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TOO FEW NEUROPATHOLOGISTS
314
Atropine is a valuable drug in alleviating the circulatory ill-effects of slow heart rhythms, but its efficacy in preventing sudden death consequent on these arrhvthmias is not proven. Department of Medicine, Green Lane Hospital, Auckland, New Zealand.
R. M. NORRIS.
TOO FEW NEUROPATHOLOGISTS SIR Your recent annotation 1 deplores the grave dearth of neuropathologists in the country, and indeed none could dispute that the situation in this regard is lamentable. Yet, surely, when considering remedies we must look beyond administrative classifications and arrangements by which, within the National Health Service, a satisfactory number of neuropathologists could be assured. We must begin with a clear modern concept of what, in 1969, the term neuropathology " refers to. It is here submitted that such a concept must be something- more ambitious and farseeing than the annotation envisages if neuropathology is to be an active science seeking the advancement of knowledge, not merely, as is proposed, to benefit the thousands already disabled by nervous illness, and to serve the diagnostic needs " of clinicians, but to endeavour to see that in future thousands are not disabled by nervous illness. How very restricted is the outlook in the article here under consideration may be further seen when it specifies that the " most vital role of the neuropathologist is to meet the of the neurosurgeon, and after that those of needs diagnostic the neurologist, and then to use advances in knowledge to aid the disabled. How and by whom these advances are to be made is not mentioned. In short, what is regarded as the neuropathologist’s role is restricted in practice and subordinate intellectually. How can we ask any young and energetic man or woman, keen to, and capable of, forging new knowledge, to commit his or her life to a career that asks and offers no more than to be a skilled technician, for this is what is implicit in the document ? It would be surprising if the College of Pathologists would be willing to endorse this pedestrian assessment of the pathologist’s role in medicine. That there can be another and more realist and impressive view of the future of neuropathology, we find in a paper by a distinguished general pathologist with a special interest in neuropathology, the late Professor George Payling Wright, from which the following passage is taken: "
"
"
" Much of the information needed before investigation on the of the many important diseases can be undertaken lies in fields of physiology and biochemistry that have yet been little explored. It is only necessary to consult major journals of physiology to realise how large is the number of papers devoted to neurons and how small is that dealing with the complicated functional and metabolic activities of the equally important neuroglial cells ... Equally barren are the journals of biochemistry, in which a long search may disclose hardly a single article upon the important enzymes that participate in the synthesis and disruption of the myelin lipids ... Neuropathologists must seek to remedy such deficiencies by initiating researches in many neglected aspects of the normal function and metabolism of structural elements in the central nervous system. " Many of the problems that require solution, for instance, the behaviour of neuroglial cells in myelination, are of a very complicated nature and are unlikely to yield to attack by any single method of investigation ... Neuropathologists alone are in a position to recognize the problems awaiting investigation; they will have to enlist the collaboration, day by day, at the bench, of physiologists, embryologists and biochemists, if they are to have any reasonable expectation of solving them. The future progress of clinical neurology will depend very much upon the extent to which neuropathologists adapt themselves to widening horizons now opening through new and powerful techniques of experimentation ".2
pathogenesis
This, surely, is what neuropathology is all about, and what its study involves and offers for those who engage in it, and this is what it must be, over and above its role of meeting 1. Lancet, 1968, ii, 1383. 2. Payling Wright, G. in Modern Trends D. H. Collins); p. 227. London, 1959.
in
Pathology (edited by
diagnostic needs. Those who are competent to advance knowledge will accept no more restricted role for it amongst the medical sciences. I confess not to know how a true science of neuropathology be fitted into the rigidly stratified scheme of a National Health Service, nor indeed whether it could live within this framework. Probably, university departments of general pathology would be the necessary seed-bed for a new generation of neuropathologists adequately trained in general pathology first. Whether those so trained, and eager to advance knowledge, would be ready so to lower their sights as to remain content with the meeting of diagnostic needs as the be-all and end-all of their lives in pathology, is a dubious proposition. In offering and asking no more, the appeal for It is half a more neuropathologists will be self-defeating. century out of date. Brampton, F. M. R. WALSHE. Hunts. can
ANTICOAGULANTS IN RENAL FAILURE
SIR,-Dr. Kincaid-Smith and her colleagues1 report functional and histological improvement in patients with " irreversible renal failure treated with heparin. I have 2 that renal damage, which is caused by heterologous reported y-globulin in rabbits, is prevented by concomitant administration of heparin, but later, as yet unpublished, results indicate that dicoumarol is far less effective in such animals. I therefore suggest that heparin should continue to be the preferred drug for the apparently effective anticoagulant therapy of renal "
failure. New
York,
New York 10033.
SAUL B. GILSON.
CIGARETTE POISONING arising from the report on cannabis3 have confirmed the official view that known hazardous or toxic substances should not normally be administered to human beings, except under strictly defined conditions such as drug-taking under medical supervision. Some form of official action is also usual to delineate the degree of hazard of these toxic substances and to prevent misuse. Serious penalties are imposed by the Law on people who by carelessness, neglect, ignorance, or design injure the health of human beings. There is, however, a significant gap in social awareness, legislation, and action regarding a poison which is carcinogenic, addictive, and causes an excess of deaths from lung cancer, chronic bronchitis, and coronary thrombosis in those people who are exposed to its action. This poison causes not less than seven times as many deaths as road injuries,4 can be sold freely to the public; has no legally enforceable labelling about being carcinogenic, addictive, or a cause of excess mortality, and is advertised to the public without warning of its dangers. If an excess of deaths from lung cancer, chronic bronchitis, and coronary thrombosis was produced by a substance taken by mouth, or by an industrial process, or by another form of controllable atmospheric pollution, public outcry would probably be enormous-and rightly soespecially if little or no effective and significant official action were taken to eliminate the hazard. If a new substance which gave rise to similar effects was produced and had to be tested for use as a drug or as a fumigant to which human beings might be exposed, it would be rejected on account of its carcinogenic and other long-term toxic effects.
SIR,—The
recent events
1. Kincaid-Smith, P., Saker, B. M., Fairley, K. F. Lancet, 1968, ii, 1360 2. Gilson, S. Thromb. Diath. hœmorrh. 1961, 7, 157. 3. Cannabis. Report by the Advisory Committee on Drug Dependence. H.M. Stationery Office, 1969. See Lancet, Jan. 18, 1969, p. 139; ibid. Feb. 1, 1969, p. 246. 4. On the State of the Public Health. The Annual Report of the Chief Medical Officer of the Ministry of Health for the year 1967. H.M. Stationery Office, 1968.
Atropine is a valuable drug in alleviating the circulatory ill-effects of slow heart rhythms, but its efficacy in preventing sudden death consequent on these arrhvthmias is not proven. Department of Medicine, Green Lane Hospital, Auckland, New Zealand.
R. M. NORRIS.
TOO FEW NEUROPATHOLOGISTS SIR Your recent annotation 1 deplores the grave dearth of neuropathologists in the country, and indeed none could dispute that the situation in this regard is lamentable. Yet, surely, when considering remedies we must look beyond administrative classifications and arrangements by which, within the National Health Service, a satisfactory number of neuropathologists could be assured. We must begin with a clear modern concept of what, in 1969, the term neuropathology " refers to. It is here submitted that such a concept must be something- more ambitious and farseeing than the annotation envisages if neuropathology is to be an active science seeking the advancement of knowledge, not merely, as is proposed, to benefit the thousands already disabled by nervous illness, and to serve the diagnostic needs " of clinicians, but to endeavour to see that in future thousands are not disabled by nervous illness. How very restricted is the outlook in the article here under consideration may be further seen when it specifies that the " most vital role of the neuropathologist is to meet the of the neurosurgeon, and after that those of needs diagnostic the neurologist, and then to use advances in knowledge to aid the disabled. How and by whom these advances are to be made is not mentioned. In short, what is regarded as the neuropathologist’s role is restricted in practice and subordinate intellectually. How can we ask any young and energetic man or woman, keen to, and capable of, forging new knowledge, to commit his or her life to a career that asks and offers no more than to be a skilled technician, for this is what is implicit in the document ? It would be surprising if the College of Pathologists would be willing to endorse this pedestrian assessment of the pathologist’s role in medicine. That there can be another and more realist and impressive view of the future of neuropathology, we find in a paper by a distinguished general pathologist with a special interest in neuropathology, the late Professor George Payling Wright, from which the following passage is taken: "
"
"
" Much of the information needed before investigation on the of the many important diseases can be undertaken lies in fields of physiology and biochemistry that have yet been little explored. It is only necessary to consult major journals of physiology to realise how large is the number of papers devoted to neurons and how small is that dealing with the complicated functional and metabolic activities of the equally important neuroglial cells ... Equally barren are the journals of biochemistry, in which a long search may disclose hardly a single article upon the important enzymes that participate in the synthesis and disruption of the myelin lipids ... Neuropathologists must seek to remedy such deficiencies by initiating researches in many neglected aspects of the normal function and metabolism of structural elements in the central nervous system. " Many of the problems that require solution, for instance, the behaviour of neuroglial cells in myelination, are of a very complicated nature and are unlikely to yield to attack by any single method of investigation ... Neuropathologists alone are in a position to recognize the problems awaiting investigation; they will have to enlist the collaboration, day by day, at the bench, of physiologists, embryologists and biochemists, if they are to have any reasonable expectation of solving them. The future progress of clinical neurology will depend very much upon the extent to which neuropathologists adapt themselves to widening horizons now opening through new and powerful techniques of experimentation ".2
pathogenesis
This, surely, is what neuropathology is all about, and what its study involves and offers for those who engage in it, and this is what it must be, over and above its role of meeting 1. Lancet, 1968, ii, 1383. 2. Payling Wright, G. in Modern Trends D. H. Collins); p. 227. London, 1959.
in
Pathology (edited by
diagnostic needs. Those who are competent to advance knowledge will accept no more restricted role for it amongst the medical sciences. I confess not to know how a true science of neuropathology be fitted into the rigidly stratified scheme of a National Health Service, nor indeed whether it could live within this framework. Probably, university departments of general pathology would be the necessary seed-bed for a new generation of neuropathologists adequately trained in general pathology first. Whether those so trained, and eager to advance knowledge, would be ready so to lower their sights as to remain content with the meeting of diagnostic needs as the be-all and end-all of their lives in pathology, is a dubious proposition. In offering and asking no more, the appeal for It is half a more neuropathologists will be self-defeating. century out of date. Brampton, F. M. R. WALSHE. Hunts. can
ANTICOAGULANTS IN RENAL FAILURE
SIR,-Dr. Kincaid-Smith and her colleagues1 report functional and histological improvement in patients with " irreversible renal failure treated with heparin. I have 2 that renal damage, which is caused by heterologous reported y-globulin in rabbits, is prevented by concomitant administration of heparin, but later, as yet unpublished, results indicate that dicoumarol is far less effective in such animals. I therefore suggest that heparin should continue to be the preferred drug for the apparently effective anticoagulant therapy of renal "
failure. New
York,
New York 10033.
SAUL B. GILSON.
CIGARETTE POISONING arising from the report on cannabis3 have confirmed the official view that known hazardous or toxic substances should not normally be administered to human beings, except under strictly defined conditions such as drug-taking under medical supervision. Some form of official action is also usual to delineate the degree of hazard of these toxic substances and to prevent misuse. Serious penalties are imposed by the Law on people who by carelessness, neglect, ignorance, or design injure the health of human beings. There is, however, a significant gap in social awareness, legislation, and action regarding a poison which is carcinogenic, addictive, and causes an excess of deaths from lung cancer, chronic bronchitis, and coronary thrombosis in those people who are exposed to its action. This poison causes not less than seven times as many deaths as road injuries,4 can be sold freely to the public; has no legally enforceable labelling about being carcinogenic, addictive, or a cause of excess mortality, and is advertised to the public without warning of its dangers. If an excess of deaths from lung cancer, chronic bronchitis, and coronary thrombosis was produced by a substance taken by mouth, or by an industrial process, or by another form of controllable atmospheric pollution, public outcry would probably be enormous-and rightly soespecially if little or no effective and significant official action were taken to eliminate the hazard. If a new substance which gave rise to similar effects was produced and had to be tested for use as a drug or as a fumigant to which human beings might be exposed, it would be rejected on account of its carcinogenic and other long-term toxic effects.
SIR,—The
recent events
1. Kincaid-Smith, P., Saker, B. M., Fairley, K. F. Lancet, 1968, ii, 1360 2. Gilson, S. Thromb. Diath. hœmorrh. 1961, 7, 157. 3. Cannabis. Report by the Advisory Committee on Drug Dependence. H.M. Stationery Office, 1969. See Lancet, Jan. 18, 1969, p. 139; ibid. Feb. 1, 1969, p. 246. 4. On the State of the Public Health. The Annual Report of the Chief Medical Officer of the Ministry of Health for the year 1967. H.M. Stationery Office, 1968.