Letters to the Editor

(Aust Prescr 1995;18:84-6)

Letters, which may not necessarily be published in full, should be restricted to not more than 250 words. When relevant, comment on the letter is sought from the author. Due to production schedules, it is normally not possible to publish letters received in response to material appearing in a particular issue earlier than the second or third subsequent issue.

The eye of Horus

Editor, I always look forward to reading Australian Prescriber and the Editor's note on the eye of Horus was of interest (Aust Prescr 1995;18:23).

I understood from my initial studies in pharmacy that the symbol R stood for 'Recipe', the Latin for 'take thou', and the tail was a sign of the god of healing. Many pharmacists look on it as an invocation to interpret what follows in the interest of the patient. One pharmacist expressed the opinion that doctors who write illegible prescriptions demonstrate insecurity, like when one scribbles a word one cannot spell.

Duncan Cruickshank
Pharmacist
Merewether West, N.S.W.

Editor, In the spirit of engendering further discussion on the matter, I was taught that Rx was an abbreviation of the Latin 'Recipe', imperative, translated as 'make up ...' as a directive to the pharmacist.

Peter Tait
General Practitioner
Alice Springs, N.T.

Editor, The symbol of the eye of Horus first appeared 5000 years ago. Horus, son of Isis, lost his sight after a vicious attack by the demon Set, but recovered his sight when his mother invoked the aid of Thoth. Thereafter, the Egyptian physicians invoked the god Horus and used as the symbol the eye, which became stylised as Fig. 1. The symbol meant health and happiness.

The symbol precedes Imhotep, the physician and advisor of Dzoser (or Zoser) in the third dynasty (circa. 2670 B.C.).1 The symbol is still present on the magnificent pectoral of Tutankhamen 1300 years later.2 Homer acknowledged that the Egyptians were skilled physicians and the sign of Horus was adopted to become the sign of Apollo by the Greek physicians. By this time, it was written as Fig. 2

Fig. 1 __________________Fig. 2

The Greek physicians who came as slaves to Rome brought with them their symbol, and Nero tried to ascribe the sign to Jupiter, the Roman god. He attempted to establish the sign as a symbol of the subjugation of the physician to the state.

The Christian Church in its turn attempted to Christianise the symbol by writing a double R and this was said to be an invocation to Raphael and his response Responsum Raphaelis. But the alchemists later returned to the original Greek symbol and this continues to this day. In the Age of Reason, the symbol was rationalised and said to be the initial R of the Latin 'Recipe' receive this prescription, or take up these ingredients.

Symbols are the secret code of mankind and the pictogram of the eye of Horus has become the symbol of the medical prescription today.

Robert F. O'Shea
Physician
Brisbane, Qld

R E F E R E N C E S
1. Aldred C. Egypt to the end of the old kingdom. London: Thames and Hudson, 1965.

2. Desroches Noblecourt C. Tutankhamen. London: G. Rainbird, 1963 (plate XXXX1).

Previously published in The Medical Journal of Australia 1979;1:1789. Reprinted with permission.

The nonpharmacological treatment of osteoarthritis

Editor, I refer to the article 'The nonpharmacological treatment of osteoarthritis' by Dr J.R. York (Aust Prescr 1995;18:2-4).

This article offers a number of strategies to prevent and manage arthritis which are not supported by the medical literature. Whilst much research has taken place into the nature of osteoarthritis, the aetiology remains in doubt.

I would have liked Dr York to provide references which demonstrate that weight reduction, occupational or sport modification, joint protection, team management, analgesics or education prevents osteoarthritis from developing or progressing.

All of the factors he has mentioned have an important role in the management of established osteoarthritis and they reduce symptoms once they occur.

The question of cruciate ligament repair remains controversial, although there is some evidence that prevention of episodes of giving way minimises the risk of articular damage or meniscal injury, therefore offering the theoretical possibility of preventing osteoarthritis. It is perhaps this singular issue which offers some possibility for prevention.

Finally, as an Australiantrained orthopaedic surgeon and current trainer of young orthopaedic surgeons, I can only say that I was taught and teach that surgery is never the best option. Surgery is the option chosen when other methods of management have failed to bring about comfort and quality of life is significantly compromised.

I write to the author because of my concern that many of the physical methods of management involve considerable human resources and expense and, unless there is evidence of their efficacy, they should be used sparingly.

Bruce R.T. Love
Orthopaedic Surgeon
East Melbourne, Vic.

Dr J.R. York, the author of the article, comments:
I thank Mr Love for his comments. I would agree that there are no documented prospective trials to prove that the techniques outlined in my paper prevent osteoarthritis from developing or progressing. The logistics of such studies present formidable problems, particularly the length of followup time required to produce meaningful results.

However, one can argue a logical case on the premise that if a particular bodily characteristic such as obesity or a person's occupation or sporting activity is associated with an increased prevalence of osteoarthritis in specific joints1,2,3, then control of these factors should be attempted. Primary prevention in the absence of a defined aetiology for the disease is elusive and Utopian, but the onus is equally on Mr Love to provide evidence that the measures outlined do not do more than reduce symptoms in affected joints.

Perhaps the question 'Is surgical treatment the best option?' may have been better expressed as 'Is surgical treatment the best available option?'. There is no question in my mind after many years of consultant rheumatology practice that the most significant advance in the management of most forms of arthritis in the last 30 years has been the development of total joint replacement.

I have no argument with Mr Love's indications for surgery or his concluding paragraph with which I concur.

R E F E R E N C E S
1. Peyron JG, Altman RD. The epidemiology of osteoarthritis. In: Moskowitz RW, Howell DS, Goldberg VM, Mankin HJ, editors. Osteoarthritis diagnosis and medical/surgical management. 2nd ed. Philadelphia: WB Saunders, 1992:15-37.

2. Anderson JJ, Felson DT. Factors associated with osteoarthritis of the knee in the First National Health and Nutrition Examination Survey (Hanes 1) : Evidence for an association with overweight, race and physical demands of work. Am J Epidemiol 1988;128:179-89.

3. Kovar PA, Allegrante JP, MacKenzie CR, Peterson MG, Gutin B, Charlson ME. Supervised fitness walking in patients with osteoarthritis of the knee. A randomized controlled trial. Ann Intern Med 1992;116:529-34.

MedicAlert

Editor, Many Australians are at risk from medications if they are unable to communicate adequately in an emergency. This may be because of drug hypersensitivity or interactions, or because they are taking medications which may be lifethreatening if stopped suddenly.

The Medic Alert Foundation's visible emblem will alert both ambulance officers and emergency carers. A telephone call to the number on the emblem will access a computerised registry of further information. The Foundation is a worldwide, nonprofit organisation staffed partly by
unpaid volunteers. It has been endorsed by the Federal Minister for Health, the Australian Medical Association, the Royal Australasian College of Physicians and the Royal Australian College of General Practitioners.

Many thousands of Australians already wear the MedicAlert emblem, but they are only a very small proportion of those who could benefit from it. The $55 cost for the standard stainless steel disc covers basic production and administrative expenses. Doctors are required to authorise the medical information on the application form to ensure its accuracy.

Further information and supplies of application forms can be obtained by phoning the Medic Alert professional line 1800882222.

Dr Robert Hecker
Director Professional Relations
Australia Medic Alert Foundation
Eastwood, S.A.

Infusion devices

Editor, I refer to the article 'Infusion pumps: guidelines and pitfalls' by Mr R. Ferrari and Dr D. Beech (Aust Prescr 1995;18:49-51).

I have seen an inexpensive controlled rate infusion device which may be useful in palliative care. The device is a silastic bulb which is prefilled with the medication in solution, and connected to the infusion needle (whether subcutaneous, or into an intravenous sidearm) by the special rate controlling connector. The cost of each device is so low that they are disposable.

I would like to know why this equipment was not discussed in the article.

Hugh Nelson
General Practitioner
Helensvale, Qld

Editor's note: Dr Nelson's letter was the first letter to the Editor to be received via electronic mail (click here for email address).

Mr R. Ferrari and Dr D. Beech, the authors of the article, comment:
We appreciate the comments from Dr Nelson on 'calibrated bore flow restricted infusion devices' or, more commonly, elastomeric pumps. Our main intention was to address some very common problems with electromechanical pumps, so other drug delivery systems such as elastomeric pumps and implantable pumps where not included in the article. Elastomeric pumps, including spring driven pumps, have been extensively marketed overseas and some models have been available in Australia for several years.