John Graunt F.R.S. (1620-74): The founding father of human demography, epidemiology and vital statistics

John Graunt, a largely self-educated London draper, can plausibly be regarded as the founding father of demography, epidemiology and vital statistics. In his only publication, based on a pioneering analysis of the London Bills of Mortality, he replaced guesswork with reasoned estimates of population sizes and the first accurate information on male:female ratios. He quantified the extent of immigration from countryside to city and his demonstration of the 'dying out' of a cohort paved the way for life table analysis. His comparison of London data with rural data provided the first recognition of the 'urban penalty'. His use of the first known tabular aggregates of health data clarified distinctions between acute diseases, which were often epidemic, and chronic illnesses which were often endemic. He quantified the high infant mortality and attempted the calculation of a case fatality rate during an epidemic of fever. He was the first to document the phenomenon of 'excess deaths' during epidemics. He provided a template for numerical analysis of demographic and health data and initiated the concepts of statistical association, statistical inference and population sampling. By making a novel concept intelligible to a broad audience he influenced the thinking of doctors, demographers and mathematicians.

Sir William Osler (1849-1919) and God's House in Ewelme

When William Osler was appointed Regius Professor of Medicine in Oxford he also became, ex officio, Master of the Almshouse at Ewelme in Oxfordshire. The link with the Almshouse, its inmates and the villagers of Ewelme gave great pleasure to both Osler and his wife, who spent much time there. This paper explores reasons why Osler found the position so attractive and rewarding.

By royal appointment - The Chase Family of Apothecaries

Medical dynasties are not uncommon, but medical dynasties which serve royalty are rare. This paper describes the work and responsibilities of three successive generations of the Chase family who served as apothecaries to a total of seven British monarchs. Two of them were also Masters of the Worshipful Society of Apothecaries of London, as also was a later member of the family.

Proactive multi-modality treatment of Pancreatic Neuroendocrine Tumours (PNETs): Potential survival benefits

BACKGROUND/OBJECTIVES

Primary and metastatic pancreatic neuroendocrine tumours (PNET) can be treated with combination of surgery, locoregional and systemic therapy. Survival benefits from individual treatments have been well reported, however, the combined outcome from multimodal treatments are not well described in the literature. We report outcomes in a cohort of PNET patients treated with proactive, multimodality therapy.

METHODS

106 patients were identified from a single tertiary referral centre prospective database. Outcomes of treatment were studied, with the primary end point being death from any cause.

RESULTS

Median follow-up was 71 months and overall 5-year survival of 62%. In patients with stage I-III disease (51 patients) estimated 5-year survival was 90%. Median survival in patients with stage IV disease was 51 months with an estimated 5-year survival of 40% in this group. A total of 80 patients (75%) had surgery of which 16% suffered complications requiring intervention. There was no perioperative mortality.

CONCLUSIONS

This study demonstrates that proactive multimodal treatment is safe and may confer a survival benefit to patients in this cohort compared to historical data.

Mistress Joyce Jeffreys and her physician, Dr Bridstock Harford (1607-1695)

The notebooks of Joyce Jeffreys, a wealthy Hereford businesswoman in the mid-17th century, provide information about the medicines she purchased and the fees she paid to her medical advisors. Her physician, Dr Bridstock Harford, was a successful doctor but a troublesome neighbour, who was often the subject of litigation. As an ardent parliamentarian, he held public offices during the Commonwealth. Later his opinions mellowed and he ended his days as a loyal subject of the king and a benefactor to his city.

Lady Brilliana Harley (1598-1643): Her medicines and her doctors

Lady Brilliana Harley was the redoubtable chatelaine of Brampton Bryan Castle in Herefordshire during the mid-seventeenth century. Her many letters reveal much about the medications which she dispensed to her family and about the family's medical attendants. Whenever possible the Harleys preferred to consult university-educated physicians rather than the local apothecary or surgeon. These physicians are all known from other sources but Brilliana's letters add to what is known of their provincial practices. In particular, they reveal their willingness to undertake blood-letting, often thought to be the province of the more lowly surgeon, and they emphasise the great distances travelled by these practitioners and the difficulties faced by two of them during the Civil War.

Thomas Paytherus (1752-1828): Entrepreneurial surgeon-apothecary and ardent Jennerian

Thomas Paytherus was born in Fownhope and apprenticed in Gloucester. He practised there and in Ross-on-Wye where he and Edward Jenner undertook an autopsy on a patient with angina that they linked causally to coronary artery ossification. In 1794 Paytherus moved to London and opened a highly successful pharmacy that he later sold to his partners Savory and Moore. Paytherus was among those who advised Jenner on the publication of his work on vaccination. Then he acted as an intermediary in the dispute between Jenner and Ingen-Housz and also alerted Jenner to Pearson's claims as a pioneer of vaccination. In 1800 he published a detailed analysis of the dispute between Jenner and Woodville whose patients had developed variola-like lesions following vaccination. Their correspondence shows that Paytherus, Jenner and their families remained firm friends. Paytherus and his family moved to Abergavenny where he died in 1828.

Medical politician and man of Olympian vision and energy: Dr William Penny Brookes (1809-95) of Much Wenlock

William Penny Brookes lived all his life in Much Wenlock in Shropshire where he worked as a general practitioner for 60 years. He is now best remembered as the founder of the Wenlock Olympian Society, as a founding member of the first national Olympian association and for his influence on Baron Pierre de Coubertin, the founder of the modern Olympic movement. He was a tireless campaigner for the introduction of physical education and a lessening of the academic workload in elementary schools. He was also an important figure in the medical reform movement of the mid-19th century. In Much Wenlock he was a much respected philanthropist and was involved in many civic activities. He was also a notable botanist and antiquarian.

Quantitative aspects of L(+)-lactate metabolism in human beings

The production rate of endogenous L(+)-lactate in the resting human being can be calculated from results of experiments during which isotopic or unlabelled lactate is infused. The merits of the different experimental techniques are discussed, although all published methods have given similar results, namely a resting production rate of about 1.3 mol . (70 kg body wt)-1 . 24 h-1. This result is similar to that found in sheep, but lower than that in dogs and rats. L(+)-lactate production in human subjects is unchanged after fasting for 36-168 h, a finding which contrasts with some animal experiments. It is not known whether this represents a true species difference or a difference in diet. Net splanchnic uptake of L(+)-lactate in the resting human being is about 0.4 mol 24 h-1 although the normal liver has the capacity to metabolize more than this. The kidney is an important site of L(+)-lactate utilization in rats, but there is no information about its role in normal human beings. There are conflicting reports concerning the uptake of L(+)-lactate by resting skeletal muscle, but there is no evidence that resting muscle can metabolize lactate.

The role of altered lactate kinetics in the pathogenesis of type B lactic acidosis

Of the two types of lactic acidosis, Type B is the most difficult to explain in terms of mechanisms of lactic acid accumulation because the tissue hypoxia that accompanies Type A is not present except as a terminal event. The methods of pharmacokinetics show that for lactate to accumulate to an extent that would disturb acid-base balance, either lactate synthesis or lactate removal would have to be increased or decreased, respectively, by about 7-10-fold. To produce lactic acidosis within a few hours, synthesis would have to increase at the same time as clearance decreased. At normal contribution of the liver to the total lactate clearance (30%-40%), a total cessation of hepatic lactate clearance would not result in lactic acidosis without a concomitant rise in the rate of lactate synthesis. Again, to produce an acidosis this increase would have to be about 8-fold at a normal fractional hepatic clearance. The control of hepatic lactate uptake is discussed in the light of the relatively low hepatic extraction of lactate and in relation to to two main models of hepatic drug (lactate) clearance; the 'well-stirred' and 'parallel-tube' models.

Some historical aspects of diabetic foot disease

During the 19th century and for much of the 20th century, disease of the lower limb in diabetic patients was conceptualized not, as it is now, as 'the diabetic foot' or as 'a diabetic foot ulcer' but as 'gangrene in the diabetic foot' or as 'diabetic gangrene'. The prognostically and therapeutically important distinction between gangrene due to vascular insufficiency and gangrene due to infection in a limb with a normal or near normal blood supply was not made until about 1893. The advent of aseptic surgery improved the survival of amputation flaps, but surgery remained a hazardous undertaking until the discovery of insulin. Although insulin therapy reduced the risk of surgical intervention, diabetic foot disease now replaced hyperglycaemic coma as the major cause of diabetic mortality. The increasing workload attributable to diabetic foot disease after the introduction of insulin is reflected in the publications on diabetes in the 1920s. In some hospitals in North America this led to initiatives in prophylactic care and patient education, the importance of which were only more widely appreciated some 60 years later. A continuing emphasis on ischemia and infection as the major causes of diabetic foot disease led to a neglect of the role of neuropathy. In consequence, the management of diabetic neuropathic ulceration entered a prolonged period of therapeutic stagnation at a time when significant advances were being made in the management of lepromatous neuropathic ulceration. Reasons for the revival of progress in the management of diabetic neuropathic ulceration in the 1980s will be discussed.

Abdominal pain and dysuria in pregnancy: urinary tract infection or life threatening haemorrhage?

This report describes the case of a 27 year old woman presenting at 19 weeks' gestation with epigastric pain and dysuria. Initially diagnosed with a urinary tract infection, she re-presented 10 days later with acute abdominal pain and haemoperitoneum. The diagnosis of placenta percreta was not made until laparotomy. This case highlights placenta percreta as a rare but serious complication of pregnancy that may become increasingly frequent as the rates of caesarean delivery rise. Early diagnosis, close monitoring, and prompt surgical management are essential as massive blood loss can occur. This can be challenging, as clinical presentation can be unusual.

Repetitive ulceration in neuropathic patients

METHODS

In a retrospective study, 83 patients with diabetic neuropathic foot ulceration were classified into two groups: those with a higher rate of ulceration defined as >/=3.5 ulcers per foot per 10 years (group H) and those with a lower rate of <3.5 ulcers per foot per 10 years (group L).

RESULTS

Higher risk was associated with neuroarthropathy, higher mean HbA(1c), men who lived alone, alcohol misuse by men, poor compliance with footwear, footcare and with non-foot aspects of diabetic self-care, higher non-attendance rates and, in patients with type 1 diabetes, delay in reporting new foot problems.

CONCLUSIONS

Reduction in ulcer recurrence rates will require improved orthotic provision in patients with neuroarthropathy and new methods to achieve behavioural change in other higher risk patients.

The implementation of nutritional advice for people with diabetes

These consensus-based recommendations emphasize the practical implementation of nutritional advice for people with diabetes, and describe the provision of services required to provide the information. Important changes from previous recommendations include greater flexibility in the proportions of energy derived from carbohydrate and monounsaturated fat, further liberalization in the consumption of sucrose, more active promotion of foods with a low glycaemic index, and greater emphasis on the provision of nutritional advice in the context of wider lifestyle changes, particularly physical activity. Monounsaturated fats are now promoted as the main source of dietary fat because of their lower susceptibility to lipid peroxidation and consequent lower atherogenic potential. Consumption of sucrose for patients who are not overweight can be increased up to 10% of daily energy provided that this is eaten in the context of a healthy diet and distributed throughout the day [corrected]. Evidence is presented for the effectiveness of advice provided by trained dieticians. The increasing evidence for the importance of good metabolic control and the growing requirement for measures to prevent Type 2 diabetes in an increasingly obese population will require major expansion of dietetic services if the standards in National Service Frameworks are to be successfully implemented.