Alopecia and cytotoxic drugs.

policy still right in principle then ? Or is there a risk that the patient may fall between two stools, for lack of what Job describes as a " daysman " ? Experience indicates that this dilemma can and does result in major and minor tragedies: like that of the schoolmaster with " consolidation of the left lower lobe " who presented in the chest ward three months later with an inoperable bronchial carcinoma; like the farmer with " fibrosis in the right upper lobe " whose sputum was positive; like the man with " an interesting x-ray ; suggest repeat in three weeks " whose right upper lobe carcinoma was even then producing superior vena caval obstruction; Like the man with " an interlobar effusion" whose malignant abscess was inoperable; like the two child contacts whose several x-rays showed " only catarrhal changes" but who had never been tuberculin-tested; like the middle-aged anxious lady who had to be seen urgently at the chest clinic because her x-ray showed " tuberculous disease at the right apex" and who needed much reassurance that it was a soundly healed calcified scar of no clinical significance. And then one recalls the men with haemoptyses and " clear chest x-ray " reports, who nevertheless had inoperable proximal carcinomata; to say nothing of the semi-crippled asthma or bronchitis patient whose x-ray shows "nothing more than slight emphysema and bronchitic changes." Doubtless one sees an unhappy selection of latecomers in hospital chest practice; and doubtless one is also influenced by the geographical implications of their previous lengthy ambulance trips to and from the x-ray department; but the fact remains that patients needing chest x-rays frequently also need a proper clinical and ventilatory assessment and in these circumstances there is much to be said for the "open door" chest clinic rather than the "open door" x-ray SIR,-The unfortunate epilating effect of cyclophosphamide and of thiotepa to which Mr. W. Calvert refers in his letter (1 October, p. 831) is shared by several other cytotoxic drugs. According to Wiltshaw,l practically every alkylating agent when given in large enough doses will produce alopecia. Alopecia probably occurs more frequently with vincristine, cyclophosphamide, and 5-fluorouracil than with other agents. Vincristine produced alopecia in 42% of a group of children with acute leukaemia reported by Evans et al.,2 in 46% of 26 patients reported by Carey et al.,' and in 65°/, of …