Iraq: Defeat after Victory

Today Tony Blair is answering questions put to him by the Chilcot committee. The atmosphere is studious and calm, which is right, although many would prefer robust interrogation to a scholarly investigation.

There are a number of background facts and problems which I suspect will not be addressed by the committee today, or maybe ever.

1. Saddam had chemical weapons, and had used them extensively against rebel Kurds. No nuclear materials were found after the invasion, but Saddam's nuclear ambitions had been apparent for years, and had led the Israelis to bomb the Osirak reactor.

The failure to find chemical or nuclear evidence is in itself suspicious. It is hard to believe that intelligence services around the world were so totally wrong in their assessments. Saddam had at least 6 months notice that invasion was likely.

And Saddam had form. His warplanes were hastily flown out to Iran when the first Gulf War opened.

Materials for nuclear and chemical weapons are not bulky, although the industrial plant to produce them may be. Fissile or chemical materials sufficient for several weapons could be transported in an industrial container on one truck. It would be interesting to know if there were unusual movements by road to Syria, or by road or sea to Iran, in the days or weeks before the invasion.

Were there Iraqi nuclear materials in the Syrian facility at Deir Al-Zor, which the Israelis attacked in 2007?

Probably we shall never know.

2. Saddam undertook to destroy his chemical and nuclear weapons programmes at the peace talks at the end of the first Gulf War in 1991. He then failed to comply and co-operate with the United Nations inspectors. Ten years later the western diplomats at the UN were in a quandary: Saddam ignored warnings that 'consequences' would follow if he continued to obstruct and evade.

The UN had to show that it meant what it said, or back off the confrontation, allowing Saddam to boast successful defiance to the Middle East. Politically much strengthened, Saddam's resurgent ambitions would threaten the entire region, indeed much of the world.

Don't threaten unless you are prepared to act: it's a rule fundamental to managing children and dictators.

Don't end a war until the enemy is comprehensively defeated and disarmed: it is an elementary principle of strategy. Ignoring this principle in 1991 was the root of the crisis which developed to a second war 12 years later.

We should never have allowed ourselves to get into that position.

3. The confrontation with Iraq went critical when the military build-up began in the autumn of 2002. Months are necessary to assemble an armoured army for an invasion. As military readiness builds, so the degree of capitulation necessary to justify a retreat increases. Preparations for war have a momentum of their own.

UN authorisation for war, if considered legally essential, should have been settled before the military build-up began in Kuwait. It was a nonsense for our Attorney General to give legal clearance just a few days before war began.

4. The Arabian deserts are an environment hostile to armies, and especially mechanised armies. Once the force is assembled and ready, it must go into action without delay. Heat, drought, dust, disease and boredom will rapidly erode its capabilities. The build-up had taken most of the cooler winter months at the end of 2002. 

The invasion began on March 20th., 2003, just about the worst time to begin a military campaign in that desert, with temperatures already stressing men and machines, and the furnace of an Iraqi summer imminent.

And don't forget that at that time the Iraqi army was still among the world's largest and well equipped, on paper at least. There was also the threat of Iraqi resort to chemical or nuclear weapons.

It was go or stand down; final defeat or victory for Saddam. The time for diplomacy had run out.

5. Despite warnings from diplomats and others experienced in the Middle East, and familiar with the Arab mind-set, I suspect Bush and Blair expected allied armies to be greeted by cheering crowds as they entered Baghdad, and full co-operation in establishing a civil government. Instead they had to deal with a frenzy of looting, a collapse of civil order and security, and an orgy of inter-communal violence.

I wrote to my MP before war began, telling him my opinion that the military campaign would quickly succeed, but major problems would begin with victory. I did not foresee just how bad the problems would be, or how long and hard the road to stability, peace and prosperity.

In our western comfort-zone it is hard to believe that Iraqis would loot incubators and surgical equipment from their own hospitals. If we do not know, let alone understand, how can we respond?

6. The final assessment of the Iraq war remains uncertain, but it will not be good. Saddam lost the war, but the west lost the peace. Now we stand weakened before a greater crisis developing with Iran.

A Beguiling Fallacy

Correlation implies causation: it is a subtle, beguiling fallacy, often persuading to foolish or dangerous conclusions.

Correlation is a statistical term. It means that changes in two sets of measurements appear to be linked: variation in one is copied by variation in another.

For example, in Britain, over the next three months the daily duration and intensity of sunshine will increase, and the mid-day temperature will increase too. Insolation data is correlated with temperature data. No surprise - we know sunshine warms us; if no correlation were observed then something would be seriously wrong.

But consider this second example. Over the past half century the human population of 'Oman has increased approximately four-fold, while the population of red deer in Scotland has increased by a comparable factor. These two population data-sets may show a good mathematical correlation, but few would conclude that they are causally related: it is hard to see why they should be.

Similarly I'm sure it would be possible to show good correlation between the length of womens' skirts and the prevalence of tuberculosis in Britain in the past century - both have reduced progressively. Most people would need a lot of convincing that one caused the other.

Correlation is no proof of causation.

It is perhaps the most important principle to remember when considering such statistics. It is especially important when they are used to support particular political, social and economic theories. 

We know that a child's chance of a university education increases with the family income. How you interpret this depends on your point of view. If you vote labour you may argue this proves it is right to tax the rich and give to the poor. If you favour the other team you might contradict this argument, and identify parental failings which inflict both family poverty and poor educational progress on their children.

It is especially difficult when the statistics match what we want to believe. So it is reasonable to predict that surgical bypass of small intestine will reduce food absorption and cause weight loss. Operations are done and patients lose weight. The theory is right!

Umm, no, more detailed studies suggest reduced appetite is a consequence of the operation, and accounts for the weight loss.

But causation and correlation can flirt and intrigue. 

At one time it was argued that the correlation between cigarette smoking and lung cancer did not prove a causative link. Maybe genes causing lung cancer also increase the desire to smoke tobacco. It was right to question the conclusion that smoking causes lung cancer, although most recognised special pleading, suspecting [rightly] the influence of tobacco money. Then we observed that doctors who stopped smoking reduced their cancer risk. Eventually the sheer mass of observations and laboratory work made it impossible to deny that in this case the correlation did indeed arise from causation. 

Correlation may suggest causation, but the link must be proved by other means.

Many argue that climate change is the most important problem we must manage. In particular Homo must reduce the amount of carbon dioxide waste dumped into the atmosphere, whatever the cost.

This prevailing opinion is based on a correlation perceived between two sets of data: mean global temperatures and atmospheric carbon dioxide concentration. Both sets show progressive increases during the past century, and carbon dioxide is a greenhouse gas - it has molecular vibration modes which capture radiant heat energy.

So there is a correlation, and a theory which explains possible causation. So the theory is supported, if not proved?

Umm, no again. Studies over much longer periods fail to confirm correlation between global temperatures and atmospheric carbon dioxide. And in the past decade global temperatures have tended downwards, while carbon dioxide has continued to increase.

Solar activity varies. Solar activity increased during the past century, especially in its second half. Since the turn of the century solar activity has reduced. Here is an alternative correlation, between solar activity and global temperature, and again there are reasons to associate the two, and maybe infer causation.

Umm, no again. Correlation still does not prove causation. If present trends in solar activity and global temperature continue then we may observe correlation during increase and decrease. That would be a stronger argument, but extended observations over several solar activity cycles would be needed before probability approaches proof.

But right now I would strongly advise our leaders to reconsider the need to borrow one hundred billion pounds to install thousands of wind turbines in our seas. In twenty years time that may prove to be a most foolish decision. By then we may be worrying about global cooling. [Even if warming picks up again, it is still a stupid decision.]

Correlation does not prove causation. It cannot be repeated too often or too loudly.

Obesity Is Not A Disease

Obesity is much in the news, yesterday because surgeons are complaining that the NHS isn't making provision for many more thousands of gastric-banding operations annually.

Without question obesity is epidemic. Without question obesity shortens life, reduces the quality of life, and inflicts huge costs on our health services.

So what might be a physician's response? The only realistic advice is depressingly ineffective.

Never let yourself get into this condition.

The hard fact is that established obesity is very difficult to reverse. Most obesity we see has developed over many years. The daily habits which have caused the obesity are difficult to change, and any change has to be determined and permanent. Almost all obese patients find this impossible, not least because weight loss is always painfully slow. And the change in habits has to include family and friends - which would be remarkable if it could be achieved.

As I was taught, in language too plain for today:

Look at the family of a fat patient and you will find a fat spouse, fat children, and a fat dog.

Why is dieting so slow to reduce weight? I think the answer lies in energy balances. One gram of fat produces about 9 Calories, so 1 kilogram of fat is 9 kiloCalories, enough energy for 3 days manual labour.

Fat is an insulator, so an obese person needs fewer Calories to maintain body temperature. Obesity causes immobility, consequently the energy demand for activity is also reduced. Many obese people need fewer than 1,500 Calories daily.

So a week of total fasting, water only, might burn off just 1 kilogram of fat.

[And the first few days will see spurious weight loss: fasting causes total body water to be reduced.]

For most people a 1000 Calorie diet is very restricting, but achieves a daily energy deficit of a few hundred Calories at best. Some severely obese people may still be in positive energy balance even at this level of dieting. 

No wonder people get disheartened and miserable, give up, eat for comfort.

In the past we sometimes admitted obese people for very strict dieting under supervision. In a warm ward, in bed or sitting most of the time, surrounded by kindly other patients with chocolates, admission was doomed management. If some reduction was achieved, then it was common to find the weight regained at the first follow-up.

'Weight-watchers', or similar group therapy, has the best chance of success, if people are sufficiently motivated. The same applies to alcoholism: 'Alcoholics Anonymous' does great work in its equally difficult specialty.

There is a genetic element in obesity, in that some people become obese especially easily. Surveys have shown that the obese often eat less than matched, lean people. Even so, the obese are taking more than they can use. There's no justice in nature.

Women are at increased risk of obesity; so are African, Arab and Asian people living a 'western' lifestyle.

In Britain the prevalence of obesity has an inverse relation to income.

'Maturity Onset' diabetes mellitus is associated with obesity. The diabetes causes obesity, and the obesity makes the diabetes more severe. I suspect anyone will become at least chemically diabetic if weight increases enough.

The converse is true: weight loss reduces the diabetic state, in the earlier stages at least. 

Sulphonylurea drugs may be prescribed when dieting fails to reduce the blood glucose values. These drugs increase insulin secretion. Dieting becomes less important in diabetic control. They improve the blood glucose chart at the expense of making weight loss even more difficult.

Other than this type of diabetes, diseases causing obesity are rare. Food intake in excess of need is by far the most prevalent cause of obesity.

And what is eaten is not so important as total energy intake. Fat and sweet foods are rich sources of energy, and so especially fattening.

There is no magic pill which achieves weight loss without dieting. A safe, effective slimming drug would be hugely profitable to its inventor, but the prize remains untaken, and is likely to remain so. We do now have a number of drugs which may be used in selected cases to increase weight loss by dieting. I have no experience of their use, so I will not comment further.

Surgery has its indications, but it is a policy of despair. Obese patients are poor candidates for anaesthesia and surgery. Complications are more frequent, and some will be severe, even fatal, for the patient. For surgeon and hospital litigation is likely to be more frequent - we heard yesterday of claims increasing after obesity surgery.

Procedures include excision of fat deposits, especially abdominal, and liposuction. Other procedures aim to reduce the capacity of the stomach, or reduce the absorption of food in the small intestine. Gastric banding can be done laparoscopically, and is a favoured operation at present.

Operations to bypass a length of small intestine were popular at one time, but a serious risk of late septicaemia became apparent.

All operations on stomach or intestines seem to work by suppressing appetite. In selected patients results can be good, but surgery is a drastic means of enforcing dieting.

So my advice to an obese person is this. Don't consult me. I can only tell you what you know already, that you are eating too much; your only hope of remedy is in determined dieting and exercise. If you want pills or an operation consult someone much younger and more enthusiastic. Don't go to a private practitioner: the prospect of fees may distort the judgement and advice of a saint.

Homo evolved in a hungry world. Our genes create us with a thrifty metabolism; we are poorly adapted to food abundance. War-time rationing proved to be good for the nation's health.

My generation may be the first never to have known hunger in Britain: compare our stature with our parents', and our childrens' with ours. But epidemic obesity warns against excess and complacency. We are now rich enough to waste food on a grand scale - truly we have grown decadent.

Those whom God wishes to destroy he first makes rich.

Haiti: To Manage a National Catastrophe

Earthquake has inflicted catastrophe on Haiti; a nation in chronic failure before accumulated geological stresses broke the rock formations on which the country is built.

The scale of the disaster overwhelms such emergency services as the country has, and the best efforts of aid agencies. Social disorder is inevitable when effective government fails, and communications are disrupted. With loss of order the disaster increases.

The reality is that the American Military is the only organization able to manage this crisis. Haiti needs martial law. The United Nations should recognize this, and should give the Americans legal authorization as necessary. Indeed this should have happened days ago. All other national and charitable aid & recovery task-forces should accept the urgent need for the American Military to manage their efforts.

The Haitian president did not control the country before the earthquake, and the Haitian government, such as it was, is destroyed.

The United Nations has moral authority only. Other countries and agencies will contribute, but their capabilities are limited, and without control there will be confusion, rivalry, even conflict.

So the best news so far is the arrival of the USS Carl Vinson, bringing communications and other headquarters facilities, helicopters, trained and disciplined troops, plus massive provision of drinking water and electrical power. The Carl Vinson can house an emergency government of Haiti. Legal, political and democratic niceties are inappropriate in a disaster of this magnitude.

French criticism of the unmatched generosity and capability of the Americans is contemptible. I have not heard M. Sarkozy offer the Charles de Gaulle to relieve the Carl Vinson.

The media are no help. They want stories and images to increase circulations and viewing figures. They shy from showing the shocking realities. Images of a child rescued from a collapsed building will be headlines; editors don't want to show a street blocked by rubble and littered with corpses left in the sun for 3 days.

On the BBC news we heard a solemn voice-over declare that delays in distributing aid were causing frustration and anger: the accompanying video clip showed men fighting over looted bottles of wine.

And then there is the disruption when celebrities visit: Hilary Clinton, Ban Ki-Moon, Bill Clinton, and God knows who else.

Unbelievably the BBC had a senior official of the UK Disasters Emergency Committee saying there was no urgency to bury bodies. Bodies should be identified and the burial recorded so loved-ones could grieve. So, many thousands of corpses are to be stacked unrefrigerated for days or weeks? How disconnected from reality can you get?

Why is it so hard to appoint a supreme commander of the allied rescue forces, with authority commensurate with responsibility? Is there any alternative to a senior American staff officer for such a post?

What might be the job description for such a commander? My provisional version would include the following.

1. To impose and maintain civil order.

2. To co-ordinate and support immediate rescue and medical efforts, and emergency provision by all contributing.

3. To clear the streets of corpses, rubble, looters and bandits.

4. Urgently to engineer supplies of clean water, and to repair and build sanitary installations.

5. Urgently to repair and expand port and airfield facilities, and to open and maintain transport links for distribution of supplies.

6. To establish secure areas where homeless people can be gathered, sheltered, fed and doctored, giving absolute priority to children, women and families.

7. To create a system of medical surveillance for infectious disease, especially dysentery and malaria, and to build reserve medical teams to move quickly to any outbreak.

This is a formidable, incomplete list. The commander will need staff and be able to delegate authority. So far as possible, the command should be freed from political and public relations duties.  Civil engineering equipment, trucks and tractors, generators and fuel must be mobilized locally or brought in urgently.

When the immediate crisis is under control, then a provisional civil government can be appointed by the UN, progressively to take over from the military, and to plan long-term redevelopment. A return to the status of Haiti before the earthquake makes no sense. There is an opportunity to bring lasting improvements to this impoverished nation, and it should not be missed.

And I do wish the media would get real, and report the facts in full.

Puzzled Again

In the House of Commons this week a Health Minister apologized for the thalidomide tragedy, which occurred 50 years ago. Such apologies are politically fashionable, but this one is especially nonsensical.

Neither the minister nor the government was responsible for the disaster, then or now. What meaning is there when apology has no link to responsibility?

Thalidomide, trade name Distaval, had satisfied the regulations then current for prescription in Britain. It was marketed and prescribed as a sedative drug with a wide margin of safety. I remember Dista's advertisement: a child on a stool at the medicine cupboard in the bathroom, looking at a handful of tablets from a bottle; the caption read "This child's life may depend on the safety of Distaval".

It proved to be beneficial in pregnancy sickness, but it had not been tested for safety in pregnancy. Foetal damage by a new drug was not recognized to be a danger at that time, and the licensing regulations were easy on this issue.

Now, of course, exhaustive testing for safety to the foetus is mandated for all new drugs: the lesson was learned.

Those made confident by 20/20 hindsight may criticize the regulations in force 50 years ago, but the justice of so doing is doubtful.

The drug was withdrawn immediately with recognition of the association between the limb deformity called phocomelia and Distaval.

More recently Distaval has been used to control the "upgrading" reactions which may occur during treatment of leprosy, with inevitable misuse of this psychotropic drug. Consequently new cases of phocomelia are reported from Brazil and other countries.

All drugs have side-effects. Extensive testing of a new drug identifies only the more common problems. Drugs may be in regular use for years before a serious hazard is identified: examples include phenformin and lactic acidosis, practalol and sclerosing peritonitis, rofecoxib [Vioxx] and thrombotic vascular crisis.

It is hard to attribute guilt and liability for a problem which could not reasonably be foreseen.

The Distaval Disaster is exceptional only because the unforeseen side-effect proved to be exceptionally tragic.

[Drug companies strongly encourage doctors to prescribe drugs by trade name. But somehow approved names become appropriate when there is a problem. So 'Thalidomide Tragedy' is now in common use; Distaval Disaster is not - despite its alliteration.]

What the government should admit is its mistake in permitting general practitioners to work office hours only, ignoring warnings of problems and dangers, with consequences now in the headlines.

Apologize when you are not guilty, but don't apologize when you are.

I just can't get my head round that.

  

A Brush with the Law

It was a tragedy. It caused huge grief and distress, made much worse by lawyers.

One Thursday afternoon was on the ward. I had an urgent call to casualty. I was not the physician on call, but I was there.

The emergency ambulance had been brought a 12 years old boy in cardiac arrest.

His class was at the swimming pool. He was in a group of boys who urged each other on to race across the pool, underwater. He reached the far side, began to pull himself out of the water, then gave a cry and fell back in.

He was quickly rescued; he was unconscious, breathing, but no pulse and no heart beat. A teacher and the pool attendant gave external cardiac massage, then mouth-to-mouth became necessary.

An ambulance arrived within minutes. The paramedics continued resuscitation during the journey to hospital. He arrived there maybe 20 minutes after the incident began.

The casualty doctors intubated him, and gave oxygen. There was no heartbeat; an ECG showed no electrical signals from the heart, the condition of asystole. Drugs and electrical shocks failed to start the heart. After 40 minutes increasingly desperate effort the boy's pupils were fixed and dilated; there were no signs of life.

They needed a consultant to declare the boy dead. This was my responsibility, and my duty. I remember a student nurse pulled her apron over her face, and ran out.

I spoke to the teacher who had given first aid. She was in her 30's, I guess, shocked and distressed in the office. I told her the bad news. I reassured her she had done skilfully everything that could be done; it was a rare catastrophe, which could not have been foreseen; in no way should she consider herself at fault.

Some weeks later I was notified the date of the inquest into the death of the boy. The casualty officer was required to attend, I was not. Nevertheless I told the coroner's officer that I would be there.

I drove to the place of the inquest in a neighbouring small town. I noticed a large, dark-blue Rolls-Royce car in the parking area. A warning bell rang in my head.

The inquest was conducted without a jury by the coroner, a gentle, elderly doctor of many years' experience. The boy's parents had briefed a Queen's Councillor, a senior barrister. He was a big, heavy, dominating figure in a lawyer's suit - black jacket and waistcoat, striped trousers, white shirt.

No one else was legally represented.

It is important to remember that an English inquest is to determine cause of death. It is not an adversarial institution. It is not there to apportion guilt or blame.

The facts of the event were quickly established. The casualty officer attested that similar cases had occurred, and are described in the medical literature, but they are very rare.

The theory is that excited boys overbreathe before the dive, in the belief they will have more oxygen, and increase their duration underwater. But in so doing they can substantially reduce blood carbon dioxide concentration, which is the main driver of respiration. In such circumstances vigorous exercise may deplete blood oxygen dangerously, before carbon dioxide has increased enough to make respiration feel urgent. Cardiac arrest is a recognised hazard in this condition.

Then the barrister stood up, and began a sustained attack on everyone concerned with the case. He criticised the manager of the pool: the water temperature was 72 degrees Fahrenheit, too cold for safety, he asserted. He criticised the local authority: they had ordered the pool to be run at this temperature to save money. He criticised the casualty officer for not persisting longer with resuscitation.

Worst of all, he laid into the two women teachers. They should not have taken the class swimming when the water was so cold. They should not have allowed the boys to swim under water. Their negligence had caused this tragedy. He reduced them to tears. I was appalled.

He finished and sat down. The court room was silent.

After a few seconds the coroner asked if I would comment on the way the event had been handled by the teachers. I used words such as exemplary; I stressed they were no way to blame. The QC rose and demanded that I agree that swimming under water is inherently dangerous: I said that crossing the road and riding a bicycle were dangerous, if that standard was right. Did I think it was a duty of teachers to stop boys swimming underwater: I had boys of my own, I had no worries about them swimming underwater, and in any case, boys are boys, how do you stop them?

The coroner asked me if a pool at 72 degrees was too cold for children to swim. No; this is normal summer sea temperature around Britain, it was a temperature for comfortable swimming. The QC challenged me again: the death of this boy was evidence the water was too cold. I rebutted that: I nearly said 'rubbish'. Surely the local authority should now run the pool warmer; no again.

I kept my cool with difficulty. He glared at me and sat down.

He did not challenge the coroner's summing up and verdict of accidental death. The coroner repeated to the teachers that they had done all they could, and were in no way to blame for the death. The QC, the instructing solicitor, and the boy's parents walked out. I saw the QC drive off in the Rolls Royce.

I spent a few minutes comforting the teachers again. I went home outraged.

Never will I pardon that QC. An honourable professional would have advised this was not a case for him. I wonder how much he charged the parents.

I suspect a tougher coroner would have controlled him. Much blame must go to the instructing solicitor: if the parents had requested a legal representation he should have acted himself; bringing in a pit-bull barrister was cruel and wrong.

Physicians and lawyers have a difficult relationship. Physicians must manage the health problems of individuals, often in distressing circumstances, and often must decide despite incomplete information. Medical practice is degraded if physicians worry about possible judgements of lawyers blessed with hindsight, taking one side of the case, in comfortable offices, months later.

Physicians and lawyers share one proverb, to often forgotten in these days of compensation culture.

Bad cases make bad practice.

Barristers, I'm told, have an unofficial motto: "It pays to be a bastard".

Policing - 'Omani Style

This happened in Muscat maybe 15 years ago. I did not witness the event, but the story was told by a woman who was there. It illustrates a few of the differences of culture and custom which an English expatriate observes in Arabia.

She worked in Muscat, commuting into town by public bus. As a woman she had to sit in the reserved section, at the front, behind the driver. Most of the passengers were low-income men from India, Pakistan or Bangladesh: they filled the bus behind the small, women-only section.

One morning she saw an 'Omani man waving to stop the bus. He was not at a bus-stop, so the driver ignored him, but pulled into a bus-stop area a hundred yards or so further on. The 'Omani man had run to the bus-stop, and caught up as the driver opened the bus door.

The 'Omani climbed onto the bus, and began shouting at the driver, another 'Omani. The altercation became heated and quickly degenerated into fisticuffs.

She saw the bus-rage develop, then heard noises behind. Turning she saw that other passengers had opened the emergency door at the back of the bus, and a lot of them were getting out and running off. She knew they would be illegals, with no papers: they guessed the police would come, and wanted to scarper.

Sure enough a police car arrived, and then, just a few seconds later, a second. Two policemen got out of each car, and proceeded to greet each other in the 'Omani way, touching noses, shaking hands, and exchanging the ritual greetings, which can go on for some time.

"Good day - how are you - all well, praise God - what is your news - all is well, thanks be to God", often repeating greetings and questions.

While this was going on the miscreant 'Omani also ran off. The policemen then entered the bus, went through the greeting ritual with the driver, then checked the ID cards of the remaining passengers. Eventually the policemen drove off, and the bus continued its journey, with a depleted company on board.

It's not a style of policing we would recognise, but maybe it has merit.

This article about a road-rage incident in Morocco reminded me of this story.

Quis Editet Ipsos Editores?

The Times newspaper is 225 years old today. To mark this event today's issue came with a facsimile of the very first. The front page has 4 columns, of which the left hand two are for advertisements. These include notices of warships soon to sail for Mediterranean ports, able to take cargo and maybe passengers. Each notice lists the coffee houses or walks where the commander may be found every morning, and the address of William Elyard, the agent I suppose. It appears the ships' commanders had a nice little earner on the side.

One advertisement caught my eye. let me quote it in full.

To the Readers of the London Medical Journal.

This day is first published, price 1s.

SYMPATHY DEFENDED; or the State

MEDICAL CRITICISM in London; written to

improve the Principles and Manners of the Editor of the

London Medical journal: To which are added the Con-

tents of the Treatise on Medical Sympathy, and a Post-

script, on account of a premature Review in a late Num-

ber of the London Medical Journal.

By a Society of Faculties;

Friends to the Public and Enemies to Imposition.

"Cum tua non edras, carpis mea carmina, Laeli,

"Carp re vel noli nostra, ede tua." 

                                                         MART. Epig.

This pamphlet has hitherto distributed gratuitously.

The repeated applications for them, particularly from the

country, have become so numerous, that the Society feel

themselves under the necessity of putting them into the

hands of a publisher.

Sold by J. Murray, Bookseller, Fleet-street.

I wonder what that was about. The London Medical Journal sounds like a professional publication. A Society of Faculties might be an association of apothecaries, barber-surgeons, snake-oil peddlers and the like. But I can only speculate.

No advertisements in The Times today carry classical epigrams, perhaps fortunately: Martial is misquoted here. The correct version follows. The Latin is lapidary, not easy to interpret, but I've done the best I could.

Cum tua non edas, carpis mea carmina, Laeli.

Carpere uel noli nostra uel ede tua.

[You do not publish yourself, yet you criticise my poems, Laelius.

Either stop carping at mine, or publish your own.]

Maybe I'll try to research this intriguing notice, to establish what occasioned it. It is rare indeed that a pamphlet is published to improve the principles and manners of the editor of a modern medical journal. No doubt many medical writers would relish the opportunity to do so.