The BMJ on the death of Charles Dickens
How true to Nature, even to their most trivial details, almost every character and every incident in the works of the great novelist whose dust has just been laid to rest, really were, is best known to those whose tastes or whose duties led them to frequent the paths of life from which Dickens delighted to draw. But none, except medical men, can judge of the rare fidelity with which he followed the great Mother through the devious paths of disease and death. In reading Oliver Twist and Dombey and Son, or The Chimes, or even No Thoroughfare, the physician often felt tempted to say, “What a gain it would have been to physic if one so keen to observe and so facile to describe had devoted his powers to the medical art.” It must not be forgotten that his description of hectic (in Oliver Twist) has found its way...

Health symptoms during midlife in relation to menopausal transition: British prospective cohort study
Objective To characterise symptoms experienced by women during the transition into natural menopause, to classify women into distinct symptom profiles or trajectories, and to relate these profiles to sociodemographic factors and health behaviours.Design Nationally representative cohort study.Setting England, Scotland, and Wales.Participants 695 women followed-up since birth in 1946 and annually from age 47 to 54 who experienced natural menopause and reported on 20 common health symptoms.Main outcome measure Longitudinal profiles for reported bothersome symptoms.Results Of 20 individual symptoms, 18 formed into four stable symptom groups: psychological, somatic, vasomotor, and sexual discomfort. Using latent class analyses, all except the somatic group of symptoms showed a clear relation with the timing of menopause for some women. A small proportion of women (10%, n=63) had a severe psychological symptom profile that peaked at or in the year after menopause. For vasomotor symptoms, 14% of women (n=83) had the early severe profile that also peaked around early postmenopause and then declined noticeably; 11% (n=67) had the late severe profile of bothersome symptoms that increased rapidly in perimenopause and remained high for four years or more after menopause. Women were less likely to have a profile for severe vasomotor symptoms if they were from a non-manual social class (odds ratio 0.79, 95% confidence interval 0.57 to 1.01) or had degree level qualifications (0.37, 0.18 to 0.77). The 14% of women (n=85) who had the late severe profile for sexual discomfort showed a similar increase in symptoms until menopause, with symptoms persisting after menopause. Married women were more likely to have the late severe or late moderate profile than women of other marital status (2.40, 1.30 to 4.41). Four profiles each were identified for somatic symptoms (mild, moderate, severe, and very severe), although these did not vary by chronological age or age at menopause.Conclusion Profiles for psychological, vasomotor, and sexual discomfort symptoms relative to age at menopause could help health professionals to tailor their advice for women with natural menopause.

Investigating focal liver lesions
Learning pointsIncidental liver lesions on medical imaging are relatively common and the vast majority are benignFatty infiltration is increasing in prevalence and can make the detection and characterisation of focal liver lesions difficultThe choice of and need for further investigation when a focal liver lesion is identified depends on several patient factors and ideally should be recommended by the reporting radiologistContrast enhanced ultrasonography, computed tomography, and magnetic resonance imaging of focal liver lesions rely on the recognition of characteristic enhancement patternsBiopsy may be needed where imaging fails to characterise a lesion adequatelyA 31 year old Anglo-Indian man presented to his general practitioner for a discussion of cardiovascular risk factors because of a strong family history of ischaemic heart disease. He had no medical history of note. The patient denied excessive consumption of alcohol, although he admitted to a relatively unhealthy, high fat diet. Routine liver function tests showed raised alanine...

Would you like your telomeres tested?
A company that is based in the United States, Life Length, is offering “telomere testing and services” from its laboratory in Spain, with the aim of “making it easy for physicians and their patients to take our biomarker test,” says its press release.1 It adds, “Telomeres are best predictors of biological age and excellent general health indicators, highly related to the emergence of age-related diseases. This test will likely become standard in checks-up and preventive healthcare. US doctors can now incorporate Life Length’s telomere test easily into their practice.”Telomeres are repeated sequences of DNA at the end of chromosomes that stabilise the chromosomes and prevent them being identified by cells as broken DNA. For some time it has been known that abnormal or shortened telomeres cause chromosomal problems, which in turn have been related to some disorders, including tumorigenesis. Life Length says that it can test anyone, no matter where...

Hormone therapy for menopausal symptoms
A recently published and much publicised paper by Shapiro and colleagues, the last in a series of four, evaluated the effects of hormone therapy on the risk of breast cancer.1 The authors of the four review articles applied epidemiological principles to the findings of two randomised placebo controlled studies from the Women’s Health Initiative (WHI; 27 347 women) and two observational studies—the Collaborative Reanalysis (53 865 women) and the Million Women Study (MWS). Shapiro and colleagues concluded in their fourth paper that the MWS had design defects, that it contained multiple biases, and that its findings were thus not robust enough to show that hormone therapy increased the risk of breast cancer.All observational studies are inherently biased because subjects are not randomly assigned to treatment or control. Adjustment for confounders and careful design of observational studies help to reduce bias. However, because there is no independent variable, such studies can tell us...

The National Health: a Radical Perspective
The NHS faces misguided reorganisation, creeping privatisation, cuts, increased waiting lists, and stagnant wages. Although they are eerily familiar, these are not just today’s problems, but also those of 1988, when the east end London general practitioner and left wing activist David Widgery wrote his book The National Health.The book was published on the 40th anniversary of the inception of the health service and was a polemical intervention against the penny pinching cuts of Margaret Thatcher’s premiership. It makes a powerful case for universal healthcare. Widgery writes movingly of being an “Atlee child,” nursed through childhood polio by the NHS, and he is keen to defend that provision.Widgery gives a historical overview of the development of the modern medical profession and health service, and how it arose from private teaching hospitals and the workhouses. He describes how the profession jealously guarded its authority against competitors such as midwives, and fought...

Extreme measures: the history of breast cancer surgery
bmj;344/feb08_1/e834/FIG1F1fig1The rage for breast surgery attained manic proportions in the late 19th century in the United States and Europe. But the trend was driven by surgeons, not women, and the results were far from aesthetic.Surgeons in ancient Egypt described breast cancer, but wisely refrained from wielding the knife. The first recorded attempt at mastectomy is attributed to the surgeon Leonides of Alexandria in about the second century AD, but caution remained the watchword. By the 1600s prints in northern Europe show women stoically undergoing breast amputations by surgeons using forceps, knives, and cauterising irons long before the arrival of anaesthesia or antisepsis.In 1748 the German surgeon Lorenz Heister described using a fork, or ropes attached to lances, to lift the breast before amputation, but warned against operating if the axillary lymph nodes were affected, because “the Virus of the Cancer, which lies concealed in the other Parts, will make the...

Leave the quacks alone
Joseph Sampson Gamgee (1828-1886) was one of three brothers all of whom made it into the Valhalla of British posthumous eminence, the Dictionary of National Biography. A surgeon, he is remembered today mainly for the absorbent dressing that he invented and whose use he advocated; he also had a quarrel with Joseph Lister over antisepsis. He was a contemporary of Lister’s at medical school and went on to examine Lister’s methods, which he praised though not without reservation. Lister took this badly, as if he who was not wholly for him was wholly against him. This is not a completely uncommon human trait, as anyone who has ever sat on a hospital committee will know. Gamgee had been a surgeon in Malta during the Crimean war and was not altogether a sweet tempered man himself, at least if the tone of his pamphlet Medical Reform: a Social Question Comprehensively Studied...

In a pilot clinical trial, non-smokers with mild cognitive impairment were randomly allocated to receive transdermal nicotine or placebo for six months, to ascertain whether stimulation of nicotinic acetylcholine receptors improved their symptoms (Neurology 2012;78:91-101, doi:10.1212/wnl.0b013e31823efcbb). The study found that the treatment was safe. However, although transdermal nicotine improved performances in some cognitive tests, and both patients and carers reported improvements, it did not change objective scores for clinical global impression of change, which was the study’s primary clinical outcome.Skin preparation solutions have varying effects on the visibility of surgical site markings. In a prospective randomised trial, surgeons used a black permanent marker to mark the skin of 20 patients undergoing hip surgery with three random letters (Journal of Bone and Joint Surgery 2012;94:97-102, doi:10.2106/jbjs.j.00838). The patients were randomly assigned to receive either a skin preparation based on chlorhexidine or another preparation based on iodine. Digital photographs were taken before...

bmj;344/feb08_1/e852/FIG1F1fig1A 53 year old woman presented with a two week history of right sided limb weakness and expressive dysphasia. Magnetic resonance imaging of the brain showed a mass in the left frontoparietal region with a concentric ring appearance. Because of alternating bands of higher and lower signal indicating layers of myelinated and demyelinated tissue, this pattern is characteristic of Balo’s concentric sclerosis, which is considered to be a rare subtype of multiple sclerosis. The disease is often monophasic and is usually treated with high dose steroids. As with this patient, brain biopsy is sometimes performed to exclude other possibilities, including the presence of tumour and abscess.