- Email: [email protected]
MEDICINE AT THE OPEN UNIVERSITY
439 It seems that our techniques are acceptable, since the number seen at the clinics is increasing. Whether we are the right people to treat these patients may be open to debate, but at least we may claim a degree of knowledge, experience, understanding, and interest. We have not considered the use of surrogates. In fact the majority of the patients have been treated by interviews at which both parties were present. We are antagonistic to the use of surrogates, believing that most sexual problems have, as a basis, an emotional difficulty between the partners. That there is an obvious need for more undergraduate and postgraduate training and teaching of doctors is very clear. Perhaps a conference on this particular problem, at national level, might prove helpful to us all.
Mornington Villas, Manningham Lane,
1
Bradford BD8 7HD.
G. A. CRAIG H. B. MILNE.
ÆTIOLOGY OF BURKITT’S LYMPHOMA
SiR,—The letter by Dr Sadoff (Dec. 30, p. 1414) suggests that pyrimethamine might be incriminated in the aetiology of Burkitt’s lymphoma by virtue of its role as an immunodepressive agent. This hypothesis is based entirely on the suggestion that this lymphoma is a " new disease " and that the children (or their mothers) have received the drug. The evidence suggests that neither of these are true. In 1901, Sir Albert Cook, writing from the Mengo Hospital, Kampala, Uganda, stated: " Malignant disease is common in Uganda-sarcoma of the jaws, upper and lower, is perhaps the most frequent form." In a review of Sir Albert’s notes we came across a classical clinical description of a Burkitt’s lymphoma in 1910, with a drawing of the child’s face. There is little doubt that this was a Burkitt’s lymphoma.2 Smith and Elmes3 also reported round-cell sarcomas in the jaws of Nigerian children, and other reports can be found in the literature before 1948. In addition, our experience in Uganda suggests that it is very unlikely that many, if any, of the children seen with Burkitt’s lymphoma in Uganda have received pyrimethamine. Most of them come from rural areas where routine malarial prophylaxis is not used and where the adults have an acquired immunity. We believe, therefore, that there is no reason for incriminating this drug in the aetiology of Burkitt’s lymphoma. St Thomas’
Hospital
Medical School, London SE1.
M. S. R. HUTT.
Medical Research Council Unit, London W1P 9LH.
D. P. BURKITT.
MEDICINE AT THE OPEN UNIVERSITY
SiR,—The Society for Open University Medical Sciences to press for a medical-sciences faculty at the Open University. Several reports published in the last few months provide arguments to support the society’s case. In September, Sir Derrick Dunlop produced World Health Organisation figures4 to show that Britain has fewer doctors per head of the population than most other has been established
European countries.
The report of the Commons ExpendiCommittee on Higher Education, published in December, called for a manpower council to relate the supply of qualified manpower to the demand for it, for
ture
1. 2. 3.
Cook, A. R. J. trop. Med. Hyg. 1901, 4, 175. Davies, J. N. P., Elmes, S., Hutt, M. S. R., Mtimavalye, L. A. R., Owor, R., Shaper, L. Br. med. J. 1964, i, 259, 336. Smith, E. C., Elmes, B. G. T. Ann. trop. Med. Parasit. 1934, 28, 461.
4. Dunlop, D., Inch, R. S. Br. med. J. 1972, iii, 749. 5. Further and Higher Education; vol. I. Report from the Expenditure Committee. H.M. Stationery Office, 48-I. Dec. 8, 1972.
closer financial monitoring of higher education, and for students to be home-based. The latest annual report of the Universities Central Council on Admissions6 showed that while in general the demand for university places had fallen, the demand for places in medicine, dentistry, and health had actually exceeded the estimates by 224 places. A new university faculty of medicine is clearly needed to provide more doctors and to meet the increased demand A medical course at’the Open for medical training. University would certainly involve a lower capital cost, and a higher proportion of home-based students, than a new It would also have the advantage of course elsewhere. being likely to meet the requirement of 5600 hours of study which, according to Lord Bowden, the European Community is likely to ask of future medical students. Moreover, many of those wishing to take the course would be mature students and, judging from the membership of the Society for Open University Medical Sciences, most of them would already have extensive experience in auxiliary medical roles. There are two difficulties in the society’s way. It is competing against a demand for an Open University law faculty (even though the University Grants Committee has come out against any new law faculties, and is instead providing for a 30%increase in places on existing courses). The society also has to face the technical and organisational problem of achieving cooperation with the medical profession for the clinical part of the course. more
16 Station
Approach, Hayes, Bromley,
IVOR SHIPLEY.
Kent BR2 7EH.
TREATMENT OF DERMATITIS HERPETIFORMIS
SIR,-Dr Fry and his colleagues (Feb. 10, p. 288) are to be
congratulated on their latest paper on the relationship between gluten and dermatitis herpetiformis (D.H.). It is an excellent example of the value of not being stampeded into abandoning a sound opinion because favourable results are not immediately forthcoming. As they noted, not even all coeliac patients respond to a gluten-free diet (G.F.D.) and an appreciable number may take several years to get the maximum response. It is therefore not surprising that many patients with D.H. take many months or even years to become free of dapsone dependence. My own very limited clinical experience with G.F.D. confirms the findings of Dr Fry and his colleagues. I should like to commend two other points. Firstly they criticise the suggestion by Marks and Shuster that the natural history of D.H. results in greatly varying requirements of dapsone from time to time, suggesting that improvement with gluten withdrawal is due to spontaneous remission. I would support this criticism in general. I have studied a large number of cases of D.H. (well over 100) over 24 years, and for 19 of these years I have used dapsone extensively. There is no doubt that the dose from patient to patient varies very widely from as little as 50 mg. weekly to as much as 300 mg. daily. In a given individual, however, the controlling dose does remain remarkably constant. It may vary when what appeared to be periods of quiescence or increased activity are induced by other influences, such as febrile illnesses or pregnancy, but once the influence of these episodes disappears the maintenance dose will be almost always found to be similar to that used previously. The textbooks talk about spontaneous remission, a view repeated since the days of Duhring and Brocq, but I agree with Dr Fry and his colleagues that what is now commonly recognised as D.H. does not in general behave in this It is a remarkably persistent disorder. Should manner. 6. Universities Central Council
on
Admissions. Tenth Report 1971-72.
Mornington Villas, Manningham Lane,
1
Bradford BD8 7HD.
G. A. CRAIG H. B. MILNE.
ÆTIOLOGY OF BURKITT’S LYMPHOMA
SiR,—The letter by Dr Sadoff (Dec. 30, p. 1414) suggests that pyrimethamine might be incriminated in the aetiology of Burkitt’s lymphoma by virtue of its role as an immunodepressive agent. This hypothesis is based entirely on the suggestion that this lymphoma is a " new disease " and that the children (or their mothers) have received the drug. The evidence suggests that neither of these are true. In 1901, Sir Albert Cook, writing from the Mengo Hospital, Kampala, Uganda, stated: " Malignant disease is common in Uganda-sarcoma of the jaws, upper and lower, is perhaps the most frequent form." In a review of Sir Albert’s notes we came across a classical clinical description of a Burkitt’s lymphoma in 1910, with a drawing of the child’s face. There is little doubt that this was a Burkitt’s lymphoma.2 Smith and Elmes3 also reported round-cell sarcomas in the jaws of Nigerian children, and other reports can be found in the literature before 1948. In addition, our experience in Uganda suggests that it is very unlikely that many, if any, of the children seen with Burkitt’s lymphoma in Uganda have received pyrimethamine. Most of them come from rural areas where routine malarial prophylaxis is not used and where the adults have an acquired immunity. We believe, therefore, that there is no reason for incriminating this drug in the aetiology of Burkitt’s lymphoma. St Thomas’
Hospital
Medical School, London SE1.
M. S. R. HUTT.
Medical Research Council Unit, London W1P 9LH.
D. P. BURKITT.
MEDICINE AT THE OPEN UNIVERSITY
SiR,—The Society for Open University Medical Sciences to press for a medical-sciences faculty at the Open University. Several reports published in the last few months provide arguments to support the society’s case. In September, Sir Derrick Dunlop produced World Health Organisation figures4 to show that Britain has fewer doctors per head of the population than most other has been established
European countries.
The report of the Commons ExpendiCommittee on Higher Education, published in December, called for a manpower council to relate the supply of qualified manpower to the demand for it, for
ture
1. 2. 3.
Cook, A. R. J. trop. Med. Hyg. 1901, 4, 175. Davies, J. N. P., Elmes, S., Hutt, M. S. R., Mtimavalye, L. A. R., Owor, R., Shaper, L. Br. med. J. 1964, i, 259, 336. Smith, E. C., Elmes, B. G. T. Ann. trop. Med. Parasit. 1934, 28, 461.
4. Dunlop, D., Inch, R. S. Br. med. J. 1972, iii, 749. 5. Further and Higher Education; vol. I. Report from the Expenditure Committee. H.M. Stationery Office, 48-I. Dec. 8, 1972.
closer financial monitoring of higher education, and for students to be home-based. The latest annual report of the Universities Central Council on Admissions6 showed that while in general the demand for university places had fallen, the demand for places in medicine, dentistry, and health had actually exceeded the estimates by 224 places. A new university faculty of medicine is clearly needed to provide more doctors and to meet the increased demand A medical course at’the Open for medical training. University would certainly involve a lower capital cost, and a higher proportion of home-based students, than a new It would also have the advantage of course elsewhere. being likely to meet the requirement of 5600 hours of study which, according to Lord Bowden, the European Community is likely to ask of future medical students. Moreover, many of those wishing to take the course would be mature students and, judging from the membership of the Society for Open University Medical Sciences, most of them would already have extensive experience in auxiliary medical roles. There are two difficulties in the society’s way. It is competing against a demand for an Open University law faculty (even though the University Grants Committee has come out against any new law faculties, and is instead providing for a 30%increase in places on existing courses). The society also has to face the technical and organisational problem of achieving cooperation with the medical profession for the clinical part of the course. more
16 Station
Approach, Hayes, Bromley,
IVOR SHIPLEY.
Kent BR2 7EH.
TREATMENT OF DERMATITIS HERPETIFORMIS
SIR,-Dr Fry and his colleagues (Feb. 10, p. 288) are to be
congratulated on their latest paper on the relationship between gluten and dermatitis herpetiformis (D.H.). It is an excellent example of the value of not being stampeded into abandoning a sound opinion because favourable results are not immediately forthcoming. As they noted, not even all coeliac patients respond to a gluten-free diet (G.F.D.) and an appreciable number may take several years to get the maximum response. It is therefore not surprising that many patients with D.H. take many months or even years to become free of dapsone dependence. My own very limited clinical experience with G.F.D. confirms the findings of Dr Fry and his colleagues. I should like to commend two other points. Firstly they criticise the suggestion by Marks and Shuster that the natural history of D.H. results in greatly varying requirements of dapsone from time to time, suggesting that improvement with gluten withdrawal is due to spontaneous remission. I would support this criticism in general. I have studied a large number of cases of D.H. (well over 100) over 24 years, and for 19 of these years I have used dapsone extensively. There is no doubt that the dose from patient to patient varies very widely from as little as 50 mg. weekly to as much as 300 mg. daily. In a given individual, however, the controlling dose does remain remarkably constant. It may vary when what appeared to be periods of quiescence or increased activity are induced by other influences, such as febrile illnesses or pregnancy, but once the influence of these episodes disappears the maintenance dose will be almost always found to be similar to that used previously. The textbooks talk about spontaneous remission, a view repeated since the days of Duhring and Brocq, but I agree with Dr Fry and his colleagues that what is now commonly recognised as D.H. does not in general behave in this It is a remarkably persistent disorder. Should manner. 6. Universities Central Council
on
Admissions. Tenth Report 1971-72.