THE RETICULOSES

619

Letters

to

the Editor

" BACK TO FRONT ?

"

SiR,—Dr. Dornhorst is manifestly trailing his coat in his article in your educational number of Sept. 5, and it would be a pity to disappoint him. Because medicine was cradled in quackery and mere empiricism, and has only slowly and painfully won through to some sort of scientific basis, he would have our students recapitulate that grim history, starting with empiricism and working backwards into science ; he would have them parachuted into the jungle, to flail about in it for a year or two before being given even a glance or two at the maps. There is surely no real risk of the extreme turtle-turn he envisages in medical education ever taking place, but perhaps it is worth marshalling a few of the arguments. History is all against Dr. Dornhorst. Basically, he repeats the old arguments for the apothecaries and the barbers, who learnt by apprenticeship, as against the physicians and (later) the surgeons, who began by acquiring some theoretical knowledge. Those arguments were tenable up to about 1800, but by that time the basic sciences had reached the stage (Morgagni was the real turning-point) of being of real use to the practising physician. The legislation and the literature alike of the ensuing century leave no doubt that those who saw the products of the apprenticeship system and the academic system side by side were quite sure which produced the better doctor. And what, fundamentally speaking, has changed since thenY No matter how the course is reconstructed the student will always have more to learn than he conveniently can in the time. How is he likely to learn most : if his observations are presented to him as a nexus of empirical facts, organised only in so far as certain sequences of events are commoner than others and can therefore be exalted into nosographical entities, or if they are presented to him as being at least in part the logical consequences of what he has already learnt about the normal body and its behaviour under stress ? This question might even be susceptible of experiment. Let Dr. Dornhorst take a group of third-year students and teach them for a term about, say, tuberculosis : let him start with patients and let him diverge into the basic sciences only in so far as the study of his patients leads him. And let at the same time an equally competent and enthusiastic teacher take a second comparable group, and teach them for half a term in the laboratory about the tubercle bacillus, the pathology and immunology of tuberculosis, and the pharmacology of the relevant drugs, and then take them into the wards for the remaining half-term. If at the end of the term the first group remember more even of the strictly clinical aspects of tuberculosis than the second, then Dr. Dornhorst will have a case : and I will eat my hat. The most precious asset of a medical school is not its lecture-theatres and its laboratories but its hospital beds. The present system does at least ensure that the student arrives at the bedside with a prepared mind, determined to waste no minute of his time there. Dr. Dornhorst’s students in the wards would be twice as numerous and only half as keen. His specialty is at the moment the most exciting in medicine. The efflorescence of physiological methods of diagnosis and pharmacological methods of treatment in the last decade or two has made it natural, even justifiable, for physicians now to believe that they have more to give their students than anyone else. The best physicians nowadays are those who most successfully contrive to treat the rest of their school as one vast clinical sideroom to the medical wards-and I use the word " best " in no pejorative sense. But the extension of that most valuable attitude to the whole medical course argues

a

proportion. We morbid anatomists used to hospitals as mere adjuncts and receiving wards regard for our post-mortem rooms. We have learnt wisdom : and that is perhaps why so many good deans have started life as pathologists. Dr. Dornhorst’s system could have some wonderful results in other trades. Botanists would have to begin life as farmers and geologists as miners. The last subject to be taught to an accountant would be arithmetic, the last to be taught to an author writing, and the last to a Reader-reading ! want of our

,

Postgraduate Medical School

of London,

London, W.12.

BERNARD LENNOX.

Sin,—I have read with great interest Dr. Dornhorst’s article on a possible reorientation of the medical curriculum. Speaking both for myself and a great many other doctors, I would most strongly support his suggestion that the French system, under which the student begins straightway on the clinical subjects, should be widely adopted. Under our present system in this country the student scarcely comes in contact with a patient until he has been receiving so-called medical education for at least two years. He is given a great deal of instruction in what one may call the background of medicine without having any realisation of its relation to the problems with which he will ultimately have to deal. It is universally recognised that in order to secure the learner’s interest and cooperation it is essential that the information given should be in response to the demand coming from the student himself. Our present method of medical education is the exact opposite of. this, so that students feel that they are being crammed with an enormous amount of factual material for which they can see no possible use. By the time a student has completed the 2nd M.B. he is frequently nauseated with all this mental pabulum for which no " appetite sauce" has been created. In consequence he tends to reject it, that is to say forget it, as soon as he has passed his examination. By the time that he has completed his clinical studies he is beginning to ask the questions to which his He earlier studies could help to supply the answers. therefore has to revise, from quite a new approach, all that he learned and forgot in the first two years. This procedure is obviously extremely wasteful of time and energy both for the student and the teacher. Dr. Dornhorst’s suggestions would in my opinion be a far sounder way of teaching medicine and enlisting the interest and understanding of the student from the very beginning of his course. I hope that this most valuable suggestion will have due consideration in the investigations that will be carried out as a result of the first World Conference on Medical Education. DORIS M. ODLUM. London, W.9. THE RETICULOSES

SiR,—Some years ago a Cambridge journalwhich is too little known published an anonymous poem which 2 seems apposite to some of the points in Dr. lSra6lS’S2 interesting lecture on the reticuloses : The species of blackberry Are very apt to cross Leaving the systematists

Completely

at a

loss,

And distinction of varieties Is really quite imposs. !

Dr. Israels says that what contributed most to the abandonment of the classification which I put forward some fifteen years ago 3 is " that practical experience has shown how difficult it is to fit the changes seen in 1. Tea Phytologist, 1939, x + 1, no. 1, p. 13. 2. Lancet, Sept. 12, 1953, p. 525. 3. J. Path. Bact. 1938, 47, 457.

620 into so rigid a series of subdivisions." Yet his classification enumerates eight out of the fifteen categories of the 1938 classification ; and of the seven which he omits three are perfectly familiar to every histologist-reactive hyperplasia, sinus catarrh, and sarcoidosis-and the other four were stated in 1938 to be doubtful entities or only to occur under experimental conditions. He also says: " another reason for the eclipse of a classification based on morbid anatomy is the frequent failure to give a precise lead on prognosis and the best form of treatment." Although it is unreasonable to expect any classification to provide this very necessary information, yet that which he himself propounds categorises the entities by their histological characters and does not appear to provide any lead on prognosis or therapy. It does, however, introduce a new nomenclature into this field of medicine which has been bedevilled for the last sixty years with a plurality of terms. My 1938 classification of lympho-reticular disorders, which, as Bodley Scott4 observed, " avoids what the late Professor Whitehead called ’the fallacy of over was a heuristic experiment in histo simplification ’ logical methodology ; the subsequent experience of over 2000 cases, of which the majority have been under follow-up either to the present day or until death, suggests to me, at any rate, that it was a successful experiment. In many cases it is now possible to prognosticate the course of the disease on the basis of the biopsy findings, and, contrariwise, one can often foretell the probable histological changes by a study of the clinical manifestations. Naturally the experimental classification of 1938 did not prove to be perfect in practice. It- can be simplified, either because histological entities mentioned in it have proved to recur so infrequently that it is doubtful if they can be regarded as clinical entities, or because it has been found that certain of the histological subdivisions are not related to clearly defined disease processes, and so, even though their histological distinction is perfectly possible, it has, at any rate at the present time, no practical value ; lastly in one or two instances, clinicopathological entities of importance have been recognised which were not set out clearly in the original classification. A brief summary of the results of the first six years’ survey was publishedó some time ago, together with an attempt to set out analytical principles by which the histological diagnoses could be achieved ; detailed accounts of the natural history of the twelve main disease-groups, apart from the reactive, inflammatory, and storage disorders, are in course of preparation by my colleagues and myself. I think, apart from its apparent complexity, that the feature of my 1938 classification which most dismayed people was the nomenclature adopted ; these lengthy descriptive terms, like the labelling of German wines, were designed to give a precis of the salient features of each category but were far from euphonious. However, the problem was and still is what one should do : of specific aetiology we know nothing ; apart from Hodgkin’s disease, there were few eponyms available as many of the clinical entities were not then recognised ; nor have we the chemist’s advantage of a standardised symbolic shorthand. It is clear that the terms which I used originally could be shortened, and this I have endeavoured but whatever nomento do in subsequent writings ; clature is adopted, if it is to be meaningful, must be defined so precisely that it can be used by others, and that is the chief defect, as I see it, of Dr. Israels’s classification. From his accounts, I would have little idea what microscopical appearances I should expect to see in a biopsy so that I could inform him that it was a case of "giant-cell reticulosis," nor what clinical

lymph-glands

"

4. Scott, R. B. Brit. J. Radiol. 1951, 24, 475. 5. Recent Advances in Clinical Pathology. chapter 34.

London,

1947;

features would lead me to suspect that a patient was suffering from " the myeloid form of reticulum-cell

reticulosis." I fully realise that in a presidential address covering a broad field it is virtually impossible to enter inta descriptive minutiae, but in matters of classification and nomenclature, which we too often forget are very different things, we should remember the principles that

Sydenham6

set out for

writing the history of a disease:

" What short way-what way at all-is there towards either the detection of the morbific cause that we must fight against, or towards the indications of treatment which we must discover, except the sure and distinct perception of peculiar symptoms ? Upon each of these points the slightest and most unimportant circumstances have their proper bearings. Something in the way of variety we may refer to the particular temperament of individuals ; something also to the difference of treatment. Notwithstanding this, Nature, in the production of disease, is uniform and consistent; so much so, that for the same disease in different persons the symptoms are for the most part the same ; and the selfsame phenomena that you would observe in the sickness of a Socrates you would observe in the sickness of a simpleton. Just so the universal characters of a plant are extended to every individual of the species; and whoever (I speak in the way of illustration) should accurately describe the colour, the of one single violet, would taste, the smell, the figure, &c., find that his description held good, there or thereabouts, for all the violets of that particular species upon the face of the earth." Radcliffe Infirmary, Oxford.

A. H. T. ROBB-SMITH.

CORTISONE AND CORTICOTROPHIN IN BLOOD DISEASES

SiR,-The

comments and conclusions of your editorial

(Aug. 8), in regard to the hormonal treatment of idiopathic thrombocytopenic purpura and Schonlein-Henoch purpura, are of great interest. As is well pointed out, evaluation of therapeutic may be difficult indeed in diseases with a variable natural history and tendency to spontaneous remissions, and no proof is yet available that cortisone and corticotrophin in any way modify the fundamental pathogenetic mechanism of idiopathic thrombocytopenic purpura. I feel, however, that hormonal treatment of the disease should not be entirely disregarded or considered of only limited value. After Robson and Duthieit is generally admitted that cortisone and, particularly," corticotrophin"will, at high doses, increase " aspecifically (or, better, unexplainably ") the resistance of the capillary wall when this is reduced (as in idiopathic thrombocytopenic purpura). Furthermore, the clottingtime of whole blood may be accelerated. As a result of these and, possibly, other effects, the bleeding tendency of idiopathic thrombycytopenic purpura is reduced by the drugs. As you remark, we have found corticotrophin and cortisone therapy useful in : (a) control of bleeding in the acute cases of disease pending occurrence of spontaneous remission ; (b) preparation for splenectomy of chronic cases of the disease ; (c) control of severe bleeding in chronic cases which have failed to recover measures

following splenectomy. Furthermore, corticotrophin and cortisone appear to potentiate the beneficial effect of platelet transfusion, and we have often obtained the impression that their use accelerated the occurrence of spontaneous remissions. The beneficial effect on bleeding of corticotrophin and cortisone extends to other thrombocytopenic states, such as those due to acute leukaemia. We have thus far

obtained first remissions in 24 of 27 cases of

lymphocytic leukaemia in children, and repeated remissions in some of these by the use of aminopterin along with corticotrophin or cortisone. We feel that these favourable results are due, at least in part, to the control acute

6. The Works of Thomas Sydenham. London, 1848 ; vol. 1, p. 15. 7. Robson, H. N., Duthie, J. J. R. Brit. med. J. 1950, ii, 971.