- Email: [email protected]
The Jubilee — Cherry, That Is
82
EDITORIALS
(There is convincing evidence of the physiologic advantage gained by an optimal P-R interval obtained by the synchronous pacemaker.P' (Another advantage is the avoidance of electronic interference, or pacer parasystole since the stimulus synchronizes with the P-waveJ These advantages are dampened to some extent by a longer thoracotomy time, or more complicated two catheter-one.,..atrial and one ventricular-pervenous placement. \Atrial fibrillation and atrial bradYxardia are contraindications of synchronous pacing. ) The ultimate in pacemaker therapy for complete heart block cannot be achieved as long as advantages of each system must be weighed against disadvantages. The same is true of electrode systems. Certainly pervenous electrode stimulation has limitations imposed by the possibility of perforation, migration, exit block, infection and fracture; while t~Only tecJinlcs likewise possess weD-known surgical complications. Although great strides have been made, further improvements are essential. The near future will certainly bring significant advances particularly in the areas of energy source and elimination of electrodes. Progress has already been made in the field of nuclear powered energy provided by plutonium atomic bombardment which, hopefully, will provide ten or more years of serviceable energy. Pacers activated by biologic energy have been shown experimentally to have depolarizing capability.\. Elimination of electrodes in the future may be achieved by high frequency penetrating energizing waves or other modalities. The goal toward perfection must necessarily arise from such progressive concepts and hopefully make obsolescent our currently employed methodology. However, in the United States, 10,000 people are annually rehabilitated and active, and have only the inconvenience of simple periodic replacement of the pacer.
David A. Nathan, MD., F.G.G.P.Miami Beach, Florida "From the Department of Medicine, Mount Sinai Hospital, Miami Beach, and the University of Miami School of Medicine. Coral Gables.
REFERENCES CHARDACIt, W. M., GAGE, A. A., AND GREATBATCH, W.: A transistorized self-contained implantable pacemaker for the long-term correction of complete heart b1ock, Surgery,
48:643,1960.
2 CARLETON, R. A., SESSIONS, R. T., AND GRAETI'INGElI, J. S Cardiac pacemake rs: Clinical and physiologic studies, Med. Clin. North America, 50:325, 1966, 3 LEMBERG, L., CASTELLANOS, A., JR., AND BERIroVITS, B. V.: Pacemaking on demand in AV block, I.A.MA,
191:106, 1965.
4 NATHAN, D., SAMET, P., CENTER, S., AND Wu, C. Y.:
2
Long-term correction of complete heart block, Progr. Cardiov. o«, 6:538. 1964. 5 CARLETON, M., PASSOVOY, M., AND GRAETTINGER, J. S.: The importance of the contribution and timing of left arterial systole, Clin. Science, 30:151, 1966. 6 SAMET, P., BER.N·STEIN, W., AND LEVINE,S.: Significance of the atrial contribution to ventricular filling, Amer. I. Cardiol., 15: 195, 1965. 7 SATINSKY, V., DREIFUS, L. S., RACINE, P., MASSI£, H. L., AND REYNOLDS, J.: Cardiac pacing by means of electrical energy derived directly from the heart, Surgery, 60:600. 1966. Reprint requests: Dr. Nathan. Mt. Sinai Hospital, Miami Beach 33140
The Jubilee -
I recently
Cherry. That Is
witnessed an impressive ritual which, though brief, was intense in feeling. It was performed in conjunction with a jubilee-but not the Biblical Jubilee or hallowed Freedom Year. The occasion was a banquet sponsored by a distinguishcd cardiologic society. Lights were dimmed at the conclusion of the main course and a smartly dressed group of waiters, proudly carrying giant sparklers, entered the hall. The story may be apocryphal, but I was told that several guests heard hushed strains of the second movement of Beethoven's Seventh Symphony; others reported hearing Colonel Bogey's March, This exquisitely organized pomp was arranged to introduce the assemhlage to the piece de resistance, that gastronomic deli~ht. cherries jubilee. \Vhat nutritional significance can one attach to the pink and white delicacy provided for each deserving guest? The total calories, per individual serving, arc approximately 302. In the ice cream, the saturated fat content is 7 per cent, unsaturated fats 4 per cent, and there is a tract' of polyunsaturated fatty acids. How ironic that r affaire cherries jubilee should have occurred 24 hours after a panel discussion on the risk factors in coronary heart disease, in which the participants paid particular attention to the high fat content of the average American meal. Lest these comments be interpreted as censure of only one or two societies, I affirm hastily that in my experience, "general arrangements committees" of all cardiologic and cardiopulmonary organizations have encouraged these culinary practices. A final judgment concerning the role of diet in the pathogenesis of atherosclerosis has not yet been rendered. There are few, however, who would disagree with the following recommendations proposed by an authoritative committee. 'The public is therefore advised: to eat less animal (saturated) DIS. CHEST, VOL. 54, NO.2, AUGUST 1968
83
EDITORIALS fat; to increase the intake of unsaturated vegetable oils and other polyunsaturated fats substituting them for saturated fats; whenever possible, to eat less food rich in cholesterol-and to apply these dietary recommendations early in life."! In spite of commendable, pioneering efforts to comply with this statement, I have been startled to find an appallingly high content of fat in the luncheons and dinners served at some official functions of the committee's sponsoring body. Obviously, it is not reasonable to condemn a particular dessert or a single meal, since it is the total dietary program which is of prime importance. However, those who have attended a four-day convention or postgraduate course appreciate how often each day the dietary recommendations cited are ignored. One need not be a devotee of diets with specific PIS ratios, or indeed, give credence to the concept of cholesterol as a causative factor in coronary heart disease to appreciate the disadvantages of meals with high fat content. Surely, the sedentary role imposed upon many professionals is challenge enough with regard to weight control, without the added burden of this type of hotel fare. How long must we accept, without complaint, time-honored but tedious menus of untrimmed steak, vegetables inundated in hutter and ice cream sundaes? The time has come to challenge the ingenuity of hotel chefs by requesting more fruit desserts, and entrees prepared in accordance with current, cardiologic tenets. In the meantime. (until the menus are changed) I must recommend with chagrin that if, indeed, the physician occupies a crucial, exemplar role for patients, it would be best if few nonmedical individuals attended these functions.
Alfred Soffer, M.D., F.C.C.P. Chicago Diet and Heart Disease: Report of the Committee on Nutrition authorized by the Central Committe for Medical and Community Program of the American Heart Association - 1965.
Maimonides: Rabbi and Physician Maimonides stands out as a notable figure among the physicians in the pre-modern era who understood the indissoluble link between the psyche and bodily ills. As an author, Maimonides repeatedly described the relationship between emotional and physical well-being, and as a clinician, he treated his patients in accordance with these concepts. He rejected the temptation to follow therapeutic cults of the 11th and 12th centurv and instead treated each patient as an individual. This is why the meDIS. CHEST, VOL. 54, NO.2, AUGUST 1968
dieval Arabic poet AI Sa id ibu Sural al Mulk wrote, "Galen's art healed only the body, but Abu Imrarn's (Maimonides) the body and the soul." Maimonides, the greatest physician of medieval Jewry, considered medicine to be a study of health, as well as disease, with the stress laid upon the former. His teaching resulted in a trend toward preventive medicine with a dietary rather than a pharmaceutical emphasis. There has been a considerable amount of interest in recent decades in the medical writings of Maimonides. Many scholars consider Sussman Muntner, M.D. of Jerusalem, Israel to be the world's authority in this sphere. A distinguished linguist, Dr. Muntner has spent half of a century studying and translating Maimonides' medical works. Becentlv, the Editorial Board of Diseases of the Chest invited Dr. Muntner to prepare a commentary on Maimonides' treatise on asthma. We are honored by his acceptance of our invitation and are pleased that his communication graces this issue. (p.I28). A. S.
The follou:ing communication by Dr. Kennedy reports one point of view; other viewpoints (some of them in opposition to Dr. Kennedy's position) will be published in forthcoming issues of Diseases of the Chest.-Editor.
Artificial Heart or Someone Else's; Which Path? The advent of a series!" of successful short-term human cardiac homotransplants by several teams during the last six months has brought about a controversy as to the direction which teleologic laboratory investigation should take for a method of treatment of the one group of cardiac patients for whom contemporary cardiac surgery has little to offer: those with bad myocardium. Whether laboratory effort and concomitant expense should be continued toward development of an intracorporeal cardiac prosthesis now that "successful" human cardiac homotransplantation has become a reality is a question which must concern all ~vho are reo sponsible for the direction or funding of research in diseases of the heart. The case for transplantation: While envisioned by Carrel' 60 years ago, clinical isotopic cardiac transplantation culminated over seven years of experimental work by several laboratories. In 1960, Lower and Shumway" reported survival of dogs six to 21 days following orthotopic heart transplantation. With the addition of methotrexate, Blumen-
3
EDITORIALS
(There is convincing evidence of the physiologic advantage gained by an optimal P-R interval obtained by the synchronous pacemaker.P' (Another advantage is the avoidance of electronic interference, or pacer parasystole since the stimulus synchronizes with the P-waveJ These advantages are dampened to some extent by a longer thoracotomy time, or more complicated two catheter-one.,..atrial and one ventricular-pervenous placement. \Atrial fibrillation and atrial bradYxardia are contraindications of synchronous pacing. ) The ultimate in pacemaker therapy for complete heart block cannot be achieved as long as advantages of each system must be weighed against disadvantages. The same is true of electrode systems. Certainly pervenous electrode stimulation has limitations imposed by the possibility of perforation, migration, exit block, infection and fracture; while t~Only tecJinlcs likewise possess weD-known surgical complications. Although great strides have been made, further improvements are essential. The near future will certainly bring significant advances particularly in the areas of energy source and elimination of electrodes. Progress has already been made in the field of nuclear powered energy provided by plutonium atomic bombardment which, hopefully, will provide ten or more years of serviceable energy. Pacers activated by biologic energy have been shown experimentally to have depolarizing capability.\. Elimination of electrodes in the future may be achieved by high frequency penetrating energizing waves or other modalities. The goal toward perfection must necessarily arise from such progressive concepts and hopefully make obsolescent our currently employed methodology. However, in the United States, 10,000 people are annually rehabilitated and active, and have only the inconvenience of simple periodic replacement of the pacer.
David A. Nathan, MD., F.G.G.P.Miami Beach, Florida "From the Department of Medicine, Mount Sinai Hospital, Miami Beach, and the University of Miami School of Medicine. Coral Gables.
REFERENCES CHARDACIt, W. M., GAGE, A. A., AND GREATBATCH, W.: A transistorized self-contained implantable pacemaker for the long-term correction of complete heart b1ock, Surgery,
48:643,1960.
2 CARLETON, R. A., SESSIONS, R. T., AND GRAETI'INGElI, J. S Cardiac pacemake rs: Clinical and physiologic studies, Med. Clin. North America, 50:325, 1966, 3 LEMBERG, L., CASTELLANOS, A., JR., AND BERIroVITS, B. V.: Pacemaking on demand in AV block, I.A.MA,
191:106, 1965.
4 NATHAN, D., SAMET, P., CENTER, S., AND Wu, C. Y.:
2
Long-term correction of complete heart block, Progr. Cardiov. o«, 6:538. 1964. 5 CARLETON, M., PASSOVOY, M., AND GRAETTINGER, J. S.: The importance of the contribution and timing of left arterial systole, Clin. Science, 30:151, 1966. 6 SAMET, P., BER.N·STEIN, W., AND LEVINE,S.: Significance of the atrial contribution to ventricular filling, Amer. I. Cardiol., 15: 195, 1965. 7 SATINSKY, V., DREIFUS, L. S., RACINE, P., MASSI£, H. L., AND REYNOLDS, J.: Cardiac pacing by means of electrical energy derived directly from the heart, Surgery, 60:600. 1966. Reprint requests: Dr. Nathan. Mt. Sinai Hospital, Miami Beach 33140
The Jubilee -
I recently
Cherry. That Is
witnessed an impressive ritual which, though brief, was intense in feeling. It was performed in conjunction with a jubilee-but not the Biblical Jubilee or hallowed Freedom Year. The occasion was a banquet sponsored by a distinguishcd cardiologic society. Lights were dimmed at the conclusion of the main course and a smartly dressed group of waiters, proudly carrying giant sparklers, entered the hall. The story may be apocryphal, but I was told that several guests heard hushed strains of the second movement of Beethoven's Seventh Symphony; others reported hearing Colonel Bogey's March, This exquisitely organized pomp was arranged to introduce the assemhlage to the piece de resistance, that gastronomic deli~ht. cherries jubilee. \Vhat nutritional significance can one attach to the pink and white delicacy provided for each deserving guest? The total calories, per individual serving, arc approximately 302. In the ice cream, the saturated fat content is 7 per cent, unsaturated fats 4 per cent, and there is a tract' of polyunsaturated fatty acids. How ironic that r affaire cherries jubilee should have occurred 24 hours after a panel discussion on the risk factors in coronary heart disease, in which the participants paid particular attention to the high fat content of the average American meal. Lest these comments be interpreted as censure of only one or two societies, I affirm hastily that in my experience, "general arrangements committees" of all cardiologic and cardiopulmonary organizations have encouraged these culinary practices. A final judgment concerning the role of diet in the pathogenesis of atherosclerosis has not yet been rendered. There are few, however, who would disagree with the following recommendations proposed by an authoritative committee. 'The public is therefore advised: to eat less animal (saturated) DIS. CHEST, VOL. 54, NO.2, AUGUST 1968
83
EDITORIALS fat; to increase the intake of unsaturated vegetable oils and other polyunsaturated fats substituting them for saturated fats; whenever possible, to eat less food rich in cholesterol-and to apply these dietary recommendations early in life."! In spite of commendable, pioneering efforts to comply with this statement, I have been startled to find an appallingly high content of fat in the luncheons and dinners served at some official functions of the committee's sponsoring body. Obviously, it is not reasonable to condemn a particular dessert or a single meal, since it is the total dietary program which is of prime importance. However, those who have attended a four-day convention or postgraduate course appreciate how often each day the dietary recommendations cited are ignored. One need not be a devotee of diets with specific PIS ratios, or indeed, give credence to the concept of cholesterol as a causative factor in coronary heart disease to appreciate the disadvantages of meals with high fat content. Surely, the sedentary role imposed upon many professionals is challenge enough with regard to weight control, without the added burden of this type of hotel fare. How long must we accept, without complaint, time-honored but tedious menus of untrimmed steak, vegetables inundated in hutter and ice cream sundaes? The time has come to challenge the ingenuity of hotel chefs by requesting more fruit desserts, and entrees prepared in accordance with current, cardiologic tenets. In the meantime. (until the menus are changed) I must recommend with chagrin that if, indeed, the physician occupies a crucial, exemplar role for patients, it would be best if few nonmedical individuals attended these functions.
Alfred Soffer, M.D., F.C.C.P. Chicago Diet and Heart Disease: Report of the Committee on Nutrition authorized by the Central Committe for Medical and Community Program of the American Heart Association - 1965.
Maimonides: Rabbi and Physician Maimonides stands out as a notable figure among the physicians in the pre-modern era who understood the indissoluble link between the psyche and bodily ills. As an author, Maimonides repeatedly described the relationship between emotional and physical well-being, and as a clinician, he treated his patients in accordance with these concepts. He rejected the temptation to follow therapeutic cults of the 11th and 12th centurv and instead treated each patient as an individual. This is why the meDIS. CHEST, VOL. 54, NO.2, AUGUST 1968
dieval Arabic poet AI Sa id ibu Sural al Mulk wrote, "Galen's art healed only the body, but Abu Imrarn's (Maimonides) the body and the soul." Maimonides, the greatest physician of medieval Jewry, considered medicine to be a study of health, as well as disease, with the stress laid upon the former. His teaching resulted in a trend toward preventive medicine with a dietary rather than a pharmaceutical emphasis. There has been a considerable amount of interest in recent decades in the medical writings of Maimonides. Many scholars consider Sussman Muntner, M.D. of Jerusalem, Israel to be the world's authority in this sphere. A distinguished linguist, Dr. Muntner has spent half of a century studying and translating Maimonides' medical works. Becentlv, the Editorial Board of Diseases of the Chest invited Dr. Muntner to prepare a commentary on Maimonides' treatise on asthma. We are honored by his acceptance of our invitation and are pleased that his communication graces this issue. (p.I28). A. S.
The follou:ing communication by Dr. Kennedy reports one point of view; other viewpoints (some of them in opposition to Dr. Kennedy's position) will be published in forthcoming issues of Diseases of the Chest.-Editor.
Artificial Heart or Someone Else's; Which Path? The advent of a series!" of successful short-term human cardiac homotransplants by several teams during the last six months has brought about a controversy as to the direction which teleologic laboratory investigation should take for a method of treatment of the one group of cardiac patients for whom contemporary cardiac surgery has little to offer: those with bad myocardium. Whether laboratory effort and concomitant expense should be continued toward development of an intracorporeal cardiac prosthesis now that "successful" human cardiac homotransplantation has become a reality is a question which must concern all ~vho are reo sponsible for the direction or funding of research in diseases of the heart. The case for transplantation: While envisioned by Carrel' 60 years ago, clinical isotopic cardiac transplantation culminated over seven years of experimental work by several laboratories. In 1960, Lower and Shumway" reported survival of dogs six to 21 days following orthotopic heart transplantation. With the addition of methotrexate, Blumen-
3