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AND TWO BACKWARDS
1263 of at least one month. Patients on long-continued therapy should have their renal function assessed; and impaired renal function should be added to the list of contraindications for its use in the first place. These contraindications already include known or suspected vascular disease, pregnancy, liver failure, and states of oederna or cachexia. Methysergide has not been proven beyond doubt to cause retroperitoneal fibrosis, and the incidence amongst the large numbers of patients treated is so low that it should not detract from the use of a valuable drug; but this is yet another warning to those who may be tempted too casually to write " rep. mist.".
TRANSPOSED GREAT ARTERIES
THE report from Great Ormond Street on p. 1233 of successful surgical treatment of transposed great arteries is exciting news, for this is a common congenital deformity of the heart-much commoner than it appears to be, because most of the affected children die in the first months of life.1 These are the first successes to be reported in this country, and there have been few elsewhere. In this disorder, although both ventricles and all four valves function well, the circulation is so grossly abnormal that few children survive more than a few months; and, as with so much heart-disease requiring treatment in early infancy, the lesions are often multiple. Treatment must therefore be undertaken in the first weeks of life if it is to succeed. A palliative operation has been needed to allow the children to survive until they are large enough to
undergo open-heart Creation of
an
using heart-lung bypass. septal defect has been widely palliative procedure since the first surgery
atrial
employed as a description by Blalock and Hanlon in 1950.2 But even in the most experienced hands the mortality-rate after this operation in infants is 25-50%. Two kinds of corrective operation have been tried. The
obvious method is to reverse the connections of the aorta and pulmonary artery, but this necessitates transferring the coronary arteries with the base of the aorta. Several techniques have been described,3-6 but none has yet
succeeded. The second method has been redirection of the venous inflow, either on the outer surface of the heart7 or within the atria. s-14 Senning 10 achieved the first clinical success; and Mustard’s technique has made this a reliable method, as the results of the Great Ormond Street team show. But it calls for a dangerous palliative operation in early infancy, and, if the vascular changes of pulmonary hypertension develop, the risks of open-heart surgery by present methods are much increased. Perhaps newer techniques of perfusion, such as the use of a membrane oxygenator, will improve the outlook. Certainly any 1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13.
14.
Fontana, R. S., Edwards, J. E. Congenital Cardiac Disease: A Review of 357 Case Studies Pathologically; p. 87. Philadelphia, 1962. Blalock, A., Hanlon, C. R. Surgery Gynec. Obstet. 1950, 90, 1. Mustard, W. T., Chute, A. L., Keith, J. D., Sirek, A., Rowe, R. D., Vlad, P. Surgery, 1954, 36, 39. Kay, E. B., Cross, F. S. ibid. 1955, 38, 712. Idriss, F. S., Goldstein, I. R., Grana, L., French, D., Potts, W. J. Circulation, 1961, 24, 5. Baffes, T. G., Ketola, F. H., Tatooles, C. H. Dis. Chest, 1961, 39, 648. Baffes, T. G. Surgery Gynec. Obstet. 1956, 102, 227. Albert, H. M. Surg. Forum, 1954, p. 74. Merendino, K. A., Jesseph, J. E., Herron, P. W., Thomas, G. I., Vetto, R. R. Surgery, 1957, 42, 898. Senning, A. ibid. 1959, 45, 966. Glotzer, P., Bloomberg, A. E., Hurwitt, E. S. Archs Surg., Chicago, 1960, 80, 12. Shumacker, H. B. Surgery, 1961, 50, 773. Barnard, C. N., Schrire, V., Beck, W. J. thorac. cardiovasc. Surg. 1962, 43, 768. Mustard, W. T. Surgery, 1964, 55, 469.
apparatus which provides prolonged assistance of the circulation will have a special contribution to make in these cases. If definitive surgery, instead of a palliative operation, could be performed in infancy, pulmonary hypertension would be much less likely to develop. The possibility of redirecting the great arteries will not be forgotten, but at present the risk of obstruction following anastomosis of small arteries, even by micro-techniques, is too great for anastomosis of coronary arteries to be
acceptable. The surgery of transposed great arteries still has a long way to go, but a promising start has been made. The British Heart Foundation, which supported the work at Great Ormond Street, has made a very rewarding investment.
...
AND TWO BACKWARDS
LAST week we expressed the hope that the council of the British Medical Association would decide, as has the General Medical Services Committee, that the unsigned forms of resignation from the National Health Service should be destroyed. The council has voted for their retention. The G.M.S.C. was apparently impressed by the negotiators’ solid conviction of the Government’s good intent. Dr. J. C. Cameron, the committee’s chairman, was sure that the whole of the Charter which the profession has placed before the Government was negotiable; and Dr. A. M. Maiden suggested that the value of the resignation forms, if kept, would in time become quite unreal.2 The truth is that, from now on, these forms will be not simply a wasting asset but a positive incubus. The determination of the Minister of Health to help in recasting general practice clearly matches the profession’s; and one way to hasten a satisfactory outcome, and implementation of the welcome new features that have already been agreed on, is for the profession to cast aside its continuing threat. It is difficult to conceive how the Minister could have gone further than he has in the past two months to meet the negotiators’ claims; and, if the entente which has evidently been established between the Ministry and the negotiators is to be maintained and strengthened, the profession should now make a gesture of trust. In proposing to keep a loaded pistol within reach while friendly and constructive talks proceed, the council is opting for a course that is both harmful and ridiculous. The medical profession lives, not in a vacuum, but in a society; and the B.M.A. would be foolish to ignore the firmness with which the lay Press has insisted that the resignation forms should now be
destroyed. Those wishing to retain the forms may feel that these would come in handy if the independent Review Body failed to make a satisfactory award on remuneration. But the Review Body’s report will appear a full year after the undated forms were signed; and no-one can reasonably expect that these old undated forms will necessarily be honoured in the altered conditions then prevailing. The negotiators’ joint report is to be considered by the Conference of Representatives of Local Medical Committees on June 16 and 17 and by a special representative meeting of the B.M.A. on June 23. We hope that sanity will prevail. 1. Lancet, June 5, 1965, p. 1203. 2. Br. med. J. June 5, 1965, Suppl. 3. ibid. p. 233.
p. 227.
TRANSPOSED GREAT ARTERIES
THE report from Great Ormond Street on p. 1233 of successful surgical treatment of transposed great arteries is exciting news, for this is a common congenital deformity of the heart-much commoner than it appears to be, because most of the affected children die in the first months of life.1 These are the first successes to be reported in this country, and there have been few elsewhere. In this disorder, although both ventricles and all four valves function well, the circulation is so grossly abnormal that few children survive more than a few months; and, as with so much heart-disease requiring treatment in early infancy, the lesions are often multiple. Treatment must therefore be undertaken in the first weeks of life if it is to succeed. A palliative operation has been needed to allow the children to survive until they are large enough to
undergo open-heart Creation of
an
using heart-lung bypass. septal defect has been widely palliative procedure since the first surgery
atrial
employed as a description by Blalock and Hanlon in 1950.2 But even in the most experienced hands the mortality-rate after this operation in infants is 25-50%. Two kinds of corrective operation have been tried. The
obvious method is to reverse the connections of the aorta and pulmonary artery, but this necessitates transferring the coronary arteries with the base of the aorta. Several techniques have been described,3-6 but none has yet
succeeded. The second method has been redirection of the venous inflow, either on the outer surface of the heart7 or within the atria. s-14 Senning 10 achieved the first clinical success; and Mustard’s technique has made this a reliable method, as the results of the Great Ormond Street team show. But it calls for a dangerous palliative operation in early infancy, and, if the vascular changes of pulmonary hypertension develop, the risks of open-heart surgery by present methods are much increased. Perhaps newer techniques of perfusion, such as the use of a membrane oxygenator, will improve the outlook. Certainly any 1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11. 12. 13.
14.
Fontana, R. S., Edwards, J. E. Congenital Cardiac Disease: A Review of 357 Case Studies Pathologically; p. 87. Philadelphia, 1962. Blalock, A., Hanlon, C. R. Surgery Gynec. Obstet. 1950, 90, 1. Mustard, W. T., Chute, A. L., Keith, J. D., Sirek, A., Rowe, R. D., Vlad, P. Surgery, 1954, 36, 39. Kay, E. B., Cross, F. S. ibid. 1955, 38, 712. Idriss, F. S., Goldstein, I. R., Grana, L., French, D., Potts, W. J. Circulation, 1961, 24, 5. Baffes, T. G., Ketola, F. H., Tatooles, C. H. Dis. Chest, 1961, 39, 648. Baffes, T. G. Surgery Gynec. Obstet. 1956, 102, 227. Albert, H. M. Surg. Forum, 1954, p. 74. Merendino, K. A., Jesseph, J. E., Herron, P. W., Thomas, G. I., Vetto, R. R. Surgery, 1957, 42, 898. Senning, A. ibid. 1959, 45, 966. Glotzer, P., Bloomberg, A. E., Hurwitt, E. S. Archs Surg., Chicago, 1960, 80, 12. Shumacker, H. B. Surgery, 1961, 50, 773. Barnard, C. N., Schrire, V., Beck, W. J. thorac. cardiovasc. Surg. 1962, 43, 768. Mustard, W. T. Surgery, 1964, 55, 469.
apparatus which provides prolonged assistance of the circulation will have a special contribution to make in these cases. If definitive surgery, instead of a palliative operation, could be performed in infancy, pulmonary hypertension would be much less likely to develop. The possibility of redirecting the great arteries will not be forgotten, but at present the risk of obstruction following anastomosis of small arteries, even by micro-techniques, is too great for anastomosis of coronary arteries to be
acceptable. The surgery of transposed great arteries still has a long way to go, but a promising start has been made. The British Heart Foundation, which supported the work at Great Ormond Street, has made a very rewarding investment.
...
AND TWO BACKWARDS
LAST week we expressed the hope that the council of the British Medical Association would decide, as has the General Medical Services Committee, that the unsigned forms of resignation from the National Health Service should be destroyed. The council has voted for their retention. The G.M.S.C. was apparently impressed by the negotiators’ solid conviction of the Government’s good intent. Dr. J. C. Cameron, the committee’s chairman, was sure that the whole of the Charter which the profession has placed before the Government was negotiable; and Dr. A. M. Maiden suggested that the value of the resignation forms, if kept, would in time become quite unreal.2 The truth is that, from now on, these forms will be not simply a wasting asset but a positive incubus. The determination of the Minister of Health to help in recasting general practice clearly matches the profession’s; and one way to hasten a satisfactory outcome, and implementation of the welcome new features that have already been agreed on, is for the profession to cast aside its continuing threat. It is difficult to conceive how the Minister could have gone further than he has in the past two months to meet the negotiators’ claims; and, if the entente which has evidently been established between the Ministry and the negotiators is to be maintained and strengthened, the profession should now make a gesture of trust. In proposing to keep a loaded pistol within reach while friendly and constructive talks proceed, the council is opting for a course that is both harmful and ridiculous. The medical profession lives, not in a vacuum, but in a society; and the B.M.A. would be foolish to ignore the firmness with which the lay Press has insisted that the resignation forms should now be
destroyed. Those wishing to retain the forms may feel that these would come in handy if the independent Review Body failed to make a satisfactory award on remuneration. But the Review Body’s report will appear a full year after the undated forms were signed; and no-one can reasonably expect that these old undated forms will necessarily be honoured in the altered conditions then prevailing. The negotiators’ joint report is to be considered by the Conference of Representatives of Local Medical Committees on June 16 and 17 and by a special representative meeting of the B.M.A. on June 23. We hope that sanity will prevail. 1. Lancet, June 5, 1965, p. 1203. 2. Br. med. J. June 5, 1965, Suppl. 3. ibid. p. 233.
p. 227.