382 release from injured muscle of adenine nucleotides subsequently metabolised to uric acid.8 Also characteristic are hypocalcaemia and hyperphosphataemia during the oliguric phase. Hypercalcaemia follows in the diuretic phase because of, among other factors, reabsorption of calcium from injured muscle, secondary hyperparathyroidism, and an increased response to parathyroid hormone as the uraemic state resolves. The serum-creatinine rises at an unusually rapid rate owing to its release from muscle.10 18 Our patient had all these features. Additional support for the diagnosis of myoglobinuric acute renal failure included muscle tenderness and pigmented casts in an orthotolidine-positive urine without hxmaturia or evidence of haemolysis. Anuria prevented specific confirmation of myoglobin in the urine. To our knowledge this is the first report of non-traumatic rhabdomyolysis and acute renal failure secondary to a psychosis. Since early treatment with a forced alkaline diuresis may prevent the renal failure,9 this complication should be considered in patients whose psychoses are manifested in unusual or intense muscular activity. WILLIAM CORYELL Departments of Psychiatry and Medicine, L. H. NORBY University of Iowa College of Medicine, L. H. COHEN Iowa City, Iowa 52242, U.S.A. ’


SIR,-Dr Waite and his colleagues (July 15, p. 132), having reported two Maori bronchiectatic females with a deficiency of dynein arms in their cilia, suggest that non-Polynesian bronchiectatics should be studied to see if all primary bronchiectatics have abnormal cilia. We are studying the ciliary ultrastructure in bronchial biopsies of patients with extensive generalised bronchiectasis. The astiology of this disease is still uncertain. Many cases are thought to be congenital. Our cases were both teenage White females with widespread, longstanding bronchiectasis and, in addition, chronic sinusitis and nasal polyps. Neither had dextrocardia and their fertility had not been tested. Cystic fibrosis and hypogammaglobulinaemia had been excluded. The bronchial biopsies were obtained during a fibreoptic bronchoscopy performed under local anaesthetic before bronchography. A patient with apparently normal lungs who was bronchoscoped for unexplained haemoptysis acted as a


SIR,-Some reports have demonstrated that polyunsatur-

fatty acids (P.U.F.A.) play a role in regulating (suppressthe immune response.1-S We and others have been unable ing) to reproduce some of these reported findings .1 Bower and Newsholme8 reported that two children with idiopathic polyneuritis recovered when they were put on a P.U.F.A. diet and postulated that administration of P.U.F.A. may suppress immune responsiveness by coming into contact with large numbers of lymphocytes within the thoracic duct. The thoracic duct is a major traffic area for recirculating lymphocytes and also the primary route for the transport of P. U. F.A. in high concentration to the systemic recirculation after intestinal absorption. We have been evaluating this postulate in rats. The thoracic ducts of normal female rats were cannulated at the same time as duodenal cannulas were placed in the duodenum. The rats were fed pure solutions of either linoleic or oleic (in sodium taurocholate acid) directly into the duodenum while thoracicduct lymph and lymphocytes were collected. The volume of thoracic-duct lymph, the thoracic-duct lymphocyte (T.D.L.) number, and the rate of flow were evaluated, as was the mitogen responsiveness of T.D.L. from normal and P.U.F.A.-treated rats. In a series of three experiments involving four experimental and four control animals per experiment, we were unable to demonstrate any change in either thoracic-duct lymph flow or T.D.L. output. The response to phytohxmagglutinin and concanavalin A was the same in T.D.L. derived from experimental or control groups. While these experiments do not definitely prove that P.U.F.A. have no effect on T.D.L. traffic and function, they lend little support to the hypothesis that T.D.L. bathed in high concentration of P.U.F.A. are less responsive than or migrate in a manner different from,cells not exposed to high concentrations ated

OfP.U.F.A. Departments of Immunology and Microbiology and Medicine, Wayne State University School of Medicine and Harper Hospital, Detroit, Michigan 48201, U.S.A.


Electronmicroscopy of the bronchial cilia ficiency of dynein arms in the two patients.


deaddition, the orientation of the central 2 filaments was normal. One case, however, had frequent, very large, compound cilia with 8-22 axial filament complexes in 1 cilium. These have been previously described in a patient with chronic bronchitis and bronchial carcinoma but not in bronchiectasis. It may be that the immotile-cilia syndrome2explains the high incidence of bronchiectasis in Maoris3 but the ciliary abnormality may be part of a more fundamental abnormality also involving the movement of phagocytic cells.4 Whichever is the case, we point out that absence of dynein arms and disorientation of cilia do not always occur in Caucasians with diffuse "congenital" bronchiectasis, but we agree that more investigation is indicated, not only in bronchiectasis, but also in other pulmonary disorders, and in normal people.

North Wales


M.R.C. Pneumoconiosis Unit, Penarth, South Glamorgan



Knochel, J. P., Dotin, L. N., Hamburger,




SIR,-A noteworthy development in medical education in


Abergele Chest Hospital, Clwyd,




J. Ann. intern. Med. 1974, 81,


(June, 1978) ruling by the Univerthat students who complete their academic sity Singapore prerequisites in the medical faculty (formerly King Edward viI College of Medicine) but do not agree to sign a bond promising to serve the government for several years will not be awarded their degrees. The official reason given is that, since the students were given a highly subsidised education, they have a moral obligation to society. This can be by serving as government medical officers for several years, or by paying liquidated damages (approximately z20 000 per student) in return for their education. The move is apparently sparked off by the sudden realisation that when two new hospital projects are completed here in the near future, there will be insufficient government medical officers to staff them. I would be very interested to know if your readers have come across a similar situation in any other country, and if it has led to any change (an improvement or a deterioration) in medical services in the country concerned. south



was a recent



Faculty of Medicine, University of Singapore, Singapore



19. 1. 2. 3. 4.

Eneas, J. F., Schoenfeld, P. Y., Humphrey, M. H. Abstr. Am. Soc. Nephrol. 1977, 14A. Ailsby, R. L., Ghadially, F. N.J. Path. 1973, 109, 75. Eliasson, R., Mossberg, B., Camner, P., Afzelius, B. New Engl. J. Med. 1977, 297, 1. Hinds, J. R. N.Z. med. J. 1958, 57, 328. Caleb, M., Lecks, H., South, M. A., Norman, M. E. New Engl. J. Med. 1977, 297, 1012.

1. 2. 3. 4. 5. 6. 7. 8.

Mertin, J., Hughes, D. Int. Archs Allergy appl. Immun. 1975, 48, 203. Smith, A. D., Tsang, W. M., Weyman, C., Belin, J. Lancet, 1976, ii, 254. Wardle, E. N. ibid. p. 423. Mertin, J. Transplantation, 1976, 21, 1. Meade, C. J., Mertin, J. Int. Archs Allergy appl. Immun. 1976, 51, 2. Frost, P., Hollander, D., Chen, J. Lancet, 1977, ii, 410. Tonkin, C. H., Brostoff, J. Int. Archs Allergy appl. Immun. 1978, 57, 171. Bower, B. D., Newsholme, E. A. Lancet, 1978, i, 583.

Medical education in Singapore.

382 release from injured muscle of adenine nucleotides subsequently metabolised to uric acid.8 Also characteristic are hypocalcaemia and hyperphosphat...
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