1292 STONE IN BILEDUCT WITH NEGATIVE CHOLANGIOPANCREATOGRAPHY
SIR,-The increasing use of endoscopic retrograde cholangiopancreatography (E.R.C.P.) to examine the bileducts preoperatively must not be allowed to lull surgeons into a false sense of security. This is illustrated by the case of a 70-year-old man who presented with biliary colic followed by obstructive jaundice which resolved within 7 days. An E.R.C.P. done when the jaundice had barely subsided showed a normal bileduct but many small stones in the gallbladder (fig. 1). 1 week after E.R.C.P., during which he remained perfectly well, the patient had a laparotomy. The gallbladder contained several small
stones, but an operative cholangiogram (USlllg image intensification) showed a single small stone 3 mm in diameter in the distal common bileduct (fig. 2). The bileduct was opened, the stone retrieved, and cholecystectomy performed. The stone may have been dislodged from the gallbladder into the bileduct at surgery, but it is equally possible that it was missed by the E.R.C.P. Surgeons should thus continue to perform per-operative cholangiography, and should not assume that a normal preoperative E.R.C.P. means that the bileduct will be normal at operation. Leeds General Infirmary, Leeds LS1 3EX
E. A. BENSON
ADRENAL CARCINOMA IN CHILD WITH HISTORY OF FETAL ALCOHOL SYNDROME
SIR,-In 1968 Lemoine et al.1 and in 1973 Jones and Smith2.3 described an association between alcohol consumption during pregnancy and altered growth and development combined with a pattern of malformations in the offspring, now known as the "fetal alcohol syndrome". Alcohol consumption has also been associated in adults with an increased incidence of cancer of the mouth, pharynx, larynx, and aesophagus.4 We have seen a child with many of the features of the fetal alcohol syndrome who, at age 13 years, had an adrenal carcinoma. This girl was born to a then 39-year-old woman who had a long history of chronic alcoholism. During the pregnancy the mother had been depressed and consumed large amounts of alcohol, mainly beer. The infant’s birth-weight was 1446 g at 36 weeks’ gestation. Strabismus and slow motor and mental development were noted. When she was evaluated at 21 months of age there was facial asymmetry, hypertelorism, epicanthal folds, alternating esotropia, and questionable hemihypertrophy on the left. In the occipital area a 1 cm by lycm cavernous haemangioma was observed. The child showed definite general developmental delay, including delayed Fig. 1.—E.R.C.P. showing stones in gallbladder (arrowed). Bileduct appears normal.
speech. At age 12 years and 11 months she presented with progressive pain, restricted motion of 3 months’ duration, and atrophy in the left upper arm. X-rays demonstrated a lytic lesion in the left scapula, and subsequent studies revealed a non-secreting adrenal cortical carcinoma with metastases to bone, lungs, liver, abdominal nodes, and bone-marrow. At that time it was learned that a cerebral astrocytoma had lately been diagnosed in a paternal uncle. The child was treated with mitotane (o,p-DDD) but died suddenly on day 41 of therapy. The maternal alcohol consumption during pregnancy and the development of a malignant tumour in the child many years later could be fortuitous. However, substances transmitted transplacentally can be both teratogenic and oncogenic.s.6 Blattner et al.’ have described a malignant mesenchymoma in
18-year-old patient with phenytoin-associated cleft lip and palate. Neuroblastoma has also been reported in individuals exposed to hydantoins in utero.s.9 Could intrauterine exposure to alcohol lead not only to the fetal alcohol syndrome but also to malignant tumours many years later? Other explanations are under consideration. Could the mild hemihypertrophy noted early be related to the tumour or might the astrocytoma
an
Lemoine, P., Harousseau, H., Borteyru, J. P., Menuet, J. C. Ouest med. 1968, 25, 477. 2. Jones, K. L., Smith, D. W., Ulleland, C. N. Lancet, 1973, i, 1267. 3. Jones, K. L., Smith, D. W. Lancet, 1973, i, 999. 4. Rothman, K. J. An Approach to Cancer Etiology and Control (edited by J. F. Fraumeni); p. 139. New York, 1975. 5. Fraumeni, J. F. Pediatrics, 1974, suppl. 53, p. 807. 6. Miller, R. W. J. nat. Cancer Inst. 1977, 58, 471. 7. Blattner, W. A., Henson, D. E., Young, R. C., Fraumeni, J. F. J. Am. med. Ass. 1977, 238, 334. 8. Pendergrass, T. W., Hanson, J. Lancet, 1976, ii, 150. 9. Sherman, S., Roisen, N. ibid. p. 517. 1.
Fig. 2—Operative cholangiogram showing (arrowed).
stone
in bileduct
1293 in the uncle be significant?1O Perhaps none of these factors are related to the tumour. A search for a history of maternal alcohol consumption during pregnancy in children and young adults with cancer may be helpful. University Affiliated Cincinnati Center for Developmental Disorders, University of Cincinnati Department, of Pediatrics, and Division of
Hematology,
LUSIA HORNSTEIN CAROL CROWE RALPH GRUPPO
Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio 45229, U.S.A.
EARLY DIAGNOSIS OF ANKYLOSING SPONDYLITIS
SIR,-Your editorial (Sept. 17, p. 591) notes the characteristic features of the pain of ankylosing spondylitis: insidious onset, persistence for 3 months, morning stiffness, relief with exercise, and age under 40. Indeed, in our controlled study’ we showed that reliance on these five historical features (selected from seventeen questions) were sensitive (95%) and specific (85%) in the differential diagnosis of 138 patients with back pain attending the Stanford University rheumatology clinic. Nevertheless, a minority of patients with definite ankylosing spondylitis2 may have other less discriminatory symptoms that can suggest mechanical spinal disease. In our study, 17% of 42 patients claimed that the disorder was "caused by an injury", 29% complained of dysaesthesiae in a lower limb, and 41% had pain radiating below the knee. However, features such as these should not deter the physician from an early diagnosis of ankylosing spondylitis, when the other four or five more discriminatory findings are present. A radiograph is diagnostic, and, as you suggest, indiscriminate use of HLA B27 typing is to be avoided. Department of Medicine, Stanford University School of Medicine, Stanford, California 94305, U.S.A.
ANDREI CALIN
WHAT IS NORMAL SERUM MAGNESIUM AND PHOSPHATE? the serum-T4 values reported by Dr MacGregor SIR,-That were (Nov. 26, p. 1129) reported in rnmol/1 and not nmol/1 is not too misleading. What is important, however, is that a serum-magnesium level of 0-85 mmol;1 should be interpreted a indicative of hypermagnesaemia, especially at a time when there is so much conflicting biochemical data relevant to treatment with lithium. Unless the reference range in Dr MacGregor’s laboratory differs appreciably from the usual reference ranges for magnesium, the figure given for serum-magnesium is normal. MacGregor also states that after removal of the parathyroid adenoma the serum-phosphate returned to normal. Was not the preoperative figure (0.88 mmol/1), itself normal? Of the concentrations given only the one for serum-calcium can be considered abnormal. Biochemistry Department, Hospital,
Airedale General
Steeton,
Keighley,
C. SANDERSON
West Yorkshire BD20 6TD
*** This letter has been shown
to
Dr
MacGregor,
whose
reply
follows.-ED. L. are nowadays usually precise but, they sometimes become inflated. When our lithium-
SIR,-Biochemical results like prices, 10. 1.
Fraumeni, J. F., Miller, R. W. J. Pediat. 1967, 70, 129. Calin, A., Porta, J., Fries, J. F., Schurman, L. J. Am.
med. Ass.
2613. 2.
Bennett, P. H. J., Burch, T. A. Bull. rheum. Dis. 1967, 17, 453.
1977, 237,
treated patient was investigated in 1975 the normal range of the serum-magnesium in our laboratory was 0.5-0-8 mmol;1. Lately, and without my knowledge, the upper limit of normal was increased to 1.0 mmol/1. On this reckoning, therefore, the serum-magnesium was normal. Nearly a third of lithiumtreated cases have, however, shown hypermagnesaemia.1 The patient had serum-phosphate levels of 0.30 and 0-35 mmol/1 when her serum-calcium was 3.1and 3.17 mmol/1, before her parathyroid adenoma was excised. The substitution of "m" for "n" in the serum-T4 results was the result of human frailty. St. Luke’s
Hospital, GERALD A. MACGREGOR
Guildford, Surrey GU1 3NT
1. Christiansen,
C., Baastrup, P. C., Transbøl, I. Lancet, 1976, ii, 969.
Commentary from Westminster From Our
Parliamentary Correspondent
The Health Tax
Cigarettes THE Government’s proposal for a cigarette health tax, announced earlier this year by Mr David Ennals, Secretary of State for Social Services, is facing strong opposition both in Brussels and at Westminster. Hopes that the tax would be settled by now have proved optimistic, and a decision this year now depends on a Ministerial meeting in Brussels next week. But further delay is not being ruled out. The proposal is that Britain should be allowed to impose a supplementary health tax on those cigarettes with the highest tar yield, covering about 20% of the market. The result would be a 7p increase on a packet of 20 plain cigarettes. But the plan is being resisted in Brussels where a meeting last week failed to reach any conclusion. The European Commission is said not to like the proposal and very few of our European partners have advanced to such a stage in policy thinking on cigarettes and health. France and Italy both have State monopoly tobacco industries, which present them with particular problems on taxation matters. Now Holland is asking why Britain alone should be given a special derogation to introduce such a tax. The Dutch want to see a general dispensation for every country. At Westminster a number of M.P.S have strongly attacked the idea of bringing the health element into on
taxation. One Conservative has declared that health something which should concern the E.E.C.-although an examination of the Register of M.P.s’ Interests reveals that he is an adviser to British American Tobacco. Other M.P.s with more conspicuous constituency interests in the tobacco industry have criticised the tax for the same reason. They see it as a threat to the industry, its 33 000 employees, the £2250 million a year taxation it pays the Exchequer, and the ,200 million worth of cigarettes it exports every year. For these M.P.s the main consideration is the need to protect the British industry. What is now concerning them is that in pressing for a health tax, the British Government might be persuaded to concede too much in the negotiations on the second stage of harmonising E.E.C. excise duties. The first stage of this harmonisation comes into effect on Jan. 1 and involves changes in the pricing structure which will put up the price of a packet of small matters are not
SIR,-The increasing use of endoscopic retrograde cholangiopancreatography (E.R.C.P.) to examine the bileducts preoperatively must not be allowed to lull surgeons into a false sense of security. This is illustrated by the case of a 70-year-old man who presented with biliary colic followed by obstructive jaundice which resolved within 7 days. An E.R.C.P. done when the jaundice had barely subsided showed a normal bileduct but many small stones in the gallbladder (fig. 1). 1 week after E.R.C.P., during which he remained perfectly well, the patient had a laparotomy. The gallbladder contained several small
stones, but an operative cholangiogram (USlllg image intensification) showed a single small stone 3 mm in diameter in the distal common bileduct (fig. 2). The bileduct was opened, the stone retrieved, and cholecystectomy performed. The stone may have been dislodged from the gallbladder into the bileduct at surgery, but it is equally possible that it was missed by the E.R.C.P. Surgeons should thus continue to perform per-operative cholangiography, and should not assume that a normal preoperative E.R.C.P. means that the bileduct will be normal at operation. Leeds General Infirmary, Leeds LS1 3EX
E. A. BENSON
ADRENAL CARCINOMA IN CHILD WITH HISTORY OF FETAL ALCOHOL SYNDROME
SIR,-In 1968 Lemoine et al.1 and in 1973 Jones and Smith2.3 described an association between alcohol consumption during pregnancy and altered growth and development combined with a pattern of malformations in the offspring, now known as the "fetal alcohol syndrome". Alcohol consumption has also been associated in adults with an increased incidence of cancer of the mouth, pharynx, larynx, and aesophagus.4 We have seen a child with many of the features of the fetal alcohol syndrome who, at age 13 years, had an adrenal carcinoma. This girl was born to a then 39-year-old woman who had a long history of chronic alcoholism. During the pregnancy the mother had been depressed and consumed large amounts of alcohol, mainly beer. The infant’s birth-weight was 1446 g at 36 weeks’ gestation. Strabismus and slow motor and mental development were noted. When she was evaluated at 21 months of age there was facial asymmetry, hypertelorism, epicanthal folds, alternating esotropia, and questionable hemihypertrophy on the left. In the occipital area a 1 cm by lycm cavernous haemangioma was observed. The child showed definite general developmental delay, including delayed Fig. 1.—E.R.C.P. showing stones in gallbladder (arrowed). Bileduct appears normal.
speech. At age 12 years and 11 months she presented with progressive pain, restricted motion of 3 months’ duration, and atrophy in the left upper arm. X-rays demonstrated a lytic lesion in the left scapula, and subsequent studies revealed a non-secreting adrenal cortical carcinoma with metastases to bone, lungs, liver, abdominal nodes, and bone-marrow. At that time it was learned that a cerebral astrocytoma had lately been diagnosed in a paternal uncle. The child was treated with mitotane (o,p-DDD) but died suddenly on day 41 of therapy. The maternal alcohol consumption during pregnancy and the development of a malignant tumour in the child many years later could be fortuitous. However, substances transmitted transplacentally can be both teratogenic and oncogenic.s.6 Blattner et al.’ have described a malignant mesenchymoma in
18-year-old patient with phenytoin-associated cleft lip and palate. Neuroblastoma has also been reported in individuals exposed to hydantoins in utero.s.9 Could intrauterine exposure to alcohol lead not only to the fetal alcohol syndrome but also to malignant tumours many years later? Other explanations are under consideration. Could the mild hemihypertrophy noted early be related to the tumour or might the astrocytoma
an
Lemoine, P., Harousseau, H., Borteyru, J. P., Menuet, J. C. Ouest med. 1968, 25, 477. 2. Jones, K. L., Smith, D. W., Ulleland, C. N. Lancet, 1973, i, 1267. 3. Jones, K. L., Smith, D. W. Lancet, 1973, i, 999. 4. Rothman, K. J. An Approach to Cancer Etiology and Control (edited by J. F. Fraumeni); p. 139. New York, 1975. 5. Fraumeni, J. F. Pediatrics, 1974, suppl. 53, p. 807. 6. Miller, R. W. J. nat. Cancer Inst. 1977, 58, 471. 7. Blattner, W. A., Henson, D. E., Young, R. C., Fraumeni, J. F. J. Am. med. Ass. 1977, 238, 334. 8. Pendergrass, T. W., Hanson, J. Lancet, 1976, ii, 150. 9. Sherman, S., Roisen, N. ibid. p. 517. 1.
Fig. 2—Operative cholangiogram showing (arrowed).
stone
in bileduct
1293 in the uncle be significant?1O Perhaps none of these factors are related to the tumour. A search for a history of maternal alcohol consumption during pregnancy in children and young adults with cancer may be helpful. University Affiliated Cincinnati Center for Developmental Disorders, University of Cincinnati Department, of Pediatrics, and Division of
Hematology,
LUSIA HORNSTEIN CAROL CROWE RALPH GRUPPO
Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio 45229, U.S.A.
EARLY DIAGNOSIS OF ANKYLOSING SPONDYLITIS
SIR,-Your editorial (Sept. 17, p. 591) notes the characteristic features of the pain of ankylosing spondylitis: insidious onset, persistence for 3 months, morning stiffness, relief with exercise, and age under 40. Indeed, in our controlled study’ we showed that reliance on these five historical features (selected from seventeen questions) were sensitive (95%) and specific (85%) in the differential diagnosis of 138 patients with back pain attending the Stanford University rheumatology clinic. Nevertheless, a minority of patients with definite ankylosing spondylitis2 may have other less discriminatory symptoms that can suggest mechanical spinal disease. In our study, 17% of 42 patients claimed that the disorder was "caused by an injury", 29% complained of dysaesthesiae in a lower limb, and 41% had pain radiating below the knee. However, features such as these should not deter the physician from an early diagnosis of ankylosing spondylitis, when the other four or five more discriminatory findings are present. A radiograph is diagnostic, and, as you suggest, indiscriminate use of HLA B27 typing is to be avoided. Department of Medicine, Stanford University School of Medicine, Stanford, California 94305, U.S.A.
ANDREI CALIN
WHAT IS NORMAL SERUM MAGNESIUM AND PHOSPHATE? the serum-T4 values reported by Dr MacGregor SIR,-That were (Nov. 26, p. 1129) reported in rnmol/1 and not nmol/1 is not too misleading. What is important, however, is that a serum-magnesium level of 0-85 mmol;1 should be interpreted a indicative of hypermagnesaemia, especially at a time when there is so much conflicting biochemical data relevant to treatment with lithium. Unless the reference range in Dr MacGregor’s laboratory differs appreciably from the usual reference ranges for magnesium, the figure given for serum-magnesium is normal. MacGregor also states that after removal of the parathyroid adenoma the serum-phosphate returned to normal. Was not the preoperative figure (0.88 mmol/1), itself normal? Of the concentrations given only the one for serum-calcium can be considered abnormal. Biochemistry Department, Hospital,
Airedale General
Steeton,
Keighley,
C. SANDERSON
West Yorkshire BD20 6TD
*** This letter has been shown
to
Dr
MacGregor,
whose
reply
follows.-ED. L. are nowadays usually precise but, they sometimes become inflated. When our lithium-
SIR,-Biochemical results like prices, 10. 1.
Fraumeni, J. F., Miller, R. W. J. Pediat. 1967, 70, 129. Calin, A., Porta, J., Fries, J. F., Schurman, L. J. Am.
med. Ass.
2613. 2.
Bennett, P. H. J., Burch, T. A. Bull. rheum. Dis. 1967, 17, 453.
1977, 237,
treated patient was investigated in 1975 the normal range of the serum-magnesium in our laboratory was 0.5-0-8 mmol;1. Lately, and without my knowledge, the upper limit of normal was increased to 1.0 mmol/1. On this reckoning, therefore, the serum-magnesium was normal. Nearly a third of lithiumtreated cases have, however, shown hypermagnesaemia.1 The patient had serum-phosphate levels of 0.30 and 0-35 mmol/1 when her serum-calcium was 3.1and 3.17 mmol/1, before her parathyroid adenoma was excised. The substitution of "m" for "n" in the serum-T4 results was the result of human frailty. St. Luke’s
Hospital, GERALD A. MACGREGOR
Guildford, Surrey GU1 3NT
1. Christiansen,
C., Baastrup, P. C., Transbøl, I. Lancet, 1976, ii, 969.
Commentary from Westminster From Our
Parliamentary Correspondent
The Health Tax
Cigarettes THE Government’s proposal for a cigarette health tax, announced earlier this year by Mr David Ennals, Secretary of State for Social Services, is facing strong opposition both in Brussels and at Westminster. Hopes that the tax would be settled by now have proved optimistic, and a decision this year now depends on a Ministerial meeting in Brussels next week. But further delay is not being ruled out. The proposal is that Britain should be allowed to impose a supplementary health tax on those cigarettes with the highest tar yield, covering about 20% of the market. The result would be a 7p increase on a packet of 20 plain cigarettes. But the plan is being resisted in Brussels where a meeting last week failed to reach any conclusion. The European Commission is said not to like the proposal and very few of our European partners have advanced to such a stage in policy thinking on cigarettes and health. France and Italy both have State monopoly tobacco industries, which present them with particular problems on taxation matters. Now Holland is asking why Britain alone should be given a special derogation to introduce such a tax. The Dutch want to see a general dispensation for every country. At Westminster a number of M.P.S have strongly attacked the idea of bringing the health element into on
taxation. One Conservative has declared that health something which should concern the E.E.C.-although an examination of the Register of M.P.s’ Interests reveals that he is an adviser to British American Tobacco. Other M.P.s with more conspicuous constituency interests in the tobacco industry have criticised the tax for the same reason. They see it as a threat to the industry, its 33 000 employees, the £2250 million a year taxation it pays the Exchequer, and the ,200 million worth of cigarettes it exports every year. For these M.P.s the main consideration is the need to protect the British industry. What is now concerning them is that in pressing for a health tax, the British Government might be persuaded to concede too much in the negotiations on the second stage of harmonising E.E.C. excise duties. The first stage of this harmonisation comes into effect on Jan. 1 and involves changes in the pricing structure which will put up the price of a packet of small matters are not
