History of brucellosis.

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Hysteria
Jon Stone and his fellow authors (December 2005 JRSM1)
rightly draw attention to the undue influence on a general
medical readership of Eliot Slater’s 1965 paper on hysteria.
However, it is perhaps misleading to describe it as ‘a
blessing for psychiatrists’. In fact, a sensible psychiatric
response which was highly influential on subsequent
psychiatric practice was Aubrey Lewis’s classic paper ‘The
survival of hysteria’,2which pips Stone et al. to the post by
30 years; and which surely must be read alongside Slater.
Besides writing a general homily on the subject, Lewis
reported a series of 98 patients who had received diagnosis
of hysteria at the Maudsley Hospital, with follow-up from
7–12 years, but with somewhat different findings to Slater
(‘. . . in very few did this raise the question of an altered
diagnosis’). Of course, Lewis’s series came from a
psychiatric hospital and Slater’s from a neurological one,
causing him to state of his results, ‘That they are not similar
to the findings on patients diagnosed at a neurological
hospital is not surprising’. Indeed it is not. The implication
that did not escape those of us for whom both Slater and
Lewis were required reading in our psychiatric training, was
that psychiatric diagnoses made in psychiatric settings may
be more robust than psychiatric diagnoses made in
neurological settings. The paper ends with one of Lewis’s
celebrated aphorisms ‘ . . . a tough old word like hysteria
dies very hard. It tends to outlive its obituarists’.
Unfortunately, it seems the same cannot be said for Lewis’s
huge contribution.
Stephen W Brown
Developmental Disability Research & Education Group, Peninsula Medical School,
Bodmin PL31 1AH, UK
E-mail: stephen.brown@pms.ac.uk
REFERENCES
1 Stone J, Warlow C, Carson A, Sharpe M. Eliot Slater’s myth of the
non-existence of hysteria. J R Soc Med 2005;98:547–8
2 Lewis A. The survival of hysteria. Psychol Med 1975;5:9–12
Huntington disease
Apropos Ben Harper (December 2005 JRSM1) on
Huntington disease: George Huntington (not George S
Huntington, an eminent American anatomist), observed
what he called ‘hereditary chorea’ not in Pomeroy, Ohio,
but in East Hampton, New York, where he grew up the son
and grandson of physicians.2As a newly qualified physician,
he moved to Pomeroy to begin a medical practice. It was in
nearby Middleport that he gave his paper On Chorea in 1872.
This history is well known.
It has also long been recognized that he was not the
first to describe this disorder in adults, namely chorea
accompanied by cognitive decline and emotional dis-
turbance, leading inexorably to death.3While most
earlier writers acknowledged the hereditary transmission
of this illness, they did so within the conventional mid-
nineteenth century paradigm of inheritance. That is, they
accepted that the disease might skip a generation before
it appeared again. Huntington evoked a radically different
pattern. In his description, an individual who did not
develop the disease during a normal life span could not
transmit it to subsequent generations. Once it failed to
appear, it would not reappear. It was this insight—based
on the observations of his father and grandfather and the
East Hampton families—that distinguished his account
from those of his predecessors, and which later
investigators acknowledged as an accurate representation
of the Mendelian dominant inheritance pattern of the
disease.
Far from being ambitious, Huntington was remarkably
modest. Though his paper had gained wide recognition
by the 1890s, he remained a small-town family physician.
Ironically, it was partly through the influence of the
Canadian turned Oxford University professor William
Osler that the malady came to be known by the
‘American’ name of Huntington’s chorea and later
Huntington disease.
Alice Wexler
Hereditary Disease Foundation, Santa Monica, California 90405, USA
E-mail: arwexler@ucla.edu
REFERENCES
1 Harper Ben. Huntington disease. J R Soc Med 2005:98:550
2 van der Weiden RMF. George Huntington and George Sumner
Huntington. A Tale of Two Doctors. Hist Phil Life Sci 1989;11:297–304
3 Harper PS. Huntington’s disease: a historical background. In: Bates G,
Harper PS, Jones L, eds. Huntington’s Disease, 3rd edn. Oxford: Oxford
University Press, 2002:3–27
Walking the walk
Phil Hadridge suggested in his article (December 2005
JRSM1) that, if the culture of patient safety is to improve in
the health service, we should take a leaf out of the oil
industry where safety since the Piper Alpha Disaster has
been paramount. He suggests leaders in the health service
should ‘walk the walk’ like in the oil industry and check fire
procedures and exits at each meeting.
He is missing the point by a mile. He is walking the
wrong walk, and I am not surprised that he has met with
incredulity when he has suggested it.
Fire is a fundamental issue in the oil industry. Fire is the
safety issue in the oil industry.
He is, however, quite right to ask what is our Piper
Alpha? MRSA perhaps? Leadership needs to walk the right
LETTERS
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walk if they are to improve patient safety. In a culture
where the patient comes first, worrying about your own
skin in a fire comes across as counter intuitive when most of
the health professionals would be looking at saving their
patients first before running for the fire exit.
James Cave
Downland Practice, Newbury RG20 8UY, UK
E-mail: ectopicmailbox-rsm@yahoo.co.uk
REFERENCE
1 Hadridge P. Leading safely: ‘ridiculous’ lessons from the oil and other
industries. J R Soc Med 2005;98:539–41
I am afraid Phil Hadridge needs to remove the inverted
commas from ‘ridiculous’ in his recent contribution
(December 2005 JRSM1). Should doctors have to be given
a detailed briefing about their immediate environment every
time they meet somewhere? It is exceedingly unlikely that,
by checking the fire escapes in a room, a doctor would
significantly reduce the risk of a catastrophe, and it certainly
would not make patients any safer. So as a direct action it is
ridiculous.
Would such an action set a good example? Well, of
course, I would like to be seen as rational and flexible:
however, checking the fire exits everywhere would give the
opposite impression. If you want to change behaviour, first
convince people that what you want is sensible and correct.
As for the ‘well it won’t hurt’ argument? Why not offer
up a quick prayer, or take a vitamin tablet at the start of
each meeting—easy, cheap and useless. The reasons that we
are bad at patient safety are that too many problems are
hard to fix, and living with unfixable problems makes it easy
to ignore the fixable ones. Some of the latter are now being
addressed—for example, the introduction of alcohol
handwash dispensers everywhere, and a new culture which
makes it easy to roll up sleeves and discard ties, jackets and
white coats, has greatly increased the frequency of
handwashing. If management are serious about patient
safety, they should make this their priority rather than
finance and DH targets. If adequate bed area cleansing were
regarded as more important than meeting the 4-hour A&E
target, and bed occupancy rates fixed at safe levels, I have
little doubt that nosocomial infection rates would fall.
There is also little doubt that patient waiting times would
increase and mangers would be sacked (or relocated). The
NHS seems to be concentrating on quantity of treatment
whilst accepting some reduction in quality. And given
resource limitations, and the fact that the vast majority of
the huge number of treatments carried out daily are
successful, the balance may not be far out. However, if we
want to improve patient safety, management mumbo jumbo
is not the answer—adequate time and space to treat
patients is.
John Main
Consultant Nephrologist, James Cook University Hospital, Middlesbrough, UK
E-mail: John.Main@stees.nhs.uk
REFERENCE
1 Hadridge P. Leading safely: ‘ridiculous’ lessons from oil and other
industries. J R Soc Med 2005;98:539–41
History of brucellosis
We read with interest Dr Wyatt’s article (October 2005
JRSM1) on Zammit’s discovery that brucellosis was
transmitted by goat milk. We would like to add the names
of some other people who were involved in the research.
First, Dr Carruana-Secluna, who accompanied Zammit
to Chadwick Lakes, carried out a great deal of work for Sir
David Bruce—he prepared the agar plates and the culture
media and cultured the causative organism from the spleen
samples of fatal cases. He never received proper recognition
for his work and Sir David Bruce did not allow him to be
co-author on any publications. Secondly, Surgeon Captain
M. Louis Hughes assisted Bruce in his studies and first
named the disease ‘undulant fever’. He also named the
organism Micrococcus melitensis, although he was wrong about
the source of infection, believing it to be resident in the soil
and inhaled by the human. Hughes was killed in the Boer
war at the age of 32.
Sir David’s wife Lady Bruce was a trained microbiol-
ogist, and took an active part in her husband’s research,
including the exquisite illustrations to his papers.2
Finally, it is worth noting that Zammit was knighted—
an honour given for his work.
Catherine Edwards
Ali S M Jawad
Department of Rheumatology, The Royal London Hospital,
London E1 4DG, UK
Correspondence to: Dr Ali S M Jawad
E-mail: alismjawad1@hotmail.com
REFERENCES
1 Wyatt HV. How Themistocles Zammit found Malta fever (brucellosis)
to be transmitted by the milk of goats. J R Soc Med 2005;98:451–4
2 Madkour M Monir. Madkour’s Brucellosis, 2nd edn. Berlin: Springer,
2001
Super hospitals
Neville Goodman (November 2005 JRSM1) bemoans the
cancellation of a giant hospital amalgamation in the West
Country after thousands of medical hours were wasted on
the planning. This will teach him not to sit on too many
committees. Who wants to be treated in a vast megolithic
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superhospital where nobody knows anyone? Who wants to
work in some vast sprawling new hospital where nobody
knows anyone? Small can often be beautiful where hospitals
are concerned where patients and staff can be respected. Dr
Goodman should put down his committee agenda, pick up
his stethoscope and start enjoying medicine again.
Graham H Barker
Consultant Gynaecologist and Obstetrician, The Portland Hospital, London, UK
E-mail: grahambarker@colposcopy.org.uk
REFERENCE
1 Goodman N. Now do it our way. J R Soc Med 2005;98:526
Death to all cliche ´ s?
About the article by Ian Forgacs on cliche ´s (December 2005
JRSM1), may I respectfully disagree, for surely Dr Forgacs
you jest! In my years teaching medical students and house
officers (at Stanford University in California) I found that
the aphorism (which I prefer to cliche ´) ‘common things
happen commonly’ was very useful in pointing out to the
fledgling doctors that the first, but not the only, diagnosis
one entertains is the most common. As with your other
examples, what I suspect you were railing about is the
tendency for many of us to speak in tongues, when we
should say what we mean, and mean what we say.
Robert L Bratman
Retired gynaecologist, Llwydcoed, Aberdare
CF44 0UP, Wales, UK
E-mail: RBratman@aol.com
REFERENCE
1 Forgacs I. Death to all cliche ´s. J R Soc Med 2005;98:554
Death to some cliche ´ s
I agree with Dr Forgacs (December 2005 JRSM1) that
referring to a patient as being ‘haemodynamically stable’ is
unacceptable and the offending practitioner should be
requested to return to basics and provide actual values.
However, I admit to being fond of ‘common things
occur commonly’ and the similar ‘when you hear the sound
of hooves, don’t look for zebras’, both of which, in the
thinking individual, do not exclude the uncommon
diagnosis. I also believe that ‘irregular irregularity’ is
perfectly acceptable when describing a pulse or a magnified
abnormal volar skin appearance.
What about cliche ´s in general? ‘See you later’ annoys
when, as is often the case, the speaker is unlikely to see you
again. The simile cliche ´ ‘ bald as a coot’ may sometimes be
accurate but it is a rude expression ready for burial.
‘Quality of life’ is expanding its meaning as it becomes
overused, and its use should be restricted.
Other cliche ´s are no doubt ‘in the pipeline’. Unoriginal
and trite they may be, but many still deserve ‘tender loving
care’ (Henry VI Part ii Act 3 Sc.2).
Julian Verbov
Royal Liverpool Children’s Hospital, Liverpool, UK
E-mail verbov@blueyonder.co.uk
REFERENCE
1 Forgacs I. Death to all cliche ´s. J R Soc Med 2005;98:554
Semmelweis and his thesis
Was the pedestal off which Irvine Loudon (December 2005
JRSM1) so neatly knocked poor Semmelweis really reserved
for the most famous name in the history of obstetrics? Does
not Caesar still stand, passive and immovable, on that one?
Cyril Sanger
Fort Lee, NJ 07024, USA
E-mail: csanger@bellatlantic.net
REFERENCE
1 Loudon Irvine. Semmelweis and his thesis. J R Soc Med 2005;98:555
CORRECTION
Shafqat S. The long shadow of cerebral localization. J R Soc
Med 2005;98:549
In line three of this paper we referred to ‘the late Raymond
Adams’. We are delighted to learn that Dr Raymond D
Adams is alive and well and still reads the JRSM.
Letters to the Editor
Please e-mail letters for publication to Dr Kamran Abbasi [kamran.abbasi@rsm.ac.uk].
Letters should be no longer than 300 words and preference will be given to letters
responding to articles published in the JRSM. Our aim is to publish letters quickly. Not
all correspondence will be acknowledged.
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