may account for our findings. We are currently involved in further studies in this field. PETER d'A SEMPLE G H BEASTALL W S WATSON ROBERT HUME Medical Division, Southern General Hospital, Glasgow G51 4TF l Semple, P d'A, et al, Thorax, in press. 2 Pugh, L G C E, British 1962, 2, 621. 3 Guerra-Garcia, R, Velasquez, A, and Coyotupa, J, J'ournal of Clinical Endocrinology and Metabolism, 1969, 29, 179. Newton, D A G, Bone, I, and Bonsor, G, Thorax, 1978, 33, 684.
Medical3Journal,
Treatment of ulcerative colitis SIR,-I was interested to read of the use of thalidomide by Dr M F R Waters and his colleagues (24 March, p 792) for the treatment of chronic ulcerative colitis. Clofazimine is another drug used for treating leprosy and erythema nodosum leprosum and this agent has been claimed to be effective in cases of pyoderma gangrenosum.' Clofazimine has also been used in the treatment of Buruli ulcers, the necrotising skin lesions caused by Mycobacterium ulcerans, and I have heard anecdotally of the successful use of thalidomide in this condition. Buruli ulcers and pyoderma gangrenosum may resemble each other closely. If further studies are to be carried out using thalidomide in patients with ulcerative colitis, then it might be interesting to concentrate on those cases which are associated with pyoderma gangrenosum. KEVIN M DE COCK
Michaelsson, G, et al, Archives of Dermatology, 112, 344.
1976,
Drug eruption or psoriasis?
SIR,-In their article giving general principles for approaching the problem of a suspected drug eruption Drs R A Hardie and J A Savin (7 April, p 935) mention that antimalarials and lithium may worsen psoriasis. This association will usually be evident from the patient's history. We recently encountered a case in which a "toxic erythema" provoked by a sulphonamide evolved imperceptibly into erythrodermic psoriasis, presenting considerable diagnostic and therapeutic difficulties. The patient was a 20-year-old black male with no past or family history of skin disease. He developed ulcerative colitis in July 1978 and was initially treated with sulphasalazine. There was a favourable response, but in October 1978 he developed an itchy symmetrical erythematous and later scaling eruption associated with fever and generalised lymphadenopathy. This subsided after
