and economic purposes rather than as a means of elevating standards of practice. I have no objection to this, since an oversupply of practitioners in any type of work is wasteful in terms of both human endeavour and economics and leads to demands for higher fees. We shall then have the problem that licensing regulations that were designed mainly to measure competence to practice will be used for the economic purpose of controlling the supply of manpower. We may find that many of these are very "blunt instruments" to use for this purpose. It is probably true that once the "undifferentiated" physician has become "differentiated" he will find it difficult to move easily from one role to another. A surplus of one type of physician and a shortage of another may develop in the same place at the same time. To be successful as a regulatory mechanism, medical licensing provisions will have to be sufficiently sensitive to this fact. MICHAEL J.C. THOMSON, FRCP[C]
27 Simco. Place Halifax, NS
Megavitamins and transplants To the editor: My experience in treating chronic asthma with megadoses of the A and D vitamins and the minerals in bone has led me to believe that the distressing symptoms of this disease most frequently arise from a "deficiency reaction" compounding and aggravating an allergic reaction. This experience and this concept have led me to a similar hypothesis concerning the rejection syndrome. My hypothesis differs from that presented by Dr. Frank Small (Can Med Assoc J 112: 1046, 1975). Though the immune mechanism is involved in the rejection syndrome, I believe it is a mechanism so altered by chronic deficiency that the part it plays cannot be properly assessed until it is considered in the light of chronic deficiency. Moreover, as in chronic asthma, this altered immune mechanism is of secondary importance in the genesis of the rejection syndrome compared with the indirect and direct influence that the milieu of deficiency - the imbalance of the ionic bath - may have on the contractile macromolecules of the adaptive smooth muscle of the coronary arteries and arterioles and other tissues. It is this combined influence on muscle of autonomic adaptation and the direct effect of deficiency that transforms the physiologic adaptive constriction of conduits into pathologic spasm sufficient to produce asthma and the important constrictive element of coronary atherosclerosis.
The rejection of transplanted organs, I believe, is largely produced by the influence of chronic deficiency on the recipient rather than by the immune mechanism, although it does work in combination with an altered immunologic reaction. One of the essential considerations in preventing the rejection syndrome is to recognize and treat effectively the responsible deficiency state in the recipient months before he receives a transplant. CARL J. REICH, MD
205A Medical Centre Calgary, Alta.
Congenital absence of vas deferens To the editor: Congenital absence of the vas deferens, either unilateral or bilateral, is among the rare anomalies of the genitourinary tract. Before vasectomy became popular, such cases were all recorded in men who were investigated for infertility. However, even with the increase in the number of vasectomies performed over the last 10 years, the number of reported cases of congenital absence of the vas deferens has not increased; hence, the condition should still be considered rare. In a personal series of over 400 consecutive men undergoing vasectomy, 1 was found to have unilateral congenital absence of the vas deferens. A 34-year-old man requested a vasectomy. Examination of the scrotum at the preliminary interview revealed a normal vas deferens on the right side but the structures of the left spermatic cord could not be palpated separately and it was not certain whether the vas deferens was present. Testes, epididymides and prostate were all normal. Because it was believed it might be necessary to explore for the left vas deferens the patient was advised to have the vasectomy under general anesthesia. A right vasectomy was easily performed. A preliminary search through a small scrotal incision did not reveal a vas deferens on the left side. The incision was closed and a small inguinal incision made just lateral to the external ring. A more thorough search of the cord was unrewarding and unilateral absence of the vas deferens was confirmed. The patient was discharged home the same day. Three postoperative analyses of seminal fluid after 4 months revealed no sperm. Intravenous pyelography revealed no associated urologic anomalies. The mesonephros gives rise to the epididymis and its duct, the efferent ductules of the testis, the seminal yeside, the vas deferens, the trigone of the bladder and the collecting system of the kidney. Congenital absence of the vas deferens is due to maldevelopment of the mesonephros, and in about 30% of instances there are associated
ipsilateral urologic anomalies.1 It is difficult to explain the cases in which there are no associated anomalies of the ipsilateral urogenital system, but it is believed this can happen if there is secondary degeneration of the mesonephric duct.1 With the increasing number of vasectomies being performed the possibility of congenital absence of the vas deferens should be kept in mind and the patient examined carefully at the preliminary interview, especially for the ease with which the vas can be felt on either side. The operation should be performed under general anesthesia in all men in whom a vas deferens is difficult to feel. When congenital absence of the vas deferens is suspected, most surgeons investigating infertility rely on a thorough exploration of the scrotum, but during a vasectomy it is probably easier and better to explore the cord structures through a small inguinal incision. Thus the cord can be searched more thoroughly and oozing from the pampiniform plexus is prevented. The morbidity is less than with wide scrotal exploration and the patient can be discharged home the same day. Seminal analysis should be done about 3 months after the operation to ensure that the patient is azoospermic. It has been suggested that if intravenous pyelograpby is done before the operation in men with suspected unilateral absence of the vas deferens and if there is an ipsilateral urologic anomaly, exploration for the vas deferens can be avoided.2 K. GOPINATHA RAG, B SC, MS, FRCS, FRCS[C], FACS
Brandon Clinic, Brandon, Man.
References 1. MERREN DD, KELLY RA: Congenital absence of vas deferens: report of three cases. / Urol 68: 1, 1952 2. EMERY CB, GOLDSTEIN AMB, MORROW Jw: Congenital absence of vas deferens with ipsilateral urinary anomalies. Urology 4: 201, 1974
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27 Simco. Place Halifax, NS
Megavitamins and transplants To the editor: My experience in treating chronic asthma with megadoses of the A and D vitamins and the minerals in bone has led me to believe that the distressing symptoms of this disease most frequently arise from a "deficiency reaction" compounding and aggravating an allergic reaction. This experience and this concept have led me to a similar hypothesis concerning the rejection syndrome. My hypothesis differs from that presented by Dr. Frank Small (Can Med Assoc J 112: 1046, 1975). Though the immune mechanism is involved in the rejection syndrome, I believe it is a mechanism so altered by chronic deficiency that the part it plays cannot be properly assessed until it is considered in the light of chronic deficiency. Moreover, as in chronic asthma, this altered immune mechanism is of secondary importance in the genesis of the rejection syndrome compared with the indirect and direct influence that the milieu of deficiency - the imbalance of the ionic bath - may have on the contractile macromolecules of the adaptive smooth muscle of the coronary arteries and arterioles and other tissues. It is this combined influence on muscle of autonomic adaptation and the direct effect of deficiency that transforms the physiologic adaptive constriction of conduits into pathologic spasm sufficient to produce asthma and the important constrictive element of coronary atherosclerosis.
The rejection of transplanted organs, I believe, is largely produced by the influence of chronic deficiency on the recipient rather than by the immune mechanism, although it does work in combination with an altered immunologic reaction. One of the essential considerations in preventing the rejection syndrome is to recognize and treat effectively the responsible deficiency state in the recipient months before he receives a transplant. CARL J. REICH, MD
205A Medical Centre Calgary, Alta.
Congenital absence of vas deferens To the editor: Congenital absence of the vas deferens, either unilateral or bilateral, is among the rare anomalies of the genitourinary tract. Before vasectomy became popular, such cases were all recorded in men who were investigated for infertility. However, even with the increase in the number of vasectomies performed over the last 10 years, the number of reported cases of congenital absence of the vas deferens has not increased; hence, the condition should still be considered rare. In a personal series of over 400 consecutive men undergoing vasectomy, 1 was found to have unilateral congenital absence of the vas deferens. A 34-year-old man requested a vasectomy. Examination of the scrotum at the preliminary interview revealed a normal vas deferens on the right side but the structures of the left spermatic cord could not be palpated separately and it was not certain whether the vas deferens was present. Testes, epididymides and prostate were all normal. Because it was believed it might be necessary to explore for the left vas deferens the patient was advised to have the vasectomy under general anesthesia. A right vasectomy was easily performed. A preliminary search through a small scrotal incision did not reveal a vas deferens on the left side. The incision was closed and a small inguinal incision made just lateral to the external ring. A more thorough search of the cord was unrewarding and unilateral absence of the vas deferens was confirmed. The patient was discharged home the same day. Three postoperative analyses of seminal fluid after 4 months revealed no sperm. Intravenous pyelography revealed no associated urologic anomalies. The mesonephros gives rise to the epididymis and its duct, the efferent ductules of the testis, the seminal yeside, the vas deferens, the trigone of the bladder and the collecting system of the kidney. Congenital absence of the vas deferens is due to maldevelopment of the mesonephros, and in about 30% of instances there are associated
ipsilateral urologic anomalies.1 It is difficult to explain the cases in which there are no associated anomalies of the ipsilateral urogenital system, but it is believed this can happen if there is secondary degeneration of the mesonephric duct.1 With the increasing number of vasectomies being performed the possibility of congenital absence of the vas deferens should be kept in mind and the patient examined carefully at the preliminary interview, especially for the ease with which the vas can be felt on either side. The operation should be performed under general anesthesia in all men in whom a vas deferens is difficult to feel. When congenital absence of the vas deferens is suspected, most surgeons investigating infertility rely on a thorough exploration of the scrotum, but during a vasectomy it is probably easier and better to explore the cord structures through a small inguinal incision. Thus the cord can be searched more thoroughly and oozing from the pampiniform plexus is prevented. The morbidity is less than with wide scrotal exploration and the patient can be discharged home the same day. Seminal analysis should be done about 3 months after the operation to ensure that the patient is azoospermic. It has been suggested that if intravenous pyelograpby is done before the operation in men with suspected unilateral absence of the vas deferens and if there is an ipsilateral urologic anomaly, exploration for the vas deferens can be avoided.2 K. GOPINATHA RAG, B SC, MS, FRCS, FRCS[C], FACS
Brandon Clinic, Brandon, Man.
References 1. MERREN DD, KELLY RA: Congenital absence of vas deferens: report of three cases. / Urol 68: 1, 1952 2. EMERY CB, GOLDSTEIN AMB, MORROW Jw: Congenital absence of vas deferens with ipsilateral urinary anomalies. Urology 4: 201, 1974
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