1088 MISUSE OF MEDICAL WOMANPOWER
ELECTROLYTE DISTURBANCES IN BEER DRINKERS
SIR,-Dr. Forster’s point (Oct. 25, p. 818) that married doctors live predominantly in the South-East is not borne out in practice, at least for senior trainees in psychiatry. As part of a recent postal survey I ascertained the place of residence of 27 senior registrars who were restricted as to where they could apply for consultant posts, usually because of family reasons. 4 were from Greater London, 3 each from Glasgow and Manchester, and 1 each from Edinburgh, Lancawomen
shire, Cambridge, Warwick, Nottingham, Leeds, Stafford, Northampton, Norwich, Sheffield, Portsmouth, Bristol, Birmingham, Abingdon, Doncaster, Newcastle, and Northern Ireland. Until proved otherwise, it must be assumed that this group is likely to be representative of all married women doctors. From this it follows that the assumption of a heavy concentration in the South-East is unfounded and therefore this should not be a factor in determining the issue of the feasibility of supernumerary posts.
Warley Hospital, Brentwood, Essex CM14 5HQ.
C. P. B. BROOK
MEDICAL TECHNOLOGY
SIR,-Dr Mahler, Director-General of the World Health Organisation, states (Nov. 1, p. 829) that the health professions place "a gross restriction in the information available" the public on health matters and that this obscurity causes "an unnecessary but inevitable dependency of the population upon the holders of these mysteries". The truth is that information and discussion on medical matters is constantly laid before the whole population by newspapers and their medical editors, health journals, radio and television talks and discussions, and the posters and literature of the Council for Health Education. The principal medical journals are available in the public reference libraries, and associations of lay and medical members exist for the care of sufferers from many disabilities like blindness, deafness, handicap in children, diabetes, arthritis, chest and heart disease, epilepsy, and spasticity.
to
p.
SIR,- The report by Dr Hilden and Dr Svendsen (Aug. 9, 245) of a specific hypo-osmolality* syndrome in beer
by us (Sept. 6, p. 455) because given and alternative explanations not excluded. We feel that these criticisms stand, despite the proponents’ reply (Oct. 25, p. 822) and that the concept, although plausible, remains unproven. Dr Demanet suggested (Sept. 6, p. 455) that he had earlier’ noted the syndrome in 4 patients, but seems to have forgotten that case 7 fulfilled the criteria for inappropriate secretion of antidiuretic hormone (A.D.H.), cases 6, 11, and 12 were anorectic and malnourished, all cases had suffered from diarrhoea or vomiting, cases 6, 7, and 11 were hypokalasmic, case 6 had cirrhosis, case 11 had emphysema, and case 12 had some evidence of renal impairment (a raised blood-urea concentration). Hyponatrxmia has drinkers
If the doctor is doing all he can to relieve the patient of his disabilities and their resultant anxiety he will want to use all the techniques of diagnosis and treatment indicated. For this reason, it is wrong for Dr Mahler to decry medical technology in a wholesale way; it is needed for discovering new preventive and curative methods and for applying them where they are needed. While decrying technology, Dr Mahler asks for the assign"of health resources within a country on a problem-solvbasis". Much of the resources spent on medical matters in ing Britain are given to solving problems already, but the answers to problems must be applied to groups of people or to individuals in a way that also needs much expenditure. ment
Dr Mahler criticises the number of references of patients by general practitioners to specialists and puts forward, as a fair comparison, of what should be, his many air journeys, when he does not expect to "be flown by a professor of aeronautical engineering rather than an experienced pilot". The analogy is wrong, because Dr Mahler flies in highly standardised and
carefully tested and maintained aircraft, not analogous to human beings with infinitely variable defects which it is the aim of the health professions to mitigate. 8 West Hill Court,
Millfield Lane, London N6.
J. M. ALSTON
commented
on
was not
been described in association with all these situations. The patient of Dr Banks and Dr Lecky (Sept. 20, p. 559) cannot be fully assessed because of therapy with bendroflumethiazide and propranolol, the high potassium intake, management by fluid restriction and sodium administration, and the lack of information on the initial urinary osmolar excretion and osmolality. Overall, it seems more likely that the patient had a sodium depletion than a water-excess syndrome, but even in the latter case diuretic therapy, hypokalxmia intrinsic renal disease,4 "appropriate",’ or inappropriate activity of A.D.H.6 could be responsible. We agree that hypo-osmolality syndromes are common in beer drinkers, but many causes are possible. We would therefore suggest that the minimal criteria for diagnosis of the proposed specific syndrome include: the formal exclusion of a misleading result, sodium depletion, and other causes of water excess, and the presence of a low urinary osmolality and a low osmolar excretion. Division of Clinical Chemistry, Institute of Medical and Veterinary Science, Frome Road, Adelaide, South Australia.
I agree with Dr Mahler that there should be the constant effort to communicate fully between patient and doctor, but he does not record that there is seldom enough time for this and that differences between races are a barrier for many of the
population.
was
positive evidence
P. J. PHILLIPS R. W. PAIN
HEPATITIS-B VIRUS INFECTION OF CHILDREN BORN TO MOTHERS WITH SEVERE HEPATITIS
SIR,-We observed 2 children born by caesarean section to mothers with severe hepatitis-B (HB) viral hepatitis. Tests for HBsAg and HBsAb were performed by counter-immunoelectrophoresis, microcomplement fixation, inhibition of passive haemagglutination, and radioimmunoassay. The mothers had severe HBs-positive hepatitis with high transaminase levels, low clotting factors, and neurological manifestations with coma (stages II and iv). Delivery was performed by cxsarean section after 7zand 8 months’ gestation. In both cases no HBsAg was found in cord blood, amniotic fluid, or placenta. HBsAg in the latter was sought by indirect and direct immunofluorescence, using human and goat antiHBsAb as well as human and chimpanzee anti-HBcAb (Dr J. Hoofnagle, National Institutes of Health, Bethesda). Both children developed HBs antigenaemia at 50 and 60 days of age. After 10 months, one child was still HBsAg positive. The second child, however, developed a mild clinical and 1.
Demanet, J. C., Bonnyns, M., Bleiberg, H., Stevens-Rocmans, C. Lancet, 1971, ii, 1115. 2. Martin, E. W., Alexander, S. F., Farage, D. J., Hassan, W. E., Martin, R D. Hazards of Medication; p. 752. Philadelphia, 1971. 3. Fichman, M. P., Vorherr, H., Kleeman, C. R., Telfer, N. Ann. intern. Med 1971, 75, 853. 4. Marcus, F. I. Am. J. Med. 1975, 58, 452. 5. Phillips, P. J. Aust. N.Z. Jl Med. 1975, 5, 287. 6. Shalhoub, R. J., Antoniou, L. D. Ann. intern. Med. 1969, 70, 943. *The correct term for the measurement of the osmotic activity of a solution is osmolality (mosm/kg of solvent) and not osmotantv (mosm/1 of solution). The numerical difference is, however, small.
1089
biological liver disease at
3 months of age, which
was
followed
by the elimination of HBsAg and by the development of HBsAb. Both mothers fully recovered, with complete disappearance of HBsAg. No anti-HBsAb has occurred in mothers up to 10 and 11 months after hepatitis. From these observations, several points can be made: (1) as reported,’ newborns infected at birth are not always prone to become HBsAg chronic carriers; (2) the maternofetal contamination was likely to have been transplacental, since the babies were born by caesarean section and immediately separated from their mother; (3) the contamination of the babies points to the lack of efficient anti-viral antibodies of maternal origin. Thus, if massive liver necrosis in the mothers was due to a
hyperimmune response, as proposed by Dudley et aI.,2 the contamination and the clinical course in the babies strongly suggest that such a mechanism would not be antibody-mediated. Centre d’Hémobiologie Périnatale, 53 boulevard Diderot, F 75012 Paris. Centre National de Transfusion
Sanguine,
F 91400 Orsay.
I.N.S.E.R.M., Laboratoire d’Immunologie, Hôpital d’Enfants, F 94270 Bicétre.
P. GIRAUD
to learn the outcome of Dr Boxall’s special group of cord-blood-negative babies with breast-milk-positive mothers. We hope that she will draw her conclusions based on the HBsAg outcome of infant’s unconcentrated serum. Our guess is that a baby may occasionally be infected by breast milk but that this is not an important mechanism of transmission.
terested
Department of Epidemiology and Clinical Investigation, U.S. Naval Medical Research Unit no. 2, Box 14, APO San Francisco 96263.
R. PALMER BEASLEY
Department of Epidemiology and International Health, University of Washington, Seattle, Washington; and
CLADD E. STEVENS
Center for Maternal and Child Health, Veterans’ General Hospital, Taipei, Taiwan.
I-SEN SHIAO HSIEN-CHIEH MENG
J. DROUET IDENTIFICATION OF HEPATITIS-B ANTIGEN
J.
M. DUPUY
BREAST-FEEDING AND HEPATITIS B
SIR,-May we reply to Dr Boxall (Nov. 15, p. 979)? The data we presented showed no correlation between breast-feeding and transmission of HBsAg from carrier mothers to their babies. This conclusion requires no assumptions about the presence or absence of HBsAg in breast milk. We were unable to detect HBsAg in unconcentrated breast-milk specimens from carrier women. Dr Boxall reports finding it in 56% of 27 concentrated specimens. Our data simply say that present or absent breast-feeding is not an important means of transmission from mother to child. It seems likely to us that very small amounts of HBsAg detected by Dr Boxall’s highly sensitive methods are not infectious. The fact remains that transmission from asymptomatic carrier mothers to their babies occurs much more frequently in Chinese than Caucasians (it is interesting and undoubtedly biologically significant that Dr Boxall’s only carrier baby is Chinese). Neither Dr Boxall nor most other investigators have commented on the proportion of the babies in their series which were breast-fed. Again, unless the vast majority are not breast-fed, this would suggest that breast-feeding is not an important means of transmission irrespective of the presence of small quantities of HBsAg in the milk of many carrier mothers. Dr Boxall correctly points out that cord-blood-positive infants are probably already infected and thus would not be "susceptible" to post-delivery infection. In our series 21% of the cord bloods were positive and virtually all these infants became carriers. Because there is controversy about the biological significance of a HBsAg-positive cord blood (transplacental infection v. contamination) and because the conclusions were unchanged by making this separation, we chose to present the results for the group without distinction as to cordblood status. The frequency of antigen positivity in cordblood-negative infants was: breast-fed 17/44 (39%); non-breast-fed 14/30 (47%). The p value is 0.5 by Fisher’s exact test. Again Dr Boxall finds a higher frequency of HBsAgpositive cord bloods by concentrating the specimens (57%), but since she has found only 1 baby who became a carrier, there again seems to be little biological meaning to this increased sensitivity. We contend that, when looking at postnatal factors, one should consider excluding only infants who are cordblood-positive and become chronic carriers. We will be in1. Dupuy, J. M., Frommel, D., Alagile, D. Lancet, 1975, i, 191. 2 Dudley, F. J., Fox, R. A., Sherlock, S. ibid. 1972, i, 723.
SiR,—The histological diagnosis of the viral nature of lesions identified in liver biopsies has always presented problems, especially to the busy histopathologist of a district general hospital with little access to immunoflurescence and electron-micoscopy facilities. Recently great hopes have been raised by the demonstration of hepatitis-B antigen (HBAg) in conventional paraffin sections of liver biopsies, using one or the other of Shikata’s staining methods.1-3 Orcein staining appears to be more specific (although the histochemical reaction involved is far from clear), and orcein-positive material seen in the cytoplasm of hepatocytes is thought to represent surface components of HBAg in excess endoplasmic reticulum.4 It has also been shown that positive Shikata staining can be obtained in sections taken from stored paraffin blocks (of liver tissue) up to 50 years of age. Reports so far indicate that orcein staining yields more positive results in biopsy material from seropositive patients with chronic liver disease than from those with acute viral hepatitis. We have reviewed 213 liver biopsies from our files representing material reported between 1964 and 1975 and covering a wide spectrum of liver diseases. Additional sections were cut from all 213 paraffin blocks and stained by a modification of Shikata’s orcein staining method; this modification compares successfully with the original method and presents technical
advantages. Results from
our
retrospective study have shown:
(1) Out of a total of 213 biopsies (including, particularly, 61 cases of cirrhotic changes, 6 cases of chronic persistent hepatitis, and 11 cases of chronic aggressive hepatitis), only 3 biopsies contained orceinpositive material. 2 of these were from 1968 and 1969 when serology for HBAg was not available. The 3rd biopsy came from a patient with positive HBAg but negative antibody. (2) On the other hand, no orcein-positive material could be demonstrated in the biopsies from 5 patients with a positive serology for HBAg and showing histologically chronic liver disease. results may be partly explained by a sampling error-i.e., orcein-positive material could be irregularly distributed in biopsy material. However, we feel that our experience casts some doubt on any over-reliance by histopathologists on these methods. Such histochemical diagnosis of the presence or absence of HBAg in liver biopsies could be deceptive if light microscopy only is used. There is a need for larger prospective studies in which the results obtained with the Shikata’s Some of
our
1. Shikara, T., Uzawa, T., Yoshiwara, N., Akatsuka, T., Yamazaki, S. Jap. J. exp. Med. 1974, 44, 25. 2. Deodhar, K. P., Tapp, E., Scheuer, P. J. J. clin. Path. 1975, 28, 66. 3. Vogel, H. M., Henning, H., Luders, C. J., Braun, H. H., Tripatzis, I Z. Gastroent. 1974, 12, 257. 4. Popper, H. Human Path. 1975, 6, 517.
ELECTROLYTE DISTURBANCES IN BEER DRINKERS
SIR,-Dr. Forster’s point (Oct. 25, p. 818) that married doctors live predominantly in the South-East is not borne out in practice, at least for senior trainees in psychiatry. As part of a recent postal survey I ascertained the place of residence of 27 senior registrars who were restricted as to where they could apply for consultant posts, usually because of family reasons. 4 were from Greater London, 3 each from Glasgow and Manchester, and 1 each from Edinburgh, Lancawomen
shire, Cambridge, Warwick, Nottingham, Leeds, Stafford, Northampton, Norwich, Sheffield, Portsmouth, Bristol, Birmingham, Abingdon, Doncaster, Newcastle, and Northern Ireland. Until proved otherwise, it must be assumed that this group is likely to be representative of all married women doctors. From this it follows that the assumption of a heavy concentration in the South-East is unfounded and therefore this should not be a factor in determining the issue of the feasibility of supernumerary posts.
Warley Hospital, Brentwood, Essex CM14 5HQ.
C. P. B. BROOK
MEDICAL TECHNOLOGY
SIR,-Dr Mahler, Director-General of the World Health Organisation, states (Nov. 1, p. 829) that the health professions place "a gross restriction in the information available" the public on health matters and that this obscurity causes "an unnecessary but inevitable dependency of the population upon the holders of these mysteries". The truth is that information and discussion on medical matters is constantly laid before the whole population by newspapers and their medical editors, health journals, radio and television talks and discussions, and the posters and literature of the Council for Health Education. The principal medical journals are available in the public reference libraries, and associations of lay and medical members exist for the care of sufferers from many disabilities like blindness, deafness, handicap in children, diabetes, arthritis, chest and heart disease, epilepsy, and spasticity.
to
p.
SIR,- The report by Dr Hilden and Dr Svendsen (Aug. 9, 245) of a specific hypo-osmolality* syndrome in beer
by us (Sept. 6, p. 455) because given and alternative explanations not excluded. We feel that these criticisms stand, despite the proponents’ reply (Oct. 25, p. 822) and that the concept, although plausible, remains unproven. Dr Demanet suggested (Sept. 6, p. 455) that he had earlier’ noted the syndrome in 4 patients, but seems to have forgotten that case 7 fulfilled the criteria for inappropriate secretion of antidiuretic hormone (A.D.H.), cases 6, 11, and 12 were anorectic and malnourished, all cases had suffered from diarrhoea or vomiting, cases 6, 7, and 11 were hypokalasmic, case 6 had cirrhosis, case 11 had emphysema, and case 12 had some evidence of renal impairment (a raised blood-urea concentration). Hyponatrxmia has drinkers
If the doctor is doing all he can to relieve the patient of his disabilities and their resultant anxiety he will want to use all the techniques of diagnosis and treatment indicated. For this reason, it is wrong for Dr Mahler to decry medical technology in a wholesale way; it is needed for discovering new preventive and curative methods and for applying them where they are needed. While decrying technology, Dr Mahler asks for the assign"of health resources within a country on a problem-solvbasis". Much of the resources spent on medical matters in ing Britain are given to solving problems already, but the answers to problems must be applied to groups of people or to individuals in a way that also needs much expenditure. ment
Dr Mahler criticises the number of references of patients by general practitioners to specialists and puts forward, as a fair comparison, of what should be, his many air journeys, when he does not expect to "be flown by a professor of aeronautical engineering rather than an experienced pilot". The analogy is wrong, because Dr Mahler flies in highly standardised and
carefully tested and maintained aircraft, not analogous to human beings with infinitely variable defects which it is the aim of the health professions to mitigate. 8 West Hill Court,
Millfield Lane, London N6.
J. M. ALSTON
commented
on
was not
been described in association with all these situations. The patient of Dr Banks and Dr Lecky (Sept. 20, p. 559) cannot be fully assessed because of therapy with bendroflumethiazide and propranolol, the high potassium intake, management by fluid restriction and sodium administration, and the lack of information on the initial urinary osmolar excretion and osmolality. Overall, it seems more likely that the patient had a sodium depletion than a water-excess syndrome, but even in the latter case diuretic therapy, hypokalxmia intrinsic renal disease,4 "appropriate",’ or inappropriate activity of A.D.H.6 could be responsible. We agree that hypo-osmolality syndromes are common in beer drinkers, but many causes are possible. We would therefore suggest that the minimal criteria for diagnosis of the proposed specific syndrome include: the formal exclusion of a misleading result, sodium depletion, and other causes of water excess, and the presence of a low urinary osmolality and a low osmolar excretion. Division of Clinical Chemistry, Institute of Medical and Veterinary Science, Frome Road, Adelaide, South Australia.
I agree with Dr Mahler that there should be the constant effort to communicate fully between patient and doctor, but he does not record that there is seldom enough time for this and that differences between races are a barrier for many of the
population.
was
positive evidence
P. J. PHILLIPS R. W. PAIN
HEPATITIS-B VIRUS INFECTION OF CHILDREN BORN TO MOTHERS WITH SEVERE HEPATITIS
SIR,-We observed 2 children born by caesarean section to mothers with severe hepatitis-B (HB) viral hepatitis. Tests for HBsAg and HBsAb were performed by counter-immunoelectrophoresis, microcomplement fixation, inhibition of passive haemagglutination, and radioimmunoassay. The mothers had severe HBs-positive hepatitis with high transaminase levels, low clotting factors, and neurological manifestations with coma (stages II and iv). Delivery was performed by cxsarean section after 7zand 8 months’ gestation. In both cases no HBsAg was found in cord blood, amniotic fluid, or placenta. HBsAg in the latter was sought by indirect and direct immunofluorescence, using human and goat antiHBsAb as well as human and chimpanzee anti-HBcAb (Dr J. Hoofnagle, National Institutes of Health, Bethesda). Both children developed HBs antigenaemia at 50 and 60 days of age. After 10 months, one child was still HBsAg positive. The second child, however, developed a mild clinical and 1.
Demanet, J. C., Bonnyns, M., Bleiberg, H., Stevens-Rocmans, C. Lancet, 1971, ii, 1115. 2. Martin, E. W., Alexander, S. F., Farage, D. J., Hassan, W. E., Martin, R D. Hazards of Medication; p. 752. Philadelphia, 1971. 3. Fichman, M. P., Vorherr, H., Kleeman, C. R., Telfer, N. Ann. intern. Med 1971, 75, 853. 4. Marcus, F. I. Am. J. Med. 1975, 58, 452. 5. Phillips, P. J. Aust. N.Z. Jl Med. 1975, 5, 287. 6. Shalhoub, R. J., Antoniou, L. D. Ann. intern. Med. 1969, 70, 943. *The correct term for the measurement of the osmotic activity of a solution is osmolality (mosm/kg of solvent) and not osmotantv (mosm/1 of solution). The numerical difference is, however, small.
1089
biological liver disease at
3 months of age, which
was
followed
by the elimination of HBsAg and by the development of HBsAb. Both mothers fully recovered, with complete disappearance of HBsAg. No anti-HBsAb has occurred in mothers up to 10 and 11 months after hepatitis. From these observations, several points can be made: (1) as reported,’ newborns infected at birth are not always prone to become HBsAg chronic carriers; (2) the maternofetal contamination was likely to have been transplacental, since the babies were born by caesarean section and immediately separated from their mother; (3) the contamination of the babies points to the lack of efficient anti-viral antibodies of maternal origin. Thus, if massive liver necrosis in the mothers was due to a
hyperimmune response, as proposed by Dudley et aI.,2 the contamination and the clinical course in the babies strongly suggest that such a mechanism would not be antibody-mediated. Centre d’Hémobiologie Périnatale, 53 boulevard Diderot, F 75012 Paris. Centre National de Transfusion
Sanguine,
F 91400 Orsay.
I.N.S.E.R.M., Laboratoire d’Immunologie, Hôpital d’Enfants, F 94270 Bicétre.
P. GIRAUD
to learn the outcome of Dr Boxall’s special group of cord-blood-negative babies with breast-milk-positive mothers. We hope that she will draw her conclusions based on the HBsAg outcome of infant’s unconcentrated serum. Our guess is that a baby may occasionally be infected by breast milk but that this is not an important mechanism of transmission.
terested
Department of Epidemiology and Clinical Investigation, U.S. Naval Medical Research Unit no. 2, Box 14, APO San Francisco 96263.
R. PALMER BEASLEY
Department of Epidemiology and International Health, University of Washington, Seattle, Washington; and
CLADD E. STEVENS
Center for Maternal and Child Health, Veterans’ General Hospital, Taipei, Taiwan.
I-SEN SHIAO HSIEN-CHIEH MENG
J. DROUET IDENTIFICATION OF HEPATITIS-B ANTIGEN
J.
M. DUPUY
BREAST-FEEDING AND HEPATITIS B
SIR,-May we reply to Dr Boxall (Nov. 15, p. 979)? The data we presented showed no correlation between breast-feeding and transmission of HBsAg from carrier mothers to their babies. This conclusion requires no assumptions about the presence or absence of HBsAg in breast milk. We were unable to detect HBsAg in unconcentrated breast-milk specimens from carrier women. Dr Boxall reports finding it in 56% of 27 concentrated specimens. Our data simply say that present or absent breast-feeding is not an important means of transmission from mother to child. It seems likely to us that very small amounts of HBsAg detected by Dr Boxall’s highly sensitive methods are not infectious. The fact remains that transmission from asymptomatic carrier mothers to their babies occurs much more frequently in Chinese than Caucasians (it is interesting and undoubtedly biologically significant that Dr Boxall’s only carrier baby is Chinese). Neither Dr Boxall nor most other investigators have commented on the proportion of the babies in their series which were breast-fed. Again, unless the vast majority are not breast-fed, this would suggest that breast-feeding is not an important means of transmission irrespective of the presence of small quantities of HBsAg in the milk of many carrier mothers. Dr Boxall correctly points out that cord-blood-positive infants are probably already infected and thus would not be "susceptible" to post-delivery infection. In our series 21% of the cord bloods were positive and virtually all these infants became carriers. Because there is controversy about the biological significance of a HBsAg-positive cord blood (transplacental infection v. contamination) and because the conclusions were unchanged by making this separation, we chose to present the results for the group without distinction as to cordblood status. The frequency of antigen positivity in cordblood-negative infants was: breast-fed 17/44 (39%); non-breast-fed 14/30 (47%). The p value is 0.5 by Fisher’s exact test. Again Dr Boxall finds a higher frequency of HBsAgpositive cord bloods by concentrating the specimens (57%), but since she has found only 1 baby who became a carrier, there again seems to be little biological meaning to this increased sensitivity. We contend that, when looking at postnatal factors, one should consider excluding only infants who are cordblood-positive and become chronic carriers. We will be in1. Dupuy, J. M., Frommel, D., Alagile, D. Lancet, 1975, i, 191. 2 Dudley, F. J., Fox, R. A., Sherlock, S. ibid. 1972, i, 723.
SiR,—The histological diagnosis of the viral nature of lesions identified in liver biopsies has always presented problems, especially to the busy histopathologist of a district general hospital with little access to immunoflurescence and electron-micoscopy facilities. Recently great hopes have been raised by the demonstration of hepatitis-B antigen (HBAg) in conventional paraffin sections of liver biopsies, using one or the other of Shikata’s staining methods.1-3 Orcein staining appears to be more specific (although the histochemical reaction involved is far from clear), and orcein-positive material seen in the cytoplasm of hepatocytes is thought to represent surface components of HBAg in excess endoplasmic reticulum.4 It has also been shown that positive Shikata staining can be obtained in sections taken from stored paraffin blocks (of liver tissue) up to 50 years of age. Reports so far indicate that orcein staining yields more positive results in biopsy material from seropositive patients with chronic liver disease than from those with acute viral hepatitis. We have reviewed 213 liver biopsies from our files representing material reported between 1964 and 1975 and covering a wide spectrum of liver diseases. Additional sections were cut from all 213 paraffin blocks and stained by a modification of Shikata’s orcein staining method; this modification compares successfully with the original method and presents technical
advantages. Results from
our
retrospective study have shown:
(1) Out of a total of 213 biopsies (including, particularly, 61 cases of cirrhotic changes, 6 cases of chronic persistent hepatitis, and 11 cases of chronic aggressive hepatitis), only 3 biopsies contained orceinpositive material. 2 of these were from 1968 and 1969 when serology for HBAg was not available. The 3rd biopsy came from a patient with positive HBAg but negative antibody. (2) On the other hand, no orcein-positive material could be demonstrated in the biopsies from 5 patients with a positive serology for HBAg and showing histologically chronic liver disease. results may be partly explained by a sampling error-i.e., orcein-positive material could be irregularly distributed in biopsy material. However, we feel that our experience casts some doubt on any over-reliance by histopathologists on these methods. Such histochemical diagnosis of the presence or absence of HBAg in liver biopsies could be deceptive if light microscopy only is used. There is a need for larger prospective studies in which the results obtained with the Shikata’s Some of
our
1. Shikara, T., Uzawa, T., Yoshiwara, N., Akatsuka, T., Yamazaki, S. Jap. J. exp. Med. 1974, 44, 25. 2. Deodhar, K. P., Tapp, E., Scheuer, P. J. J. clin. Path. 1975, 28, 66. 3. Vogel, H. M., Henning, H., Luders, C. J., Braun, H. H., Tripatzis, I Z. Gastroent. 1974, 12, 257. 4. Popper, H. Human Path. 1975, 6, 517.
