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SURGICAL TREATMENT OF VARICOSE VEINS
299
following pregnancy was of special interest as it was a local condition in Christchurch associated with endemic goitre, and that pregnancy was far the commonest predisposing or precipitating cause of mild hypothyroidism. He considered that the diagnosis had to be made by a careful history, if possible with confirmatory evidence from relations ; there were no abnormal signs, but he diagnosed with confidence if lassitude, cold sensitivity, and dry and usually falling hair were present ; and he found that thyroid was not likely He found to be effective if any of these features were absent. that dried thyroid gr. 1/2 daily caused slight improvement, but gr. 1 a day was better ; younger patients could stop treatment in four to six months, and usually remained well. Relapse almost always followed a. later pregnancy ; and thyroidectomy almost always led to hypothyroidism after a pregnancy. No reference to his work has been noted in any recent
physical
or textbooks. In 1950, his symptom-complex began to be noted in women in the third and fourth decades, who were referred to the department at West Hartlepool General Hospital for the investigation of possible ansemia as a cause of their " tiredness." Their symptoms were found to date back, with a varying degree of closeness, toa confinement, either comparatively recent or a few or more years before, and to conform closely to the Roberton syndrome."
journals
difficult to keep in touch with, possibly because, as with Dr. Malleson’s case 2, they have felt so well that they considered it unnecessary to report to their own doctor. This syndrome is quite distinct from typical-even mild-subthyroidism, which is also fairly common in this district. Typical subthyroidism has, however, been seen here dating from a pregnancy ; and in a few other cases patients have presented features such as to make the differentiation between the Roberton syndrome and the typical mild subthyroidism blurred. Insufficient time has passed to obtain a clear idea as to how long thyroid treatment is necessary in this syndrome of atypical subthyroidism ; it is hoped that an opportunity will arise later for a more detailed description of the cases. Department of Pathology, General Hospital, West Hartlepool, R. T. COOKE. co. Durham. SURGICAL TREATMENT OF VARICOSE VEINS
SiR,-I was fascinated by Mr. D. Lang Stevenson’s letter of July 25. As the procedure to which he refers-namely, stripping -has been reimported from the United States, it is probably of value to determine our Atlantic cousins’ view of this stretching and tearing," now dignified by the title " surgical treatment." One of America’s leading textbooks of medicine,! recently reviewed in your columns, discusses stripping techniques in the following terms : "These operations were practically abandoned many years ago as being too dangerous, but now surgeons " are returning to them, who knows why3 STANLEY STANLEY RIVLIN. "
They are chronically tired and listless, both physically mentally, and, whether they sleep well or’not at night, they awake unrefreshed ; they are " always cold," and their hair has " lost its life " and may comb out easily. ,_. They are depressed and have bouts of weeping, and their irritability is commented on by relations ; the appetite varies ; there are commonly aches in the thighs and buttocks. Typically these women are slim or thin and the tracheal rings can be easily felt ; the thyroid isthmus is just palpable or THE KIDNEY AND METABOLIC DISEASE not at all. One important point about the cases seen here, SiR,ŃYour leading article of July 25 gives an explanaand not mentioned by Roberton, is the typical and frequent loss of libido. If a question concerning this is kept until tion of the high ammonia coefficient of the urine in many cases of the de Toni-Fanconi syndrome which is probably the end of the history, it will provoke an answer such as "I have lost all interest," " It is causing trouble with my incorrect. It has been suggested2 that this is due to a high concentration of amino-acids in the lumen of husband," " It was this that really made me go to my doctor." The basal metabolic rate has been estimated on many of the distal renal tubule, which increases the amount of
and
-
expect
an initial result in the these cases, and I have come to lower normal range ; but an anomalous feature has been noted in that after several weeks or a few months on thyroid treatment a repeat test may show a lower figure than before.
substrate for ammonia synthesis. Considerable doubt is thrown on this explanation by observations showing that ammonia synthesis is perfectly normal in hepatolenticular degeneration where there is a similar increase of amino-acid substrate.34 High urinary ammonia may be expected in any condition where there- is a combination of systemic acidosis and an intact distal tubular mechanism for ammonia synthesis. Chronic acidosis causes an increase of glutaminase and amino-acid oxidase in renal tissue5with consequent increase of ammonia synthesis from the The emphasis. same concentration of plasma amino-acid. should therefore be placed on increase of enzymes within the renal cells rather than on an increase of substrate. concentration within the tubular lumen. In the de Toni-Fanconi syndrome there is a definite correlation between the presence of a high - urinary ammonia coefficientt and systemic acidosis.67 Normal or low ammonia production may, however, be found in cases. showing normal acid-base balance or in cases where there is damage to the mechanisms of ammonia synthesis. as a result of more extensive renal failure. .
In general, the response to a slowly increased dose of thyroid over several months has given improvement convincing both to the women and their doctors. The loss of sex feeling is the symptom last to improve. It is of interest that recent work with radioactive iodine has shown that when thyroid hormone is given to normal humans, a depression of endogenous thyroid function results (thus of 25 subjects, a third showed marked thyroid depression on gr. 1. daily for three weeks, and all but 4 showed marked thyroid depression on gr. 2 daily).
(Greer 1951)3
The mental and
physical vitality which returns to the a vivid improvement in facial or two cases where photographs
patient may give quite appearance, and, in one
have been taken before and after treatment, observers have hardly believed that they belong to the same person. One patient became pregnant while taking thyroid ; this
stopped in the early months and she has kept well to date, 4 months after her confinement ; she recalls how well the
was
tablets made her feel previously. (Some of Roberton’s patients said that they never felt so well as when pregnant.) Another, aged 32, when first seen with symptoms dating from the birth of her second child two years before, had had a thyroidectomy done when she was 16, for symptoms which suggest thyrotoxicosis. Another had had a severe megalocytic aneemia during the significant pregnancy.
One or two of the patients have been investigated while on holiday from other parts of the country : and, besides these, some of the local patients have been 3.
Greer, M.
A.
New Engl. J. Med.
1951, ii, 385.
Postgraduate Medical School of London. W.12.
M. D. MILNE.
1. Beckman, H. Pharmacology in Clinical Practice. Philadelphia and London. 1952. 2. Milne, M. D., Stanbury, S. W., Thomson, A. E. Quart. J. Med. 1952, 21, 61. A. 3. Cooper, M., Eckhardt, R. D., Faloon, W. W., Davidson, C. S. J. clin. Invest. 1950, 29, 265. 4. Milne, M. D. Unpublished observations. 5. Davies, B. M. A., Yudkin, J. Biochem. J. 1952, 52, 407. 6. McCune, D. J., Mason, H. H., Clarke, H. T. Amer. J. Dis. Child. 1943, 65, 81. 7. Bickel, H., Smallwood, W. C., Smellie, J. M., Hickmans, E. M. Acta Pœdiat. Stockh. 1952, 42, suppl. 90, 27.
following pregnancy was of special interest as it was a local condition in Christchurch associated with endemic goitre, and that pregnancy was far the commonest predisposing or precipitating cause of mild hypothyroidism. He considered that the diagnosis had to be made by a careful history, if possible with confirmatory evidence from relations ; there were no abnormal signs, but he diagnosed with confidence if lassitude, cold sensitivity, and dry and usually falling hair were present ; and he found that thyroid was not likely He found to be effective if any of these features were absent. that dried thyroid gr. 1/2 daily caused slight improvement, but gr. 1 a day was better ; younger patients could stop treatment in four to six months, and usually remained well. Relapse almost always followed a. later pregnancy ; and thyroidectomy almost always led to hypothyroidism after a pregnancy. No reference to his work has been noted in any recent
physical
or textbooks. In 1950, his symptom-complex began to be noted in women in the third and fourth decades, who were referred to the department at West Hartlepool General Hospital for the investigation of possible ansemia as a cause of their " tiredness." Their symptoms were found to date back, with a varying degree of closeness, toa confinement, either comparatively recent or a few or more years before, and to conform closely to the Roberton syndrome."
journals
difficult to keep in touch with, possibly because, as with Dr. Malleson’s case 2, they have felt so well that they considered it unnecessary to report to their own doctor. This syndrome is quite distinct from typical-even mild-subthyroidism, which is also fairly common in this district. Typical subthyroidism has, however, been seen here dating from a pregnancy ; and in a few other cases patients have presented features such as to make the differentiation between the Roberton syndrome and the typical mild subthyroidism blurred. Insufficient time has passed to obtain a clear idea as to how long thyroid treatment is necessary in this syndrome of atypical subthyroidism ; it is hoped that an opportunity will arise later for a more detailed description of the cases. Department of Pathology, General Hospital, West Hartlepool, R. T. COOKE. co. Durham. SURGICAL TREATMENT OF VARICOSE VEINS
SiR,-I was fascinated by Mr. D. Lang Stevenson’s letter of July 25. As the procedure to which he refers-namely, stripping -has been reimported from the United States, it is probably of value to determine our Atlantic cousins’ view of this stretching and tearing," now dignified by the title " surgical treatment." One of America’s leading textbooks of medicine,! recently reviewed in your columns, discusses stripping techniques in the following terms : "These operations were practically abandoned many years ago as being too dangerous, but now surgeons " are returning to them, who knows why3 STANLEY STANLEY RIVLIN. "
They are chronically tired and listless, both physically mentally, and, whether they sleep well or’not at night, they awake unrefreshed ; they are " always cold," and their hair has " lost its life " and may comb out easily. ,_. They are depressed and have bouts of weeping, and their irritability is commented on by relations ; the appetite varies ; there are commonly aches in the thighs and buttocks. Typically these women are slim or thin and the tracheal rings can be easily felt ; the thyroid isthmus is just palpable or THE KIDNEY AND METABOLIC DISEASE not at all. One important point about the cases seen here, SiR,ŃYour leading article of July 25 gives an explanaand not mentioned by Roberton, is the typical and frequent loss of libido. If a question concerning this is kept until tion of the high ammonia coefficient of the urine in many cases of the de Toni-Fanconi syndrome which is probably the end of the history, it will provoke an answer such as "I have lost all interest," " It is causing trouble with my incorrect. It has been suggested2 that this is due to a high concentration of amino-acids in the lumen of husband," " It was this that really made me go to my doctor." The basal metabolic rate has been estimated on many of the distal renal tubule, which increases the amount of
and
-
expect
an initial result in the these cases, and I have come to lower normal range ; but an anomalous feature has been noted in that after several weeks or a few months on thyroid treatment a repeat test may show a lower figure than before.
substrate for ammonia synthesis. Considerable doubt is thrown on this explanation by observations showing that ammonia synthesis is perfectly normal in hepatolenticular degeneration where there is a similar increase of amino-acid substrate.34 High urinary ammonia may be expected in any condition where there- is a combination of systemic acidosis and an intact distal tubular mechanism for ammonia synthesis. Chronic acidosis causes an increase of glutaminase and amino-acid oxidase in renal tissue5with consequent increase of ammonia synthesis from the The emphasis. same concentration of plasma amino-acid. should therefore be placed on increase of enzymes within the renal cells rather than on an increase of substrate. concentration within the tubular lumen. In the de Toni-Fanconi syndrome there is a definite correlation between the presence of a high - urinary ammonia coefficientt and systemic acidosis.67 Normal or low ammonia production may, however, be found in cases. showing normal acid-base balance or in cases where there is damage to the mechanisms of ammonia synthesis. as a result of more extensive renal failure. .
In general, the response to a slowly increased dose of thyroid over several months has given improvement convincing both to the women and their doctors. The loss of sex feeling is the symptom last to improve. It is of interest that recent work with radioactive iodine has shown that when thyroid hormone is given to normal humans, a depression of endogenous thyroid function results (thus of 25 subjects, a third showed marked thyroid depression on gr. 1. daily for three weeks, and all but 4 showed marked thyroid depression on gr. 2 daily).
(Greer 1951)3
The mental and
physical vitality which returns to the a vivid improvement in facial or two cases where photographs
patient may give quite appearance, and, in one
have been taken before and after treatment, observers have hardly believed that they belong to the same person. One patient became pregnant while taking thyroid ; this
stopped in the early months and she has kept well to date, 4 months after her confinement ; she recalls how well the
was
tablets made her feel previously. (Some of Roberton’s patients said that they never felt so well as when pregnant.) Another, aged 32, when first seen with symptoms dating from the birth of her second child two years before, had had a thyroidectomy done when she was 16, for symptoms which suggest thyrotoxicosis. Another had had a severe megalocytic aneemia during the significant pregnancy.
One or two of the patients have been investigated while on holiday from other parts of the country : and, besides these, some of the local patients have been 3.
Greer, M.
A.
New Engl. J. Med.
1951, ii, 385.
Postgraduate Medical School of London. W.12.
M. D. MILNE.
1. Beckman, H. Pharmacology in Clinical Practice. Philadelphia and London. 1952. 2. Milne, M. D., Stanbury, S. W., Thomson, A. E. Quart. J. Med. 1952, 21, 61. A. 3. Cooper, M., Eckhardt, R. D., Faloon, W. W., Davidson, C. S. J. clin. Invest. 1950, 29, 265. 4. Milne, M. D. Unpublished observations. 5. Davies, B. M. A., Yudkin, J. Biochem. J. 1952, 52, 407. 6. McCune, D. J., Mason, H. H., Clarke, H. T. Amer. J. Dis. Child. 1943, 65, 81. 7. Bickel, H., Smallwood, W. C., Smellie, J. M., Hickmans, E. M. Acta Pœdiat. Stockh. 1952, 42, suppl. 90, 27.