the prognostic significance of thyroid antibodies in thyrotoxicosis

1
1115 MEDICAL AID FOR DEVELOPING COUNTRIES P. W. HUTTON. SIR,-Permit me to comment on your leader of Nov. 10. It is to be hoped that the initiative of Sir Arthur Porritt will not go unsupported. The new Department of Technical Cooperation cannot be expected to shoulder the whole burden. Indeed it expressly points out that it expects assistance from other Government departments and the British people. The medical profession in Britain can assist with professional and technical advice. To be acceptable, however, this must be disinterested and augmented with appropriate assistance. The important problems facing these countries are the maintenance of professional standards, the supply of trained medical manpower indigenous and expatriate, and the training of indigenous personnel abroad or in this country. It should be remembered that the Minister of Health is the principal supplier of medical facilities and the principal em- ployer of medical labour in this country. This includes much imported labour, apparently vital to his service. If significant material assistance is to be given, then the legalistic barriers which protect him from exercising any Commonwealth respon- sibility should be removed. He may then be able to spare a few redundant scraps from his well-nourished Health Service to feed the medically starved Commonwealth. Legislative adjust- ments are after all not impossible to him or his colleagues. It should also be remembered that since the days of James Lind, the medical profession as a whole have notoriously neglected medicine overseas. It is to be hoped that they will now no longer confine their overseas interests solely to the other side of the Atlantic. THE PROGNOSTIC SIGNIFICANCE OF THYROID ANTIBODIES IN THYROTOXICOSIS SIR,-Like Dr. Irvine and his colleagues (Oct. 27) we too have been interested in the prognostic implications of a positive serum complement-fixation reaction to thyroid extract in relation to the surgical treatment of thyrotoxicosis. Our conclusions were reported briefly to the Surgical Research Society in November, 1960, and were based on 130 patients with thyrotoxicosis treated by subtotal thyroidectomy in whom precipitation and com- plement-fixation tests had been done before operation. As a result of our findings it appeared logical to us to recommend a less radical removal of thyroid tissue in those patients possessing antibody in a complement- fixation test. While agreeing that a positive complement-fixation test provides a guide to the incidence of postoperative hypothyroid- ism, our results did not show a very close correlation between the titre of complement-fixing antibodies and the incidence of postoperative hypothyroidism as reported by Irvine et al. and Buchanan et al.2, and this point certainly deserves further investigation. In our series, of 44 patients with a positive complement- fixation test, 12 (27-3%) developed postoperative hypothyroid- ism compared with 9 (8-8%) out of 86 patients with a negative complement-fixation test. The serum from 29 patients had a titre of complement-fixing antibody of 1 : 16 or under; 8 of these patients became hypothyroid within a few months of operation. Only 4 among 15 patients whose serum titre of complement-fixing antibody was 1 32 and over became hypothyroid. We found that the titre of complement-fixing antibody fell off or became negative with the development of hypothyroidism. 1. Gammie, W. F. P., Marshall, A. H. E., White, R. G. Brit. J. Surg. 1961, 48, 466. 2. Buchanan, W. W., Koutras, D. A., Crooks, J., Alexander, W. D., Brass, W., Anderson, J. R., Goudie, R. B., Gray, K. G. J. Endocrin. 1962, 24, 115. On the other hand, some patients can maintain a high titre of complement-fixing antibodies at a constant level from before thyroidectomy for at least five years afterwards and still remain in a euthyroid state. Rather than subject such individuals to permanent thyroxine therapy as suggested by Irvine et al., it seems preferable to follow the complement-fixing antibody after thyroidectomy until a drop indicates the likely onset of future hypothyroidism. On current evidence surgery remains the treatment of choice in most cases of thyrotoxicosis, and although hypothyroidism following operation is preferable to recurrent thyrotoxicosis, ideally the patient should be rendered euthyroid and require no further therapy. W. F. P. GAMMIE A. H. E. MARSHALL R. G. WHITE. The London Hospital, London, E.1. CORONER’S POSTMORTEM EXAMINATIONS C. F. Ross. St. Peter’s Hospital, Chertsey, Surrey. SIR,-Dr. Thurston (Nov. 3) is partly right. What I really want is a National Forensic Pathology Service. I have no quarrel with the legal system and have always found coroners helpful and cooperative. I am rather surprised at his attitude, as a salaried Crown official, to a suggested salaried forensic pathology service. Private practice in this field seems to me to be an anachronism. Dr. Coghill (Nov. 17) has stated, perhaps more clearly than I, the conditions under which many pathologists working for coroners (" Coroner’s pathologists ", pace Dr. Thurston) have to perform their necropsies. I do not think these can be considered good enough and I feel that more full-time forensic pathologists, with facilities for every laboratory aspect of the work, are greatly needed. I hope the " distinguished pathologists " to whom Dr. Thurston refers will not disagree. MANAGEMENT OF TRACHEOTOMY IN INFANTS SIR,-I read with interest the comments by Mr. Fennell (Oct. 20). Some points, I feel, require further explanation from the aneasthetist’s point of view. Anasthesia.-It is often easy to intubate without anaes- thesia any baby up to four weeks of age. Nitrous oxide, oxygen, and halothane, with or without a muscle relaxant to aid intuba- tion in the older baby, produce safe rapid anaesthesia in experienced hands. For the inexperienced anaesthetist, ether and no relaxant are safer. Preoxygenation is always valuable, to offset the difficulties of induction in these patients. The endotracheal tube should be a fairly firm plain-rubber Magill tube of appropriate size, with a connector allowing for suction (such as the Cardiff connector). Suction.-Disposable plastic suction catheters, or fine gum- elastic catheters, lubricated before use, will pass with ease down infant endotracheal tubes. Rubber catheters are not reliable. Operation.-The endotracheal tube should be left in the trachea after withdrawal above the stoma, until it is certain that the tracheostomy tube is in the correct position. Re- insertion may be difficult. Apnrea is fairly common after insertion of the tracheostomy tube, and some means of artificial ventilation through this tube must be available. The Ayre’s T-piece, with open-ended bag attached, and a curved connector fitting into the tracheostomy tube, provides a safe way of ventilating these babies both during and after operation. Postoperatively a high humidity must be maintained, using atomised cold water in an infant oxygen tent. Bronchial lavage with a saturated solution of sodium bicarbonate is extremely effective in removing viscid secretion. It should be accompanied by gentle rapid

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Page 1: THE PROGNOSTIC SIGNIFICANCE OF THYROID ANTIBODIES IN THYROTOXICOSIS

1115

MEDICAL AID FOR DEVELOPING COUNTRIES

P. W. HUTTON.

SIR,-Permit me to comment on your leader of Nov. 10.It is to be hoped that the initiative of Sir Arthur Porrittwill not go unsupported. The new Department ofTechnical Cooperation cannot be expected to shoulderthe whole burden. Indeed it expressly points out that itexpects assistance from other Government departmentsand the British people.The medical profession in Britain can assist with professional

and technical advice. To be acceptable, however, this must bedisinterested and augmented with appropriate assistance.The important problems facing these countries are the

maintenance of professional standards, the supply of trainedmedical manpower indigenous and expatriate, and the trainingof indigenous personnel abroad or in this country.

It should be remembered that the Minister of Health is the

principal supplier of medical facilities and the principal em-ployer of medical labour in this country. This includes muchimported labour, apparently vital to his service. If significantmaterial assistance is to be given, then the legalistic barrierswhich protect him from exercising any Commonwealth respon-sibility should be removed. He may then be able to spare a fewredundant scraps from his well-nourished Health Service tofeed the medically starved Commonwealth. Legislative adjust-ments are after all not impossible to him or his colleagues.

It should also be remembered that since the days ofJames Lind, the medical profession as a whole have

notoriously neglected medicine overseas. It is to be

hoped that they will now no longer confine their overseasinterests solely to the other side of the Atlantic.

THE PROGNOSTIC SIGNIFICANCE OF

THYROID ANTIBODIES IN THYROTOXICOSIS

SIR,-Like Dr. Irvine and his colleagues (Oct. 27) wetoo have been interested in the prognostic implicationsof a positive serum complement-fixation reaction to

thyroid extract in relation to the surgical treatment ofthyrotoxicosis. Our conclusions were reported brieflyto the Surgical Research Society in November, 1960, andwere based on 130 patients with thyrotoxicosis treated bysubtotal thyroidectomy in whom precipitation and com-plement-fixation tests had been done before operation.As a result of our findings it appeared logical to us torecommend a less radical removal of thyroid tissue inthose patients possessing antibody in a complement-fixation test.While agreeing that a positive complement-fixation test

provides a guide to the incidence of postoperative hypothyroid-ism, our results did not show a very close correlation betweenthe titre of complement-fixing antibodies and the incidence ofpostoperative hypothyroidism as reported by Irvine et al. andBuchanan et al.2, and this point certainly deserves furtherinvestigation. ’

In our series, of 44 patients with a positive complement-fixation test, 12 (27-3%) developed postoperative hypothyroid-ism compared with 9 (8-8%) out of 86 patients with a negativecomplement-fixation test. The serum from 29 patients had atitre of complement-fixing antibody of 1 : 16 or under; 8 ofthese patients became hypothyroid within a few months ofoperation. Only 4 among 15 patients whose serum titre ofcomplement-fixing antibody was 1 32 and over becamehypothyroid.We found that the titre of complement-fixing antibody fell

off or became negative with the development of hypothyroidism.1. Gammie, W. F. P., Marshall, A. H. E., White, R. G. Brit. J. Surg. 1961,

48, 466.2. Buchanan, W. W., Koutras, D. A., Crooks, J., Alexander, W. D., Brass,

W., Anderson, J. R., Goudie, R. B., Gray, K. G. J. Endocrin. 1962,24, 115.

On the other hand, some patients can maintain a high titre ofcomplement-fixing antibodies at a constant level from beforethyroidectomy for at least five years afterwards and still remainin a euthyroid state. Rather than subject such individuals topermanent thyroxine therapy as suggested by Irvine et al., itseems preferable to follow the complement-fixing antibodyafter thyroidectomy until a drop indicates the likely onset offuture hypothyroidism.On current evidence surgery remains the treatment of

choice in most cases of thyrotoxicosis, and althoughhypothyroidism following operation is preferable to

recurrent thyrotoxicosis, ideally the patient should berendered euthyroid and require no further therapy.

W. F. P. GAMMIEA. H. E. MARSHALLR. G. WHITE.

The London Hospital,London, E.1.

CORONER’S POSTMORTEM EXAMINATIONS

C. F. Ross.St. Peter’s Hospital,

Chertsey,Surrey.

SIR,-Dr. Thurston (Nov. 3) is partly right. What Ireally want is a National Forensic Pathology Service.I have no quarrel with the legal system and have alwaysfound coroners helpful and cooperative. I am rather

surprised at his attitude, as a salaried Crown official, to asuggested salaried forensic pathology service. Privatepractice in this field seems to me to be an anachronism.Dr. Coghill (Nov. 17) has stated, perhaps more clearlythan I, the conditions under which many pathologistsworking for coroners (" Coroner’s pathologists ", paceDr. Thurston) have to perform their necropsies. I do notthink these can be considered good enough and I feel thatmore full-time forensic pathologists, with facilities for

every laboratory aspect of the work, are greatly needed.I hope the " distinguished pathologists " to whom Dr.Thurston refers will not disagree.

MANAGEMENT OF TRACHEOTOMY IN INFANTS

SIR,-I read with interest the comments by Mr. Fennell(Oct. 20). Some points, I feel, require further explanationfrom the aneasthetist’s point of view.

Anasthesia.-It is often easy to intubate without anaes-

thesia any baby up to four weeks of age. Nitrous oxide, oxygen,and halothane, with or without a muscle relaxant to aid intuba-tion in the older baby, produce safe rapid anaesthesia in

experienced hands. For the inexperienced anaesthetist, etherand no relaxant are safer. Preoxygenation is always valuable,to offset the difficulties of induction in these patients. Theendotracheal tube should be a fairly firm plain-rubber Magilltube of appropriate size, with a connector allowing for suction(such as the Cardiff connector).

Suction.-Disposable plastic suction catheters, or fine gum-elastic catheters, lubricated before use, will pass with ease downinfant endotracheal tubes. Rubber catheters are not reliable.

Operation.-The endotracheal tube should be left in thetrachea after withdrawal above the stoma, until it is certainthat the tracheostomy tube is in the correct position. Re-insertion may be difficult. Apnrea is fairly common afterinsertion of the tracheostomy tube, and some means ofartificial ventilation through this tube must be available.The Ayre’s T-piece, with open-ended bag attached, and acurved connector fitting into the tracheostomy tube, providesa safe way of ventilating these babies both during and afteroperation.

Postoperatively a high humidity must be maintained,using atomised cold water in an infant oxygen tent.

Bronchial lavage with a saturated solution of sodiumbicarbonate is extremely effective in removing viscidsecretion. It should be accompanied by gentle rapid