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HYPOTHYROIDISM AFTER THYROIDECTOMY
467 HYPOTHYROIDISM AFTER THYROIDECTOMY
SIR.—MayI enlarge on a point made by Dr. D. N. Baron in his valuable survey of hypothyroidism (Aug. 11)? Analysing the incidence of postoperative hypothyroidism, which he found to be 4% after subtotal thyroidectomies, he concluded that " there is no apparent difference in ihf incidence of hypothyroidism following thyroidectomy fur toxic and for non-toxic disease of the thyroid gland." For the sake of brevity, he did not differentiate in his paper between various types of goitres ; and, as the likelihood of developing postoperative myxoedema particularly depends on the type of goitre in non-toxic thyroid deseases, I have obtained from him some further urformation : Of the 11 patients with hypothyroidism following operation :.,r non-toxic conditions, 4 had lymphadenoid goitres, - 4 had " simple " non-toxic nodular goitres, 2 had mitral stenosis for which hypothyroidism was induced, and 1 remained mrrdeed. During the period under review 317 thyroidectomies
were
found
have
to
done in non-toxic
cases, of which only 10 lymphadenoid goitre.
were
carried out recently of proved Hashimoto at Middlesex Hospital in 1934-56. Of 35 cases in our records, it was possible to assess the thyroid status in 31 ; and all except 1 required full doses of thyroid. 19 were given gr. 11/2-41/2 of thyroid extract soon after operation and have been maintained on full 10 patients omitted thyroid dosage continuously. after operation or later) and developed profound luyxcedema within four to six weeks ; 1 patient died of myxœdema coma after a period of mental confusion when - .he refused treatment. Only 1 patient was euthyroid without substitution therapy two years after operation, and on examination it was found that she had a recurrence of the goitre. The 19 patients who had had continuous thyroid therapy since operation stated that they were unable to do without their tablets, for after three to five days they began to feel tired and unwell. These figures show once more that, though postuperative myxcedema is relatively uncommon after removal of simple " non-toxic nodular goitre, it occurs in well over 90% of patients with Hashimoto’s goitre. A survey
cases
was
operated
on
(directly
"
Institute of Clinical Research, Middlesex Hospital Medical School, 40, Hanson Street, London, W.1.
DEBORAH DONIACH.
VAGOTOMY FOR CHRONIC PEPTIC ULCER
SIR,—I was interested to read the report (Aug. 4) by Mr. Slaney and his colleagues, giving their five-year results of vagotomy without gastric drainage in the treatment of peptic ulceration. In this report they menthe problem of incomplete nerve section, and this must always be considered when this operation is used. When was introduced some ten years ago, ’he detailed anatomy of the vagus nerves in man at the ’tupbragm level was studied by several workers. It seems that the abdominal approach is more certain to allow of comlplete nerve section than the thoracic. The nerves were found as two trunks (one anterior and one posterior) :’approximately 70% of bodies examined, as three in 25%, and as four or more trunks in 4%. I first used the operation of vagotomy and gastroin a few cases in 1948. At that time there much doubt about the value of the operation. I therefore, no more until last year, and then only a study had been made of the five-year results of a series of cases of duodenal ulceration treated by nerve section with gastric drainage. This investigawhich was undertaken by Mr. John Lloyd Davies, - ’ : the results of which will soon be published, was made the cooperation of many surgeons in this and by the generous help of the Dan Mason Foundation of the West London Hospital
vagotomy
School.
In my early cases I failed to keep a record of the number of nerve-trunks found and proved by histological examination ; but in this recent series of only 32 cases two nerve-trunks (one anterior and one posterior) were found in 75%, three trunks in 19%, and four in 6%. Certainly in any large series the number of nerve-trunks found must agree with the anatomical facts. HAROLD BURGE. London, N.W.I. FŒTAL STETHOSCOPES
at a loss to understand why the foetalheart stethoscope should be so popular with obstetricians and midwives when the foetal heart is heard much more easily with a standard binaural stethoscope : there is also less chance of one sustaining a " disc lesion " when using the general-purpose instrument !
SIR,—I
am
Manygates Maternity Hospital, Wakefield.
A. BERRY
THE BASE DEGREES BY WHICH WE RISE
SIR,—Even at this distance of time and space, may we be allowed to support the remarks of Dr. Woodliff, in his reply to Dr. " Davey," in your issue of April 14 ? We agree with him that more accuracy and less wit is probably desirable in the writings of one so imbued with the urge for true scientific pursuit of knowledge as Dr. Davey. Further, we maintain that the D.PATH. is a useful examination and the PH.D. not as frightening as Dr. Davey suggests. It may be desirable in a large department to have people with one or the other
qualification. We would like to point to a further development which is taking place here and which no doubt could be followed in England. In Melbourne on Aug. 31 the inaugural meeting of the College of Pathologists of Australia will take place-an event which we hope will be of some importance in the years to come. The college is supported by the majority of pathologists in Australia and is to be an autonomous body with its own board of censors and admission standards. It will supersede the Australian Association of Clinical Pathologists and provides for membership by private, hospital, and academic patholo-
gists. If Dr. Davey is in Melbourne in early September we shall be pleased to entertain him and attempt to persuade him that D.PATHS may be useful and D.PHILS not odd or frightening but unmistakably medical. Perhaps he may also be persuaded to found that R.PATH.S. General Hospital, Brisbane.
J. T. DUHIG G. M. WINDRUM.
PRIMARY ALDOSTERONISM
SIR,-I read with great interest the article (Aug. 18) of Professor
van
Buchem and his co-workers
on
Conn’s
syndrome. The fact that their case was found to be due to hyperplasia, and not to a neoplasm, of the adrenal cortex opens up speculation about the site of secretion of aldosterone. Histological examinations showed the glomerulosa and especially the fasciculata to be hyperplastic-a which, Professor van Buchem says, makes it probable that both zones are concerned in the production of aldosterone. I feel that such a statement is not quite justifiable when experience of hypersecreting fasciculata does not allow the hypothesis that aldosterone is secreted in abundance, while, on the other hand, the above case, on which such a hypothesis is based, seems to be complicated by other endocrine anomalies unrelated to
finding
aldosterone. For example, there is a pronounced deficit in bone age : the stature is of childish contours ; there is practically an absence of axillary, pubic, and facial hair ; and, as far as it can be judged from the photograph, there may be some hypogonadism too. Most of these could be taken to indicate
SIR.—MayI enlarge on a point made by Dr. D. N. Baron in his valuable survey of hypothyroidism (Aug. 11)? Analysing the incidence of postoperative hypothyroidism, which he found to be 4% after subtotal thyroidectomies, he concluded that " there is no apparent difference in ihf incidence of hypothyroidism following thyroidectomy fur toxic and for non-toxic disease of the thyroid gland." For the sake of brevity, he did not differentiate in his paper between various types of goitres ; and, as the likelihood of developing postoperative myxoedema particularly depends on the type of goitre in non-toxic thyroid deseases, I have obtained from him some further urformation : Of the 11 patients with hypothyroidism following operation :.,r non-toxic conditions, 4 had lymphadenoid goitres, - 4 had " simple " non-toxic nodular goitres, 2 had mitral stenosis for which hypothyroidism was induced, and 1 remained mrrdeed. During the period under review 317 thyroidectomies
were
found
have
to
done in non-toxic
cases, of which only 10 lymphadenoid goitre.
were
carried out recently of proved Hashimoto at Middlesex Hospital in 1934-56. Of 35 cases in our records, it was possible to assess the thyroid status in 31 ; and all except 1 required full doses of thyroid. 19 were given gr. 11/2-41/2 of thyroid extract soon after operation and have been maintained on full 10 patients omitted thyroid dosage continuously. after operation or later) and developed profound luyxcedema within four to six weeks ; 1 patient died of myxœdema coma after a period of mental confusion when - .he refused treatment. Only 1 patient was euthyroid without substitution therapy two years after operation, and on examination it was found that she had a recurrence of the goitre. The 19 patients who had had continuous thyroid therapy since operation stated that they were unable to do without their tablets, for after three to five days they began to feel tired and unwell. These figures show once more that, though postuperative myxcedema is relatively uncommon after removal of simple " non-toxic nodular goitre, it occurs in well over 90% of patients with Hashimoto’s goitre. A survey
cases
was
operated
on
(directly
"
Institute of Clinical Research, Middlesex Hospital Medical School, 40, Hanson Street, London, W.1.
DEBORAH DONIACH.
VAGOTOMY FOR CHRONIC PEPTIC ULCER
SIR,—I was interested to read the report (Aug. 4) by Mr. Slaney and his colleagues, giving their five-year results of vagotomy without gastric drainage in the treatment of peptic ulceration. In this report they menthe problem of incomplete nerve section, and this must always be considered when this operation is used. When was introduced some ten years ago, ’he detailed anatomy of the vagus nerves in man at the ’tupbragm level was studied by several workers. It seems that the abdominal approach is more certain to allow of comlplete nerve section than the thoracic. The nerves were found as two trunks (one anterior and one posterior) :’approximately 70% of bodies examined, as three in 25%, and as four or more trunks in 4%. I first used the operation of vagotomy and gastroin a few cases in 1948. At that time there much doubt about the value of the operation. I therefore, no more until last year, and then only a study had been made of the five-year results of a series of cases of duodenal ulceration treated by nerve section with gastric drainage. This investigawhich was undertaken by Mr. John Lloyd Davies, - ’ : the results of which will soon be published, was made the cooperation of many surgeons in this and by the generous help of the Dan Mason Foundation of the West London Hospital
vagotomy
School.
In my early cases I failed to keep a record of the number of nerve-trunks found and proved by histological examination ; but in this recent series of only 32 cases two nerve-trunks (one anterior and one posterior) were found in 75%, three trunks in 19%, and four in 6%. Certainly in any large series the number of nerve-trunks found must agree with the anatomical facts. HAROLD BURGE. London, N.W.I. FŒTAL STETHOSCOPES
at a loss to understand why the foetalheart stethoscope should be so popular with obstetricians and midwives when the foetal heart is heard much more easily with a standard binaural stethoscope : there is also less chance of one sustaining a " disc lesion " when using the general-purpose instrument !
SIR,—I
am
Manygates Maternity Hospital, Wakefield.
A. BERRY
THE BASE DEGREES BY WHICH WE RISE
SIR,—Even at this distance of time and space, may we be allowed to support the remarks of Dr. Woodliff, in his reply to Dr. " Davey," in your issue of April 14 ? We agree with him that more accuracy and less wit is probably desirable in the writings of one so imbued with the urge for true scientific pursuit of knowledge as Dr. Davey. Further, we maintain that the D.PATH. is a useful examination and the PH.D. not as frightening as Dr. Davey suggests. It may be desirable in a large department to have people with one or the other
qualification. We would like to point to a further development which is taking place here and which no doubt could be followed in England. In Melbourne on Aug. 31 the inaugural meeting of the College of Pathologists of Australia will take place-an event which we hope will be of some importance in the years to come. The college is supported by the majority of pathologists in Australia and is to be an autonomous body with its own board of censors and admission standards. It will supersede the Australian Association of Clinical Pathologists and provides for membership by private, hospital, and academic patholo-
gists. If Dr. Davey is in Melbourne in early September we shall be pleased to entertain him and attempt to persuade him that D.PATHS may be useful and D.PHILS not odd or frightening but unmistakably medical. Perhaps he may also be persuaded to found that R.PATH.S. General Hospital, Brisbane.
J. T. DUHIG G. M. WINDRUM.
PRIMARY ALDOSTERONISM
SIR,-I read with great interest the article (Aug. 18) of Professor
van
Buchem and his co-workers
on
Conn’s
syndrome. The fact that their case was found to be due to hyperplasia, and not to a neoplasm, of the adrenal cortex opens up speculation about the site of secretion of aldosterone. Histological examinations showed the glomerulosa and especially the fasciculata to be hyperplastic-a which, Professor van Buchem says, makes it probable that both zones are concerned in the production of aldosterone. I feel that such a statement is not quite justifiable when experience of hypersecreting fasciculata does not allow the hypothesis that aldosterone is secreted in abundance, while, on the other hand, the above case, on which such a hypothesis is based, seems to be complicated by other endocrine anomalies unrelated to
finding
aldosterone. For example, there is a pronounced deficit in bone age : the stature is of childish contours ; there is practically an absence of axillary, pubic, and facial hair ; and, as far as it can be judged from the photograph, there may be some hypogonadism too. Most of these could be taken to indicate