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HYPOPHYSECTOMY
971
equal to ? What proof is there that beta-emitting 90Sr is not more dangerous than, say, radium ? Particularly in low concentrations ? Is it not true that the areas of our ignorance of the precise mechanism of cell-mutation are such that not only would it be not pertinent but also dangerous to be too categorical? The more so, since otherwise one might well find one’s self in the position of having unwittingly sanctioned the possible extinction of human life. or even
In fact, the confession of
ignorance of the aetiology of
leukxmia and its non-linear increase, followed
by the dogmatic asseveration
it is cause it as
about what does not wonder whether Dr. Loutit has really considered all the evidence. The greatest mystery about leukxmia to me is the reluctance to consider the obvious. PAUL HAMMET. Bilston, Staffs.
makes
section of the stalk are outweighed by the relatively minor discomfort to the patient following radiation hypophysectomy by the screw technique. A. P. M. FORREST D. W. BLAIR Western Infirmary and J. M. VALENTINE Regional Physics Department, A. T. SANDISON. Glasgow.
one
HYPOPHYSECTOMY
PITUITARY TUMOURS AFTER ADRENALECTOMY FOR CUSHING’S SYNDROME
SIR,-Dr. Montgomery and his coworkers (Oct. 31) a patient in whom a pituitary tumour developed following adrenalectomy for Cushing’s syndrome. They commented that it was hard to explain why she had no described
symptoms of Addison’s disease in the presence of
no
functioning adrenal tissue. Her pigmentation and the assay for corticotrophin that Dr. Stack-Dunne made on her pituitary tumour suggest that she was secreting large amounts of corticotrophin. Corticotrophin in large doses has many extra-adrenal metabolic activities 1; it is an interesting speculation that these activities may have made
SIR,-In your leading article of Nov. 14 you state that in our recent report1 we claim that the implantation of two activated sintered rods of 90Y, 6 x 2 mm., with a total dose of 11 mC regularly produces ’virtually complete’ destruction " (of the pituitary gland). This statement does not include an essential qualification made by up for the loss of adrenal cortisol secretion. Sheffield Centre for the Investigation in the of centre us-that one source (should be placed) and Treatment of Rheumatic Diseases, HARRY F. WEST. each half of the gland ". Meeting this qualification, by Nether Edge Hospital, Sheffield. means of a new technique, is in our view the most COAGULASE-NEGATIVE STAPHYLOCOCCI significant advance contained in our recent publication. IN BLOOD-CULTURES In our report we emphasised that free rods of 90Y cannot consistently be placed in the optimum position and Resnekov SIR,-Dr. (Oct. 17) reported from this hoswill not regularly destroy the gland. In our opinion, and pital 10 cases of subacute bacterial endocarditis following that of Fraser et all misplaced rods in the upper part mitral valvotomy. In 9 of them coagulase-negative of the fossa may necrose the diaphragma sellx allowing staphylococci were isolated from blood-cultures. Assessof The incidence of fluid. rhinorment of the significance of finding coagulase-negative leakage cerebrospinal rhcea in published reports of transnasal insertion of free staphylococci in blood-cultures is always difficult because rods of 90Y has been estimated at approximately 20%.3 of the presence of these organisms on human skin, and of the ease with which blood-cultures may become conWe showed that accurate placing of 90Y rods can be taminated. It therefore seemed important to determine achieved by the method of screw implantation and is consistently followed by 98-100% destruction of the the frequency with which coagulase-negative staphylointracapsular portion of the gland. Although this tech- cocci were isolated in blood-cultures from patients with nique was described in detail in 1958 in your columns4 other conditions, because it is against this background that the significance of Dr. Resnekov’s findings has to be and further reported in our later paper,’ it receives no assessed. mention in your leading article. Accurate placing of the 90Y rods by the screw techThe laboratory records for 1958, the year in which the nique has led to a significant reduction in the incidence of majority of the investigations of Dr. Resnekov’s patients were rhinorrhoea, and in our paper we reported that this undertaken, showed that blood-cultures were made from 176 and that coagulase-negative staphylococci were complication developed in 3 of 33 patients who had patients isolated from 56. This material was analysed to allow comimplants of approximate activity 14 mC. The incidence parison between the following three groups of patients: has been further reduced by lowering the dose to 9 mC Group 1.- The 10 patients with subacute bacterial endocarditis (1 out of 43 patients). Postmortem studies have now following mitral valvotomy. confirmed that the smaller dose is sufficient to destroy the n.ň56 surgical patients, from whom blood was taken Group intracapsular portion of the gland. within five minutes of endotracheal intubation. These bloodAlthough you state that no danger of rhinorrhoea cultures were made during an investigation of the risk of bactersmia attends intracranial application of radioactive isotopes we after intubation. Group ill.ň110 patients, who suffered from a variety of clinical would point out that Evans et al. recently reported that conditions for which diagnostic blood-culture was requested. cerebrospinal rhinorrhcea developed in 5 of 45 patients The blood of the patients in groups i and III was usually treated by the transcranial insertion of 90Y pellets into the collected by resident house-officers or medical students, and pituitary fossa. delivered into bottles containing " liquoid " broth. Three Our aim is the development of a simple, safe method of bottles were submitted to the laboratory on most occasions, palliative treatment for patients with metastatic breast and incubated respectively aerobically, anaerobically, and in an cancer. We feel that the theoretical advantages of high atmosphere containing 10% carbon dioxide. The bottles "
"
1. Forrest, A. P. M., Sandison, A. T.,
Blair, D. W., Peebles Brown, D. A., Stewart, H. J., Harrington, R. W., Valentine, J. M., Carter, P. T. Brit. J. Surg. 1959, 47, 61. 2. Fraser, R., Joplin, G. F., Laws, J. W., Morrison, R., Steiner, R. E. Lancet, 1959, i, 382. 3. Forrest, A. P. M. in Cancer (edited by R. W. Raven); vol. VI. London, 1959.
4. 5.
Forrest, A. P. M., Blair, D. W., Valentine, J. M. Lancet, 1958, ii, 192. Evans, J. P., Kelly, W. A., Harper, P. V. Surg. Gynec. Obstet. 1959, 108, 393.
kept for one to two weeks, and made. The other two bottles were 2, kept for six weeks, or until growth occurred, and subcultures on blood-agar plates were made at weekly intervals after the first week. The plates were incubated for twenty-four hours under the same conditions as the bottles. In group II, all
incubated 3
or
anaerobically
4 subcultures
1.
were
were
White, J. E., Engel, F.
L.
J. clin. Invest. 1958, 37, 1556.
equal to ? What proof is there that beta-emitting 90Sr is not more dangerous than, say, radium ? Particularly in low concentrations ? Is it not true that the areas of our ignorance of the precise mechanism of cell-mutation are such that not only would it be not pertinent but also dangerous to be too categorical? The more so, since otherwise one might well find one’s self in the position of having unwittingly sanctioned the possible extinction of human life. or even
In fact, the confession of
ignorance of the aetiology of
leukxmia and its non-linear increase, followed
by the dogmatic asseveration
it is cause it as
about what does not wonder whether Dr. Loutit has really considered all the evidence. The greatest mystery about leukxmia to me is the reluctance to consider the obvious. PAUL HAMMET. Bilston, Staffs.
makes
section of the stalk are outweighed by the relatively minor discomfort to the patient following radiation hypophysectomy by the screw technique. A. P. M. FORREST D. W. BLAIR Western Infirmary and J. M. VALENTINE Regional Physics Department, A. T. SANDISON. Glasgow.
one
HYPOPHYSECTOMY
PITUITARY TUMOURS AFTER ADRENALECTOMY FOR CUSHING’S SYNDROME
SIR,-Dr. Montgomery and his coworkers (Oct. 31) a patient in whom a pituitary tumour developed following adrenalectomy for Cushing’s syndrome. They commented that it was hard to explain why she had no described
symptoms of Addison’s disease in the presence of
no
functioning adrenal tissue. Her pigmentation and the assay for corticotrophin that Dr. Stack-Dunne made on her pituitary tumour suggest that she was secreting large amounts of corticotrophin. Corticotrophin in large doses has many extra-adrenal metabolic activities 1; it is an interesting speculation that these activities may have made
SIR,-In your leading article of Nov. 14 you state that in our recent report1 we claim that the implantation of two activated sintered rods of 90Y, 6 x 2 mm., with a total dose of 11 mC regularly produces ’virtually complete’ destruction " (of the pituitary gland). This statement does not include an essential qualification made by up for the loss of adrenal cortisol secretion. Sheffield Centre for the Investigation in the of centre us-that one source (should be placed) and Treatment of Rheumatic Diseases, HARRY F. WEST. each half of the gland ". Meeting this qualification, by Nether Edge Hospital, Sheffield. means of a new technique, is in our view the most COAGULASE-NEGATIVE STAPHYLOCOCCI significant advance contained in our recent publication. IN BLOOD-CULTURES In our report we emphasised that free rods of 90Y cannot consistently be placed in the optimum position and Resnekov SIR,-Dr. (Oct. 17) reported from this hoswill not regularly destroy the gland. In our opinion, and pital 10 cases of subacute bacterial endocarditis following that of Fraser et all misplaced rods in the upper part mitral valvotomy. In 9 of them coagulase-negative of the fossa may necrose the diaphragma sellx allowing staphylococci were isolated from blood-cultures. Assessof The incidence of fluid. rhinorment of the significance of finding coagulase-negative leakage cerebrospinal rhcea in published reports of transnasal insertion of free staphylococci in blood-cultures is always difficult because rods of 90Y has been estimated at approximately 20%.3 of the presence of these organisms on human skin, and of the ease with which blood-cultures may become conWe showed that accurate placing of 90Y rods can be taminated. It therefore seemed important to determine achieved by the method of screw implantation and is consistently followed by 98-100% destruction of the the frequency with which coagulase-negative staphylointracapsular portion of the gland. Although this tech- cocci were isolated in blood-cultures from patients with nique was described in detail in 1958 in your columns4 other conditions, because it is against this background that the significance of Dr. Resnekov’s findings has to be and further reported in our later paper,’ it receives no assessed. mention in your leading article. Accurate placing of the 90Y rods by the screw techThe laboratory records for 1958, the year in which the nique has led to a significant reduction in the incidence of majority of the investigations of Dr. Resnekov’s patients were rhinorrhoea, and in our paper we reported that this undertaken, showed that blood-cultures were made from 176 and that coagulase-negative staphylococci were complication developed in 3 of 33 patients who had patients isolated from 56. This material was analysed to allow comimplants of approximate activity 14 mC. The incidence parison between the following three groups of patients: has been further reduced by lowering the dose to 9 mC Group 1.- The 10 patients with subacute bacterial endocarditis (1 out of 43 patients). Postmortem studies have now following mitral valvotomy. confirmed that the smaller dose is sufficient to destroy the n.ň56 surgical patients, from whom blood was taken Group intracapsular portion of the gland. within five minutes of endotracheal intubation. These bloodAlthough you state that no danger of rhinorrhoea cultures were made during an investigation of the risk of bactersmia attends intracranial application of radioactive isotopes we after intubation. Group ill.ň110 patients, who suffered from a variety of clinical would point out that Evans et al. recently reported that conditions for which diagnostic blood-culture was requested. cerebrospinal rhinorrhcea developed in 5 of 45 patients The blood of the patients in groups i and III was usually treated by the transcranial insertion of 90Y pellets into the collected by resident house-officers or medical students, and pituitary fossa. delivered into bottles containing " liquoid " broth. Three Our aim is the development of a simple, safe method of bottles were submitted to the laboratory on most occasions, palliative treatment for patients with metastatic breast and incubated respectively aerobically, anaerobically, and in an cancer. We feel that the theoretical advantages of high atmosphere containing 10% carbon dioxide. The bottles "
"
1. Forrest, A. P. M., Sandison, A. T.,
Blair, D. W., Peebles Brown, D. A., Stewart, H. J., Harrington, R. W., Valentine, J. M., Carter, P. T. Brit. J. Surg. 1959, 47, 61. 2. Fraser, R., Joplin, G. F., Laws, J. W., Morrison, R., Steiner, R. E. Lancet, 1959, i, 382. 3. Forrest, A. P. M. in Cancer (edited by R. W. Raven); vol. VI. London, 1959.
4. 5.
Forrest, A. P. M., Blair, D. W., Valentine, J. M. Lancet, 1958, ii, 192. Evans, J. P., Kelly, W. A., Harper, P. V. Surg. Gynec. Obstet. 1959, 108, 393.
kept for one to two weeks, and made. The other two bottles were 2, kept for six weeks, or until growth occurred, and subcultures on blood-agar plates were made at weekly intervals after the first week. The plates were incubated for twenty-four hours under the same conditions as the bottles. In group II, all
incubated 3
or
anaerobically
4 subcultures
1.
were
were
White, J. E., Engel, F.
L.
J. clin. Invest. 1958, 37, 1556.