valvular heart disease but no rheumatic history. Generally, the main distinguishing characteristics of this subgroup are a more equal sex distribution, isolated mitral valve disease, a relatively short history of symptoms before surgery, and, in many cases, the need for surgery at a comparatively early age. These findings are difficult to equate with the generally accepted concept of the aetiology of acquired valvular heart disease. This traditional view is that virtually all cases are rheumatic. In patients with no history of rheumatic fever or chorea their valvular disease is usually attributed to subclinical rheumatic carditis. Since it is not possible to investigate patients at the time of onset of subclinical carditis, however, the assertion that all such cases are rheumatic is speculative. It could, nevertheless, be argued for the traditional view that patients with no rheumatic history-that is, those with allegedly subclinical rheumatic carditis-differ fundamentally from those who have had classical rheumatic fever and that this may, in some way, account for clinically observed differences between those with and those without a rheumatic history. In this context the AW19 antigens might be a factor predisposing to the development of subclinical, as opposed to overt, rheumatic carditis. This line of reasoning, however, does not explain why patients with AW19 antigens differ clinically from those other patients with no rheumatic history (group 2) who are also assumed to have had subclinical rheumatic carditis. The aetiology of these cases of valvular heart disease, if not rheumatic, is unknown. It has, however, been suggested that viruses may sometimes be implicated. In animals viruses can produce valve lesions with many of the characteristics of chronic rheumatic heart disease in man.' There is also evidence in man that viruses' 4 and similar organisms6 may cause valvular damage. Other suggestions have been made which postulate a link between HLA antigens and some virus infections. For example, the neurotropism of polio virus appears to be partly dependent on the presence of HLA antigens A3 or B7.7 In more general terms it has been suggested that these particular antigens might govern the response of the central nervous system to a common product of different viruses. Possibly the cardiotropism of viruses, such as those of Coxsackie group B, which is currently unexplained, has an analogous basis. This in turn could account for the association we have described between valvular disease and the HLA antigens A29 and AW30,131-that is, these HLA antigens might act as a conditioning factor8 which occasionally transforms a mild viral myocarditis-a common occurrence9into a severe pancarditis. Our study does not directly implicate viruses as a cause of acquired valvular heart disease. It does, however, provide further evidence which is inconsistent with the traditional "rheumatic" explanation. It also indicates a possible line of research into the aetiology of obscure heart disease which has not yet been explored. Qu...

SUMMARY The mean small intestinal intraepithelial lymphocyte count in seven children with untreated cow's milk protein intolerance (CMPI) on a milk-containing diet was significantly higher than 22 control children also having a milk-containing diet. Ten milk-intolerant children on a milkfree diet had a mean intraepithelial lymphocyte count which was significantly lower than the level in the 22 control children on a milk-containing diet. When these 10 children were challenged with cow's milk they relapsed clinically, and in every case the intraepithelial lymphocyte count rose, although it remained within normal limits. Nineteen children on milk-free diets who had recovered from CMPI had a mean lymphocyte count which was also significantly lower than controls on normal diets, suggesting that when milk is removed from the diet the lymphocyte count is low regardless of whether the child is milk sensitive or not. The reaction of intraepithelial lymphocytes to milk in CMPI is markedly different from their response to gluten in coeliac disease.

SUMMARY Two hundred and seventy-eight duodenal biopsy specimens taken consecutively from children using either a single port paediatric Crosby capsule or a double port modification were examined both histologically and by dissecting microscopy, in order to determine the incidence of patchy mucosal lesions. One hundred and six specimens were abnormal and 49 of these were patchy. Patchy lesions occurred most commonly in cow's milk sensitive enteropathy where 66% of 33 specimens were patchy; in comparison all children with undiagnosed coeliac disease taking a normal diet showed a uniformly flat mucosa. Twenty-two per cent of specimens taken using the double port and 10% using the single port capsule were patchy, a statistically significant difference (P = 0-01) using standard errors. Where lesions were uniform, grading by dissecting microscopy correlated well with histological grading; 18 (37 %) of specimens were, however, recognised as patchy only on gross appearance. The high incidence of patchy lesions of the proximal small intestine reflected the prevalence of cow's milk protein intolerance and the postenteritis syndrome in these children. The use of the double port capsule and of dissecting microscopy also contributed to the high incidence found.Post-mortem studies of the mucosal morphology of the small intestine in children (Walker-Smith, 1972) and adults (Thompson, 1974) with gastrointestinal disease have demonstrated variation in severity of mucosal damage within a small areathat is, patchy enteropathy. A biopsy specimen of the proximal small intestinal mucosa obtained using the Crosby capsule (Crosby and Kugler, 1957), or its paediatric modification, may not, therefore, be fully representative of a diseased mucosa. Recently, patchiness on biopsy has been documented in adult coeliac disease and dermatitis herpetiformis (Scott and Losowsky, 1976), the authors using the hydraulic multiple biopsy instrument (Quinton Instruments, Seattle) a technique not easily applied to infants and young children. Other workers have described biopsy instruments, suitable for use in infants, which take two mucosal specimens (Latham et al., 1969;Ament and Rubin, 1973). Since 1974, a double port modification of the Crosby capsule (Kilby, 1976), which provides two mucosal specimens has been used in our department. This allows more tissue to be obtained with safety from infants, and samples from a wider area.The present study aims, firstly, to confirm the existence of a patchy enteropathy in children, secondly, to relate the incidence of patchy lesions to Received for publication 23 September 1978 diagnosis, and, thirdly, to compare the 'pick up rate' of patchy lesions using the single port Watson modification of the paediatric Crosby capsule and the double port modification. MethodsTwo hundred and seventy-eight proximal small intestinal biopsies (100 single port capsule and 178 double port capsule) taken over an 18 month period (1 July-31 December 1976), during routine investigation from children with a variety of gastrointest...

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