"Enquire into All the Circumstances of the Patient Narrowly": John Rutherford's Clinical Lectures in Edinburgh, 1749-53.

Early eighteenth-century Edinburgh provided a unique learning environment for aspiring practitioners: one in which the unity of medicine and surgery was appreciated and clinical observations and a reasoning practitioner became the well spring of proper patient care. John Rutherford, a surgical apprentice in this environment, student on the wards of London hospitals and under Boerhaave at Leiden, became one of the original medical professors at the University of Edinburgh medical school in 1726. Rutherford taught the popular, theory-based Practice of Medicine for twenty-two years. Then at the end of 1748 he convinced Royal Infirmary of Edinburgh managers to allow him to begin a new lecture series, entitled Clinical Lectures, conducted at the patient's bedside. Pedagogically, the new lecture series integrated medical theory and its application on the ward. Pragmatically, Rutherford used the Clinical Lectures to transition students into practitioners. He oriented the student to the medical profession at large and placed him simultaneously at the patient-disease-physician interface. He taught that systematic patient observation and examination, when combined with experience and reasoning, were essential to accurate diagnoses and proper therapeutic interventions. Importantly too, Rutherford prepared his students for failure through humility, introspection, and the speculative nature of medical practice.

Joseph Lovell, MD (1788-1836): First US army surgeon general.

Joseph Lovell, trained in medicine at Harvard and in military medicine/surgery by the War of 1812, became the first Surgeon General to sit on the reorganised army staff at the tender age of 29 in 1818. With a keen intellect, medical acumen, and wartime experiences for his tools and a close supporting relationship with Commanding General Jacob Jennings Brown and Secretary of War John C Calhoun (1728-1850), Lovell constructed an efficient and effective organisational and administrative framework for the new Medical Department of the US Army. Moreover, he not only redefined the role of the American military physician but also established the professional dignity, respectability and value of the medical officer among line officers and staff. Lovell's 18-year tenure came to an abrupt end, but the operational framework he created became both foundation and legacy for his successors.

John Warren (1753-1815): American surgeon, patriot and Harvard Medical School founder.

Dr John Warren was educated in the medical apprenticeship tradition of mid-18th century Boston, Massachusetts. As a surgeon in the American Continental Army he honed not only his surgical but also his teaching skills by providing continuing medical education to his colleagues in Boston's military hospital. Warren became a driving force in post-war Boston medicine. His organizational talents, zeal for science and vision for Massachusetts medicine led to the creation of Harvard Medical School.

A systematic process to prioritize prevention activities sustaining progress toward the reduction of military injuries.

BACKGROUND: To sustain progress toward injury reduction and other health promotion goals, public health organizations need a systematic approach based on data and an evaluation of existing scientific evidence on prevention. This paper describes a process and criteria developed to systematically and objectively define prevention program and policy priorities. METHODS: Military medical surveillance data were obtained and summarized, and a working group of epidemiology and injury experts was formed. After reviewing the available data, the working group used predefined criteria to score leading military unintentional injury causes on five main criteria that assessed factors contributing to program and policy success: (1) importance of the problem, (2) effectiveness of existing prevention strategies, (3) feasibility of establishing programs and policies, (4) timeliness of implementation and results, and (5) potential for evaluation. Injury problems were ranked by total median score. RESULTS: Causes with the highest total median scores were physical training (34 points), military parachuting (32 points), privately-owned vehicle crashes (31 points), sports (29 points), falls (27 points), and military vehicle crashes (27 points). CONCLUSIONS: Using a data-driven, criteria-based process, three injury causes (physical training, military parachuting, and privately owned-vehicle crashes) with the greatest potential for successful program and policy implementation were identified. Such information is useful for public health practitioners and policymakers who must prioritize among health problems that are competing for limited resources. The process and criteria could be adapted to systematically assess and prioritize health issues affecting other communities.

Risk factors for injuries during military parachuting.

INTRODUCTION: Parachuting is an activity performed by a variety of occupational groups including the military, firefighters (smoke jumpers), and rescue groups. METHODS: This paper systematically reviewed the literature on injury risk factors for soldiers performing static line parachuting from military aircraft. Jump-related injuries were defined as those occurring from the time the soldier exited the aircraft until he or she released their parachute harness on the ground. RESULTS AND DISCUSSION: Despite methodological differences, where two or more studies examined a particular risk factor, results were generally similar. Higher injury risk was associated with higher wind speed, night jumps, jumps from airplanes (vs. balloons and helicopters), jumps wearing additional equipment jumps without ankle braces, uneven terrain on the drop zone, and female gender. Risk factors identified in only single studies included a greater number of soldiers exiting the aircraft, winds from the rear of the aircraft, simultaneous exits from doors on opposite sides of the aircraft, smaller parachute canopies, higher ambient air temperatures, and airborne refresher courses (vs. introductory courses). Further studies are needed which use a multivariate approach to evaluate the relative impact of the various risk factors and their interactions. CONCLUSIONS: This paper identified a number of risk factors relevant to all parachutists (e.g., wind speed, female gender) and some relevant primarily to the military and other tactical parachutists such as smoke jumpers (e.g., equipment weight). Knowledge of these risk factors can assist parachutists and those that train them in their risk analysis.

An outbreak of pneumococcal pneumonia among military personnel at high risk: control by low-dose azithromycin postexposure chemoprophylaxis.

In the winter of 1998-1999 an outbreak of pneumococcal pneumonia occurred among Ranger students undergoing high-intensity training. Thirty pneumonia cases (attack rate = 12.6%) were identified among a group of 239 students. Eighteen students were hospitalized; Streptococcus pneumoniae-positive cultures were detected in 11 (61.1%) of these 18 hospitalized cases. Pneumococci were also identified in throat swabs of 30 (13.6%) of 221 nonhospitalized students surveyed. Serum antipneumolysin seroconversions were detected in 30 (18.3%) of 164 students tested. An association between development of serum antipneumolysin antibody and pneumococcal pharyngeal carriage/colonization was found. Of 30 seroconverters, eight (26.7%) had S. pneumoniae-positive cultures compared with only 17 (12.7%) of 134 nonseroconverters (relative risks = 2.02, 95% confidence interval = 1.02-4.02, p = 0.05). The outbreak was controlled by administrating lowdose, oral azithromycin prophylaxis (250 mg weekly for 2 weeks) and was associated with a 69% reduction in pneumococcal carriage and a 94% reduction in pneumonia rates.