By tradition this talk, given each year at the beginning of October, has been used to welcome the new draft of medical students to the hospital. It has another function, that of allowing a senior (elderly), and in the case of this hospital, generally male, member of the medical staff, the opportunity of airing views on some topic of interest to himself if not to any one else. Tradition also dictates that the presentation is not a lecture. It is an oration and perhaps this is as well. In July 2005, in the Guardian, David Hare mused on the word “lecture1”. He wondered when it acquired its negative connotations. He recalled a review of one of his plays: “it was more like a lecture than a play”’ - lectures may be remembered for long windedness, boredom and scolding. Perhaps the Staff of the Hospital has felt that calling it an oration provides some insurance against tedium, even promises something grander or uplifting. You will have also noticed that the title gives little away about the topic. This should not be taken as an indication that I wished to be obscure. At the time I was asked for a title I had only a vague notion of what the content would be. Something essentially non-restrictive seemed very necessary at that time. And there is advice about suitable titles. Richard Asher in 1972, perhaps mischievously, suggested that some should be avoided.2 “Whither medicine today?” was one such – his warning in 1972 came too late for Harold Rodgers who had given such a talk in this institution some 12 years previously. So, what are iron cages and winged chariots? The cages come from Max Weber, (Fig 1) often looked on as the father of modern sociology and I will say more of him later. The winged chariot is from an earlier source, a poem by Andrew Marvell (1621 – 1678) (Fig 2). Marvell lived in the troubled times of the English civil war. Initially perhaps of royalist sympathies, he later came to have some admiration for Cromwell – but this is not to imply puritanical tendencies. The poem containing the winged chariot is a witty exhortation ‘To his to his Coy Mistress’, encouraging her not to delay too long in resisting his attentions, for life is short and: “………… at my back I always hear Time's winged chariot hurrying near And yonder all before us lye Deserts of vast eternity”. Fig 1 Max Weber – 1864 – 1920. The father of modern sociology. Fig 2 Andrew Marvell, Politician and Poet (National Portrait Gallery) The ‘winged chariot’ emphasises the rapid passage of time and part of my talk deals with some of the changes that have occurred in my lifetime in medical practice. It is for me an alarming thought that it is now 39 years since I attended my first oration as a student in 1966. Dr Richard Clarke's superb history of The Royal Hospital tells me that the orator was Dr Harry Shepherd, a noted local radiologist.3 I know I must have been there as attendance was obligatory, but I have absolutely no recollection of what was said – perhaps a sad indication of the fate of all orators.

compatible with the thesis that the defibrillation threshold in calves depends on body weight. The extrapolation of this observa- tion to man is extremely controversial. In this issue, two original articles present data in man which are at some variance with the observation in calves. In view of the importance of the required energy levels for human defibrillation, we are including two editorials on this subject. We hope that these viewpoints will stimulate the design of more definitive studies in man to settle this crucial issue.

BACKGROUND:Severe cardiotoxicity is a documented, but very unusual side-effect of intravenous 5-fluorouracil therapy. The mechanism producing cardiotoxicity is poorly understood.CASE PRESENTATION:A case of 5-fluorouracil-induced cardiotoxicity, possibly due to coronary artery spasm, and mimicking acute anterolateral myocardial infarction is presented and discussed. Electrocardiographs highlighting the severity of the presentation are included in the report along with coronary angiograms demonstrating the absence of significant coronary atherosclerosis.CONCLUSION:Severe 5-fluorouracil-induced cardiotoxicity is rare, but can be severe and may mimic acute myocardial infarction, leading to diagnostic and therapeutic dilemmas. Readministration of 5-fluorouracil is not advised following an episode of cardiotoxicity.

Background: Thrombolytic therapy has frequently been withheld from patients with complete heart block following acute myocardial infarction because of significant hypotension and the risk of bleeding should temporary transvenous pacing be required. We assessed the course of patients with acute myocardial infarction complicated initially by complete heart block who received thrombolytic therapy.Methods: Patients had clinical and ECG evidence of acute myocardial infarction of less than 6 hours' duration , were in complete heart block when first assessed, and were suitable for thrombolytic therapy. Coronary angiography was performed during the hospital stay, and left ventricular function was assessed by radionuclide ventriculography during convalescence.Results: Twenty-one patients were treated: 20 had an inferior myocardial infarction and 17 patients were first seen outside the hospital. Initial systolic blood pressure in 13 of 21 (62%) was 90 mm Hg or less. Thrombolytic therapy commenced at 154 minutes (mean) after the onset of infarction and 12 patients received prehospital thrombolysis. All patients had received intravenous atropine, and in seven 1:1 atrioventricular conduction had occurred. Of the 12 who remained in complete heart block at the time of receiving the thrombolytic agent, 10 reverted to 1:1 atrioventricular conduction and one to chronic atrial fibrillation within 2 hours. Of the two in second-degree atrioventricular block, both reverted to 1:1 atrioventricular conduction within 7 hours. Only four patients required temporary transvenous pacing (in three for complete heart block). Coronary artery patency was 79% (15 of 19), and mean global left ventricular ejection fraction was 57% +/- 10%. No hemorrhagic complications occurred; only one patient with anterior myocardial infarction and cardiogenic shock died.Conclusions: Thrombolytic therapy administered to patients with myocardial infarction complicated by complete heart block is safe and frequently results in resumption of normal atrioventricular conduction, thus reducing the need for pacing and improving prognosis.

Fifty-nine consecutive patients presenting within 6 hours of the onset of symptoms of an acute myocardial infarction were treated with 150 mg of soluble aspirin orally, and either 70 or 100 mg of alteplase divided into 2 intravenous bolus injections separated by 30 minutes. Dosage regimens were either 20 followed by 50 mg (group A), 50 followed by 20 mg (group B), or 50 followed by 50 mg (group C). Coronary angiography 60 minutes after the first bolus showed infarct-related coronary artery patency (Thrombolysis in Myocardial Infarction score 2 or 3) in 13 of 16 (81%) patients in group A, 12 of 17 (71%) in group B, and 10 of 11 (91%) in group C (overall patency rate at 60 minutes: 35 of 44 [80%] patients; 95% confidence interval 68 to 91%). At 90 minutes, patency rates were 15 of 20 (75%) patients in both groups A and B, and 18 of 19 (95%) in group C (overall patency rate 48 of 59 [81%] patients; 95% confidence interval 72 to 91%). Residual thrombus was identified with the 90-minute angiogram in 7 patients in group A, 5 in group B, and 3 in group C. Although there was no statistically significant difference in patency between the 3 dosage regimens at either 60 or 90 minutes there was a trend toward increased patency and more complete thrombolysis at 90 minutes in group C. No episodes of bradyarrhythmia, hypotension or cerebrovascular bleeding were observed after double bolus therapy. There were 7 episodes (12%) of reocclusion, and 3 deaths (5%) within 1-month follow-up. Double bolus alteplase therapy is a convenient and highly effective method of promoting early coronary artery patency.