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Famous Hungarian physicians
Correspondence
Genetics of stroke Pankaj Sharma (June 5, 2004, p1839),1 in reviewing a genetics study of stroke in an isolated Icelandic population,2 commented that “Controversially, patients with haemorrhagic and all causes of ischaemic stroke . . . were combined” in the analysis. The researchers had made a whole genome scan for risk factors for the common types of stroke and identified a locus at 5q12 with an impressive lod score of 4·4. This fulfilled accepted criteria for high genome-wide significance. In a later report the researchers identified the responsible gene as probably PDE4E. I was equally fascinated by another aspect of Sharma’s Commentary: the suggestion of a common cause for both types of stroke, which (in Sharma’s words) “should be two distinct pathological processes”. In the 1960s, the late Drew Thomson and I3 examined the arterial supply of the brain in 94 cadavers at the Middlesex Hospital. We noted no significant difference in the amount and extent of stenotic or occlusive disease of cerebral arteries in the neck or within the skull, in people who had died with cerebral infarction and in those with intracerebral haemorrhage. We also collected from post-mortem records the details of 121 male and 105 female cadavers who had died with strokes.4 For each sex separately analysed, we noted no significant difference between the mean heart weight of those who had died with cerebral infarcts and those who had died with cerebral haemorrhage, although most people with strokes had been hypertensive and had heart weights greater than average. There are therapeutic implications if haemorrhage commonly follows ischaemic damage. People forget that lowering blood pressure protects against cerebral haemorrhage, which has nothing to do with preventing arteries bursting under pressure. Normal cerebral arteries can withstand a distending pressure of 2 atmospheres (1520 mm Hg) without leaking. Cerebral arteries leak because of previous ischaemic damage. The protective effect of lowering blood pressure trades on cerebral autoregulation and may also prevent damaging arterial spasm. www.thelancet.com Vol 364 August 14, 2004
Available data5 suggest that when blood pressure is reduced by sympatholytic drugs, by spinal anaesthesia, or by deliberate bleeding, cerebral blood flow (by Kety’s method) is substantially increased. The evidence convinces me that intracerebral haemorrhage and infarction both result from impaired blood supply to the brain. I look forward to clinical trials in stroke management in which not only blood-pressure-lowering but also thrombolytic drugs are given immediately after the event, without waiting for an MRI scan to exclude bleeding. One would only need to specify that there was no strong previous clinical evidence to suggest a subarachnoid leak of blood (such as young age or sudden extremely severe headache). Acute stroke is a treatable emergency almost comparable to cardiac arrest. Its effects can ruin lives. I am happy—in advance—to absolve publicly from blame any doctor who treats me (aged 77 years) for an acute stroke in this way. I contend that my risk of brain damage from bleeding will be more than offset by the reduced risk of permanently losing brain cells.
C John Dickinson [email protected] Wolfson Institure of Preventive Medicine, Queen Mary, London EC1M 6BQ, UK 1
2
3
4
5
Sharma P. Cracking the genetics of cerbrovascular disease. Lancet 2004; 363: 1839–40. Gretarsdottir S, Sveinbjornsdottir S, Johnsson HH, et al. Localisation of a susceptibility gene for common forms of stroke to 5q12. Am J Hum Genet 2002; 70: 593–603. Dickinson CJ, Thomson AD. A post mortem study of the main cerebral arteries with special reference to the cause of strokes. Clin Sci 1961; 20: 131–42. Dickinson CJ, Thomson AD. High blood pressure and stroke: necropsy study of heart-weight and left ventricular hypertrophy. Lancet 1960; 2: 342–45. Dickinson CJ. Neurogenic hypertension. Oxford: Blackwell Scientific Publications, 1965: 137.
Famous Hungarian physicians In Ed Holt’s Feature about the AIDS situation in Slovakia (May 22, p 1703),1 you display a list of “famous Slovak physicians”. I wish to point out that some of
these clinicians and scientists were in fact Hungarian. The area known as Slovakia today was an integral part of Hungary for more than a millennium, right up to the conclusion of the treaty of Trianon in 1920. Árpád Gerster (born in Kassa, now Kosice) emigrated from his native Hungary to the USA in 1873, a half-century before the disintegration of Austria-Hungary. Subsequently, he introduced thoracic surgery to Mount Sinai Medical School and became the President of the American Surgical Society. However, he maintained strong ties with Hungary. In the USA, he cared for poor Hungarian immigrants and for this charitable work he received acknowledgments from his native country.2 His pioneering professional work (as well as his Hungarian ethnic origin) was recently acknowledged again.3 János (or Hans, as his mother was Austrian) Selye was likewise erroneously mentioned among famous Slovak physicians. The “father of stress”, János Selye also immigrated to the USA. Here, in 1980, he became Honorary President of the Hungarian Medical Association of America, a position he accepted with great pride and affection. In his hometown of Komárom (Komarno), a hospital, a Hungarian-language high school, and now, after decades of desperate political struggle, the first Hungarian-language university in Slovakia bears his name.
András Mogyorósi [email protected] Division of Nephrology, Virginia Commonwealth University/Medical College of Virginia and McGuire VAMC, Richmond, VA 23249, USA 1
2 3
Holt E. Slovakia has kept AIDS out despite money problems. Lancet 2004; 363: 1703–06. Rutkow IM. American surgical biographies. Surg Clin North Am 1987; 67: 1153–80. Kirschner PA. The history of thoracic surgery at Mount Sinai. Mt Sinai J Med 2003; 70: 326–32.
I enjoyed Agnes Csonka’s Feature on the Hungarian health system (June 12, p 1957).1 Her list of famous Hungarian physicians based on international reputation does not agree with the official national list, but is in my opinion an improvement. 581
Genetics of stroke Pankaj Sharma (June 5, 2004, p1839),1 in reviewing a genetics study of stroke in an isolated Icelandic population,2 commented that “Controversially, patients with haemorrhagic and all causes of ischaemic stroke . . . were combined” in the analysis. The researchers had made a whole genome scan for risk factors for the common types of stroke and identified a locus at 5q12 with an impressive lod score of 4·4. This fulfilled accepted criteria for high genome-wide significance. In a later report the researchers identified the responsible gene as probably PDE4E. I was equally fascinated by another aspect of Sharma’s Commentary: the suggestion of a common cause for both types of stroke, which (in Sharma’s words) “should be two distinct pathological processes”. In the 1960s, the late Drew Thomson and I3 examined the arterial supply of the brain in 94 cadavers at the Middlesex Hospital. We noted no significant difference in the amount and extent of stenotic or occlusive disease of cerebral arteries in the neck or within the skull, in people who had died with cerebral infarction and in those with intracerebral haemorrhage. We also collected from post-mortem records the details of 121 male and 105 female cadavers who had died with strokes.4 For each sex separately analysed, we noted no significant difference between the mean heart weight of those who had died with cerebral infarcts and those who had died with cerebral haemorrhage, although most people with strokes had been hypertensive and had heart weights greater than average. There are therapeutic implications if haemorrhage commonly follows ischaemic damage. People forget that lowering blood pressure protects against cerebral haemorrhage, which has nothing to do with preventing arteries bursting under pressure. Normal cerebral arteries can withstand a distending pressure of 2 atmospheres (1520 mm Hg) without leaking. Cerebral arteries leak because of previous ischaemic damage. The protective effect of lowering blood pressure trades on cerebral autoregulation and may also prevent damaging arterial spasm. www.thelancet.com Vol 364 August 14, 2004
Available data5 suggest that when blood pressure is reduced by sympatholytic drugs, by spinal anaesthesia, or by deliberate bleeding, cerebral blood flow (by Kety’s method) is substantially increased. The evidence convinces me that intracerebral haemorrhage and infarction both result from impaired blood supply to the brain. I look forward to clinical trials in stroke management in which not only blood-pressure-lowering but also thrombolytic drugs are given immediately after the event, without waiting for an MRI scan to exclude bleeding. One would only need to specify that there was no strong previous clinical evidence to suggest a subarachnoid leak of blood (such as young age or sudden extremely severe headache). Acute stroke is a treatable emergency almost comparable to cardiac arrest. Its effects can ruin lives. I am happy—in advance—to absolve publicly from blame any doctor who treats me (aged 77 years) for an acute stroke in this way. I contend that my risk of brain damage from bleeding will be more than offset by the reduced risk of permanently losing brain cells.
C John Dickinson [email protected] Wolfson Institure of Preventive Medicine, Queen Mary, London EC1M 6BQ, UK 1
2
3
4
5
Sharma P. Cracking the genetics of cerbrovascular disease. Lancet 2004; 363: 1839–40. Gretarsdottir S, Sveinbjornsdottir S, Johnsson HH, et al. Localisation of a susceptibility gene for common forms of stroke to 5q12. Am J Hum Genet 2002; 70: 593–603. Dickinson CJ, Thomson AD. A post mortem study of the main cerebral arteries with special reference to the cause of strokes. Clin Sci 1961; 20: 131–42. Dickinson CJ, Thomson AD. High blood pressure and stroke: necropsy study of heart-weight and left ventricular hypertrophy. Lancet 1960; 2: 342–45. Dickinson CJ. Neurogenic hypertension. Oxford: Blackwell Scientific Publications, 1965: 137.
Famous Hungarian physicians In Ed Holt’s Feature about the AIDS situation in Slovakia (May 22, p 1703),1 you display a list of “famous Slovak physicians”. I wish to point out that some of
these clinicians and scientists were in fact Hungarian. The area known as Slovakia today was an integral part of Hungary for more than a millennium, right up to the conclusion of the treaty of Trianon in 1920. Árpád Gerster (born in Kassa, now Kosice) emigrated from his native Hungary to the USA in 1873, a half-century before the disintegration of Austria-Hungary. Subsequently, he introduced thoracic surgery to Mount Sinai Medical School and became the President of the American Surgical Society. However, he maintained strong ties with Hungary. In the USA, he cared for poor Hungarian immigrants and for this charitable work he received acknowledgments from his native country.2 His pioneering professional work (as well as his Hungarian ethnic origin) was recently acknowledged again.3 János (or Hans, as his mother was Austrian) Selye was likewise erroneously mentioned among famous Slovak physicians. The “father of stress”, János Selye also immigrated to the USA. Here, in 1980, he became Honorary President of the Hungarian Medical Association of America, a position he accepted with great pride and affection. In his hometown of Komárom (Komarno), a hospital, a Hungarian-language high school, and now, after decades of desperate political struggle, the first Hungarian-language university in Slovakia bears his name.
András Mogyorósi [email protected] Division of Nephrology, Virginia Commonwealth University/Medical College of Virginia and McGuire VAMC, Richmond, VA 23249, USA 1
2 3
Holt E. Slovakia has kept AIDS out despite money problems. Lancet 2004; 363: 1703–06. Rutkow IM. American surgical biographies. Surg Clin North Am 1987; 67: 1153–80. Kirschner PA. The history of thoracic surgery at Mount Sinai. Mt Sinai J Med 2003; 70: 326–32.
I enjoyed Agnes Csonka’s Feature on the Hungarian health system (June 12, p 1957).1 Her list of famous Hungarian physicians based on international reputation does not agree with the official national list, but is in my opinion an improvement. 581