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Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on Although a selection of rapid responses will be included online and in print as readers' letters, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window. Letters are indexed in PubMed.

Re: Vampires George Dunea. 318:doi 10.1136/bmj.318.7176.135a

The review of the film Vampires was quite on point; it was not the
best of its genre. However, Dunea's reference to erythropoietic porphyria
as an explanation for the vampires of folklore was rather far a field.
This medical myth may have originated in a 1985 article in the New York
Times where porphyria was reported as an explanation for the vampire of

The 18th and 19th centuries were the time of the folkloric vampire.
This lore was so deeply ingrained that in parts of Serbia scores of
vampires were exhumed and `killed' weekly.(2) The belief in a literal
vampire was so rampant that one Victorian surgeon commented that
"Vampyrism [sic] spread like a pestilence through Servia [sic] and
Wallachia, causing numerous deaths and disturbing all the land with fear
of the mysterious visitation, against which no one felt himself

Erythropoietic porphyria is one of a group of rare genetic diseases
(it being the rarest with about two hundred cases diagnosed since its
discovery in 1890) in which the production and synthesis of haemoglobin go
awry. (4,5) Erythropoietic porphyria manifests itself in extreme
sensitivity to sunlight. On exposure to light the skin blisters, and with
infection can become so severely scarred disfigurement results. Such
disfigurement can result in the loss, sometimes spontaneously, of
extremities (fingers, etc.) and parts of the face (nose, eyelids,

With the signs and symptoms of erythropoietic porphyria being as they
are, it is easy to see where one could infer vampiric associations.
However, when one takes into account the high incidence of vampire
exhumations that were occuring in the 18th and 19th centuries, the rarity
of porphyria in the general population, erythropoietic porphyria's
disfiguring properties, and that the folkloric vampire on being exhumed
was always described in terms of being quite healthy looking ("as they
were in life"), it is highly unlikely that this is a valid explanation for
the almost pathological belief in vampires at that time.

1. Boffey PM. Rare disease proposed as cause for `vampire'. New York
Times May 31, 1985;A15.

2. Barber P. The real vampire: forensic pathology and the lore of the
undead. Nat Hist (October)1990;74-83.

3. Copper B. The vampire in legend fact and art. Secaucus, N.J.: The
Citadel Press, 1974:153.

4. Meola T, Lim HW. The porphyrias. Dermatol Clin 1993;11:583-596.

5. Moore MR. Biochemistry of porphyria. Int J Biochem 1993;25:1353-

6. Kauppinen R, Timonen K, Mustajoki P. Treatment of the porphyrias.
Ann Med (Feb.)1994;26:31-38.

Competing interests: No competing interests

12 January 1999
Ann M Cox
Royal Victoria Hospital Medical Library, Montreal, Quebec, Canada
Re: Community care does not increase homicide risk in UK Richard Woodman. 318:doi 10.1136/bmj.318.7176.77

We have a specialist section that works with people who have special
needs ,over a hundred of these have Mental Illness.
The general Housing staff and the maintenance section are particularly
worried about assessing those who maybe violent.
We realise that contact with social & health services as soon as
possible is vital and do this so that we can be prepared if we are dealing
with clients who maybe verbally or physically aggressive.
My research time is very limited but I wonder if anybody could send me
info about assessment forms used to assess the likelihood of a person
becoming violent ,which professions are most at risk and methods of
prevention and management.

Alan Gunn

0181-2571220 h
0181-4517526 w from 15/1/99

Competing interests: No competing interests

12 January 1999
Alan Gunn
Manager Housing Support Work
Harlesden/Brent & Paddington /Westminster
Re: Female medical leadership: cross sectional study Editorial by Showalter Kari J Kværner, Olaf G Aasland, Grete S Botten. 318:doi 10.1136/bmj.318.7176.91


"Female medical leadership" (1) and "Improving the position of women
in medicine" (2) echo the hurdles which any woman doctor in Britain has to
overcome in pursuing professional ambition. The editorial states "women
doctors want the same things as other women and other doctors, challenging
work and fulfilling personal lives". We agree. Though different health
service and training from Norway, England has similarities: 54% women
medical graduates, 32% doctors on the register, only 20% women

Women doctors do not reach senior posts as easily.

Norway has more generous social benefits but not increased numbers of
women doctors as leaders: senior members of a hierarchical profession, a
very masculine definition of "leadership". England has increased women
consultants annually since 1987, 14% women consultants: five specialities
doubled percentage women consultants in ten years, paediatrics, accident
and emergency, obstetrics and gynaecology, surgery and general medicine;
some from a low base. Percentage women in specialist training rose 1987 to
1997 25% to 34%. (3) When present registrars complete training, women
consultants' percentage will rise.

That public health's regulated hours show more women in leadership
may hold answers. General practice's potentially more flexible working
arrangements and shorter training look 'increasingly attractive', not
'less prestigious'. Fewer women in administration may reflect women
choosing a clinical role not authoritarian management.

Women 'trade off between career posts associated with power and
influence and family and emotional responsibilities.' (4) The prolonged,
highly structured medical postgraduate training occurs for most women
during their childbearing years. "Dual career families are now the norm"
in Britain as in Norway, but pregnancy still occurs only for women and
although each family defines individual roles, most caring for children
and sick ageing relatives falls on women whatever their career ambitions.

Viewing medicine from the USA with a report from Norway, neither
comment on opportunities for part time flexible training and working in
the National Health Service, implemented nationally from 1979, adapted to
registrar training after Calman Report(1996). Medical Women's Federation
(MWF) members pioneered part time training and work, allowing women full
professional potential and personal life. We recently presented to the
House of Commons' Select Committee on Education and Employment the need to
allow all doctors to use their training fully at all stages of their
careers. At present too much is left to chance and local patronage. (5)

We continue to press for more flexible working for all doctors.

Joan Trowell, President
Mollie McBride, Hon Secretary
Medical Women's Federation
Tavistock House North
Tavistock Square
London WC1H 9HX

(1) Kari J Kvaerner , Olaf G Aasland, Grete S Botten. Female medial
leadership: cross sectional study. BMJ 1999;7176:91-94 ((9. January 1999)

(2) Elaine Showalter Improving the position of women in medicine BMJ
1999;7176: 71-72. (9. January 1999)

(3) Statistical bulletin: Hospital, Public Health Medicine and
Community Health Service Medical and Dental Staff in England 1987 to 1997
Department of Health, August 1998

(4) Allen I. Doctors and their careers: a new generation. London :
Policy Studies Institute, 1994

(5) "Part time Working" Report of House of Commons Select Committee
on Education and Employment. MWF evidence submitted October 1998

Competing interests: No competing interests

Re: Caring for and about acute general medicine Ian Forgacs. 318:doi 10.1136/bmj.318.7176.73

Dear Sir

Forgacs' article (BMJ 1999,312:73-4 (9 January) was interesting,
worrying and thought provoking. He concludes with the statement that '
there is thus a pressing need for a national audit to evaluate the quality
of emergency
medical care and the demands it makes on those who deliver it'.

I retired from the NHS almost seven years ago. My official title was
'consultant physician and gastroenterologist' and throughout my career as
a consultant I took my turn on the 'on-take' rota. However I ceased to see
general medical patients in out-patients' many years ago, and over time
felt increasingly insecure regarding my non-gastroenterol- ogical in-
patients. I can only hope that, largely due to the input of a succession
of very well informed medical registrars, the general medical patients
that were admitted in my name received better that average care.

To return to Forgacs' editorial - I am saying nothing new when I
suggest that, with the need for the specialist to know more and more, he
cannot do justice to the general field where over time he will inevitably
know less and less. It is unrealistic to believe otherwise.

It is unfair to specialist consultants and to their patients to
continue to expect the former to practice general medicine, and to admit
such patients as part of their on-call responsibilities. There are
alternative approaches.

Perhaps Forgacs could approach this problem in a further article.
This would be a natural sequel to his excellent analysis of some of the
relevant difficulties.

KFR Schiller
Emeritus Consultant
The Mill
Oxford OX44 9HQ

Competing interests: No competing interests

Re: Medicopolitical digestBMA starts debate on presumed organ donationDefence medicine in UK given a boostMoving nearer to PCGsJDC sets priorities for next session . 318:doi 10.1136/bmj.318.7176.131

The Surgeon-General and his Directors-General are to be congratulated on
their negotiations with government which will help to repair some of the
serious damage done to the Defence Medical Services by the last
administration - BMJ 9 Jan 99, p.131. In the present situation it is sad
recall that the closure of the military hospitals in Woolwich and
Aldershot lost up to 20 well staffed intensive care beds which were freely
available to NHS patients, as indeed were all their other facilities
whenever possible. As to the intention to set up a 'centre of academic
for Defence medicine , which is entirely laudable, it is also sad to
recall that such a College existed at Millbank , but that this was moved
unwisely and prematurely to Haslar before the adjacent hospital could
establish itself as a training institution, against the declared views of
the Council and ARM of the BMA. Now that the Royal Hospital Haslar is to
close, the opportunity must be grasped to restore the tri-service College
to the Millbank site, to which it was moved from the Solent in 1903
because of the
closeness to the London teaching hospitals and the Royal Colleges ,which
would continue to the clear benefit of Service medicine.

Dr. George Cowan
Dean of Postgraduate Medicine
University of London (North Thames)
33 Millman St
London WC1N 3EJ

Competing interests: No competing interests

Re: Opening up BMJ peer review Richard Smith. 318:doi 10.1136/bmj.318.7175.4

Writers and reviewers will be watching your experiment carefully.
You write, "the main argument against open peer review - a sad one - is
that junior reviewers will be reluctant to criticize the work of senior
researchers for fear of reprisals." The short story by Montague James
"Casting the Runes" is required reading for your prospective reviewers,
but let us trust that it will not implant ideas
in the minds of those whose papers are rejected. In Montague's short
story, based on the authority of peer review the Council of a Learned
Association rejects Mr Karswell's paper "The Truth of Alchemy". On appeal
the writer was assured by the secretary of the Association that
the fullest consideration was given to the submitted draft, and that it
was declined on the judgement of a most competent authority, whose name it
was impossible for the Association to reveal. On second appeal, which
requested the name of the reviewer, the secretary refused the request and
closed the correspondence. Sadly, as you know writers can guess or
discover the identity of reviewers.

Mr Karswell's earlier book "A history of witchcraft" had been
rejected by Mr John Harrington FRS, a scholar found dead three months
after his review, having fallen off a tree in mysterious circumstances.
Mr Karswell quickly identified Mr Dunning as the reviewer of "The Truth
of Alchemy". Strange events soon overtook Mr Dunning. Black magic was
at work. Within days he was a nervous wreck, who dared not go home or his
place of study, the museum, for fear that Karswell might turn up there.
His appearance became forlorn, his conversation empty. Clearly,
Harrington's fate awaited Dunning. Clearly, he had misjudged the truth of
the content of the paper!

This story of inadvertent `open' scientific peer review had a
murderous end. I shall not spoil the story by telling you and BMJ readers
who murdered who. I hope for a less macabre outcome of your bold

Yours sincerely

Prof Raj Bhopal

Department of Epidemiology and Public Health,
School of Health Sciences,
The Medical School,
University of Newcastle upon Tyne,
Framlington Place,
Newcastle NE2 4HH


1.Smith R, Opening up BMJ peer review, BMJ, 1999: (318); 4-5

2.James MR, Casting the runes (from, Ghost stories of an antiquary,
1911). Reprinted in, The Oxford Library of Classic English Short Stories
Volume 1. Guild Publishing, London, 1989.

Competing interests: No competing interests

Re: Only half of GPs in study knew that advance directives could carry legal force in UK Kevin Stewart, Lesley Bowker, Suzy Hayes, Michael Gill. 318:doi 10.1136/bmj.318.7176.123a

There was an error in our fourth reference in this letter; it was not
the Sidaway case. A better reference might have been Re C. (Adult: Refusal
of Treatment) (1994) for which the references are 1 All E.R. 819 [1994];
or 1 W.L.R. 290 [1994].

The point remains valid; patients detained under the Mental Health
Act can still make a valid directive provided the treatment to which they
refer is not covered by the terms of their detention under the Act.

We apologise for any confusion which this error has caused.

Competing interests: No competing interests

12 January 1999
Kevin Stewart
Consultant Physician
Re: Modernising mental health services Max Marshall. 318:doi 10.1136/bmj.318.7175.3

In addition to Marshall's editorial (1), we were a little surprised
to see that the Government's plans for modernising the NHS Mental Health
services are not based on any of the findings from its own R&D
Programme (2).

Although we appreciate these are 'emerging findings' and
many of the recommendations are based on examples of good practice, not a
single systematic review nor barely a randomised controlled trial was
quoted. The Cochrane Library for example provides readily available
evidence for mental health policy on case management(3), assertive
outreach (4), use of hospital beds (5) and effective Community Mental
Health Teams (6).

Surely at a time when the Government itself is
encouraging all clinicians to use evidence-based medicine (through the
National Institute for Clinical Excellence, and the Commission for Health
Improvement), there should be a clear link between committing £700M on new
policies and evidence of effectiveness.

Paul Johnstone,
Consultant in Public Health Medicine Berkshire, and Honorary Clinical
Senior Lecturer. University of Oxford.

Chrissy Allot,
Berkshire Health Authority


1. Marshall M. Modernising mental health services: time to define the
boundaries of psychiatric care, BMJ 1999;318:3-4

2. Department of Health. Modernising mental health services: safe,
sound and supportive. London: Department of Health, 1998

3. Marshall, M, Gray, A, Lockwood, A, Green, R. Case management for
people with severe mental disorders, Cochrane Review. In:The Cochrane
Library, Issue 3. Oxford:Update Software;1998. Updated quarterly.

4. Marshall, M, Lockwood, A. Assertive community treatment for people
with severe mental disorders. Cochrane Review. In:The Cochrane Library,
Issue 3. Oxford:Update Software;1998. Updated quarterly.

5. Johnstone P Zolese G. Long versus short term hospitalization for
serious mental illness. Cochrane Review. In:The Cochrane Library, Issue 3.
Oxford:Update Software;1998. Updated quarterly.

6.Tyrer, P, Coid, J, Simmonds, S, Joseph, P, Marriott, S. Community
mental health team management for those with severe mental illnesses and
disordered personality. Cochrane Review. In:The Cochrane Library. Issue
3. Oxford:Update Software, 1998. Updated quarterly.

Dr P Johnstone
Berkshire Health Authority
57-59 Bath Road
Berkshire RG30 2BA

Competing interests: No competing interests

Re: Private company wins rights to Icelandic gene database Abi Berger. 318:doi 10.1136/bmj.318.7175.11

In your January 2nd issue you published an article (Private company
wins rights to Icelandic gene database. BMJ 1999; 318:11) which gives an
inaccurate and biased account of a complex issue.

The proposed database will not exclude biotechnology companies or
pharmaceutical companies from access to data on Icelandic patients, nor
are exclusive rights given to one company to develop new drugs or to test
candidate drugs. These studies will continue to be allowed, as long as
they adhere to our regulations that are similar to those of any other
western country.

The central database will be privately owned and run, but Icelandic
health authorities will have access to the information, provided that they
comply with specific regulations. Other scientists also will have access
unless commercial interests are involved.

The data will remain were it origins, i.e. at hospitals and health
care stations, and will continue to be used for patient care and research.
Scientists are of course free to cooperate with anyone they choose.

Let us assure you that the Government of Iceland and an unusually
well educated public predominantly in favour of this experiment would not
consider it´s implementation unless they were convinced that the numerous
stipulations in the system set up to preserve patient rights were
sufficient. The legislation on a medical database is supplemented by a
recent law on patient rights as well as a comprehensive legislation on
data protection, reflecting European resolutions and directives.

Extraordinary steps have been taken to ensure that the many relevant
bodies concerned did have an opportunity to comment on the bill at various
stages and we did indeed get numerous valuable suggestions that improved
the bill.

The various international obligations that Iceland has undertaken
have indeed been analysed and adhered to, and many experts on these issues
have maintained that our precautions are indeed outstanding and will lead
the way for other similar databases, that are certainly on the way.

Those of your readers that would like more information on the issues
are referred to

Ragnheiður Haraldsdóttir
Deputy Permanent Secretary
Ministry of Health and Social Security

Competing interests: No competing interests

12 January 1999
Ragnheiour Haraldsdottir
Deputy Permanent Secretary
Ministry of Health and Social Security
Re: Only half of GPs in study knew that advance directives could carry legal force in UK Kevin Stewart, Lesley Bowker, Suzy Hayes, Michael Gill. 318:doi 10.1136/bmj.318.7176.123a

Stewart and others have confused two cases. The case of the detained
patient who refused amputation is Re C (Adult: Refusal of Treatment)
[1994] 1 All ER 819. He was able to comprehend and retain the relevant
information, believe it and weigh it in such a way as to reach a choice,
however unwise this seemed to his surgeon.

Mrs Sidaway was an unfortunate
lady who had suffered damage to her spinal column during surgery aimed at
relieving neck pain. She said that she had not been warned that this was a
risk of the procedure. Judicial remarks in this case have prompted lawyers
to encourage doctors to be more forthcoming with information about the
possible risks of proposed treatments. There is no suggestion that Mrs
Sidaway was detained: had she been, the courts would have protected her
anonymity by calling her case Re S.

Competing interests: No competing interests

12 January 1999
Bryan Vernon
Lecturer in the Ethics of Health Care
University of Newcastle upon Tyne