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FUTURE OF POSTGRADUATE MEDICAL EDUCATION
1248 has been previously argued,l,6rather than to high plasmacholesterol. To conclude further that patients with this feature should not be candidates for heart transplantation seems unjustifiable, particularly since this patient did so well. Heart transplantation is a palliative procedure, and this lesion is similar to that which characteristically causes rejection in most allotransplanted organs in chronically, inadequately, immunosuppressed individuals. It was some time ago confidently predictedthat this would be the fate of long-surviving human allotransplanted hearts. It was, at the same time, concluded that the natural history of this particular involvement of the coronary system would follow the usual unpredictable course of coronary disease, and that, by allotransplanting a heart, one eventually brought the patient full circle back to coronary vascular occlusion. Professor Thomson’s lucid report fully confirms all that, so he may well ponder how the patient avoided infarction. It is surely the lipoprotein content 8 we should now be concerned with both from a clinical and an antigenic point of view. The thought has probably occurred to many people that, since the heart donor was an individual from a social group with a relatively low incidence of coronary sclerosis, this factor had a major influence on the allograft’s survival. The essential elements of arteriosclerosis are to be found in transplant obliterative disease; but the similarity probably ends there (a) because of the plasma-cell involvement, and (b) because narrowing is not an essential feature of coronary sclerosis,9 whereas it is always present in transplant obliterative disease (which is not just a simple organisation of mural thrombus). Are we not edging towards an immunological explanation of arteriosclerosis more profound than the milk-antibody theory 10 ? Are we looking at a perverted healing process, or is arteriosclerosis to be yet another autoimmune disease ? If so, are we witnessing a graft-versus-host reaction in organ allotransplants ? Any one for tennis-or lymphocyte typing ? Department of Surgery, Royal Postgraduate Medical School, W. J. DEMPSTER. London W.12. as
SIR,-Professor Thomson’s interesting report not only confirms the danger of putting old wine into new bottles, but, as he says, raises some important points in relation to the morphogenesis of atheroma. It has been shown that atheromatous changes develop following the repair of experimental endarterectomy in animals with induced hypercholesterxmia 11 and in the new formed intima of arterial homografts and synthetic prostheses in man.12 In a 63-year-old patient who died 18 months after endarterectomy for atherosclerotic narrowing of the internal carotid artery, it was possible to identify a new formed intima, nearly 2 mm. thick, which showed atheromatous changes.13 The appearance of the coronary vessels described by Professor Thomson-semi-translucent, distended with atheroma, extending to the apex of the heart-can also be seen in young adults with familial and secondary hypercholesteraemia, I have a section, almost identical with Professor Thomson’s second figure, from the heart of an untreated 26-year-old diabetic (a Christian Scientist) who died from myocardial ischemia. French, F. E. Pathologia Microbiol. 1967, 30, 653. Dempster, W. J. Br. med. J. 1968, i, 695. Brown, D. F. Am. J. Med. 1969, 46, 691. Duguid, J. B., Robertson, W. B. Lancet, 1957, i, 1205. Davies, D. F. J. atheroscler. Res. 1969, 10, 253. Gryeska, F. J. Surgery, Baltimore, 1959, 45, 655; Sabiston, D. C., Gatelius, J., Vasko, J. S. ibid. 1960, 48, 894. 12. Szclagyi, D. E., McDonald, R. T., Smith, R. F., Whitcomb, J. G. Archs Surg. 1957, 75, 506; Tibbs, D. J. Lancet, 1960, ii, 1313. 13. Gunning, A., Pickering, G., Robb-Smith, A., Russell, R. Q. Jl Med. 1964, 33, 155. 6. 7. 8. 9. 10. 11.
Professor Thomson’s findings in no way invalidate the Duguid hypothesis in respect of occlusive atherosclerosis, but re-emphasise the fallacy of assuming a unitary explanation for all forms of " degenerative " vascular disease. Department of Pathology, The Gibson Laboratories, Radcliffe Infirmary, A. H. T. ROBB-SMITH. Oxford.
FUTURE OF POSTGRADUATE MEDICAL EDUCATION
SIR,-Iwelcome Dame Janet Vaughan’s article (Nov. 8, 995) stimulating universities to provide postgraduate teaching. I would not, however, agree that the Todd p.
was unduly weighted in attention to the National Health Service, and I feel we need to be careful that we do not over-interpret the lead Dame Janet now seeks from universities. She quotes that we should not subordinate teaching to practice; but it would be equally unreasonable to subordinate practice to teaching. Surely we must see each member of the cooperative triad in terms of its full function-universities for teaching and research, the regional boards for staffing, and the Royal Colleges, through their close contact with practice, to set standards and define the useful advances which need to be taught. Unless these three are all in equilibrium I do not see that we can simultaneously provide a service, uphold standards, and sustain an instructional programme. To bridge administrative problems, I should like to see formal Health Service representation on university decision-making bodies, so that the universities are reminded of the nature of the task and the number of personel required if their discoveries and their teaching are to be put into practice. Department of Hæmatology,
Report
Stobhill General Hospital, Glasgow N.1.
MARY D. SMITH.
DENTAL ANÆSTHESIA SIR,-I was interested in your annotation on dental anxsthesia (Nov. 15, p. 1054), but feel that certain points arising from it need further clarification. Cardiac arrhythmias are known to accompany many minor surgical procedures, 1,2 and, indeed, are being increasingly documented during every-day activities.3.4Their significance, as a purely isolated finding, in patients without pre-existing cardiovascular disease, still remains highly debatable, and it seems unsound to evaluate different anaesthetic techniques simply on arrhythmia incidence, without regard to other cardiovascular parameters such as cardiac output and tissue blood-flow. At the Royal Dental Hospital, London, I recently monitored 300 outpatients having dental extractions under general anaesthesia consisting of nitrous oxide, oxygen, and halothane from a nosepiece.5 The overall arrhythmia-rate was 24% and multifocal ventricular ectopics accounted for 75% of the total. Approximately 10,000 general anaesthetics using this technique are administered every year at the Royal Dental Hospital, which means that roughly 2500 patients yearly are exhibiting these arrhythmias. Despite this, during the last 5-year period, involving 50,000 antsthetics, with 12,500 patients at arrhythmia risk, only one patient has required intensive resuscitation. This case probably followed a period of respiratory obstruction, and Usubiaga J. E., Gustafson W., Moya F., Goldstein H., Br. J. Anœsth. 1967, 39, 867. 2. Koster N., Neilsen S. E. Anœsthesia, 1968, 23, 27. 3. Taggart. P., Gibbons D., Somerville W. Br. med. J. 1969, 4, 130. 4. Wilde H. New Engl. J. Med. 1958, 258, 753. 5. Thurlow A. C. Proceedings of a Symposium on Methohexitone, 1969 (in the press) 1.
SIR,-Professor Thomson’s interesting report not only confirms the danger of putting old wine into new bottles, but, as he says, raises some important points in relation to the morphogenesis of atheroma. It has been shown that atheromatous changes develop following the repair of experimental endarterectomy in animals with induced hypercholesterxmia 11 and in the new formed intima of arterial homografts and synthetic prostheses in man.12 In a 63-year-old patient who died 18 months after endarterectomy for atherosclerotic narrowing of the internal carotid artery, it was possible to identify a new formed intima, nearly 2 mm. thick, which showed atheromatous changes.13 The appearance of the coronary vessels described by Professor Thomson-semi-translucent, distended with atheroma, extending to the apex of the heart-can also be seen in young adults with familial and secondary hypercholesteraemia, I have a section, almost identical with Professor Thomson’s second figure, from the heart of an untreated 26-year-old diabetic (a Christian Scientist) who died from myocardial ischemia. French, F. E. Pathologia Microbiol. 1967, 30, 653. Dempster, W. J. Br. med. J. 1968, i, 695. Brown, D. F. Am. J. Med. 1969, 46, 691. Duguid, J. B., Robertson, W. B. Lancet, 1957, i, 1205. Davies, D. F. J. atheroscler. Res. 1969, 10, 253. Gryeska, F. J. Surgery, Baltimore, 1959, 45, 655; Sabiston, D. C., Gatelius, J., Vasko, J. S. ibid. 1960, 48, 894. 12. Szclagyi, D. E., McDonald, R. T., Smith, R. F., Whitcomb, J. G. Archs Surg. 1957, 75, 506; Tibbs, D. J. Lancet, 1960, ii, 1313. 13. Gunning, A., Pickering, G., Robb-Smith, A., Russell, R. Q. Jl Med. 1964, 33, 155. 6. 7. 8. 9. 10. 11.
Professor Thomson’s findings in no way invalidate the Duguid hypothesis in respect of occlusive atherosclerosis, but re-emphasise the fallacy of assuming a unitary explanation for all forms of " degenerative " vascular disease. Department of Pathology, The Gibson Laboratories, Radcliffe Infirmary, A. H. T. ROBB-SMITH. Oxford.
FUTURE OF POSTGRADUATE MEDICAL EDUCATION
SIR,-Iwelcome Dame Janet Vaughan’s article (Nov. 8, 995) stimulating universities to provide postgraduate teaching. I would not, however, agree that the Todd p.
was unduly weighted in attention to the National Health Service, and I feel we need to be careful that we do not over-interpret the lead Dame Janet now seeks from universities. She quotes that we should not subordinate teaching to practice; but it would be equally unreasonable to subordinate practice to teaching. Surely we must see each member of the cooperative triad in terms of its full function-universities for teaching and research, the regional boards for staffing, and the Royal Colleges, through their close contact with practice, to set standards and define the useful advances which need to be taught. Unless these three are all in equilibrium I do not see that we can simultaneously provide a service, uphold standards, and sustain an instructional programme. To bridge administrative problems, I should like to see formal Health Service representation on university decision-making bodies, so that the universities are reminded of the nature of the task and the number of personel required if their discoveries and their teaching are to be put into practice. Department of Hæmatology,
Report
Stobhill General Hospital, Glasgow N.1.
MARY D. SMITH.
DENTAL ANÆSTHESIA SIR,-I was interested in your annotation on dental anxsthesia (Nov. 15, p. 1054), but feel that certain points arising from it need further clarification. Cardiac arrhythmias are known to accompany many minor surgical procedures, 1,2 and, indeed, are being increasingly documented during every-day activities.3.4Their significance, as a purely isolated finding, in patients without pre-existing cardiovascular disease, still remains highly debatable, and it seems unsound to evaluate different anaesthetic techniques simply on arrhythmia incidence, without regard to other cardiovascular parameters such as cardiac output and tissue blood-flow. At the Royal Dental Hospital, London, I recently monitored 300 outpatients having dental extractions under general anaesthesia consisting of nitrous oxide, oxygen, and halothane from a nosepiece.5 The overall arrhythmia-rate was 24% and multifocal ventricular ectopics accounted for 75% of the total. Approximately 10,000 general anaesthetics using this technique are administered every year at the Royal Dental Hospital, which means that roughly 2500 patients yearly are exhibiting these arrhythmias. Despite this, during the last 5-year period, involving 50,000 antsthetics, with 12,500 patients at arrhythmia risk, only one patient has required intensive resuscitation. This case probably followed a period of respiratory obstruction, and Usubiaga J. E., Gustafson W., Moya F., Goldstein H., Br. J. Anœsth. 1967, 39, 867. 2. Koster N., Neilsen S. E. Anœsthesia, 1968, 23, 27. 3. Taggart. P., Gibbons D., Somerville W. Br. med. J. 1969, 4, 130. 4. Wilde H. New Engl. J. Med. 1958, 258, 753. 5. Thurlow A. C. Proceedings of a Symposium on Methohexitone, 1969 (in the press) 1.