Henry Miller

Early Diagnosis of Medullary Carcinoma of the Thyroid Gland by Means of Calcitonin Assay

Abstract Medullary thyroid carcinoma was predicted correctly by means of radioimmunoassay of serum and urine calcitonin in 11 members of one family. An increased concentration of calcitonin in seru...

Bladder Dysfunction in Multiple Sclerosis

Disturbances of micturition are important in multiple sclerosis, not only because of their high incidence, the amount of discomfort and embarrassment they cause, and their contribution to the mortality of the disease, but because control of the excretory functions is the most important single factor which determines the patients admission to hospital. Under satisfactory home conditions many patients with this disease can remain with their families for many years, but the development of urinary retention demands urgent admission to hospital, while incontinence very often necessitates long-terminstitutional

Natural history of familial medullary thyroid carcinoma: effect of a program for early diagnosis.

To detect familial medullary thyroid carcinoma in a premetastatic stage, we administered tests provocative of calcitonin secretion (infusion of calcium or pentagastrin or both) each year for seven years to members of a pedigree now numbering 107. Since 1970, 21 patients converted from normal to abnormal secretory responses (two separate tests in which calcitonin levels exceeded 0.58 ng per milliliter). Twenty of 21 glands removed showed C-cell hyperplasia, and eight of the 20 also showed foci of carcinoma. As compared to the 12 patients with tumors detected during the first year of screening, all of whom had bilateral carcinoma (seven of 12 with local metastases), later carcinomas were smaller (mean diameter of 0.2 vs. 0.8 cm), were unilateral (in all but two cases) and occurred in younger patients (mean age of 14.9 vs. 36.4 years), and none had detectable metastases.

Accident Neurosis—II

went with them. The Medical Records Officers of the London Hospital and St. Bartholomews Hospital kindly supplied data about their cases of leukaemia. The late Dr. A. Mackenzie, of the G*-neral Register Office, suggested the analysis of the cases by length of history and was most helpful in other ways. Dr. Richard Doll kindly made analyses of mortality data available. Professor J. N. Morris and my colleagues in the Social Medicine Res2arch Unit and the London Hospital gave me much help.

EPIDEMIOLOGY OF MULTIPLE SCLEROSIS IN THE COUNTIES OF NORTHUMBERLAND AND DURHAM.

Considerable variations in the scope and the methods of ascertainment employed in different epidemiological studies, to say nothing of divergent diagnostic criteria, have seriously jeopardized the value ofmany such observations in estimating the true prevalence of multiple sclerosis in various parts of the world. Acheson has pointed out that studies based on mortality statistics (Limburg, 1950; Acheson, 1961) are subject to misreporting and under-reporting which reduce their accuracy and comparability. Studies of hospital records (Chiavacci, Hoff, and Polvan, 1950), augmented on occasion by interviews of practising physicians and examination of death certificates (Ipsen, 1950), represent further attempts to obtain more accurate data. Investigations of special population groups such as U.S. veterans (Acheson and Bachrach, 1960; Acheson, Bachrach, and Wright, 1960), for which comprehensive medical records are available, have afforded opportunities for more circumscribed studies. However, the personally conducted population survey, drawing on every available source to compile a comprehensive register of patients, has been recognized as a superior method. Essential to the survey is the establishment of firm diagnostic criteria, which not only lend reliability to the investigation but also permit the subsequent employment of data in authentic comparative studies. One such survey in the field of multiple sclerosis was published more than 30 years ago (Allison, 1931) and important contributions on similar lines have been made by MacLean, Berkson, Woltman, and Schionneman (1950), Allison and Millar (1954), Hyllested (1956), Sutherland (1956), and Alter, Allison, Talbert, and Kurland (1960). These observations furnish a valuable frame of reference for studies now under way in several other parts of the world.

Surgical approach to early familial medullary carcinoma of the thyroid gland

Abstract The application of a radioimmunoassay for human calcitonin to a high risk family group has predicted the diagnosis of medullary carcinoma of the thyroid in twelve persons. With the calcium infusion test, elevated levels of calcitonin have been measured in the serum and urine in these patients with medullary carcinoma. In eleven, the tumors were clinically occult. In all twelve patients the tumors were found to be bilateral, and in six patients the lymph nodes contained metastases in the periglandular and paratracheal areas. On the basis of these findings, total thyroidectomy, removal of the inferior parathyroid glands, and limited neck dissection of the central zone of the neck was carried out. Postoperative studies have shown an abnormal serum calcitonin response to calcium infusion in two patients consistent with persistent disease. Venous catheterization studies with calcitonin analysis for localization of the residual tumor are projected for these patients. Four of the twelve patients with thyroid tumors were also found to have pheochromocytomas. These tumors in three were removed prior to the thyroid surgery. An additional pheochromocytoma was found and removed in one member of the family without evidence of medullary carcinoma. Ten of those having thyroidectomy also showed parathyroid hyperplasia. Four had a history of renal calculi. It is anticipated that new cases of thyroid carcinoma will become evident as the children and young adults at risk are repeatedly tested, and hopefully these will become detectable still earlier. The effectiveness of this approach in altering the ultimate outcome or course of the disease needs to be demonstrated by long term follow-up study.

Total thyroidectomy for occult familial medullary carcinoma of the thyroid in children

Experience with 17 children in one kindred with familial medullary carcinoma of the thyroid and pheochromocytoma has demonstrated the utility and validity of periodic provocative testing by calcium infusion or pentagastrin injection in the identification of children with early medullary carcinoma of the thyroid or its premalignant precursor, C-cell hyperplasia. In these 17 patients with two consecutive elevations of calcitonin levels greater than 0.55 ng/ml after stimulation all but one have had MTC or CCH at operation. Total thyroidectomy has been well tolerated and can be performed with an acceptably low incidence of complications in this group of patients.

Fate of the retained rectum after subtotal colectomy for inflammatory disease of the colon.

Of forty-nine consecutive patients who underwent subtotal colectomy for inflammatory disease of the colon, 73.5 per cent required subsequent combined abdominoperineal resection of the retained rectum and only two patients had successful ileoproctostomy. For the patient whose rectum is substantially diseased along with the rest of the colon, one-stage total proctocolectomy is the preferred operation.

Aetiological Aspects of Multiple Sclerosis: II

PART ht The essential clue to the causation of multiple sclerosis may be lacking amongst the observations outlined in Part I, and may await some apparently unconnected advance in another field of medicine, just as subacute combined degeneration and kernicterus were clarified by new haematological knowledge, or Wilsons disease by studies of copper metabolism. It is also possible that more convincing evidence than hitherto may be forthcoming to link the occurrence of the disease with tuberculosis (Ahringsmann, 1949-50), highdietary fat intake (Swank, 1953), or the geographical distribution of heavy nmetals or trace elements (Campbell et al., 1947, 1950); that the roles of microthrombosis (Putnam and Alexander, 1939), vasospasm (Brickner, 1950), or red-cell sludging (Roizin et al., 1953) may prove to be more than incidental; or that the recent experimental production of demyelination by such agents as potassium cyanide, sodium azide, or anoxia may be more relevant to the human disease than appears at first sight.

Polyradiculitis (Landry-Guillain-Barré Syndrome)

An air of defeatism tends to surround the subject of multiple sclerosis. The reasons for this attitude are examined in some detail. Aetiology is discussed with especial reference to the allergic theory. A diagnosis of multiple sclerosis is usually not made until the fourth or fifth year of the disease. The causes of this delay are discussed and early symptomatology is reviewed. The traditional belief that multiple sclerosis inevitably leads to increasing disability and premature death requires modification in the light of recent studies. A brief reference is made to the concept of varying degrees of resistance and to a benign form of the disease. A plea is made for a more positive attitude towards treatment. In an early case more attention should be paid to the constitutional and environmental background of the patient. Stress is laid on the importance of rest during active phases of the disease, followed by prolonged convalescence. In responsible adults an explanation of the nature of their illness is essential in order to obtain intelligent co-operation in treatment.