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Publications written by doctors about subjects outside their professional activities are often widely read and may be more enduring than their technical publications. Dr Graeme Robertson, Sir Clive Fitts and Professor Richard Lovell were three doctors from Victoria who wrote with skill and artistry about subjects outside their professional work. Here I discuss these publications and the reasons these doctors came to write them, and offer some reasons for the enduring interest of these publications.

Three patients, in whom tumour overkill by cytotoxic treatment, including high dose methotrexate with folinic acid rescue, resulted in the 'phosphate shower syndrome' (hyper-uricaemia, hyperkalaemia and hyperphosphataemia with hypocalcaemia and tetany, with metabolic acidosis and acute renal impairment) are described. Severe methotrexate toxicity occurred in two of these patients. High dose methotrexate would appear contra-indicated in situations where massive tumour lysis is possible.

Two patients with multiple myeloma died in acute liver failure. Both had been treated with the anabolic steroid oxymetholone and both subsequently developed severe cholestatic hepatitis. In one the histological lesion progressed despite cessation of oxymetholone therapy. Myeloma infiltration of the liver and peliosis hepatis were not seen. As a fatal outcome from cholestatic hepatitis due to oxymetholone is rare it is possible that an unknown potentiating factor is present in multiple myeloma that can lead to a fatal outcome. If oxymetholone therapy is to be used in such patients then close clinical and laboratory assessment of liver function should be carried out in an attempt to prevent this unusual and fatal complication.

Creation of an artificial subcutaneous arteriovenous fistula was attempted in five patients with malignant haematological disorders (two with Hodgkin's disease, two with acute lymphatic leukaemia, and one with acute myeloid leukaemia). The average time from the start of treatment to attempted creation of the fistulae was four years. Neither direct arteriovenous anastomosis nor an interposition mandril graft was successful in any patient. Failure was attributed to impaired venous run-off secondary to previous episodes of thrombophlebitis induced by the intravenous administration of cytotoxic drugs. The use of an arteriovenous fistula early in the course of the disease might minimize these later problems.

The clinical and pathological features of histiocytic medullary reticulosis (HMR) are described in five patients. Treatment by splenectomy and the MOPP routine resulted in a transient improvement in platelet and neutrophil counts and resolution of anaemia and apparent prolongation of survival in two of the five patients. The relationship of HMR to other histiocytic disorders is discussed. HMR is defined as a unique malignant histiocytosis in which malignant histiocytes engage in phagocytosis of eryrhrocytes, leucocytes and platelets.

A continuous flow blood separator was used for leucapheresis in two patients with chronic myeloid leukaemia, complicated by pregnancy and leukastasis respectively, and for thrombocytopheresis in a patient with megakaryocytic myelosis. The cases described, outline some of the clinical uses of this machine in the myeloproliferative syndrome.

The therapeutic armamentarium in the treatment of cancer is now expanded to include surgery, radiotherapy, chemotherapy and immunotherapy. The aim is to achieve cure where possible. For some cancers the concept of cure can be questioned, and for many patients, cancer must be regarded as a chronic disease. A vigorous approach to palliation, particularly in regard to special problems such as hypercalcaemia, yields good dividends. Human values remain of paramount importance, and active antitumour treatment with attendant side effects must not be continued where there is no expectation of worthwhile response.

This report describes the occurence in Australia of non-endemic Burkitt's lymphoma in a 43-yr-old European migrant. The patient presented with cervical lymphadenopathy and massive bone marrow involvement, and died 6 mth later with intracranial spread of the tumour. The pathological features, course and treatment of the disease are described.

Angiotensin converting enzyme was measured in the serum of 52 patients with sarcoidosis, 67 healthy control subjects and 64 patients with pulmonary and non-pulmonary diseases. The patients with sarcoidosis were classified on clinical grounds as having active or inactive disease. In 26 patients with active sarcoidosis not taking corticosteroids the mean serum ACE was significantly higher than in normal controls (P less than 0 . 001). 73% of these patients had elevated serum ACE. Only two out of 12 (17%) patients with inactive sarcoidosis not taking corticosteroids had elevated serum ACE. Serum ACE was normal in patients taking oral corticosteroids for longer than two weeks. Eighty per cent of patients with active sarcoidosis with radiological evidence of pulmonary parenchymal involvement had an elevated serum ACE compared to 25% in patients with normal chest X-rays and 60% of those with bilateral hilar lymphadenopathy. All sarcoid patients with hypercalcaemia had elevated serum ACE whereas only half of those with normal serum calcium had elevated ACE. In the patients with other thoracic and granulomatous conditions serum ACE was normal or rarely marginally elevated. Serum ACE appears to be of value in the diagnosis of active sarcoidosis.

Fifty-eight patients with a variety of haematological lymphoproliferative or myeloproliferative disorders were given bivalent subunit influenza virus vaccine, and their antibody responses after vaccination were compared with those of a normal control group. Although geometric mean titres of the patient group showed lower initial antibody levels, smaller increments, and lower final titres, after vaccination 83% of this group achieved satisfactory antibody levels to the A/Pt Chalmers strain, and 57% to the B/Hong Kong strain. The lowest antibody levels and smallest responses occurred in patients with non-Hodgkin's lymphoma, Hodgkin's disease, and multiple myeloma. Four of seven patients who showed low antibody levels, and no response to the first injection, responded to a second dose.

Repeated single doses of busulfan (50-200 mg) were given over 1--2 days to 17 patients with chronic myeloid leukemia. The mean survival time was 137 weeks. In this small trial the drug was shown to be safe in most but not all patients and as effective as continous busulfan.

A series of 77 gallium-67 citrate (67Ga citrate) scans of the abdomen revealed lymphoma in 12 cases (nine of non-Hodgkin's lymphoma, three of Hodgkin's disease). Scanning was undertaken (i) to confirm the suspicion of lymphoma, or (ii) as part of a staging procedure when the diagnosis of lymphoma had been established, or (iii) as a follow-up investigation after treatment of lymphoma. The diagnosis of lymphoma in the upper part of the abdomen is difficult with conventional techniques such as lymphography, and it is in this area that 67Ga citrate scanning is shown to be of value.

Of 13 cases of polycythaemia vera in which direct bone marrow culture was carried out for chromosome analysis, a consistent count of 48 chromosomes was found in two on admission to the hospital. Neither patient showed evidence of blastic transformation.

Eighty-six adults with malignant disease were given high doses of methotrexate with folinic acid rescue, with acceptable toxicity. Protocal violations in two cases led to death. The results of therapy in some diagnostic groups are encouraging.

81 patients, 24 with sarcoidosis and the remainder with various other diseases, were tested with three batches of Kveim material prepared from the same spleen. Positive Kveim tests were observed in sarcoidosis, tuberculosis, Hodgkin's disease, ulcerative colitis, rheumatoid arthritis, and Weber-Christian disease. These results show that a positive Kveim reaction to the material under test was not specific to sarcoidosis.