A PROFESSOR EMIGRATES

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316 A PROFESSOR EMIGRATES StR,—Professor McLachlan (March 27, p. 685) is a well- trained, gifted, mature radiologist with a desire to devote his professional life to the pursuit of the academic side of radio- logy. He was appointed to the chair at Leeds, which had been vacant for some time, and resigned because he was unable to see a convincing career prospect ahead of him. It is not, per- haps, without relevance that his other academic colleague is, likewise, emigrating. Most radiologists would be proud and delighted to have either of these two men associated with them. So, why are they emigrating? Professor Dudley (April 10, p. 795) writes from a well-estab- lished department, and in his comments on Professor McLach- lan’s reasons for departure he speaks from a position of strength, and with, I suspect, a total lack of appreciation of the problems involved. Some of these problems are outlined by Professor Brumfitt and his colleagues (May 15, p. 1072) in their letter-sympathetically because the problems of ancillary departments, especially those bearing on morale, are peculiar to themselves. Having been in British radiology for twenty-five years and at the very hub of it for ten, I feel there are certain points which need to be made to get the picture straight. The diagnostic side of the Faculty (now Royal College) of Radiologists has been pressing for academic departments, not just chairs, for over twenty years. The reasons were the same as those which justify the creation of any and all academic units anywhere. They were: because it was felt that radiology provides an ideal medium for teaching pathological processes to undergraduates; because radiology plays a large role in the care of patients and a knowledge of its use and abuse is, there- fore, a necessity in the education of most doctors; because it is a basic essential service, perhaps the most expensive one, the proper evolution of which should proceed logically and not to be left to the whims of individual interest, enthusiasm, and expertise; and because radiology provides valuable research opportunity in the study of many disease processes. These pressures have been blocked by three main counter- ing factors-lack of support by most of our clinical colleagues; the lure of private practice, at least in the London area; and luke-warm endorsement by influential radiotherapists. In Lon- don, two academic departments have evolved, one in a post- graduate school and one in a combined research and service hospital. They have both proved their worth. Two personal chairs have recently been awarded; one in a postgraduate and one in a neurological environment. Outside London, in con- trast, four academic departments have been developed in un- dergraduate teaching centres, to the credit of the universities and individuals concerned. Others are projected. But what went wrong at Leeds, as Professor Dudley asks? The matter at issue seems to be the basic requirements for academic departments in order that they may function success- fully. The appointment of one or two individuals in an N.H.S. or private practice milieu is not sufficient. The whole project must be properly planned and staffed, and so provided with space, facilities, and personnel that it may act as a centre of professional stimulation to the teaching hospital and surround- ing community. It seems that the basic requirement is four or five experts in general and specialised radiology of consultant level, with supporting junior staff. The academic base must comprise at least two non-committed radiographic rooms where specialised studies can be done without interfering with service requirements. There must be space for both teaching and research, a library, a photographic department, and so on. But this does not still touch the core of the problem when, in most instances, the department is to be grafted onto an estab- lished set-up-namely, the professor’s status and responsibili- ties with regard to the existing diagnostic department, its bud- get, staffing, and service requirements. This is thin ice, over which skating must take place if a working compromise is to result. In a new medical schoool, these matters may be settled by preliminary discussion, design, and planning, but when an aca- demic department is to be grafted onto an existing medical- school/hospital complex it is most unlikely that it will get enough space, staff, or money to give it a proper start. It will almost certainly have to evolve in an atmosphere of prejudice, reaction, and suspicion, especially if the personnel are brought in from outside. If there is a requirement for, and the means to afford, academic departments of radiology in Britain, let them be properly planned, staffed, and financed. There will be no dearth of first-class doctors to inhabit them and, carry worthily the torch of medical quality. Nor, I believe, will these doctors then wish to emigrate. Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, Connecticut 06510, U.S.A. JOHN HODSON ANÆMIA AND IMMUNE RESPONSE SIR,-Srikantia et al. have demonstrated impaired cell-me- diated immune response in nutritional anaemia. Experience with parenterally hyperalimented patients at this institution may lend support to their observations. 100 patients receiving total parenteral nutrition were stu- died retrospectively. Their ages ranged from 2 to 89 years with a mean of 51.8 years. Total parenteral nutrition was used for a variety of reasons. Three-quarters of the patients received parenteral nutrition in the preoperative and postoperative periods. Most patients had gastrointestinal disease (e.g., peptic ulcer, pancreatitis, regional enteritis, and diverticulitis) or malignancy. There were 7 episodes of’sepsis in this group of patients-5 with Candida, 1 with Pneumococcus, and 1 with Enterococcus. CHARACTERISTICS OF SEPTIC AND NON-SEPTIC GROUPS IN TOTAL PARENTERAL NUTRITION (T.P.N.): MEAN±S.E.M. Several factors distinguished the septic group of patients from the non-septic group (table). Among these were a longer duration of hyperalimentation, a lower serum-phosphorus, and a lower haematocrit. All other indices, including previous infection, prior antibiotic therapy, age, leucocyte-count, serum-creatinine, and serum-albumin were comparable in the, two groups. Anasmia may interfere with immune response as suggested by Srikantia et al. and by others.2 3 In addition, the observa- tions presented here suggest that anaemia may predispose to in- fection in hyperalimented patients. It must be emphasised, however, that other factors, such as hypophosphataemia, fre- quently accompany nutritional deficiency and may also play a role in the integrity of the immune system. It has been shown, for example, that chemotaxis of polymorphonuclear leucocytes is depressed in hypophosphataemia.4 Future studies must take into account the multiple interacting factors affecting host defence. Department of Medicine, University Hospitals of Cleveland, Cleveland, Ohio 44105, U.S.A. PHILIP J. SPAGNUOLO 1. Srikantia, S. G., Prasad, J. S., Bhaskaram, C., Krishnamachari, K. A. V. R. Lancet, 1976, i, 1307. 2. Joynson, D. H. M., Jacobs, A., Murraywalker, D., Dolby, A. E. ibid. 1972, ii, 1058. 3. Bhaskaram, C., Reddy, V. Br. med. J. 1975, iii, 552. 4. Craddock, R., Yawata, Y., VanSanten, L., Gilberstadt, S., Silvis, S., Jacob, H. S. New Engl. J. Med. 1974, 290, 1403.

Transcript of A PROFESSOR EMIGRATES

316

A PROFESSOR EMIGRATES

StR,—Professor McLachlan (March 27, p. 685) is a well-

trained, gifted, mature radiologist with a desire to devote hisprofessional life to the pursuit of the academic side of radio-logy. He was appointed to the chair at Leeds, which had beenvacant for some time, and resigned because he was unable tosee a convincing career prospect ahead of him. It is not, per-haps, without relevance that his other academic colleague is,likewise, emigrating. Most radiologists would be proud anddelighted to have either of these two men associated with them.So, why are they emigrating?

Professor Dudley (April 10, p. 795) writes from a well-estab-lished department, and in his comments on Professor McLach-lan’s reasons for departure he speaks from a position of

strength, and with, I suspect, a total lack of appreciation of theproblems involved. Some of these problems are outlined byProfessor Brumfitt and his colleagues (May 15, p. 1072) intheir letter-sympathetically because the problems of ancillarydepartments, especially those bearing on morale, are peculiarto themselves.

Having been in British radiology for twenty-five years andat the very hub of it for ten, I feel there are certain pointswhich need to be made to get the picture straight.The diagnostic side of the Faculty (now Royal College) of

Radiologists has been pressing for academic departments, notjust chairs, for over twenty years. The reasons were the sameas those which justify the creation of any and all academicunits anywhere. They were: because it was felt that radiologyprovides an ideal medium for teaching pathological processesto undergraduates; because radiology plays a large role in thecare of patients and a knowledge of its use and abuse is, there-fore, a necessity in the education of most doctors; because itis a basic essential service, perhaps the most expensive one, theproper evolution of which should proceed logically and not tobe left to the whims of individual interest, enthusiasm, andexpertise; and because radiology provides valuable researchopportunity in the study of many disease processes.These pressures have been blocked by three main counter-

ing factors-lack of support by most of our clinical colleagues;the lure of private practice, at least in the London area; andluke-warm endorsement by influential radiotherapists. In Lon-don, two academic departments have evolved, one in a post-graduate school and one in a combined research and servicehospital. They have both proved their worth. Two personalchairs have recently been awarded; one in a postgraduate andone in a neurological environment. Outside London, in con-trast, four academic departments have been developed in un-dergraduate teaching centres, to the credit of the universitiesand individuals concerned. Others are projected. But whatwent wrong at Leeds, as Professor Dudley asks?The matter at issue seems to be the basic requirements for

academic departments in order that they may function success-fully. The appointment of one or two individuals in an N.H.S.or private practice milieu is not sufficient. The whole projectmust be properly planned and staffed, and so provided withspace, facilities, and personnel that it may act as a centre ofprofessional stimulation to the teaching hospital and surround-ing community. It seems that the basic requirement is four orfive experts in general and specialised radiology of consultantlevel, with supporting junior staff. The academic base mustcomprise at least two non-committed radiographic rooms

where specialised studies can be done without interfering withservice requirements. There must be space for both teachingand research, a library, a photographic department, and so on.But this does not still touch the core of the problem when, inmost instances, the department is to be grafted onto an estab-lished set-up-namely, the professor’s status and responsibili-ties with regard to the existing diagnostic department, its bud-get, staffing, and service requirements. This is thin ice, overwhich skating must take place if a working compromise is toresult.

In a new medical schoool, these matters may be settled by

preliminary discussion, design, and planning, but when an aca-demic department is to be grafted onto an existing medical-school/hospital complex it is most unlikely that it will getenough space, staff, or money to give it a proper start. It willalmost certainly have to evolve in an atmosphere of prejudice,reaction, and suspicion, especially if the personnel are broughtin from outside. If there is a requirement for, and the meansto afford, academic departments of radiology in Britain, letthem be properly planned, staffed, and financed. There will beno dearth of first-class doctors to inhabit them and, carryworthily the torch of medical quality. Nor, I believe, will thesedoctors then wish to emigrate.Department of Diagnostic Radiology,Yale University School of Medicine,New Haven, Connecticut 06510, U.S.A. JOHN HODSON

ANÆMIA AND IMMUNE RESPONSE

SIR,-Srikantia et al. have demonstrated impaired cell-me-diated immune response in nutritional anaemia. Experiencewith parenterally hyperalimented patients at this institutionmay lend support to their observations.

100 patients receiving total parenteral nutrition were stu-died retrospectively. Their ages ranged from 2 to 89 years witha mean of 51.8 years. Total parenteral nutrition was used fora variety of reasons. Three-quarters of the patients receivedparenteral nutrition in the preoperative and postoperativeperiods. Most patients had gastrointestinal disease (e.g., pepticulcer, pancreatitis, regional enteritis, and diverticulitis) or

malignancy. There were 7 episodes of’sepsis in this group ofpatients-5 with Candida, 1 with Pneumococcus, and 1 withEnterococcus.

CHARACTERISTICS OF SEPTIC AND NON-SEPTIC GROUPS IN TOTAL

PARENTERAL NUTRITION (T.P.N.): MEAN±S.E.M.

Several factors distinguished the septic group of patientsfrom the non-septic group (table). Among these were a longerduration of hyperalimentation, a lower serum-phosphorus,and a lower haematocrit. All other indices, including previousinfection, prior antibiotic therapy, age, leucocyte-count,serum-creatinine, and serum-albumin were comparable in the,two groups.

Anasmia may interfere with immune response as suggestedby Srikantia et al. and by others.2 3 In addition, the observa-tions presented here suggest that anaemia may predispose to in-fection in hyperalimented patients. It must be emphasised,however, that other factors, such as hypophosphataemia, fre-quently accompany nutritional deficiency and may also play arole in the integrity of the immune system. It has been shown,for example, that chemotaxis of polymorphonuclear leucocytesis depressed in hypophosphataemia.4 Future studies must takeinto account the multiple interacting factors affecting hostdefence.

Department of Medicine,University Hospitals of Cleveland,Cleveland, Ohio 44105, U.S.A. PHILIP J. SPAGNUOLO

1. Srikantia, S. G., Prasad, J. S., Bhaskaram, C., Krishnamachari, K. A. V. R.Lancet, 1976, i, 1307.

2. Joynson, D. H. M., Jacobs, A., Murraywalker, D., Dolby, A. E. ibid. 1972,ii, 1058.

3. Bhaskaram, C., Reddy, V. Br. med. J. 1975, iii, 552.4. Craddock, R., Yawata, Y., VanSanten, L., Gilberstadt, S., Silvis, S., Jacob,

H. S. New Engl. J. Med. 1974, 290, 1403.