- Email: [email protected]
MUSHROOM POISONING AND FORCED DIURESIS
854 DETAILS OF CASES
CONTENTS OF SELECTED POTASSIUM-RICH FOODS AND APPROXIMATE QUANTITIES REQUIRED TO SUPPLEMENT ORAL REHYDRATION THERAPY WITH A SIMPLE SUGAR/SALT SOLUTION*
OC = oral contraception; PCB = post.coital bleeding. *All smear reports confirmed by re-examination retrospectively. In patient B an earlier smear (1978) reported as mild dyskaryosis was retrospectively diagnosed as moderate
dyskaryosis.
of certain external factors. Stern4 has proposed that oral contraception may be such a factor. All our patients had been on oral contraceptives for at least five years. This is not surprising in our population. 70% of patients at the centre use this birth control method. It would be interesting to know the contraceptive history of
Berkeley’s patients. The age of these patients lends support to the growing body of in favour of a far more active cervical screening policy in women than current D.H.S.S. guidelinesallow for. young
opinion
WALTER PRENDIVILLE
JOHN GUILLEBAUD Margaret Pyke Centre and Middlesex Hospital, London W1
4. Stern E.
PHILIP BAMFORD
JACK BEILBY STUART J. STEELE
Steroid contraceptive use and cervical dysplasia. Science 1977; 196: 1460-61.
DHSS screening policy puts young women unnecessarily at risk. Med 1980; 15 (13): 21-26.
5. Cotton R. Why
World
POTASSIUM SUPPLEMENTS FOR ORAL DIARRHŒA REGIMENS
SiR,-Dr Cutting (July 5, p. 35) refers to our clinical study of oral rehydration in Honduras. In a controlled study we compared the efficacy and safety of a simple oral formula containing sugar, salt, and water (without potassium or bicarbonate) with glucose/electrolyte rehydration solutions (GES) in infant diarrhoea. As Cutting mentioned, although the sugar/salt solution appeared to be as adequate as GES for correcting dehydration and acidosis, hypokalxniia was a problem with the simple formula. In attempting to provide dietary K supplementation we chose the banana, which contains 0’ 1 mol K+/g or 9-13 (not 60) mmol K /banana, depending on size. Since the study was double-blind, we fed infants in both groups 30 ml (one cup) of banana-milk puree. It is not surprising that this small amount was not enough to replace the potassium deficits in those who received the simple formula lacking K’. In retrospect, those infants would have required at least 320 ml of the banana puree (two to three bananas, or 280 ml of mashed banana) to get the K consumed in GES over 24 h by patients in the control group.
Several authorities have advocated the addition of a squeeze of or orange juice (as a natural source ofK+) to sugar/salt oral rehydration solutions. 1,2We tested these and several food sources for K + and Na content by flame photometry; our results coincided + with those in a U.S. handbook. In addition, we determined the K concentrations in breast milk samples from 8 Honduran mothers and in special food preparations commonly fed to Honduran infants
* Devised from data obtained from in the clinical study at Hospital Escuela, Tegucigalpa, Value of American Food in Common Units.I Honduras (1980) and from 7VM:nf
We were surprised to find that the juices of raw lemons and oranges have very low concentrations of K+ per volume. Many other foods are impractical as K supplements because of the
quantities required. The banana as a dietary K+ supplement offers many advantages: compared with other foods, it contains one of the highest concentrations of K+ per volume; and in many countries, such as Honduras, it is cheap, widely available throughout the year, and culturally acceptable as food for infants (even during episodes of diarrhoea). However, before we can with confidence recommend the banana as an effective Ksupplement, we must determine whether children with diarrhoea can digest larger volumes of banana and absorb sufficient K+ while also receiving oral therapy with a simple sugar/salt solution. Such studies will be underway shortly. Development, University of Maryland School of Medicine, Division of Infectious Diseases, Baltimore, Maryland 21201, U.S.A.
MARY LOU CLEMENTS MYRON M. LEVINE ROBERT E. BLACK TIMOTHY P. HUGHES
Pan American Health Washington, D.C.
JAMES RUST
Center for Vaccine
Organisation,
Department of Pædiatrics, Hospital Escuela, Universidad Nacional Autonoma, Tegucigalpa, Honduras
FRANCISCO CLEAVES TÓME
** Dr W. A. M. Cutting writes: "I wish to apologise for two inaccuracies in the last paragraph of my July 5 letter-for ascribing the Honduras research on potassium replacement with bananas to Prof. P. S. E. G. Harland, although he had been involved in discussion on the subject, and for giving the potassium content of the average Honduran banana as 60 mmol."-ED.L.
lemon
(table). a method for teaching mothers. Trop Doc 1972; 2: 119-21. 2. Morley D. Treatment of diarrhœa. In: Pædiatric priorities in the developing world London: Butterworth, 1973; 185-92. 3. Nutritive Value of American Food in Common Units. Agriculture Handbook no.456. Agriculture Research Service U.S. D.A., U.S. Government Printing Office, 1975: stock no 0100-03184.
1. Church MA. Fluids for the sick child:
MUSHROOM POISONING AND FORCED DIURESIS
SIR,-Your Aug. 16 editorial emphasises the need for early detoxification in the management of Amanita phalloides poisoning. Drawing on our clinical experience of more than 50 cases observed in a five-year period we fully agree with such an approach: the major aim of therapy must be to lower the serum concentration of toxins as soon as possible and so shorten the time of exposure of highly susceptible cells, such as hepatocytes, to toxic levels. You also state that "forced diuresis is an effective way of removing toxin from the blood but is inadvisable because it may increase renal exposure" and suggest the use of early haemodialysis over charcoal
855 in severely poisoned patients. Since amatoxins in vitro exhibit their cells of all types the possibility of toxic effects on renal toxicity must not be overlooked; however, there is strong evidence that kidney damage sometimes observed in poisoned patients is mainly due to dehydration and hypovolaemia and to severe hepatic failure, and can be largely prevented by correction of water deficit and metabolic abnormalities.2,3 In our experience of 53 patients, including the 6 who died, only 1 patient (who had a late and inadequate treatment) had severe renal injury, and in all cases death was due to massive liver necrosis.4 Patients with very high urinary levels oftoxins5 measured by RIA (as high as 57 ng/ml) did not show clinical signs of renal impairment. The hepatic involvement is by far the most prominent feature of this form of poisoning, both clinically and pathologically, and the final outcome mainly depends on the extent of the liver damage. While the renal toxicity of amatoxins is probably of secondary importance, there is good evidence that forced diuresis is an effective removal procedure. RIA measurements showed that large quantities of toxins (from to 10 000 to 25 000 ng) have been excreted in 6 patients treated with forced diuresis over a few hours, with rapid disappearance of detectable levels both in serum and in urine within 36 h of ingestion.6Amatoxins are easily dialysable and eliminated by glomerular filtration: conceivably, forced diuresis may enhance their excretion rate and prevent tubular reabsorption. With a high urinary flow two aims can be achieved- rapid reduction of the pool of toxins in the body and a decrease in their urinary concentration, thus lowering the risk of renal exposure. This treatment can be immediately instituted in almost all patients soon after admission while volume replacement is done: no special equipment is required and an emergency department can manage several cases at the same time if need be. This allows treatment to be started without delay: there is general agreement that the survival rate may be significantly improved if removal therapy is
eukaryotic
applied as
soon as
possible.
We believe that forced diuresis can be considered as the removal procedure of choice in A. phalloides poisoning; extracorporeal purification with hxmoperfusion on charcoal or polymeric adsorbants could be considered whenever forced diuresis is contraindicated or in high risk patients. Institute of Anæsthesiology and Medical Clinic II,
University of Milan, 20122 Milan, Italy
S. VESCONI M. LANGER D. COSTANTINO
PLASMA EXCHANGE AND THE PAID DONOR SYSTEM
SIR,-Your Aug. 2 editorial refers to the scarcity of replacement fluids for plasma exchange. These shortages are due to the failure of the volunteer-only system used in Western Europe. The impending expansion of therapeutic plasma exchange will put an increasing strain on the already insufficient volume of albumin collected in those countries. It is shameful that concern about paying donors should deny life-saving blood products to the patients who need them. The shortages caused by this policy will eventually raise the price, the balance of supply and demand being undermined by unwise attitudes. You say "There are doubts about this material (plasma derivatives)" implying that the Food and Drug Administration is not doing a good job. Yet the F.D.A. regulates 70% of the world’s 1. Faulstich H. New aspects of Amanita poisoning. Klin Wschr 1979; 57: 1143-52. 2. Costantino D, Falzi G, Langer M, Rivolta E: Amanitaphalloides related nephropathy. Contr Nephrol 1978; 10: 84-97. 3. Zanandrea G, Cantaluppi G, Fabiani MP, et al. Avvelenamento da Amanita Falloide e danno renale. Anest Rianim; 1977; 18: 79-93. 4. Langer M, Vesconi S, Iapichino G, Costantino D, Radrizzani D. Die frühzeitige
Elimination der Amanita Toxine in der Therapie der Knollenblätterpilzvergiftung. Klin Wschr 1980; 58: 117-23. 5 Fiume L, Busi C, Campadelli-Fiume G, Franceschi C. Production of antibodies to amanitins as the basis for their radioimmunoassay. Experientia 1975; 31: 1233. 6 Langer M, Vesconi S, Costantino D, Busi C. Pharmacodynamics amatoxins in human poisoning. In: Faulstich H, Kommerell B, Wieland T,eds. Amanitatoxins and poisoning. New York: Witzstrock, 1979.
Are there scientific, medical doubts-or only social doubts? The U.S. fills a world medical need neglected by Britain and other countries. If the volunteer plasma collection system worked, there would be no "billion dollar" industry. The volunteer system cannot supply the plasma needs of patients. Thus the U.S., with its payment system, supplies itself and much of the rest of the world. The maximum allowable donation (60 litres of plasma a year) is very rarely attained by any donor. This would need 104 donations, and the average is about 30. F.D.A. regulations require a protein determination at each donation, which is an indication of an "adequate diet and a healthy liver". I am pleased to read that the old prejudice about "skid-row donors" has been dispelled and that the "hepatitis bogey" has also
plasma derivatives.
been laid to rest. You refer to Council of Europe "regulations"; this advisory group can only recommend. True, the Council of Europe’s view (12 litres per year) differs from the U.S. 60 litres per year. The U.S. regulation is based on statistical data from 5 years of drawing 70% of the world’s plasma under close F.D.A. regulation. This is approximately 15 million litres and 30 million donations. The F.D.A. and the U.S. pharmaceutical industry base their regulations on this massive experience and not on sentiment. The F.D.A. has done a superb job. Your reference to a shortfall of plasma in the U.S. is incorrect. From the U.S. an excess of plasma or fractions is shipped to Britain and other countries with volunteer blood donor systems. Virtually’ no plasma is collected from poor countries, yet these poor countries demand plasma components derived from plasmapheresis. Britain and others think it is more moral to permit volunteer-only plasma donations, and let patients suffer or die for lack of plasma components. I believe in a higher morality: first take care of all patients’ needs, and then worry about the morality of paying donors. The plasma donor is paid because, unlike the whole blood donor who spends 20 minutes at most five times per year, the plasma donor spends 2 hours once or twice a week. He is paid for his time, not his blood. The W.H.O. guidelines serve as recommendations to the underdeveloped countries, but in no way should be interpreted as ’
regulations. Alpha Therapeutic Corporation, Los Angeles, California 90032, U.S.A.
CLYDE MCAULEY
CARCINOMA OF PENIS AND CERVIX
SiR,-We were most interested to read the letter from Dr Smith and others (Aug. 23, p. 417) providing further evidence, in terms of mortality, linking carcinoma of the penis and cervix. Since we reported the group of cases in one locality of both spouse pairs and a neighbourhood cluster (Jan. 12, p.97) we asked all local urologists to report new cases of carcinoma of the penis to us, through the auspices of the Yorkshire Regional Cancer Organisation, to make some assessment of female morbidity. Three cases were reported early this year and a cervical smear was taken from one spouse. This smear showed cellular atypia, and a later one showed definite carcinoma-in-situ. We believe that these diseases have a strongly infectious component and that the wives of men with carcinoma of the penis should be regarded as a high risk group requiring regular cervical cytology until the risks involved can be accurately estimated. Careful examination of the early smear, mentioned above, gave the suggestion that some cells were infected with the human wart virus. Some of the cases of carcinoma of the penis in our first report were described as being related to penile condylomas. We suggest that human wart virus is one of the major astiological factors in the pathogenesis of both diseases. We base this hypothesis on the above observations and on the following points. Cervical I wart virus infection is common— 1 % of routine smears in Quebec, A, Fortin R, Roy M. Condylomatous lesions of the cervix: colposcopic and histopathologic study Acta Cytol 1977; 21: 379
1. Meisels
II
Cytologic
CONTENTS OF SELECTED POTASSIUM-RICH FOODS AND APPROXIMATE QUANTITIES REQUIRED TO SUPPLEMENT ORAL REHYDRATION THERAPY WITH A SIMPLE SUGAR/SALT SOLUTION*
OC = oral contraception; PCB = post.coital bleeding. *All smear reports confirmed by re-examination retrospectively. In patient B an earlier smear (1978) reported as mild dyskaryosis was retrospectively diagnosed as moderate
dyskaryosis.
of certain external factors. Stern4 has proposed that oral contraception may be such a factor. All our patients had been on oral contraceptives for at least five years. This is not surprising in our population. 70% of patients at the centre use this birth control method. It would be interesting to know the contraceptive history of
Berkeley’s patients. The age of these patients lends support to the growing body of in favour of a far more active cervical screening policy in women than current D.H.S.S. guidelinesallow for. young
opinion
WALTER PRENDIVILLE
JOHN GUILLEBAUD Margaret Pyke Centre and Middlesex Hospital, London W1
4. Stern E.
PHILIP BAMFORD
JACK BEILBY STUART J. STEELE
Steroid contraceptive use and cervical dysplasia. Science 1977; 196: 1460-61.
DHSS screening policy puts young women unnecessarily at risk. Med 1980; 15 (13): 21-26.
5. Cotton R. Why
World
POTASSIUM SUPPLEMENTS FOR ORAL DIARRHŒA REGIMENS
SiR,-Dr Cutting (July 5, p. 35) refers to our clinical study of oral rehydration in Honduras. In a controlled study we compared the efficacy and safety of a simple oral formula containing sugar, salt, and water (without potassium or bicarbonate) with glucose/electrolyte rehydration solutions (GES) in infant diarrhoea. As Cutting mentioned, although the sugar/salt solution appeared to be as adequate as GES for correcting dehydration and acidosis, hypokalxniia was a problem with the simple formula. In attempting to provide dietary K supplementation we chose the banana, which contains 0’ 1 mol K+/g or 9-13 (not 60) mmol K /banana, depending on size. Since the study was double-blind, we fed infants in both groups 30 ml (one cup) of banana-milk puree. It is not surprising that this small amount was not enough to replace the potassium deficits in those who received the simple formula lacking K’. In retrospect, those infants would have required at least 320 ml of the banana puree (two to three bananas, or 280 ml of mashed banana) to get the K consumed in GES over 24 h by patients in the control group.
Several authorities have advocated the addition of a squeeze of or orange juice (as a natural source ofK+) to sugar/salt oral rehydration solutions. 1,2We tested these and several food sources for K + and Na content by flame photometry; our results coincided + with those in a U.S. handbook. In addition, we determined the K concentrations in breast milk samples from 8 Honduran mothers and in special food preparations commonly fed to Honduran infants
* Devised from data obtained from in the clinical study at Hospital Escuela, Tegucigalpa, Value of American Food in Common Units.I Honduras (1980) and from 7VM:nf
We were surprised to find that the juices of raw lemons and oranges have very low concentrations of K+ per volume. Many other foods are impractical as K supplements because of the
quantities required. The banana as a dietary K+ supplement offers many advantages: compared with other foods, it contains one of the highest concentrations of K+ per volume; and in many countries, such as Honduras, it is cheap, widely available throughout the year, and culturally acceptable as food for infants (even during episodes of diarrhoea). However, before we can with confidence recommend the banana as an effective Ksupplement, we must determine whether children with diarrhoea can digest larger volumes of banana and absorb sufficient K+ while also receiving oral therapy with a simple sugar/salt solution. Such studies will be underway shortly. Development, University of Maryland School of Medicine, Division of Infectious Diseases, Baltimore, Maryland 21201, U.S.A.
MARY LOU CLEMENTS MYRON M. LEVINE ROBERT E. BLACK TIMOTHY P. HUGHES
Pan American Health Washington, D.C.
JAMES RUST
Center for Vaccine
Organisation,
Department of Pædiatrics, Hospital Escuela, Universidad Nacional Autonoma, Tegucigalpa, Honduras
FRANCISCO CLEAVES TÓME
** Dr W. A. M. Cutting writes: "I wish to apologise for two inaccuracies in the last paragraph of my July 5 letter-for ascribing the Honduras research on potassium replacement with bananas to Prof. P. S. E. G. Harland, although he had been involved in discussion on the subject, and for giving the potassium content of the average Honduran banana as 60 mmol."-ED.L.
lemon
(table). a method for teaching mothers. Trop Doc 1972; 2: 119-21. 2. Morley D. Treatment of diarrhœa. In: Pædiatric priorities in the developing world London: Butterworth, 1973; 185-92. 3. Nutritive Value of American Food in Common Units. Agriculture Handbook no.456. Agriculture Research Service U.S. D.A., U.S. Government Printing Office, 1975: stock no 0100-03184.
1. Church MA. Fluids for the sick child:
MUSHROOM POISONING AND FORCED DIURESIS
SIR,-Your Aug. 16 editorial emphasises the need for early detoxification in the management of Amanita phalloides poisoning. Drawing on our clinical experience of more than 50 cases observed in a five-year period we fully agree with such an approach: the major aim of therapy must be to lower the serum concentration of toxins as soon as possible and so shorten the time of exposure of highly susceptible cells, such as hepatocytes, to toxic levels. You also state that "forced diuresis is an effective way of removing toxin from the blood but is inadvisable because it may increase renal exposure" and suggest the use of early haemodialysis over charcoal
855 in severely poisoned patients. Since amatoxins in vitro exhibit their cells of all types the possibility of toxic effects on renal toxicity must not be overlooked; however, there is strong evidence that kidney damage sometimes observed in poisoned patients is mainly due to dehydration and hypovolaemia and to severe hepatic failure, and can be largely prevented by correction of water deficit and metabolic abnormalities.2,3 In our experience of 53 patients, including the 6 who died, only 1 patient (who had a late and inadequate treatment) had severe renal injury, and in all cases death was due to massive liver necrosis.4 Patients with very high urinary levels oftoxins5 measured by RIA (as high as 57 ng/ml) did not show clinical signs of renal impairment. The hepatic involvement is by far the most prominent feature of this form of poisoning, both clinically and pathologically, and the final outcome mainly depends on the extent of the liver damage. While the renal toxicity of amatoxins is probably of secondary importance, there is good evidence that forced diuresis is an effective removal procedure. RIA measurements showed that large quantities of toxins (from to 10 000 to 25 000 ng) have been excreted in 6 patients treated with forced diuresis over a few hours, with rapid disappearance of detectable levels both in serum and in urine within 36 h of ingestion.6Amatoxins are easily dialysable and eliminated by glomerular filtration: conceivably, forced diuresis may enhance their excretion rate and prevent tubular reabsorption. With a high urinary flow two aims can be achieved- rapid reduction of the pool of toxins in the body and a decrease in their urinary concentration, thus lowering the risk of renal exposure. This treatment can be immediately instituted in almost all patients soon after admission while volume replacement is done: no special equipment is required and an emergency department can manage several cases at the same time if need be. This allows treatment to be started without delay: there is general agreement that the survival rate may be significantly improved if removal therapy is
eukaryotic
applied as
soon as
possible.
We believe that forced diuresis can be considered as the removal procedure of choice in A. phalloides poisoning; extracorporeal purification with hxmoperfusion on charcoal or polymeric adsorbants could be considered whenever forced diuresis is contraindicated or in high risk patients. Institute of Anæsthesiology and Medical Clinic II,
University of Milan, 20122 Milan, Italy
S. VESCONI M. LANGER D. COSTANTINO
PLASMA EXCHANGE AND THE PAID DONOR SYSTEM
SIR,-Your Aug. 2 editorial refers to the scarcity of replacement fluids for plasma exchange. These shortages are due to the failure of the volunteer-only system used in Western Europe. The impending expansion of therapeutic plasma exchange will put an increasing strain on the already insufficient volume of albumin collected in those countries. It is shameful that concern about paying donors should deny life-saving blood products to the patients who need them. The shortages caused by this policy will eventually raise the price, the balance of supply and demand being undermined by unwise attitudes. You say "There are doubts about this material (plasma derivatives)" implying that the Food and Drug Administration is not doing a good job. Yet the F.D.A. regulates 70% of the world’s 1. Faulstich H. New aspects of Amanita poisoning. Klin Wschr 1979; 57: 1143-52. 2. Costantino D, Falzi G, Langer M, Rivolta E: Amanitaphalloides related nephropathy. Contr Nephrol 1978; 10: 84-97. 3. Zanandrea G, Cantaluppi G, Fabiani MP, et al. Avvelenamento da Amanita Falloide e danno renale. Anest Rianim; 1977; 18: 79-93. 4. Langer M, Vesconi S, Iapichino G, Costantino D, Radrizzani D. Die frühzeitige
Elimination der Amanita Toxine in der Therapie der Knollenblätterpilzvergiftung. Klin Wschr 1980; 58: 117-23. 5 Fiume L, Busi C, Campadelli-Fiume G, Franceschi C. Production of antibodies to amanitins as the basis for their radioimmunoassay. Experientia 1975; 31: 1233. 6 Langer M, Vesconi S, Costantino D, Busi C. Pharmacodynamics amatoxins in human poisoning. In: Faulstich H, Kommerell B, Wieland T,eds. Amanitatoxins and poisoning. New York: Witzstrock, 1979.
Are there scientific, medical doubts-or only social doubts? The U.S. fills a world medical need neglected by Britain and other countries. If the volunteer plasma collection system worked, there would be no "billion dollar" industry. The volunteer system cannot supply the plasma needs of patients. Thus the U.S., with its payment system, supplies itself and much of the rest of the world. The maximum allowable donation (60 litres of plasma a year) is very rarely attained by any donor. This would need 104 donations, and the average is about 30. F.D.A. regulations require a protein determination at each donation, which is an indication of an "adequate diet and a healthy liver". I am pleased to read that the old prejudice about "skid-row donors" has been dispelled and that the "hepatitis bogey" has also
plasma derivatives.
been laid to rest. You refer to Council of Europe "regulations"; this advisory group can only recommend. True, the Council of Europe’s view (12 litres per year) differs from the U.S. 60 litres per year. The U.S. regulation is based on statistical data from 5 years of drawing 70% of the world’s plasma under close F.D.A. regulation. This is approximately 15 million litres and 30 million donations. The F.D.A. and the U.S. pharmaceutical industry base their regulations on this massive experience and not on sentiment. The F.D.A. has done a superb job. Your reference to a shortfall of plasma in the U.S. is incorrect. From the U.S. an excess of plasma or fractions is shipped to Britain and other countries with volunteer blood donor systems. Virtually’ no plasma is collected from poor countries, yet these poor countries demand plasma components derived from plasmapheresis. Britain and others think it is more moral to permit volunteer-only plasma donations, and let patients suffer or die for lack of plasma components. I believe in a higher morality: first take care of all patients’ needs, and then worry about the morality of paying donors. The plasma donor is paid because, unlike the whole blood donor who spends 20 minutes at most five times per year, the plasma donor spends 2 hours once or twice a week. He is paid for his time, not his blood. The W.H.O. guidelines serve as recommendations to the underdeveloped countries, but in no way should be interpreted as ’
regulations. Alpha Therapeutic Corporation, Los Angeles, California 90032, U.S.A.
CLYDE MCAULEY
CARCINOMA OF PENIS AND CERVIX
SiR,-We were most interested to read the letter from Dr Smith and others (Aug. 23, p. 417) providing further evidence, in terms of mortality, linking carcinoma of the penis and cervix. Since we reported the group of cases in one locality of both spouse pairs and a neighbourhood cluster (Jan. 12, p.97) we asked all local urologists to report new cases of carcinoma of the penis to us, through the auspices of the Yorkshire Regional Cancer Organisation, to make some assessment of female morbidity. Three cases were reported early this year and a cervical smear was taken from one spouse. This smear showed cellular atypia, and a later one showed definite carcinoma-in-situ. We believe that these diseases have a strongly infectious component and that the wives of men with carcinoma of the penis should be regarded as a high risk group requiring regular cervical cytology until the risks involved can be accurately estimated. Careful examination of the early smear, mentioned above, gave the suggestion that some cells were infected with the human wart virus. Some of the cases of carcinoma of the penis in our first report were described as being related to penile condylomas. We suggest that human wart virus is one of the major astiological factors in the pathogenesis of both diseases. We base this hypothesis on the above observations and on the following points. Cervical I wart virus infection is common— 1 % of routine smears in Quebec, A, Fortin R, Roy M. Condylomatous lesions of the cervix: colposcopic and histopathologic study Acta Cytol 1977; 21: 379
1. Meisels
II
Cytologic