- Email: [email protected]
PARATHYROID INSUFFICIENCY
1007 " word is find ". EganGershon-Cohen,9and others 10 11 have demonstrated carcinomas which were impalpable by mammography. The following case falls into this category also.
Case2 A patient, aged in the mid-forties, had mastectomy for carcinoma 21/2 years previously. She thought she felt a small lump in the other breast in August, 1963. Clinicians were doubtful if anything was palpable (September, 1963). Mammography (October, 1963) showed a spiculated opacity (fig. 2). Mastectomy confirmed the presence of a small carcinoma. Not only is this an example of the positive diagnosis of a preclinical carcinoma of the breast, but it also empha-
of routine mammography of the in breast the lesion being bilateral carcinoma, remaining in 2-3% of cases.5 In brief, mammography, in common with most other radiological procedures, is a useful adjuvant to clinical assessment in all types of breast disorders. In many instances it can be decisive in arriving at a diagnosis, and, in some, by demonstrating a preclinical lesion, it can establish a diagnosis earlier than conventional clinical methods. ERIC SAMUEL Radiodiagnostic Department, The Royal Infirmary, BRUCE YOUNG. 3. Edinburgh, sises the
importance
*** Our annotation in fact referred
the findings of Egan and Gershon-Cohen, which indicate clearly the "positive value " of mammography; and we would hardly have devoted so much space to this subject if we had thought it of little value. We are glad to have this confirmatory evidence from Dr. Samuel and Dr. Young. to
- fun T
CONFESSIONS OF A PÆDIATRICIAN
with this title in your issue of Oct. 26 is one which should be preached by a. senior member of our profession to all physicians at least annually. As we grow older, the truth and value of Dr. Apley’s theme is more and more apparent to us. The text for this sermon, incidentally, is to be found in1 Corinthians, 10, 12: " Wherefore let him that thinketh he standeth take heed lest he fall." H. CLARK BALMER.
SiR,—The
sermon
PARATHYROID INSUFFICIENCY
SIR,-At this unit the
recent
we
noted with considerable interest
articles and
insufficiency
after
correspondence thyroidectomy.
on
parathyroid
In the past, serum-calcium estimations have not been the routine in our cases, particularly since the follow-up of these patients did not point to their necessity. Following the interest aroused by these articles, however, it was decided to add this investigation to the list already demanded by modern medicine. Serum-calcium estimations were carried out before operation, a week after thyroidectomy, and, finally, 3 to 24 months later at the
follow-up In
clinic.
series of 60 unselected patients who had underfor non-malignant goitre (toxic and nontoxic) there was no appreciable lowering of the serum-calcium in any of the patients. In fact, the majority ended with a higher figure! (Allowing for a 0.2 mg. variation, 9 patients remained stationery, 12 ended with a slightly lower reading, while 39 gone
8. 9. 10.
a recent
thyroidectomy
R. L.
Egan, Amer. J. Roentgenol. 1963, 89, Gershon-Cohen, J. J. Amer. med. Ass. 1961, 176, 1114. Martin, J. E., Keegan, J. M., Lemak, L. L., Yates, C. W. Amer. J. Roentgenol. 1962, 88, 1102. 11. Holmes, P. Proc. R. Soc. Med. 1963, 56, 775. 129.
ended with a higher final reading.) In view of these findings and the lack of relevant symptoms at the follow-up clinics, it is not considered that calcium-deprivation tests are worth
performing. It is our practice not to dissect the recurrent laryngeal nerve, though we do like, if possible, to identify the nerve if it does not involve disturbance of the " vital " area. It is also our routine to ligate the trunk of the inferior thyroid artery in continuity, with non-absorbable material, at the point where it emerges from under the carotid artery. Great care is of course taken when sectioning the gland to ensure that no parathyroid glandules are damaged or removed with the goitre. New End Hospital, M. J. LANGE. London, N.W.3.
SPLINT-MAKERS’ SALARIES
SIR,-You rightly give attention (Aug. 31, p. 449) and to the pioneering of new concepts of dynamic limb splintage at the Rancho Los Amigos Hospital, California, credit
under the direction of Vernon L. Nickle. All who have visited him have left inspired by his achievements and by the way he is trying to integrate all specialties in producing new aids for an ever-increasing range of disabled people. You conclude that in this country we must look increasingly to the new scientific disciplines if we are to make comparable progress. I venture to suggest that, while that is necessary, there are very serious deficiencies in pre-existing structure needing correction. British splint-makers have been craftsmen of the highest grade, producing appliances of quality. Splints produced in our orthopaedic workshops have been the envy of many visitors from abroad who know how vital these appliances are for the care of their patients. Today experienced splint-makers are and embittered disgruntled by their meagre salary and feel trapped in the service by the superannuation contributions already made and by anticipation of a retirement pension. Nickle told me " we just have to attract good bright young and have them make a career in this field..., of course this and adequate salary ". What is the status of British surgical splint-makers ? Many feel themselves neglected " backroom boys " inasmuch as they are relegated into dingy quarters, converted often from basements or outhouses. Of the three senior men in this city engaged in this work, one has the dubious distinction of occupying a room unique in possessing a gutter to collect the rain outside and a second gutter on the inside to collect rainwater dripping through the ceiling. These men are vocational craftsmen, but their salary is grossly unfair. It is unfair to them because they are not paid enough; their absolute maximum is E825 per annum; and one of the men receiving this has put 36 years into this type of work and another 40 years. In considering salary, one must note that men holding a comparable position in private-enterprise splint firms would earn E1200 a year and would also be superannuated; and the men who make Dr. Nickle’s splints in America earn the equivalent of E2600 a year. A curious anomaly is that at a teaching hospital some years ago a clerk was-installed to take charge of the order forms for a splint-maker (later she was called the appliance officer) and today she gets approximately S850 a year, whereas his salary is E754. This salary scale is also unfair to the whole concept of splintmaking in Britain; and it seems that the national pattern is similar to that in Birmingham. Young men come into these workshops as apprentices, and receive a training in splintmaking over 4 to 5 years, after which they leave to take up positions either in general engineering or in private-enterprise splint-making firms where salaries are more attractive. The result is that the service is running on ageing men and
men
means status
replacements
are not forthcoming. really matter ? Many feel the answer is to close hospital workshops and to supply splints from private enterprise. This would be folly of the highest magnitude. The experienced splint-maker is a great craftsman in leather and
Does this
Case2 A patient, aged in the mid-forties, had mastectomy for carcinoma 21/2 years previously. She thought she felt a small lump in the other breast in August, 1963. Clinicians were doubtful if anything was palpable (September, 1963). Mammography (October, 1963) showed a spiculated opacity (fig. 2). Mastectomy confirmed the presence of a small carcinoma. Not only is this an example of the positive diagnosis of a preclinical carcinoma of the breast, but it also empha-
of routine mammography of the in breast the lesion being bilateral carcinoma, remaining in 2-3% of cases.5 In brief, mammography, in common with most other radiological procedures, is a useful adjuvant to clinical assessment in all types of breast disorders. In many instances it can be decisive in arriving at a diagnosis, and, in some, by demonstrating a preclinical lesion, it can establish a diagnosis earlier than conventional clinical methods. ERIC SAMUEL Radiodiagnostic Department, The Royal Infirmary, BRUCE YOUNG. 3. Edinburgh, sises the
importance
*** Our annotation in fact referred
the findings of Egan and Gershon-Cohen, which indicate clearly the "positive value " of mammography; and we would hardly have devoted so much space to this subject if we had thought it of little value. We are glad to have this confirmatory evidence from Dr. Samuel and Dr. Young. to
- fun T
CONFESSIONS OF A PÆDIATRICIAN
with this title in your issue of Oct. 26 is one which should be preached by a. senior member of our profession to all physicians at least annually. As we grow older, the truth and value of Dr. Apley’s theme is more and more apparent to us. The text for this sermon, incidentally, is to be found in1 Corinthians, 10, 12: " Wherefore let him that thinketh he standeth take heed lest he fall." H. CLARK BALMER.
SiR,—The
sermon
PARATHYROID INSUFFICIENCY
SIR,-At this unit the
recent
we
noted with considerable interest
articles and
insufficiency
after
correspondence thyroidectomy.
on
parathyroid
In the past, serum-calcium estimations have not been the routine in our cases, particularly since the follow-up of these patients did not point to their necessity. Following the interest aroused by these articles, however, it was decided to add this investigation to the list already demanded by modern medicine. Serum-calcium estimations were carried out before operation, a week after thyroidectomy, and, finally, 3 to 24 months later at the
follow-up In
clinic.
series of 60 unselected patients who had underfor non-malignant goitre (toxic and nontoxic) there was no appreciable lowering of the serum-calcium in any of the patients. In fact, the majority ended with a higher figure! (Allowing for a 0.2 mg. variation, 9 patients remained stationery, 12 ended with a slightly lower reading, while 39 gone
8. 9. 10.
a recent
thyroidectomy
R. L.
Egan, Amer. J. Roentgenol. 1963, 89, Gershon-Cohen, J. J. Amer. med. Ass. 1961, 176, 1114. Martin, J. E., Keegan, J. M., Lemak, L. L., Yates, C. W. Amer. J. Roentgenol. 1962, 88, 1102. 11. Holmes, P. Proc. R. Soc. Med. 1963, 56, 775. 129.
ended with a higher final reading.) In view of these findings and the lack of relevant symptoms at the follow-up clinics, it is not considered that calcium-deprivation tests are worth
performing. It is our practice not to dissect the recurrent laryngeal nerve, though we do like, if possible, to identify the nerve if it does not involve disturbance of the " vital " area. It is also our routine to ligate the trunk of the inferior thyroid artery in continuity, with non-absorbable material, at the point where it emerges from under the carotid artery. Great care is of course taken when sectioning the gland to ensure that no parathyroid glandules are damaged or removed with the goitre. New End Hospital, M. J. LANGE. London, N.W.3.
SPLINT-MAKERS’ SALARIES
SIR,-You rightly give attention (Aug. 31, p. 449) and to the pioneering of new concepts of dynamic limb splintage at the Rancho Los Amigos Hospital, California, credit
under the direction of Vernon L. Nickle. All who have visited him have left inspired by his achievements and by the way he is trying to integrate all specialties in producing new aids for an ever-increasing range of disabled people. You conclude that in this country we must look increasingly to the new scientific disciplines if we are to make comparable progress. I venture to suggest that, while that is necessary, there are very serious deficiencies in pre-existing structure needing correction. British splint-makers have been craftsmen of the highest grade, producing appliances of quality. Splints produced in our orthopaedic workshops have been the envy of many visitors from abroad who know how vital these appliances are for the care of their patients. Today experienced splint-makers are and embittered disgruntled by their meagre salary and feel trapped in the service by the superannuation contributions already made and by anticipation of a retirement pension. Nickle told me " we just have to attract good bright young and have them make a career in this field..., of course this and adequate salary ". What is the status of British surgical splint-makers ? Many feel themselves neglected " backroom boys " inasmuch as they are relegated into dingy quarters, converted often from basements or outhouses. Of the three senior men in this city engaged in this work, one has the dubious distinction of occupying a room unique in possessing a gutter to collect the rain outside and a second gutter on the inside to collect rainwater dripping through the ceiling. These men are vocational craftsmen, but their salary is grossly unfair. It is unfair to them because they are not paid enough; their absolute maximum is E825 per annum; and one of the men receiving this has put 36 years into this type of work and another 40 years. In considering salary, one must note that men holding a comparable position in private-enterprise splint firms would earn E1200 a year and would also be superannuated; and the men who make Dr. Nickle’s splints in America earn the equivalent of E2600 a year. A curious anomaly is that at a teaching hospital some years ago a clerk was-installed to take charge of the order forms for a splint-maker (later she was called the appliance officer) and today she gets approximately S850 a year, whereas his salary is E754. This salary scale is also unfair to the whole concept of splintmaking in Britain; and it seems that the national pattern is similar to that in Birmingham. Young men come into these workshops as apprentices, and receive a training in splintmaking over 4 to 5 years, after which they leave to take up positions either in general engineering or in private-enterprise splint-making firms where salaries are more attractive. The result is that the service is running on ageing men and
men
means status
replacements
are not forthcoming. really matter ? Many feel the answer is to close hospital workshops and to supply splints from private enterprise. This would be folly of the highest magnitude. The experienced splint-maker is a great craftsman in leather and
Does this