Volume 174 Issue 1

Defining Moments In Medicine A golden age defined Fifty years of medical advances MJA 2001; 174: 8

Bronwyn Gaut

Defining Moments In Medicine General practice MJA 2000; 174: 9

Max Kamien

Defining Moments In Medicine Internal medicine MJA 2001; 174: 9-11

Colin I Johnston · Mark E Cooper · Andrew J Taylor · James A Shaw

Defining Moments in Medicine Pathology MJA 2001; 174: 11-12 College of Pathologists of Australia: The College of Pathologists of Australia was established in 1956, and from 1980 became the Royal College of Pathologists of Australasia. The College has established the internationally recognised journal Pathology, and from about 1983 the College has spread its influence to several countries, including Singapore, Malaysia, Hong Kong and Saudi Arabia, as well as Australia and New Zealand. Automated cell counters: These were initially used in haematology in the 1960s and subsequently applied more generally in flow cytometry. The principle of the Coulter counter, with blood cells counted as they pass in single file across a light or other energy source, has been applied in many aspects of clinical and research pathology. Automated clinical chemistry: Initially, in the early 1970s, multichannel analysers were used, then sequential analysis and dry chemistry techniques were introduced and, more recently, "near-patient" testing. Introduction of Medicare: Medicare's introduction in 1975 profoundly affected many aspects of clinical care, and has been partly responsible for a great increase in private pathology practices. Improved standards of forensic pathology and science: The debacle of the forensic investigation for the prosecution of the Azaria Chamberlain case in the 1980s showed up the appalling state of forensic pathology and forensic science in Australia, and was an impetus for the development of excellent forensic institutes and facilities in many Australian centres, with much-improved training programs and standards of practice. Frozen-section techniques and biopsies: Frozen-section techniques, percutaneous biopsies of kidney, liver and heart and, more recently, fine-needle aspiration and endoscopic biopsies have greatly improved knowledge of many disease processes, as well as provided accurate pathological diagnoses from very small samples. Medical laboratory accreditation: Nationwide medical laboratory accreditation in the early 1980s, together with quality control and quality assurance programs under the aegis of unique cooperative arrangements between the National Association of Testing Authorities and the Royal College of Pathologists of Australasia (NATA/RCPA) began in the late 1970s and continue to operate to a large extent as peer-review systems. Decline in hospital autopsies: The progressive decline in numbers of hospital autopsies during the latter part of the 20th century has resulted in the inevitable loss of clinicopathological correlations and valuable learning resources. Surveys of hospital deaths have shown large discrepancies between the clinical opinion of cause of death and comorbidities, and findings at autopsy. Advances in microscopy and staining: In both research and diagnostic pathology, the application of transmission and scanning electron microscopy and fluorescent and immunohistochemical techniques has contributed significantly to understanding the pathogenesis of many diseases, and to their accurate diagnosis. Advances in cytological techniques: Exfoliative cytology was initially used largely in gynaecology and pulmonary medicine, but subsequently in many other circumstances. More recently, cytology has been vastly expanded with the widespread use of fine-needle aspiration, and automated techniques for screening are coming into use, increasing overall diagnostic accuracy. Molecular pathology: Application of techniques of molecular biology and genetic analysis to diagnosis in pathology has had profound effects in all disciplines of pathology. Role of Helicobacter pylori: After the initial observations by pathologist Robin Warren and gastroenterologist Barry Marshall, in Perth in the early 1980s, the aetiological role of this organism in gastric and duodenal ulceration and cancer is now accepted by gastroenterologists and pathologists worldwide. Elucidation of aspects of viral infections: Elucidation of many aspects of viral infections, including the hepatitis viruses and HIV, is having profound effects on blood donations and blood transfusion technology, and patterns of behaviour in the community. Importance of apoptosis: The role of apoptosis (certain cells are programmed to die at a particular time) in embryological development has been known for 100 years or so. Its importance in normal adult physiology and in a large number of disease processes only became apparent after pioneering work undertaken by Brisbane pathologist John Kerr in the late 1960s. Corporatisation of private pathology practices: The increasing corporatisation of private pathology practices in Australia, with ownership going from practising pathologists to other individuals or companies, and public laboratories becoming business units, is cause for concern. More and more individual practices are controlled by fewer and fewer people. Peter B Herdson Forensic Pathologist, Canberra, ACT Richard A Scolyer Anatomical Pathologist Royal Prince Alfred Hospital, Sydney, NSW Alistair R McGregor Director, Microbiology and Infectious Diseases Royal Hobart Hospital, Hobart, TAS Above photograph courtesy Alfred Hospital Heritage Committee, Melbourne. Make a comment

Peter B Herdson · Richard A Scolyer · Alistair R McGregor

Defining Moments In Medicine Surgery MJA 2001; 174: 12-13

John P Maddern · Guy J Maddern

Defining Moments In Medicine Obstetrics and gynaecology MJA 2001; 174: 13-14 Family planning clinics: These clinics developed in the 1960s but were able to offer much more effective management once the oral contraceptive pill became readily available. The clinics improved access to contraceptive advice and therapeutic abortion, particularly among women of lower socioeconomic background. Cancer screening: Screening for cervical cancer has improved gradually over the past 50 years, initially with the use of routine Pap smears and colposcopy and, more recently, with human papillomavirus typing. Earlier detection of cancer of the uterine endometrium has been made possible by ultrasound scanning, endometrial sampling by intrauterine catheters and hysteroscopy with biopsy. Treatment of rhesus iso-immunisation: In 1961, New Zealander A W Liley first published on the management of pregnancy complicated by rhesus sensitisation. His pioneering work on analysis of the amniotic fluid was used to assess the need for exchange transfusion, leading eventually to the development of cordocentesis for accurate measurement of fetal haemoglobin. Sexual dysfunction clinics: The first Australian clinic for sexual dysfunction was founded by Elsie Koadlow at the Queen Victoria Memorial Hospital for Women, Melbourne, in the late 1960s. Fetal monitoring during labour: Methods to monitor the health of the fetus during labour were introduced in the mid-1960s. It became possible to monitor fetal heart rate continuously and to measure metabolic parameters in fetal scalp blood. The success of these techniques in reducing death and brain damage from hypoxia and circulatory failure was demonstrated by the world's first randomised controlled trial of new techniques for fetal monitoring at the Queen Victoria Memorial Hospital in 1969. Corticosteroid therapy for preterm delivery: In 1972, New Zealander G C Liggins found that exposing infants born between 24 and 34 weeks' gestation to corticosteroids before delivery halved the incidence of respiratory distress syndrome, protected against intraventricular haemorrhage and reduced mortality by 40%. It is now standard practice to give corticosteroids to women at 24-38 weeks' gestation at risk of preterm delivery. Royal Australian and New Zealand College of Obstetricians and Gynaecologists: Before 1978, Australians travelled to the United Kingdom to study and take the Royal College of Obstetricians and Gynaecologists' examinations. Formation of the Australian College in 1978 led to increased postgraduate education and better clinical standards, and encouraged research. In 1998, the Australian and New Zealand Colleges combined as the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. In-vitro fertilisation: The world's first in-vitro fertilisation (IVF) pregnancy was achieved in Melbourne in 1973. Although it was sustained for only a week, it heralded the world's first IVF baby in the United Kingdom in 1978. IVF became more practicable in 1980, when ovarian stimulation was first used to produce multiple eggs (and resulted in several pregnancies) at the Queen Victoria Medical Centre, Melbourne. With the world's first frozen-embryo baby and first donor-egg baby, produced by the Monash IVF team in 1983 and 1984, respectively, IVF became more acceptable and applicable to a wider variety of infertility problems. Ultrasound examination: Ultrasound has revolutionised obstetrics and gynaecology, with numerous diagnostic applications in pregnancy and labour, and in abnormalities of the ovaries, fallopian tubes and uterus. It has also made possible many operative procedures. Epidural anaesthesia: This has made a major contribution to obstetrics, both relieving pain in labour and allowing women to be conscious during caesarean section. It has added humanity to the too often accepted notion that labour should be synonymous with suffering. Prostaglandins: These drugs have altered management of second- and third-trimester pregnancies. Both gemeprost and dinoprostone vaginal gel can be used to induce labour. Misoprostol is an effective abortifacient, and is used increasingly in Australia as a cervical ripening agent before suction curettage in nulliparous women with a missed abortion. Hormone replacement therapy: Managing menopause with hormone replacement therapy (HRT) has become a specialty of its own. Although the risk of breast cancer is slightly increased, it is minuscule compared with the risks of developing the complications of postmenopausal osteoporosis. Endoscopic surgery: Operative laparoscopy has expanded to include techniques for nearly all procedures previously performed only by laparotomy. By the late 1990s, a small but increasing number of gynaecologists perform 90% or more of gynaecological surgery by laparoscopy. Endometriosis: An awareness of the burden of this disease, which affects 600 000 Australian women, developed only in the 1990s. Recent studies have shown that 90% of women with severe menstrual pain affecting work or school attendance have endometriosis. Surgical treatment has been improved by applying the principles of cancer surgery, while a polygenetic basis for the disease has been discovered. Subspecialty training: Over the past four years, obstetrics and gynaecology has been subdivided to produce subspecialists with particular expertise. Certification and accreditation is now available in Australasia in gynaecology, high-risk obstetrics, ultrasound, reproductive medicine and urogynaecology. Carl E Wood Emeritus Professor, Department of Obstetrics and Gynaecology Monash University, Melbourne, VIC Simon J Gordon Gynaecologist, Mercy Hospital for Women, Melbourne, VIC Make a comment

Carl E Wood · Simon J Gordon

Defining Moments In Medicine Radiology MJA 2001; 174: 14-15

David A Lisle

Defining Moments In Medicine Paediatrics MJA 2001; 174: 16-17 Australian Paediatric Association: Founded in 1950, the Association was of vital importance to the developing specialty of paediatrics in Australia. It became the Australian College of Paediatrics in 1978 and then joined with the Royal Australasian College of Physicians in 1998 to form the Division of Paediatrics and Child Health. Chemotherapy for childhood leukaemia: Melbourne paediatrician John Colebatch published the first Australian controlled trial in 1950, testing a chemotherapeutic drug in children with acute lymphatic leukaemia. This was followed by multicentre trials in Australia of treatment for leukaemia and other childhood malignancies. A majority of children with acute leukaemia can now be cured, and national and international collaborative randomised controlled trials have become the standard method for evaluating treatment. Management of premature infants: Recognition by Kate Campbell (Melbourne paediatrician) in 1951 that high concentrations of ambient oxygen caused retrolental fibroplasia in premature infants led to a major change in the management of premature infants and was an important milestone in the development of neonatology as a paediatric subspecialty. Introduction of triple antigen: Triple antigen was introduced to Australia in 1953. In 1957, the Australian Paediatric Association's recommendation to the National Health and Medical Research Council that all infants should be vaccinated routinely with triple antigen against diphtheria, pertussis and tetanus was accepted. Liberal hospital visiting times: Daily visiting by parents was introduced at the Royal Children's Hospital, Melbourne, in 1953, and two years later the Royal Alexandra Hospital for Children, Sydney, introduced extended visiting. This substantially reduced the emotional trauma of hospital admissions. Previously, visiting had been restricted in the erroneous belief that cross-infection would be increased, and the children would be upset and more difficult to care for. Vaccination for Aboriginal children: In 1954, to help reduce communicable diseases -- whooping cough, diphtheria and tetanus -- a routine vaccination program was commenced for Aboriginal children in the Northern Territory. Nasotracheal intubation: Melbourne anaesthetists Ian McDonald and John Stocks, in the British Journal of Anaesthesia in 1965, described prolonged nasotracheal intubation in infants and children, which was crucial in the development of intensive care for infants and children. It provided an alternative to tracheostomy for artificial ventilation, which had a very high complication rate. Australian Paediatric Journal: Established in 1965 by the Australian Paediatric Association, the Australian Paediatric Journal subsequently became the Journal of Paediatrics and Child Health. It publishes quality research in paediatrics from Australia and the Asia-Pacific region. Management of childhood asthma: From 1969 onwards, Howard Williams and Ken McNicol (of Melbourne's Royal Children's Hospital Research Foundation) published a series of articles clarifying the prevalence and natural history of asthma in children. These articles substantially changed the way childhood asthma was managed. They emphasised the importance of basing treatment on the pattern of symptoms, and the use of bronchodilators, rather than antibiotics, in the treatment of wheezy episodes. Preventing childhood injury: From 1969 regulations and programs were introduced in Australia to reduce morbidity and mortality of childhood injury (eg, safety standards for children's nightwear, other programs to reduce the risk of burns, compulsory child restraints in motor vehicles, and legislation to require that crash helmets be worn by bicyclists). Rotavirus in viral gastroenteritis: In 1973, Ruth Bishop, Ian Holmes, Geoff Davidson and colleagues (from the Royal Children's Hospital, Melbourne, and the Department of Microbiology, University of Melbourne) showed that rotavirus was the most important cause of viral gastroenteritis in infants and children. This was an important step in the understanding of this major worldwide cause of childhood morbidity and mortality. Vaccines are being developed in attempts to prevent this infection. Emergency transport services: The Neonatal Emergency Transport Service and the Paediatric Emergency Transport Service were established in Melbourne in 1976 and 1980, respectively. These two services have reduced morbidity and mortality from critical illness in neonates, infants and children presenting away from major tertiary centres. Fragile X syndrome: Recognition of fragile sites in chromosomes and identification in 1977 by Grant Sutherland (Adelaide Children's Hospital) of the fragile X syndrome, one of the more common causes of mental retardation, has led to an understanding of its familial nature and to in-vitro diagnosis. Adolescent Health Survey: Undertaken in Melbourne in 1992, this survey of 4000 adolescents provided essential information on risk factors for health problems and prevalence of such problems in adolescents. It was crucial in establishing adolescent health as an independent specialty with an academic base. Australian Childhood Immunisation Register: Established in 1995, the Register is an essential database of the vaccination status of Australian children and allows those whose vaccination is incomplete to be identified. There are now incentives for parents to to have their children fully vaccinated. Peter D Phelan Emeritus Professor of Paediatrics University of Melbourne, Melbourne, VIC Don M Roberton McGregor Reid Professor of Paediatrics University of Adelaide, Adelaide, SA Mike South Director, Department of General Medicine Royal Children's Hospital Melbourne, VIC and Associate Professor, Department of Paediatrics University of Melbourne, VIC Above photograph courtesy Royal Children's Hospital Archive, Victoria. Photographer: Laurie Richards. Make a comment

Peter D Phelan · Don M Roberton · Mike South

Defining Moments In Medicine Anaesthesia MJA 2001; 174: 17-18 New anaesthetic agents: Anaesthesia has been revolutionised over the past 50 years by the development of new anaesthetic agents. In 1957, the volatile agent halothane supplanted ether as the anaesthetic of choice. It is more pleasant for patients, potent and non-flammable. Later refinements were isoflurane and sevoflurane, the latter being particularly useful in children. Another key change was the introduction, in 1952, of the first short-acting, depolarising muscle relaxant, suxamethonium, while in 1967 pancuronium replaced d-tubocurarine as the main long-acting, non-depolarising muscle relaxant. The intravenous induction agent propofol (1986) was a major improvement on thiopentone, while the local anaesthetic bupivacaine (1963) provides longer duration of action for regional anaesthesia. Monitoring of anaesthetic deaths: Australia has led the world in the quality and safety of anaesthesia. In 1960, Ross Holland (Director of Anaesthesia at Lidcombe Hospital, Sydney) pioneered investigation of deaths associated with anaesthesia and education of anaesthetists to reduce anaesthesia-related mortality in New South Wales. Other States followed, and national data have been published triennially since 1985, documenting the safety of anaesthesia in Australia. Faculty of Anaesthetists: In 1952, postgraduate training in anaesthesia was formalised with the formation of the Faculty of Anaesthetists within the Royal Australasian College of Surgeons. In 1992, the Faculty became the Australian and New Zealand College of Anaesthetists. It has accredited training programs in Australia, New Zealand, Hong Kong, Malaysia and Singapore. Anaesthesia as an academic discipline: Anaesthesia advanced as an academic discipline in Australia with the appointment in 1962 of Douglas Joseph to the first chair in anaesthetics -- the Nuffield Chair at the University of Sydney. Subsequently, other chairs in anaesthesia were established in Brisbane, Melbourne, Sydney, Newcastle, Adelaide and Perth. Launch of Anaesthesia and Intensive Care: The journal Anaesthesia and Intensive Care was launched by the Australian Society of Anaesthetists in 1972. Specific training in intensive care: The world's first training and examination system in intensive care was established by the Faculty of Anaesthetists in 1976. After formation of the College of Anaesthetists, a Faculty of Intensive Care was inaugurated in 1993, with Geoff Clarke (Head of Intensive Care, Royal Perth Hospital) as the first Dean. Specific training in pain medicine: Training in pain medicine was begun by the College of Anaesthetists in 1996, and in 1998 a multidisciplinary Faculty of Pain Medicine was formed, with Michael Cousins (Head of Anaesthesia and Pain Management, Royal North Shore Hospital, Sydney) as the first Dean. Board members are drawn from the Australian and New Zealand College of Anaesthetists, the Royal Australasian College of Physicians and its Faculty of Rehabilitation Medicine, the Royal Australasian College of Surgeons and the Royal Australian and New Zealand College of Psychiatrists. Minimum standards for anaesthesia: Minimum standards for anaesthesia have been developed progressively and published over the past 50 years by the Faculty, and later College, of Anaesthetists. They have had a major impact on development of standards in hospitals throughout Australia, New Zealand and South-East Asia. Improved patient monitoring: Equipment that allows beat-by-beat monitoring of oxyhaemoglobin levels by pulse oximetry and breath-by-breath monitoring of end-tidal carbon dioxide levels by capnometry has significantly improved the safety of anaesthesia. Both became widely available in the 1980s and were required to meet Australian and other countries' standards. Laryngeal mask: Described by Archie Brain (Reading, UK) in 1983, this mask is an airway device that provides a hands-free method of maintaining the airway without intubation. It has become popular with many anaesthetists and is useful in situations when intubation is difficult. Medical retrieval of the critically ill: From the 1960s onwards, medical retrieval of the critically ill has provided intensive care and safe transport to major centres from anywhere in Australia. These multidisciplinary, multimodal services have extended the vision of John Flynn (founder of the Royal Flying Doctor Service) in an extraordinary way. J E (Fred) Gilligan (Director of Retrieval and Resuscitation, Royal Adelaide Hospital) is one of the longest-serving leaders in this field. Malignant hyperthermia: In 1960, the familial disease malignant hyperthermia, which is triggered by some anaesthetic agents in susceptible individuals, was first described by Michael Denborough and colleagues from Royal Melbourne Hospital. Recognition of the genetic nature of this disease has allowed members of affected families to be screened, while awareness of the early changes and appropriate management, including dantrolene and intensive care, has reduced mortality from around 80% to less than 10%. Continuing medical education: CME in anaesthetics has developed and expanded in Australia from its beginnings at section meetings of the Australasian Medical Congress (British Medical Association) in the 1950s. Indeed, in 1996, the Australian Society of Anaesthetists hosted the World Congress of Anaesthesiology in Sydney, with nearly 6000 delegates. Furthermore, Australian anaesthetists have conducted education and examinations in the South Pacific region, Papua New Guinea, Hong Kong, Malaysia and Singapore. Garry D Phillips Professor of Anaesthesia and Intensive Care Flinders Medical Centre, Adelaide, SA Above photograph of surgeons, 1959. (Courtesy of Wolfgang Sievers) Make a comment

Garry D Phillips

Defining Moments In Medicine Psychiatry MJA 2001; 174: 18-19 Lithium: While Melbourne psychiatrist John Cade both discovered the antimanic effects of lithium and published his findings in the Journal in the 1940s, its distinctive impact on bipolar disorder management only crystallised in Australia in the 1970s after extensive developmental work, and with a mid-90s article in Science estimating that, since 1970, lithium therapy had saved the US economy alone US$145 billion in health costs. Chlorpromazine: The introduction of this "major tranquilliser" in 1952, described by David Healy (University of Wales College of Medicine) as "the single most important breakthrough in psychiatric treatment", had a dramatic impact on the management of schizophrenia: for the first time some patients became non-psychotic, and the acute management of schizophrenia improved markedly. Improving the practice of ECT: Electroconvulsive therapy is still psychiatry's most powerful treatment for depression. Despite major advances -- the introduction of anaesthetics and muscle relaxants, stimulus dosing and electroencephalographic monitoring -- the antipathy of patients (and the community) to ECT has regrettably only slightly lessened. Lessons from military psychiatry and refugee groups: Principles developed between World War II and the Vietnam War (ie, making psychiatric care immediately available "on the spot", and communicating an expectation that recovery would occur) were intrinsically important and diffused into other practice domains, such as community psychiatry, and the management of post-traumatic stress disorder. Deinstitutionalisation: This misnomer was used to describe the moving of patients in the 1960s from maxi-institutional lives in large psychiatric hospitals to mini-institutional existences in boarding houses and nursing homes, often to be even more forgotten and neglected. Yet, we progressively recognised an old principle -- that while risking "dying with one's rights on", people value personal freedom above institutional existence. Forced community assimilation also modified images of the "insane" to softer, disability images. Mainstreaming: Moving the care of psychiatric patients from the Dickensian, isolated psychiatric institutions to general hospitals helped bring Australian clinical psychiatry into general medicine, reducing stigma and resulting in superior lines of responsibility. Malfeasance responses: Disturbing revelations of the Royal Commission into Deep Sleep Therapy at the Chelmsford Private Hospital, and the Queensland Commission of Inquiry into assault and maltreatment of patients in the psychiatric ward of the Townsville General Hospital, reports of sexual misconduct and other boundary violations surfaced in the past 20 years. Grave community concerns resulted in impressively non-defensive responses by the profession and the monitoring authorities to redress such issues, including increased legal involvement (and procedures) now intertwined with public mental health services. Formalised professional markers: The establishment in 1964 of a Royal College (the RANZCP) linking Australian and New Zealand psychiatrists, and, in 1967, of a professional journal (The Australian and New Zealand Journal of Psychiatry), together with the development of an innovative membership examination, were markers of a move from a small network of individual psychiatrists to a formalised grouping -- now one of the largest professional medical specialties in the region. Growth in Australian academic psychiatry: Once a "home alone" model (eg, David Maddison, Professor of Psychiatry, Sydney University, and Foundation Dean of the Newcastle University Medical School being one of a small set of identifiable local produce) or "run away from home" expatriate model (eg, local Adelaide lad, Aubrey Lewis, dominating British academic psychiatry), now "home grown" dominance is evident, with a disproportionately successful Australian impact on international research publications, but also a decrease in "critical attitude" by academics and an overvaluation of quantitative research. Clozapine: This "atypical" neuroleptic drug was produced in 1962, but only taken up in Australia in the past decade (because of its side effect of agranulocytosis). Despite its monitoring requirements and its expense, its wide prescribing by Australian public mental health services is noteworthy. Its use gradually causes a considerable number of patients with schizophrenia to "normalise", and its capacity to restore suggested cognitive limitations has changed our understanding of a disorder once called "dementia praecox". Growth of biological psychiatry and psychiatry as a neuroscience: This movement has delivered striking results in understanding the determinants of many major psychiatric disorders, in establishing a dominant and successful research paradigm, and in integrating psychiatry with medical research. Caveats emerge from overly zealous or inappropriate application of the model -- "the sin of biologism". At risk is rejection of psychiatry's distinctive contribution to the practice of medicine -- a pluralistic model, respecting and integrating (in formulation and management) the multiple paradigms of sentient human beings. Detumescence of psychotherapy: Psychotherapy has been shrunk less by failure to produce an evidence base, ad hominem attacks and growth of alternative contenders (eg, cognitive behavioural therapy) than by a loss of significance and relevance as biological psychiatry has "Pac-Manned" the old Zeitgeist. Psychotherapy requires revisionism, repositioning and more pragmatic advocacy. Introduction of "new" antidepressants and "atypical" antipsychotic drugs: The selective serotonin reuptake inhibitors (SSRIs) are not merely antidepressants, but non-addictive "anti-worry" agents, with the potential to modify "neurosis", a feat once thought impossible. The "atypical" antipsychotic drugs may only be slightly more effective for treating schizophrenia, but their more benign side-effect profile improves quality of life and medication compliance. Formulation of clinical depression as an economic problem: The number of people with depression is not growing substantially, despite historical formulations of depression as a response, a disorder, an illness and a disease. Its recent reformulation as a major economic cost due to its disabling effects, endorsed by the World Bank, Harvard University and the World Health Organization, provided the spin, attracting public, media, health department and political attention. Consumerism: At last year's RANZCP Conference, psychiatrists danced in a congo line to music played by a band of consumers. As the Convenor, Bob Barrett, observed: "It was a delicious sight indeed to see psychiatrists dancing, for the first time, to the tune of the patients." Consumers and their advocates have had a more difficult row to hoe in psychiatry than in most other medical specialties, with their contribution and impact on professional attitudes humbling. On doctors and nurses: Once non-psychiatrist doctors married their hospitals and, on the rebound, the ward sister, who was ever able to undertake ward rounds at home ("Are all the children in bed, sister?"). Once psychiatrists were strange schizoid creatures (to wit, "alienists"). Now doctors no longer marry nurses (most are professors now) and psychiatrists are rugby-following, tie-wearing, non-intellectual conservatives. As biological psychiatry has reached its zenith, psychiatry is no longer as attractive or distinctive to those seeking "different" medical careers. The "magic" in the therapeutic process has gone -- magic that could lead to foolishness and invite ridicule or, alternatively, which imbued psychiatrists with a luminous sense of understanding. Recruitment is down and there is a lack of plurality in the air. Has psychiatry been mainstreamed away from its ineffable status? Has it not become stale to medical student and graduates seeking a specialty? How will it reconstitute itself above and beyond its procrustean biological bed? The January 2051 issue of The Medical Journal of Australia will detail the rollback. Gordon B Parker Professor and Head School of Psychiatry University of New South Wales Prince of Wales Hospital, Sydney, NSW John H Ellard Psychiatrist Bead Lane Specialist Centre, Sydney, NSW Above photograph. Ambulatory psychiatric patients, who have been put to bed in broad day-light, Callan Park Mental Hospital, Sydney, circa 1960. From the Report of the Royal Commission into Callan Park Mental Hospital, 1961. Crown copyright. Make a comment

Gordon B Parker · John Ellard