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IMMUNOLOGY OF THYROID DISEASE
1247 authors and also by Salvesen and Böe,l cannot be fortuitous, and he believes, that this combination is a definite ".yndrome." He also mentions our analysis of 85 cases of steatorrhoea, in which we concluded that hypoparathyroidism often exists in this condition, because the serum-calcium remains low, instead of being raised by increased activity of the parathyroids, whose function it is to keep the serum-calcium at a normal level. But this is a secondary hypoparathyroidism, which we have seen in relation to the effect of undernutrition on the endocrine glands, so apparent in sprue.2 The hypocalcaemia in ordinary cases of sprue is primarily caused by vitamin-D insufficiency and by loss of calcium as calcium soaps with the fatty stools. In the " syndrome " cases mentioned by Dr. Jackson the hypocalcaemia is primarily due to an existing idiopathic hypoparathyroidism and the development of gteatorrhoea with foecal loss of calcium should tend to aggravate the hypocalcsemia. These two different kinds of hypoparathyroidism in sprue should not be confused. We have pointed out1 that bone lesions of osteomalacia seem to be more pronounced in the cases with a normal or nearly normal serum-calcium and a low serum-phosphorus, indicating a high activity of the parathyroids with resultant loss of calcium from the The secondary hypoparathyroidism in other bones. eases in a certain way protects the bones, but exposes the individuals to the dangers of tetany. University Medical Clinic B, Rikshospitalet, Oslo, Norway.
H. A. SALVESEN.
FATAL CARDIAC ARREST WITH FLUOTHANE
SIR,-Dr. C. A. Foster has given a timely warning (June 1) that ’’Fluothane’ (halothane) is an extremely powerful anaesthetic, and if pushed to high concentration will cause a dangerous fall of blood-pressure, and, in an unatropinised patient, rapid cardiac arrest. Fluothane allows a quiet trouble-free induction without or bronchial irritation, and stabilisation of anaesthesia is quickly obtained ; and, so long as the patient breathes automatically, and there is no excessive fall in blood-pressure, there is no safer non-explosive volatile agent. But it is essential to keep constant record of the blood-pressure, preferably by an oscillometer, as apart from the lengthening of expiration which, with the quiet breathing associated with halothane anaesthesia, may be difficult to detect, the falling blood-pressure is the most important warning of increasing blood concentration. Owing to the present cost, closed-circuit techniques have naturally become popular. Using a Waters’ canister, completely closed, a flow of not exceeding 1 litre of oxygen blown over the surface of a fully open Boyle’s bottle, containing 40 c.cm. of fluothane, will produce adequate light anaesthesia with practically no fall in
laryngeal
blood-pressure. Bronchial relaxation is
so
complete
that
respiration
is easily controlled. It must be remembered, however, that under such conditions it is only too- easy to reduce to the heart
by increasing intrapleural and so lower the blood-pressure ; if at the same concentration of fluothane has been in any way increased, cardiac arrest is possible. venous return
pressure time the
This is
condemnation of fluothane, but of the Fluothane is an excellent anaesthetic agent. Its ease of administration is perhaps its greatest danger, because with a powerful drug a demand is essential for no
technique. greater
vigilance.
Christie Hospital & Holt Radium Institute, Withington, Manchester, 20.
W. B. BACON.
1. Salvesen, H. A., Böe, J. Acta med. scand. 1953, 146, 290. 2. Perloff, W. H., Lasché, E. M., Nordin, J. H., Schneberg, N., Wieillard, C. B. J. Amer. med. Ass. 1954, 155, 1307.
IMMUNOLOGY OF THYROID DISEASE
SiR,-Professor Wyburn (June 1) has drawn attention to the pioneer and apparently forgotten work of Leo Loeb in the field of tissue transplantation and
orgaii
specificity. This prompts me to point out that Loebalso invented tissue-culture, ten years before the classical paper of Ross Harrison2 who is usually credited with the discovery. Furthermore, Loeb and Fleischer3 were the first In this to culture adult mammalian organs in vitro. work they discovered the importance of using a gas
phase of oxygen rather than air, when adult, as distinct embryonic, tissues were to be cultivated. Even today this latter point is not fully appreciated.
from
M.R.C.
Radiobiological Unit, Harwell, Berkshire.
O. A. TROWELL.
SiR,-In your leading article of May 25 you suggest that the initial event in Hashimoto’s disease is a leakage of thyroglobulin from the acini ; and that the complement-fixing antibody is specific for extracts of thyrotoxic
glands. If this is true a high incidence of Hashimoto’s disease should be found among cases of hypothyroidism following partial thyroidectomy, and the search for antibodies and the histological examination of the thyroid remnants in these cases would be rewarding. Supporting this idea is the fact that postoperative hypothyroidism is much commoner in Graves’s disease, where thyrotoxic tissue must be cut across, than in toxic nodular goitre, where the toxic tissue is usually removed intact.4 Bartels states also that a high incidence of strumitis," defined as excessive lymphocytic infiltration and fibrosis," is found in the resected specimens in cases where hypothyroidism subsequently develops. Perhaps it is stretching the idea too far to suggest that the rather surprising success of partial thyroidectomy in Graves’s disease may be partly due to the " Hashimoto process " initiated by surgery. A. POLLARD. "
"
ANÆSTHESIA FOR CÆSAREAN SECTION
SIR,-I am interested in the anaesthetic implications of the article on elective caesarean section and neonatal deaths by Dr. Strang and his colleagues (May 11). While there are no anaesthetic details, the phrases " The times taken to establish. normal respiration (mean 5 minutes) are longer than after vaginal delivery. This anaesthesia " and delay was probably due to the maternal " The baby is usually anaesthetised " deserve comment. In the Blackburn Hospital Group we have for some time used a method of anaesthesia for caesarean section which does not anaesthetise the infant, and spontaneous normal respirations usually occur within a minute of delivery. The mother is visited by the anaesthetist on the day before operation for the usual preoperative examination, and a full explanation of preoperative procedure. She is given a barbiturate sedative the night before operation and where the operation is to take place in the afternoon, she might also be given methylpentynol three to four hours before coming to theatre. Atropine gr. 1/100 is given 45 minutes before operation, and in theatre all the skin preparation, towelling, is done before the anaesthetic induction. When all is 0-3 or 0-4 g. of a 21/2% solution of thiopentone mixed with 80 mg. of gallamine (’ Flaxedil ’) is injected intravenously, followed by 25-30 mg. of pethidine. A syringe containing 0-5 mg. ergometrine is attached to the same needle, and strapped to the arm so that it can be injected immediately the baby’s head is born. The incision is made as soon as the thiopentone-gallamine injection is completed. The maternal
&c.,
ready,
1. Loeb, L. Über die Entstehung von Bindegewebe, Leucocyten und roten Blutkörperehen aus Epithel und über eine Methode, isolierte Gebewesteile zu züchten. Chicago, 1897. 2. Harrison, R. G. Anat. Rec. 1907, 1, 116. 3. Loeb, L., Fleischer, M. S. J. med. Res. 1919, 40, 509. 4. Bartels, E. C. J. clin. Endocrin. 1953, 13, 95.
H. A. SALVESEN.
FATAL CARDIAC ARREST WITH FLUOTHANE
SIR,-Dr. C. A. Foster has given a timely warning (June 1) that ’’Fluothane’ (halothane) is an extremely powerful anaesthetic, and if pushed to high concentration will cause a dangerous fall of blood-pressure, and, in an unatropinised patient, rapid cardiac arrest. Fluothane allows a quiet trouble-free induction without or bronchial irritation, and stabilisation of anaesthesia is quickly obtained ; and, so long as the patient breathes automatically, and there is no excessive fall in blood-pressure, there is no safer non-explosive volatile agent. But it is essential to keep constant record of the blood-pressure, preferably by an oscillometer, as apart from the lengthening of expiration which, with the quiet breathing associated with halothane anaesthesia, may be difficult to detect, the falling blood-pressure is the most important warning of increasing blood concentration. Owing to the present cost, closed-circuit techniques have naturally become popular. Using a Waters’ canister, completely closed, a flow of not exceeding 1 litre of oxygen blown over the surface of a fully open Boyle’s bottle, containing 40 c.cm. of fluothane, will produce adequate light anaesthesia with practically no fall in
laryngeal
blood-pressure. Bronchial relaxation is
so
complete
that
respiration
is easily controlled. It must be remembered, however, that under such conditions it is only too- easy to reduce to the heart
by increasing intrapleural and so lower the blood-pressure ; if at the same concentration of fluothane has been in any way increased, cardiac arrest is possible. venous return
pressure time the
This is
condemnation of fluothane, but of the Fluothane is an excellent anaesthetic agent. Its ease of administration is perhaps its greatest danger, because with a powerful drug a demand is essential for no
technique. greater
vigilance.
Christie Hospital & Holt Radium Institute, Withington, Manchester, 20.
W. B. BACON.
1. Salvesen, H. A., Böe, J. Acta med. scand. 1953, 146, 290. 2. Perloff, W. H., Lasché, E. M., Nordin, J. H., Schneberg, N., Wieillard, C. B. J. Amer. med. Ass. 1954, 155, 1307.
IMMUNOLOGY OF THYROID DISEASE
SiR,-Professor Wyburn (June 1) has drawn attention to the pioneer and apparently forgotten work of Leo Loeb in the field of tissue transplantation and
orgaii
specificity. This prompts me to point out that Loebalso invented tissue-culture, ten years before the classical paper of Ross Harrison2 who is usually credited with the discovery. Furthermore, Loeb and Fleischer3 were the first In this to culture adult mammalian organs in vitro. work they discovered the importance of using a gas
phase of oxygen rather than air, when adult, as distinct embryonic, tissues were to be cultivated. Even today this latter point is not fully appreciated.
from
M.R.C.
Radiobiological Unit, Harwell, Berkshire.
O. A. TROWELL.
SiR,-In your leading article of May 25 you suggest that the initial event in Hashimoto’s disease is a leakage of thyroglobulin from the acini ; and that the complement-fixing antibody is specific for extracts of thyrotoxic
glands. If this is true a high incidence of Hashimoto’s disease should be found among cases of hypothyroidism following partial thyroidectomy, and the search for antibodies and the histological examination of the thyroid remnants in these cases would be rewarding. Supporting this idea is the fact that postoperative hypothyroidism is much commoner in Graves’s disease, where thyrotoxic tissue must be cut across, than in toxic nodular goitre, where the toxic tissue is usually removed intact.4 Bartels states also that a high incidence of strumitis," defined as excessive lymphocytic infiltration and fibrosis," is found in the resected specimens in cases where hypothyroidism subsequently develops. Perhaps it is stretching the idea too far to suggest that the rather surprising success of partial thyroidectomy in Graves’s disease may be partly due to the " Hashimoto process " initiated by surgery. A. POLLARD. "
"
ANÆSTHESIA FOR CÆSAREAN SECTION
SIR,-I am interested in the anaesthetic implications of the article on elective caesarean section and neonatal deaths by Dr. Strang and his colleagues (May 11). While there are no anaesthetic details, the phrases " The times taken to establish. normal respiration (mean 5 minutes) are longer than after vaginal delivery. This anaesthesia " and delay was probably due to the maternal " The baby is usually anaesthetised " deserve comment. In the Blackburn Hospital Group we have for some time used a method of anaesthesia for caesarean section which does not anaesthetise the infant, and spontaneous normal respirations usually occur within a minute of delivery. The mother is visited by the anaesthetist on the day before operation for the usual preoperative examination, and a full explanation of preoperative procedure. She is given a barbiturate sedative the night before operation and where the operation is to take place in the afternoon, she might also be given methylpentynol three to four hours before coming to theatre. Atropine gr. 1/100 is given 45 minutes before operation, and in theatre all the skin preparation, towelling, is done before the anaesthetic induction. When all is 0-3 or 0-4 g. of a 21/2% solution of thiopentone mixed with 80 mg. of gallamine (’ Flaxedil ’) is injected intravenously, followed by 25-30 mg. of pethidine. A syringe containing 0-5 mg. ergometrine is attached to the same needle, and strapped to the arm so that it can be injected immediately the baby’s head is born. The incision is made as soon as the thiopentone-gallamine injection is completed. The maternal
&c.,
ready,
1. Loeb, L. Über die Entstehung von Bindegewebe, Leucocyten und roten Blutkörperehen aus Epithel und über eine Methode, isolierte Gebewesteile zu züchten. Chicago, 1897. 2. Harrison, R. G. Anat. Rec. 1907, 1, 116. 3. Loeb, L., Fleischer, M. S. J. med. Res. 1919, 40, 509. 4. Bartels, E. C. J. clin. Endocrin. 1953, 13, 95.