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CYTOMEGALOVIRUS AND BILIARY ATRESIA
1206 with proteinaceous casts and giant cells within and without the lumens were typical of a " myeloma kidney ". Also, there was evidence of acute tubular necrosis and superimposed mild pyelonephritis. Analysis of Bence Jones protein (obtained by ammonium sulphate fractionation, dialysis, and lyophilisation) by sedimentation velocity ultracentrifugation (59, 780 r.p.m., 20°C, pH 7-0) indicated a predominance of a 7-68 S species rather than a 3-5 S peak of the usual Bence Jones dimer (molecular weight 44,000). Chromatographic fractionation of this protein through ’Sephadex ’ G-100 in sodium-phosphate/ NaCI buffer (u 0-1, pH 7-0) gave predominantly two species: 47% of the protein having a molecular weight of 220,000, and 40% having a molecular weight of 92,000. Only a trace of dimer was present. Interestingly, a 150 mg. per ml. solution of this protein in the above buffer gelled on standing at room temperature (23°C) for 12 hours. This gel easily redissolved on addition of a few drops of dilute sodium-bicarbonate solution. The protein solution was not unusually viscous initially. Similar studies on the Bence Jones protein (excretion rate 11 g. per day) of another patient with only moderate renal impairment (urine volume 1-2 1. per day, serum creatinine of 2-2 mg. per 100 ml.) provided contrasting results: a comparable solution of this protein did not gel on standing, and on gel filtration over 77 % was in the typical dimer form with less than 4% of higher aggregates. Although these findings do not preclude the possibility of other causal factors such as direct cellular toxicityó in the development of acute renal failure in multiple myeloma, they do provide substance to the hypothesis that the degree of aggregation of individual Bence Jones proteins is related to the degree of renal impairment and that alkalinisation of urine along with diuresis and destruction of the malignant cells is a rational therapeutic endeavour. Department of Medicine, University of Kentucky Medical Center, Lexington, Kentucky 40506,
JODAVID FINE ROBERT G. LUKE E. DOUGLAS REES.
U.S.A.
PITUITARY ABLATION FOR LEUCOERYTHROBLASTOSIS IN CARCINOMA OF BREAST
mg. three times daily) as adjunctive The longest survivor underwent bilateral adrenalectomy for recrudescence sixteen months after oophorectomy with a dramatic response. The only postmenopausal patient in the series was treated primarily by adrenalectomy. She obtained six months’ good remission before dying suddenly at home. Our findings thus confirm the value of endocrine ablation in this situation. However, we would recommend oophorectomy as first-line treatment in menopausal or premenopausal patients. We regard this as a relatively minor procedure. Operative bleeding has not proved to be a major difficulty and the results have been gratifying. In addition, after response to oophorectomy, one may hopefully anticipate further remission after subsequent endocrine ablative testosterone
procedures (adrenalectomy
In the last two years at the surgical unit breast clinic, University Hospital of Wales, we have treated 6 new patients with leucoerythroblastic anaemia due to metastatic
breast carcinoma. This ansemia was the initial presenting condition in 3 patients, while the other 3 had undergone mastectomy, six weeks, four years, and twelve years previously. Marrow examination revealed infiltration with undifferentiated carcinoma cells in all patients. Mean at was 7-2 100 ml. g. per haemoglobin presentation (range
6-0-8-9). 1 patient died 48 hours after admission, from uncontrolled spontaneous hxmorrhage due to thrombocytopenia. 4 of the remaining 5 patients were between 40 and 50 years and they underwent bilateral oophorectomy as primary treatment. All had objective regression and are alive eleven, twelve, and twenty-one months after oophorseven, ectomy. Only 1 has active disease, the others being well and not requiring blood-transfusions. 2 received methyl5. Preuss, H.,
et
al. J. clin. Invest. 1971,
50,
74a.
hypophysectomy). PAUL M. BOLTON D. J. T. WEBSTER P. E. PREECE M. BAUM L. E. HUGHES.
CYTOMEGALOVIRUS AND BILIARY ATRESIA
SIR,-From a necropsy-studied case of neonatal cystic fibrosis, coincidentally infected with cytomegalovirus (c.M.v.), Dr Oppenheimer and Dr Esterly (Nov. 3, p. 1031) suggested that this virus may be a cause of biliary atresia. c.M.v. can be isolated from the urine of as many as 1 % of all neonates; and is it well known that the incidence of its isolation from the cervices of pregnant women is much higher. For these reasons it is important to consider the possibility that chronic intrauterine infection by c.M.v. may damage the fetus. In a recently reported case2 severe C.M.v. infection of
the bile ducts was observed in a spontaneously aborted fetus of 19 weeks’ gestation. Although the gross features of the bileducts were not examined, the light-microscopy findings support Dr Oppenheimer and Dr Esterly’s
speculation. Fels Feto-Placental Unit, General Hospital, Cincinnati, Ohio 45229, U.S.A.
SIR,-We agree with the views of Dr Akinsete and others p. 1050) that endocrine ablative surgery can pro-
implantation.
or
University Department of Surgery, Heath Park, Cardiff CF4 4XN.
(Nov. 10,
duce worth-while palliation for leucoerythroblastosis in carcinoma of the breast. They reported a beneficial response in 3 out of 4 patients treated by yttrium-90 pituitary ablation, with a mean survival time of ten months following
(5
treatment.
GEOFFREY ALTSHULER.
MEDICINE BY REMOTE CONTROL
SIR,-On belatedly reading The Lancet’s Round the World column for Sept. 15,I became somewhat angered by several inaccuracies in your correspondent’s account of the inability of American medical students to express themselves. His statement that examinations from high school through medical school are all of the multiple-choice type is false. I have had two multiple-choice examinations in medical school, along with multiple-choice examinations for entrance into college and medical school, and for licensing purposes. Otherwise, every examination I have had in high school, college, and medical school has been of the essay type. The alleged inability of American medical students to express themselves has nothing at all to do with advocacy of problem-oriented medical records, which have much to recommend them. Your correspondent is probably correct in asserting that the verbal proficiency of the medical profession in this country is decreasing, but I rather think this is a phenomenon affecting the Englishspeaking world. His own use of such phrases as between them they " "
1. 2.
Weller, T. H. New Engl. J. Med. 1971, 285, 267. Altshuler, G., McAdams, A. J. Am. J. Obstet. Gynec. 1971, 111, 295.
JODAVID FINE ROBERT G. LUKE E. DOUGLAS REES.
U.S.A.
PITUITARY ABLATION FOR LEUCOERYTHROBLASTOSIS IN CARCINOMA OF BREAST
mg. three times daily) as adjunctive The longest survivor underwent bilateral adrenalectomy for recrudescence sixteen months after oophorectomy with a dramatic response. The only postmenopausal patient in the series was treated primarily by adrenalectomy. She obtained six months’ good remission before dying suddenly at home. Our findings thus confirm the value of endocrine ablation in this situation. However, we would recommend oophorectomy as first-line treatment in menopausal or premenopausal patients. We regard this as a relatively minor procedure. Operative bleeding has not proved to be a major difficulty and the results have been gratifying. In addition, after response to oophorectomy, one may hopefully anticipate further remission after subsequent endocrine ablative testosterone
procedures (adrenalectomy
In the last two years at the surgical unit breast clinic, University Hospital of Wales, we have treated 6 new patients with leucoerythroblastic anaemia due to metastatic
breast carcinoma. This ansemia was the initial presenting condition in 3 patients, while the other 3 had undergone mastectomy, six weeks, four years, and twelve years previously. Marrow examination revealed infiltration with undifferentiated carcinoma cells in all patients. Mean at was 7-2 100 ml. g. per haemoglobin presentation (range
6-0-8-9). 1 patient died 48 hours after admission, from uncontrolled spontaneous hxmorrhage due to thrombocytopenia. 4 of the remaining 5 patients were between 40 and 50 years and they underwent bilateral oophorectomy as primary treatment. All had objective regression and are alive eleven, twelve, and twenty-one months after oophorseven, ectomy. Only 1 has active disease, the others being well and not requiring blood-transfusions. 2 received methyl5. Preuss, H.,
et
al. J. clin. Invest. 1971,
50,
74a.
hypophysectomy). PAUL M. BOLTON D. J. T. WEBSTER P. E. PREECE M. BAUM L. E. HUGHES.
CYTOMEGALOVIRUS AND BILIARY ATRESIA
SIR,-From a necropsy-studied case of neonatal cystic fibrosis, coincidentally infected with cytomegalovirus (c.M.v.), Dr Oppenheimer and Dr Esterly (Nov. 3, p. 1031) suggested that this virus may be a cause of biliary atresia. c.M.v. can be isolated from the urine of as many as 1 % of all neonates; and is it well known that the incidence of its isolation from the cervices of pregnant women is much higher. For these reasons it is important to consider the possibility that chronic intrauterine infection by c.M.v. may damage the fetus. In a recently reported case2 severe C.M.v. infection of
the bile ducts was observed in a spontaneously aborted fetus of 19 weeks’ gestation. Although the gross features of the bileducts were not examined, the light-microscopy findings support Dr Oppenheimer and Dr Esterly’s
speculation. Fels Feto-Placental Unit, General Hospital, Cincinnati, Ohio 45229, U.S.A.
SIR,-We agree with the views of Dr Akinsete and others p. 1050) that endocrine ablative surgery can pro-
implantation.
or
University Department of Surgery, Heath Park, Cardiff CF4 4XN.
(Nov. 10,
duce worth-while palliation for leucoerythroblastosis in carcinoma of the breast. They reported a beneficial response in 3 out of 4 patients treated by yttrium-90 pituitary ablation, with a mean survival time of ten months following
(5
treatment.
GEOFFREY ALTSHULER.
MEDICINE BY REMOTE CONTROL
SIR,-On belatedly reading The Lancet’s Round the World column for Sept. 15,I became somewhat angered by several inaccuracies in your correspondent’s account of the inability of American medical students to express themselves. His statement that examinations from high school through medical school are all of the multiple-choice type is false. I have had two multiple-choice examinations in medical school, along with multiple-choice examinations for entrance into college and medical school, and for licensing purposes. Otherwise, every examination I have had in high school, college, and medical school has been of the essay type. The alleged inability of American medical students to express themselves has nothing at all to do with advocacy of problem-oriented medical records, which have much to recommend them. Your correspondent is probably correct in asserting that the verbal proficiency of the medical profession in this country is decreasing, but I rather think this is a phenomenon affecting the Englishspeaking world. His own use of such phrases as between them they " "
1. 2.
Weller, T. H. New Engl. J. Med. 1971, 285, 267. Altshuler, G., McAdams, A. J. Am. J. Obstet. Gynec. 1971, 111, 295.