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CEREBRAL INJURY FOLLOWING CARDIAC OPERATIONS
325
Letters
to
CEREBRAL
the Editor
INJURY FOLLOWING CARDIAC OPERATIONS
SI VIEILLESSE POUVAIT the SIR,-In House of Lords on Jan. 22 Lord Brain said: "General practice, as we know, is a strenuous life, and it is not unnatural that the older man and woman should feel that they have done a fair share of the more arduous part of it. But a reduction in their lists must mean a reduction in their earnings, which is contrary to the established practice in many other walks of life, and it is surely quite paradoxical
penalise in this way seniority and experience."1 May I put a different view which applies to all walks of life " ? It is that old men get too much. I do not deny the to
"
value of experience, but I think most doctors would agree that the prime of a doctor’s life is between 45 and 55 years of age. There are exceptions at both ends of the scale. At this time he is still energetic, still keeping up with modern medicine, reading as much as he did after qualifying, and asking his juniors to do less than he will in the next ten years. Moreover, in these ten years, or perhaps before, expenses are probably heaviest. The present generation of doctors marry and produce children at a much earlier age than those who qualified between the
Education bills
start 6 years or so after doctor has three children within marriage, and, assuming 7-10 years of marriage, these may continue for 24 years. Nowadays students get generous grants which pay almost all university costs. Those who have sons or daughters who become chartered accountants, lawyers, or doctors may have to continue paying for their children slightly longer. But if the doctor of today marries between the age of 23-27, and I think it is usually earlier, his education bills are over by the time he is 50. wars.
usually
a
By 55, whether he is in consulting or general practice, he will usually want to do a little less work, and in my opinion he will not mind earning less, provided his work of distinction in his forties and early fifties has been fully recognised. Lord Brain went on to say: I hope that my general practitioner colleagues have "
finally ruled out the possibility of some system of distinction awards. Though the system, as it is applied to consultants, would need to be modified, if the principle were accepted for general practice and, if an adequate amount of their remuneration was set aside for the purpose, I believe that it could be made to work and that it could be the system in general practice by which special merit, possibly combined with seniority, could be recognised." not
again " seniority " is singled out for special mention, although qualified by possibly ". I would like Here
"
all distinction awards to end at 60 but to start five years earlier. I realise that this would mean adjustments for pensions, but what is more important is that the scheme could not work unless the Treasury provided the money to allow the present distinction awards to continue until the recipients had reached the age of 65. Nevertheless this type of outlay has been provided before-e.g., to abolish the purchase and sale of practices. I remember Sir Will Spens saying how impressed he was by the high incidence of early coronaries among doctors. Would some such plan as I suggest help to avoid those stresses and strains in middle life which almost inevitably precede those catastrophes ? Even if it did not, I believe early recognition of distinction is desirable and that we should forget about seniority after 60, when indeed if it was not for the National Health Service most consultants alreadv would have retired. R. E. SMITH. Rugby 1.
Hansard, House of Lords, Jan. 22, 1964, col. 963-964.
SIR,-Mr. Williams comments that the rise in cerebrovascular resistance which accompanies intracarotid cooling can be prevented by the use of ganglion-blocking agents such as halothane. However, it has been shown that halothane reduces blood-flow through the cerebral cortex and increases cerebrovascular resistance in normothermic
dogs.l Mr. Williams reports that, in the dog, when cold blood is perfused into the brain, halothane anaesthesia increases by 37%
the blood-flow through the common carotid artery. But the anatomy of the carotid arterial tree of the dog is vastly different from that of man, in that extensive anastomoses exist between the internal and external systems.2 Because of the peripheral vasodilatation produced by halothane, as a result of central vasomotor depression and relaxation of vascular smoothmuscle,4 we would suggest that all the observed increases in carotid flow may well be due to a rise in the large extracranial component of flow in the common carotid artery. Mr. Williams has explained his finding of a reduction in common carotid flow during CO2 administration as being due to vasoconstriction in the muscle mass of the head and neck. By the same argument, could the increase in common carotid flow with halothane not be the result of vasodilatation in these same muscles ? We would question, therefore, whether one can use results obtained by this technique to indicate changes in cerebrovascular resistance. Departments of Anæsthetics and Surgery, Royal Infirmary, Glasgow, C.4.
D. G. MCDOWALL A. MURRAY HARPER.
MULTIPLE-CHOICE EXAMINATIONS
SIR,-May we attempt to answer Dr. McFie’s arguments (Jan. 25) against the multiple-choice examination paper, advocated by Sir Charles Illingworth (Dec. 14) ? Examinations have many subsidiary functions, of which the right direction of the learning processes of the student is one: but their primary aim is to test his knowledge and understanding of the subject. If they fail to do this reliably, if they give a misleading picture of his achievement, they are bad examinations. If they take an excessive amount of time to produce a reliable result, they are also bad. Now, it has been shown often enough that multiple-choice papers will give results which are much more accurate and reproducible than essay papers unless the number of essays is very large, and that (except with small classes) they save a great deal of time. Arguments from the United States, where their use may, in places, have got out of hand, or from elementary schools, may be very misleading. Weè showed some time agoand have recently confirmed,6 in a situation far more relevant to the present situation than those Dr. McFie quotes, that multiple-choice papers in class examinations were the best predictors of the performance of students in a subsequent professional examination in the same subject, though the latter contained only essay papers. The educational value of essay-writing is of course great,
and
we
The
have
never
advocated
abandoning it, preferring multiple-choice papers in parallel. complementary, the essay to set down his thoughts ability
to use essay and two are to some extent
always
testing the student’s clearly and in logical order and to draw conclusions; the objective paper has the advantages of testing knowledge over a wide field, and of being suited to analysis of students’ answers, which often reveal misconceptions arising from 1.
2. 3. 4. 5. 6.
McDowall, D. G., Harper, A. M., Jacobson, I. Brit. J. Anæsth. 1963, 35, 394. De La Torre, E., Netsky, M. G., Meschan, I. Amer. Anat. 1959, 105, 343. Burn, J. H., Epstein, H. G., Fagen, G. A., Paton, W. D. M. Brit. med. J. 1957, ii, 479. Burn, J. H., Epstein, H. G. Brit. J. Anæsth. 1959, 31, 199. Lennox, B., Anderson, J. R., Moorhouse, P. Lancet, 1957, ii, 396. Anderson, J. R., Lennox, B., Low, A. ibid. Jan. 11, 1964, p. 96.
Letters
to
CEREBRAL
the Editor
INJURY FOLLOWING CARDIAC OPERATIONS
SI VIEILLESSE POUVAIT the SIR,-In House of Lords on Jan. 22 Lord Brain said: "General practice, as we know, is a strenuous life, and it is not unnatural that the older man and woman should feel that they have done a fair share of the more arduous part of it. But a reduction in their lists must mean a reduction in their earnings, which is contrary to the established practice in many other walks of life, and it is surely quite paradoxical
penalise in this way seniority and experience."1 May I put a different view which applies to all walks of life " ? It is that old men get too much. I do not deny the to
"
value of experience, but I think most doctors would agree that the prime of a doctor’s life is between 45 and 55 years of age. There are exceptions at both ends of the scale. At this time he is still energetic, still keeping up with modern medicine, reading as much as he did after qualifying, and asking his juniors to do less than he will in the next ten years. Moreover, in these ten years, or perhaps before, expenses are probably heaviest. The present generation of doctors marry and produce children at a much earlier age than those who qualified between the
Education bills
start 6 years or so after doctor has three children within marriage, and, assuming 7-10 years of marriage, these may continue for 24 years. Nowadays students get generous grants which pay almost all university costs. Those who have sons or daughters who become chartered accountants, lawyers, or doctors may have to continue paying for their children slightly longer. But if the doctor of today marries between the age of 23-27, and I think it is usually earlier, his education bills are over by the time he is 50. wars.
usually
a
By 55, whether he is in consulting or general practice, he will usually want to do a little less work, and in my opinion he will not mind earning less, provided his work of distinction in his forties and early fifties has been fully recognised. Lord Brain went on to say: I hope that my general practitioner colleagues have "
finally ruled out the possibility of some system of distinction awards. Though the system, as it is applied to consultants, would need to be modified, if the principle were accepted for general practice and, if an adequate amount of their remuneration was set aside for the purpose, I believe that it could be made to work and that it could be the system in general practice by which special merit, possibly combined with seniority, could be recognised." not
again " seniority " is singled out for special mention, although qualified by possibly ". I would like Here
"
all distinction awards to end at 60 but to start five years earlier. I realise that this would mean adjustments for pensions, but what is more important is that the scheme could not work unless the Treasury provided the money to allow the present distinction awards to continue until the recipients had reached the age of 65. Nevertheless this type of outlay has been provided before-e.g., to abolish the purchase and sale of practices. I remember Sir Will Spens saying how impressed he was by the high incidence of early coronaries among doctors. Would some such plan as I suggest help to avoid those stresses and strains in middle life which almost inevitably precede those catastrophes ? Even if it did not, I believe early recognition of distinction is desirable and that we should forget about seniority after 60, when indeed if it was not for the National Health Service most consultants alreadv would have retired. R. E. SMITH. Rugby 1.
Hansard, House of Lords, Jan. 22, 1964, col. 963-964.
SIR,-Mr. Williams comments that the rise in cerebrovascular resistance which accompanies intracarotid cooling can be prevented by the use of ganglion-blocking agents such as halothane. However, it has been shown that halothane reduces blood-flow through the cerebral cortex and increases cerebrovascular resistance in normothermic
dogs.l Mr. Williams reports that, in the dog, when cold blood is perfused into the brain, halothane anaesthesia increases by 37%
the blood-flow through the common carotid artery. But the anatomy of the carotid arterial tree of the dog is vastly different from that of man, in that extensive anastomoses exist between the internal and external systems.2 Because of the peripheral vasodilatation produced by halothane, as a result of central vasomotor depression and relaxation of vascular smoothmuscle,4 we would suggest that all the observed increases in carotid flow may well be due to a rise in the large extracranial component of flow in the common carotid artery. Mr. Williams has explained his finding of a reduction in common carotid flow during CO2 administration as being due to vasoconstriction in the muscle mass of the head and neck. By the same argument, could the increase in common carotid flow with halothane not be the result of vasodilatation in these same muscles ? We would question, therefore, whether one can use results obtained by this technique to indicate changes in cerebrovascular resistance. Departments of Anæsthetics and Surgery, Royal Infirmary, Glasgow, C.4.
D. G. MCDOWALL A. MURRAY HARPER.
MULTIPLE-CHOICE EXAMINATIONS
SIR,-May we attempt to answer Dr. McFie’s arguments (Jan. 25) against the multiple-choice examination paper, advocated by Sir Charles Illingworth (Dec. 14) ? Examinations have many subsidiary functions, of which the right direction of the learning processes of the student is one: but their primary aim is to test his knowledge and understanding of the subject. If they fail to do this reliably, if they give a misleading picture of his achievement, they are bad examinations. If they take an excessive amount of time to produce a reliable result, they are also bad. Now, it has been shown often enough that multiple-choice papers will give results which are much more accurate and reproducible than essay papers unless the number of essays is very large, and that (except with small classes) they save a great deal of time. Arguments from the United States, where their use may, in places, have got out of hand, or from elementary schools, may be very misleading. Weè showed some time agoand have recently confirmed,6 in a situation far more relevant to the present situation than those Dr. McFie quotes, that multiple-choice papers in class examinations were the best predictors of the performance of students in a subsequent professional examination in the same subject, though the latter contained only essay papers. The educational value of essay-writing is of course great,
and
we
The
have
never
advocated
abandoning it, preferring multiple-choice papers in parallel. complementary, the essay to set down his thoughts ability
to use essay and two are to some extent
always
testing the student’s clearly and in logical order and to draw conclusions; the objective paper has the advantages of testing knowledge over a wide field, and of being suited to analysis of students’ answers, which often reveal misconceptions arising from 1.
2. 3. 4. 5. 6.
McDowall, D. G., Harper, A. M., Jacobson, I. Brit. J. Anæsth. 1963, 35, 394. De La Torre, E., Netsky, M. G., Meschan, I. Amer. Anat. 1959, 105, 343. Burn, J. H., Epstein, H. G., Fagen, G. A., Paton, W. D. M. Brit. med. J. 1957, ii, 479. Burn, J. H., Epstein, H. G. Brit. J. Anæsth. 1959, 31, 199. Lennox, B., Anderson, J. R., Moorhouse, P. Lancet, 1957, ii, 396. Anderson, J. R., Lennox, B., Low, A. ibid. Jan. 11, 1964, p. 96.