Petr Skrabanek: the abominable no-man.

Petr Skrabanek (1940-94) was a Czech-born doctor, polemicist and literary scholar. He qualified in medicine in Ireland, and spent most of his career at the Medical School of Trinity College Dublin. He was an outspoken critic of modern medicine, particularly of what he called 'coercive healthism'. Skrabanek's sceptical and iconoclastic ideas are more relevant today than ever. This essay aims to rekindle interest in his life and work.

When is feeding via a percutaneous endoscopic gastrostomy indicated?

PURPOSE OF REVIEW: This review addresses current controversies regarding appropriate indications for percutaneous endoscopic gastrostomy (PEG) insertion. We address specific indications, namely, dementia, stroke, aspiration, motor neurone disease/amyotrophic lateral sclerosis, and head and neck cancer. We recommend practical strategies for improving patient selection. RECENT FINDINGS: There is now a general consensus in the United States that PEG feeding does not benefit patients with advanced dementia. 'Early' PEG insertion following stroke is similarly of no benefit. It is currently unclear whether patients with amyotrophic lateral sclerosis and head and neck tumors should have PEG or radiologically inserted gastrostomy. SUMMARY: Decisions relating to PEG insertion remain difficult. The gastroenterologist, working as a member of a multidisciplinary nutrition team, needs to take a lead role in this regard, rather than functioning as a technician.

W Somerset Maugham (1874-1965) and St Thomas's Hospital: Medical School and the making of a writer.

William Somerset Maugham was one of the most successful and prolific authors of the twentieth century. He excelled in several genres, writing novels, plays, short stories, travel-books, memoir and criticism. His prose style was simple, witty; his world view weary and cynical. His childhood was marred by bereavement, losing both parents before the age of ten years. He spent a lonely adolescence under the guardianship of his uncle, an emotionally distant clergyman. He enrolled as a medical student at St Thomas's Hospital mainly to escape from his uncle and also to live in London. From his teens his sole ambition was to be a writer: medicine did not interest him. Despite his lack of vocation, his five years at medical school proved to be the key experience in his artistic development. He observed and learned about people; he saw poverty, squalor and death. His experience as an Obstetric Clerk in the slums of London inspired his first novel, Liza of Lambeth. He qualified but never practised. In old age he wrote 'I learned pretty well everything I know about human nature in the 5 years I spent at St Thomas's Hospital'. The example of Maugham suggests that medical education may have value other than the training of doctors-to-be.

Ethereal and material gain: unanticipated opportunity with illness or disability.

When caregivers address the positive aspects of illness or disability, there is a risk of patronising the sufferer. It is equally problematic when secondary gain is judged in a negative light and impedes an effective doctor-patient relationship. Changing attitudes, and particularly the negative perception of a patient's gain from illness, are reflected in biographies of artists, philosophers and other creative individuals. In contrast, some memoirs about illness feature a retrospective discussion of the positive features of the experience - from one who is now free from the ordeal. The experience of continual sufferers may be more instructive. We examine contemporary examples of unanticipated advantage or gain arising from ongoing disability or illness. The contribution of disability/illness to remarkable achievement promotes enhanced self-appreciation for patients and may foster in others a better understanding of what it means to suffer and live with disability.

Malignancy-associated gastroparesis: an important and overlooked cause of chronic nausea and vomiting.

A 69-year-old woman was referred to a gastroenterology clinic with a 1-year history of protracted nausea and postprandial vomiting. She had a background of gastro-oesophageal reflux disease, irritable bowel syndrome and chronic obstructive pulmonary disease with a significant smoking history. Her laboratory work-up including autoimmune screen, coeliac serology and synacthen test were unremarkable. Upper gastrointestinalendoscopy and CT imaging ruled out mucosal and obstructive causes. Gastric emptying studies demonstrated a delayed gastric emptying consistent with diagnosis of gastroparesis. Concurrently, she underwent a CT of the thorax for unresolved consolidation on her chest X-ray. This revealed a locally advanced primary lung carcinoma. In this context, with all other causes excluded, her gastroparesis was deemed to represent a paraneoplastic phenomenon. Gastroparesis is a frequent, under-recognised and important complication of cancer.

In Praise of Richard Asher (1912-1969).

This essay aims to stimulate a reawakening of interest in the writings of the physician Richard Asher (1912-1969), who is now best known for coining the term "Munchausen's syndrome." Asher's essays are as relevant now as when first published. His articles were a model of clarity, wit and elegance: he argued consistently for precision in thought and expression, for logic in clinical thinking, and for evidence in treatment.

Against narrative medicine.

This essay aims to provoke debate on how and what the medical humanities should teach. It argues that the field has been dominated (to its detriment) by two misguided movements, postmodernism and narrative medicine, and that it should be redirected from utilitarian aims towards the goal of exposing medical students to a climate of thought and reflection.