Reflections

Is hope or optimism required for dealing with cancer? We all have hopes and dreams. For people affected by cancer, these can be even more vivid. I (L R M) have seen many people who have taught me about the power of hope and the value of asking “What are you hoping for?” I was looking forward to playing in the next concert of the Corpus Medicorum (the chamber orchestra of the Australian Doctors Orchestra), but worried about how difficult my part looked. Then I heard that our soloist only had one lung! Sue, a professional tuba player and a non-smoker, was diagnosed with an aggressive lung cancer for which the treatment was a left pneumonectomy. Her surgeon, Phillip (P A), who happened to be a talented viola player, ran the Corpus Medicorum as a hobby, and could imagine what it might be like never to be able to play music again. No one knew if Sue would be able to play her tuba after surgery. She described how Phillip had made a deal with her; “If you can play afterwards, when you are well, you will come and play a concerto with my orchestra.” The night before her surgery she was still playing at 4 am, “in case this was the last time”. The day she got home from hospital, she waited until her family had tucked her into bed and left. Then she gingerly picked up her tuba, which weighed over 10 kg, and proved to herself that she could still play a single octave scale, if not very well. Eighteen months later, after four cycles of adjuvant chemotherapy and much hard work, Sue kept her side of the bargain: she played the very difficult three-movement tuba concerto by Vaughan-Williams brilliantly, sitting alongside Phillip as principal viola. As I played my clarinet, my thoughts strayed to the bassoon player I often sat next to in the orchestra. I hoped he might be inspired to stop smoking, instead of telling me he didn’t need to because he drank green tea. Our usual much-loved conductor of the orchestra had not been able to conduct, but was hoping to be able to come to the concert, since he had chosen the music and written the program notes. At 81, he had recovered from lymphoma but myelodysplasia was now robbing him of his energy, and he required regular blood transfusions. Everyone was delighted that he made it to the concert, sat in the front row, and got up and told the audience why and how he had constructed the program. He reduced us to tears of laughter by singing a folk song from his English childhood, “Training to be a village idiot”. He died just 2 months later. Many people describe how overwhelming and frightening it is to come into the cancer treatment centre for the first time and see so many sick people. But, over time, they come to appreciate that we are all in it together, with each person having their own stories of hopes and dreams. Health professionals often feel frustrated by patients and families whose hopes appear unrealistic, particularly the refusal to contemplate that the end of their life may be near. It is important to distinguish between hope and optimism. Hope has been defined as “a process of anticipation that involved the interaction of thinking, acting, feeling and relating, and is directed towards a future fulfilment that is personally meaningful”.1 Hope can be either generalised (with no specific goal) or particular (directed towards a specific goal), for example, our conductor hoping to be well enough to attend our concert.1 In contrast, optimism refers to having a generally positive outlook on life or “viewing the glass as half full”. The distinction between optimism and hope is that of agency — exerting control over one’s future. The classic definition of dispositional optimism is having a global expectation that good things will be plentiful in the future and bad things scarce. Optimistic individuals believe that their goals can be achieved in the face of adversity and will continue to try to attain the goals, but pessimistic individuals are more likely to give up.2 We know that the psychological coping style of people diagnosed with cancer is not associated with survival or recurrence rates.3-5 But this is not what people want to hear. The study by Schofield and colleagues demonstrating that a person’s level of optimism had no impact on their survival from locally advanced lung cancer attracted hate mail from patients around the world.4 When people with metastatic colorectal cancer on a phase III clinical trial were surveyed, neither the levels of hope nor optimism had any impact on overall or progression-free survival times, but those with high depression scores had significantly worse survival times.5 Other studies have suggested that lower optimism levels are significant predictors of anxiety and depression in patients with ovarian cancer and their caregivers.6 These studies are not intended to destroy hope, as some of the hate mail suggested. We know that maintaining some hope is very important to patients with cancer, but it is reassuring to be able to tell a distressed patient that they don’t need to be positive all the time. Having a bad day or a cry will not make the cancer grow faster. Patients can also be reassured that they need not feel guilty if they are not naturally optimistic, but depression needs to be detected and treated. We also know that the level of optimism among doctors varies. Perhaps not surprisingly, a study by Jennens and colleagues, which assessed knowledge about the benefits of palliative chemotherapy for metastatic lung cancer among doctors, showed that respiratory physicians were more like to be pessimistic about outcomes with chemotherapy, and medical oncologists were more likely to be optimistic.7 Oncologists need to be aware of their own levels of dispositional optimism and try to present a balanced view. It is important to be aware that patients with unrealistic levels of optimism, such as that displayed by our bassoon player, may be more likely to participate in risky behaviours, such as continuing to smoke after cancer treatment. Some studies also report that patients and caregivers may defer palliative care or refuse “do-not-resuscitate” orders because they equate this with giving up hope. Higher levels of hope and optimism are also reported to correlate with positive psychological changes or “post-traumatic personal growth” following a diagnosis of cancer.1 A desire to maintain hope and optimism are also described as powerful motivators to participate in phase I clinical trials, even when the chance of therapeutic benefit is low. While it is essential to ascertain that patients have sufficient understanding to give informed consent to participate in a trial, it is also important to respect that, for some people, part of their expression of optimism and hope is belief in a high chance of personal benefit. One study suggests that phase I participants with high levels of treatment-specific optimism have fewer symptoms of depression at the beginning and the end of treatment.8 Part of the art of oncology is to help people maintain hope about achieving goals that are important to them but also realistic; to hope for the best-case scenario but have a plan for the worst-case scenario. The recent model suggested by Kiely and colleagues is a useful tool for helping oncologists discuss potential survival times with specific treatment regimens in advanced cancer, in a way that is realistic but maintains hope.9 They found from an analysis of randomised controlled trials in metastatic breast cancer that the worst-case scenario for survival could be simply approximated as one-quarter of the median survival time reported in the trial, and the best-case scenario as more than three to four times the median. For some, like Sue the tuba player, playing music will be a goal in itself, but there are broader benefits. It has been shown that listening to music causes dopamine release onto the nucleus accumbens, an area classically thought to mediate reward perception and addiction. A recent review found that music interventions may have beneficial effects on anxiety, pain, mood and quality of life in people with cancer, and small beneficial effects on heart rate, respiratory rate and blood pressure were identified.10 When caring for people with cancer, a willingness to be flexible, to listen and to encourage realistic hopes can be just as important and rewarding as giving the right treatment to the right person at the right time. Be prepared whenever appropriate to do things like rearrange the chemotherapy dates to fit around special events and holidays. Encourage people to go out and live life as best they can, despite their cancer. Treat people as you would hope to be treated, and you will not go far wrong.

Linda R Mileshkin MD, FRACP, MBioeth(Mon) · Phillip Antippa MB BS, FRACS · Penelope Schofield BSc(Hons), PhD, MAPS

John Cawte had an extraordinary passion for the human condition that made him an innovator in the field of transcultural psychiatry. His mentors included anthropologist Margaret Mead and Kamilaroi Elder Bill Reid. His belief that doctors working with Indigenous people had to understand and respect the different cultural and spiritual belief systems of their patients — a given today — was revolutionary for its time. Born in Adelaide in 1925, John graduated from the University of Adelaide Medical School in 1949. From 1951 to 1963, he was Superintendent at Enfield Receiving House in Adelaide — an experience eloquently described in his memoir The last of the lunatics (Melbourne University Press, 1998). From 1955 to 1956, John studied community-based psychiatry as a Harkness Fellow at Johns Hopkins and Harvard Universities. In the early 1960s, John helped to establish the University of New South Wales School of Psychiatry and School of Public Health and Community Medicine. He held a personal chair in psychiatry and community medicine at the university until his retirement in 1991. Spending all his free time working in remote communities, John recognised earlier than most the important role of traditional healers, documented in Medicine is the law: studies in psychiatric anthropology of Australian tribal societies (University Press of Hawaii, 1974). In 1967, he developed the Arid Zone Project, establishing medical and community services centred around Bourke in western NSW. The project continued for 30 years and was a model for university–community partnerships. Through it, University of NSW academics, including Fred Hollows, formed warm relationships with Aboriginal leaders and developed holistic models of health and community services. In 1977, John founded the Aboriginal Health Worker, now in its fourth decade of national publication. An initiated member of the Warramirri clan from Elcho Island, he worked with the Elders to help record some of their healing practices — at their request — to promote cultural understanding. This project resulted in the publication of The universe of the Warramirri: art, medicine and religion in Arnhem Land (UNSW Press, 1993) and Healers of Arnhem Land (UNSW Press, 1996). In 1989, John was made an Officer of the Order of Australia, for his services to psychiatry and Aboriginal health. John died, aged 86, at Little Bay on 26 October 2011, and is survived by his five children and five grandchildren.

Rose Ellis · Max Kamien

Your guide to paediatric anaesthesia. Craig Sims, Chris Johnson. Sydney: McGraw-Hill 2011 (374 pp, $129.95). ISBN 9780071000222. THIS GUIDE aims to provide expert practical information across the breadth of paediatric anaesthesia without getting bogged down by details. The vast clinical experience of the editors (and their team of contributors) ensures that these aims are fulfilled in an informed, practical way. Chapters covering basic science and techniques relating to anaesthesia and resuscitation for children are complemented by others discussing anaesthesia for a comprehensive range of surgical subspecialities as well as for specific paediatric conditions. Care has been taken to include discussion of current issues that have generated controversy. The target audience includes trainees wanting a pithy summary of paediatric anaesthesia to inform their clinical experience and assist in preparation for exams. Both editors are examiners for the Australian and New Zealand College of Anaesthetists, which means they understand how high the bar is for those exams. The general anaesthetist with an interest in paediatrics wanting an easy-to-read update will also be well served. The book reads very comfortably, often with the tone of the consultant who has an interest in teaching, but the style does not allow for exhaustive explanation, detailed debate over alternative approaches or extensive referencing. However, it is sure to be stimulating for the career paediatric anaesthetist. The search for academic defensibility has led to some bloated, heavily referenced texts that often leave the reader wondering what they would actually do when confronted with a clinical scenario. The source of much clinical teaching is expert opinion, as a consultant works with a trainee. This volume gives expert opinion a voice. Neither online resources nor standard tomes on the topic address the needs of those this volume aims to assist. It is a great resource for trainees and anaesthetists with a paediatric interest and promises to be a springboard for discussion among paediatric anaesthetists.

Ian M McKenzie

Dr Hilton Immerman and Dr Josef McDonald (“Macca”) speak of their association as mentor and Indigenous medical student HiltonIn late 2004, Macca successfully completed the bridging course for Indigenous students to gain entry to the University of New South Wales (UNSW). He started the 6-year Medicine degree in March 2005. Since he is from the Newcastle area, he had to find accommodation near campus for his first year-and-a-half. However, he and his family were no longer able to cover the high cost of his accommodation. He had also felt alienated living where he was and was uncomfortable about revealing his Indigenous identity. In 2005, we had just established the Shalom Gamarada Indigenous Scholarship Program, which provides board and lodging, tutoring and other forms of support at Shalom College — the college I have been running since 1989. Macca succeeded in gaining a scholarship in July 2006. He received the Sabina Ross Slater Memorial Medical Scholar-ship, which was provided by Edna Ross in memory of her mother, who had died the year before. I remember interviewing him. He had a sense of humour and a mischievous sparkle in his eyes. I sensed that he might prove a handful as a resident of a UNSW college with an academic culture, accommodating 129 other students. My intuition was proven right. Macca for me exemplified the wonderful Aussie term “larrikin”. In the early years of his studies, he was a bit of a rascal and scallywag — but one with endearing qualities. If ever there were pranks or mischief in college, chances were that Macca was involved! On quite a few occasions, I had to summon him to my office to discuss his youthful indiscretions. As stern as I tried to be, I suspect that I never really succeeded in concealing the fact that I was genuinely fond of and believed in him. In 2007, I was invited to speak about Shalom College’s Indigenous scholarship program to a chapter of Rotary. I proposed that one of our scholarship students would join me and talk about it from his perspective. To be honest, my first choice was a more senior female scholarship holder, but she was not available at the time. So, I decided to take the plunge and ask Macca if he would accompany me. During his talk, to a crowded room, he commented on his former experiences of racism and self-doubt and explained how, ironically, a Jewish college had given him the opportunity to explore and take pride in his Indigenous identity for the first time. At this point, he was so filled with emotions about which he had not previously spoken publicly, that he burst into tears. There were not many dry eyes in the room — mine included! Each year since the scholarship has been running, we have held a Shalom Gamarada Aboriginal Art Exhibition to publicise and raise funds for it. This is an excerpt of what Macca wrote for a display board: “Receiving the Shalom Gamarada Scholarship has been a life-changing experience for me. Apart from the advantages it offers my studies, another great benefit of the program is that it offers a racism-free environment in which Indigenous students can live and discuss Indigenous issues and what it means to be Indigenous. “Without it, [the scholarship] it would be impossible for me to study medicine as there is no way my family could afford for me to live in Sydney.” At the end of 2008, after Macca had successfully completed his 4th Year, he decided to defer his studies in 2009 to support his family over a difficult period. Some had doubts about whether he would return and I confess to sharing their concerns. I endeavoured to keep in touch with him over the course of the year and to involve him in various scholarship-related activities, including the annual art fair. He has always been generous with his time and this was no exception. Macca came back to Shalom College and his studies in 2010. In semester 2 of 2010, he successfully applied to become a college tutor — a role he has ably filled since. He’s been a great mentor and role model to other students, both Indigenous and non-Indigenous. At the recent formal dinner for the new bridging course run by the Nura Gili Indigenous centre at UNSW, Macca was one of four UNSW students interviewed. At the end, he was asked if he had any words of advice for the new students. After deliberating briefly, he said: “If you succeed in getting into medicine and law next year, you’re likely to feel like an imposter. I did. Your peers in the program will be the brightest and most privileged students from around Australia and the world. Many will have come from exclusive, private schools. Most of you come from underprivileged and disadvantaged backgrounds. But, you must never forget that you will have earned your place in your course. You deserve to be there and you owe it to yourselves, your families and your communities to succeed. You can and must!” I feel so much emotion and pride in him when I reflect on how he has grown from being a mischievous adolescent, who was frequently in trouble in college, to a mature and wise adult. On 16 December 2011, I was a member of the academic procession at the UNSW graduation ceremony at which he formally became a doctor.

Hilton Immerman

MaccaMedicine was one of many options that I considered at the end of high school, along with engineering and even astronomy. But my interests in science and social justice drew me to medicine and, in the summer before commencing my studies, I was naively confident and felt as though the world was my oyster. These feelings were short-lived when I moved to Randwick in February 2005 to begin my medical studies at the University of New South Wales. I found the content challenging, and studying occupied most of my time. I also found socialising to be very challenging, as my peers were quite different from those I had spent my time with at home. This caused a feeling of alienation and I succumbed to the “imposter syndrome”, where I felt as though I did not deserve to be in medicine. Everyone appeared to be smarter, better educated, better supported, better travelled and more articulate than me. As a result, I mainly focused on my work and avoided engaging in medicine-related extracurricular activities. I travelled back home to Newcastle every weekend because I was homesick, and this affected my academic performance. Travelling home often reinforced a very poor habit of only studying towards the exam period, which caused lots of anxiety and little sleep, eroding my enthusiasm. My friends and I used humour to maintain a positive mental attitude, often to the delight of spectators. However, despite my best efforts, I was losing stamina quickly and didn’t think I could continue my studies at this rate. I had lost all my pleasurable pastimes — I found little opportunity to go fishing in Sydney. The only thing I seemed to gain during the early years of my medical studies was 15 kg. At 11 o’clock one morning I received a phone call from Professor Lisa Jackson Pulver (Director of the Muru Marri Indigenous Health Unit at the university). She encouraged me to apply for the Shalom Gamarada Indigenous Scholarship Program and, in mid-2006, I was accepted into the program by the Master of Shalom College, Dr Hilton Immerman. Receiving a Shalom Gamarada scholarship was crucial to my personal development and my transformation into a doctor. If it wasn’t for the support of the people on the scholarship program, I doubt that I would have successfully completed medicine. I started to become less homesick, as Shalom College offered a very welcoming, racism-free environment, with fellow students from an Indigenous background. Hilton and the other staff at Shalom should be congratulated for this, as it is only due to ongoing vigilance that a racism-free college can be achieved. I became less homesick and more confident to spend time in Sydney and with my peers, knowing that if I had a bad day, I always had a safe place to return to. My results instantly improved. I started engaging with the material and taking responsibility for my medical career — although not without some bumps along the way. Seeing people like Hilton and Lisa model professional behaviour was another crucial element in my success in the medicine program. I usually saw Hilton in his office, often by his request, to discuss something that happened over the weekend. My friends and I came to dread the 9 am phone call on the Monday after an eventful weekend. Hilton was always fair and this appealed to our sense of justice. I felt comfortable to “pop in” to Hilton’s office to ask him questions about my studies, relationships or personal conduct, and his opinions were always valued. I no longer felt like a rudderless ship. My self-esteem was greatly improved, knowing that I had support and finally had a place in Sydney that I knew I could call home. It was the first time in my life that I felt empowered to achieve anything I set my mind to. It was an indescribable feeling seeing Shalom College and Muru Marri staff at my graduation. What I have achieved still hasn’t sunk in, and I cannot be thankful enough to those who gave me this opportunity. What I do understand very well is that if it had not been for a phone call, the great work of Shalom College, and my very generous benefactor, I could have been in a very different place. Hilton (left) and Macca at Macca's graduation in December 2011. Photograph: Shirli Kirschner

Josef McDonald

Reproductive and sexual health: an Australian clinical practice handbook, 2nd ed. Sydney: Family Planning NSW, 2011 (197 pp, $65.00). ISBN 9781877026218. THIS HANDBOOK is an excellent resource for all primary care providers and medical students. The first edition was published in 2006. Since then, there have been a number of developments within the practice of reproductive and sexual health. The book is divided into 13 easily digestible chapters. There are organ-specific chapters as well as chapters on individual topics, covering pregnancy, menopause, fertility, sexually transmitted infections, pelvic inflammatory disease and sexual assault. Male sexual health issues are discussed as well. History-taking, examination, investigation and management of each area are covered in a comprehensive manner. Key points are boxed and highlighted. As many practitioners feel uncomfortable taking a sexual history and have limited experience in this area, the first chapter deals with consultation skills. The challenges involved when working with people from culturally and linguistically diverse backgrounds are discussed. The book also provides a detailed and clear guide to the management of sexual assault. This is particularly useful for providers (most, I suspect) who deal with this difficult problem very infrequently. Particularly useful, given our ageing population, is an expanded chapter covering urogynaecological issues, including urinary incontinence and pelvic organ prolapse. This book is more manual than textbook. For those requiring further information, a reference section at the end of each chapter includes useful books, articles and websites. Perhaps the book could benefit from photographs, but it does have useful diagrams, lists and flow charts. This book is up to date, succinct, well written and easily accessible. It is bound to be of everyday practical use to primary care providers working in the area.

Janice G Newton

Starlight: An Australian Army doctor in Vietnam. Tony White. Brisbane: Copyright Publishing, 2001 (xii + 183 pp: $25.00). ISBN 9871876344689. RETIRED COLONEL Tony White of the Royal Australian Army Medical Corps served in South Vietnam in 1967, and this narrative is largely based on his detailed correspondence with his family at the time. The title, Starlight, refers to the radio call sign for army doctors and medics. Following a move, midway in his medical studies, from the University of Cambridge in the United Kingdom to the University of Sydney in Australia, White accepted an undergraduate scholarship from the Australian Army to complete his studies. After finishing his hospital residency, he was posted as Regimental Medical Officer (RMO) to the newly formed 5th Battalion, Royal Australian Regiment (5RAR). Flying into Saigon’s Tan Son Nhut Airport brought the young 25-year-old RMO to the so-called “Sufferer’s Paradise”. The Vietnam War, in essence a civil war, became the longest and most controversial of Australia’s military conflicts to date. Twelve of the book’s 17 chapters are devoted to White’s wartime experiences with the 5RAR at the Australian base at Nui Dat in Phuoc Tuy Province. The battalion took many casualties during its deployment. February 1967 was the battalion’s critical period, when two tragic episodes beset the unit — White describes them with sensitivity and compassion, but also with a sense of despair. The final segments of the book are devoted to White’s subsequent civilian medical career in dermatology in Sydney. This compact, hardcover book is well illustrated, with several photographs and a map. It contains a handy list of abbreviations and terminologies, as well as a comprehensive index. The text is also supported by appropriate end notes. This moving work is a welcome addition to the few publications of military medical officers’ accounts of their experiences in the Vietnam War. It is recommended to those who partook of that war, to the wider non-military readership who remember the era, as well as to today’s younger generation.

Bruce H Short

Despite having spent many a rapturous hour staring at the back of cereal packets, I tried not to take it personally when I heard Professor Bruce Neal from the George Institute saying, on ABC Radio, that anyone who reads and understands an Australian nutritional panel is a weirdo....

Ruth M Armstrong

Clement J Walter was a talented, innovative and understated ophthalmologist. He was born in Pambula, New South Wales, on 29 August 1915 and grew up near Bega. He lost his parents and sister when young and was brought up by family friends. Clem was dux of Bega High School and graduated in optometry from Sydney Technical College with a special medal in 1939. Having no close family support, Clem’s sole income was derived from hard work and lecturing in optometry. He began his medical studies at the University of Sydney in 1941, graduating in 1947 with a distinguished undergraduate record. During this time, he married Sue in 1942 and, in 1946, their daughter Michele was born. After residency at Sydney Hospital, Clem undertook ophthalmic training at Sydney Eye Hospital and gained his Diploma in Ophthalmology in 1951. He then became a Staff Ophthalmologist at Royal Newcastle Hospital, where he worked until 1974. Clem provided the best possible expertise to patients irrespective of their income and he excelled in his public and private work. In 1972, Clem received Fellowship of the Royal Australian and New Zealand College of Ophthalmologists. Clem was always interested in medical retinal work and, when he moved to Sydney in 1975, he developed a large city laser and medical retina practice consisting solely of tertiary referrals. He imported the first Nd:YAG laser to Australia when there were only three such lasers functioning in the world. Ill health forced Clem to retire officially in the late 1980s. However, Fred and Ian Wechsler persuaded him to assist in their comprehensive ophthalmic practice in Burwood for many years. They admired his intellect, ingenuity and talent. He set the gold standard for a medical ophthalmic consultation and refraction. He designed his own indirect ophthalmoscope. He bred a camellia (which bears his name), and carried out all his own boat and car repairs. His humility was like a breath of fresh air in an era of advertising and aggressive self-promotion. After a stroke, he retired in 2001 and joined his daughter Michele, her husband Malcolm and their two boys in Berwick, Victoria. We all mourn the passing on 27 June 2011 of a truly remarkable pioneer who contributed so much to ophthalmology.

Alfred W Wechsler · Donald B Dunlop · Ian B Wechsler

Anthony Leong was born in Singapore in 1945 and graduated from the University of Malaya in 1969. He pursued postgraduate training in America, where he completed his pathology residency at the University of Washington, Seattle, between 1971 and 1973. In 1976, he migrated to Adelaide to continue his work in lymphoma and tissue processing, especially tissue staining and immunohistochemistry. He excelled in research and, in 1980, received a doctorate in medicine from the University of Adelaide, where he was Clinical Professor of Pathology from 1981 until 1996. From 1996, he dedicated most of his effort and time to the Asia–Pacific region, where he held a number of leading posts including Professor of Anatomical and Cellular Pathology at the Chinese University of Hong Kong and Honorary Professor of Pathology at the Post Graduate Medical Institute, Beijing. From 1999, Anthony was Professor of Anatomical Pathology at the University of Newcastle and Medical Director of the Hunter Area Pathology Service. He was a Fellow of the colleges of pathologists of Australasia, the United Kingdom and America, as well as an honorary Fellow of the Hong Kong and Thai colleges. He served as President of the International Academy of Pathology, Australasian Division in 1995–1996 and was the foundation President of the Asia–Pacific Society for Molecular Immunohistology in 2005–2006. He was also a founding member of the Society of Applied Immunohistochemistry and the International Society for Analytical and Molecular Morphology. Anthony’s most influential footprint was in the field of immunohistochemistry, where he left a great legacy of excellence in research and an unsurpassed love of pathology. He was a prolific author of over 370 original papers, reviews and book chapters, and more than 23 textbooks and monographs. He was a great teacher, a wise mentor and a wonderful leader, who was full of humour and interesting anecdotes. His favourite pastime was golf, and he was a proud member of the “four amigos” golf team at his local club. However, it is fair to say that his golfing never matched the dizzying heights of his academic record! Anthony passed away in late June 2011 after a short battle with cancer. He is survived by his wife Wendy and two children Trishe and Joel, both pathologists.

Huy A Tran · Glen E M Reeves · Frederick W Hetherington

Walter Lowen was born in Vienna on 10 March 1916 and spent his childhood in Lwow, Poland. A national junior table tennis champion, Walter contributed to Poland’s bronze medal at the Swaythling Cup world championships in London in 1935. Religious persecution in Europe spurred his migration to Australia in July 1939, a few months before he was due to complete his medical degree at the University of Lwow. In 1940, Walter was accepted into medicine at the University of Melbourne and, in 1941, he married Sima, whom he had met en route to Australia. Walter still pursued table tennis, winning the Australian singles title in 1948 as well as many state singles titles. In 2000, he was inducted into the Table Tennis Victoria Hall of Fame. Walter graduated in 1945 and undertook his residency at Launceston General Hospital. In 1948, he returned to Melbourne, where he practised as a general practitioner in Reservoir and Ashburton. In 1958, he moved to The Alfred Hospital, Melbourne, where he trained in radiology and, in 1961, he gained Fellowship of the Royal Australasian College of Radiologists. He then developed his diagnostic expertise at the Melbourne Radiology Clinic in female infertility, obstetrics, and thoracic and renal radiology. During this time, he published papers on medullary sponge kidney disease, cavitating pulmonary metastases and radionuclide placental localisation. Walter’s obstetric and gynaecological imaging expertise led to his appointment as Director of Radiology at Royal Women’s Hospital, Melbourne, between 1962 and 1975. From 1976 until his retirement in 1994, he continued sessional work at Royal Southern Memorial Hospital, Bairnsdale Regional Hospital and Preston and Northcote Community Hospital. After he retired from medicine, Walter concentrated on his family and competitive bridge. As a Grand Master, he helped Victoria win the open teams event at the Australian National Bridge Championships in 1972. Walter remained intellectually sharp until he died peacefully, aged 94, in Melbourne on 11 January 2011, survived by Sima and their three children Richard, Mark and Norma. Walter was inspirational and generous to many, and is remembered with affection as a gentle giant.

Richard J Lowen · Mark Lowen · Norma Gilbert

Whiplash: evidence base for clinical practice. Michele Sterling, Justin Kenardy. Sydney: Elsevier 2011 (xv + 197 pp, $77.25). ISBN 9780729639463. WHIPLASH is a controversial, but widely accepted, “diagnostic” term that describes a putative causal mechanism for a constellation of symptoms that are generally not underpinned by recognisable pathology. This reference book has the stated aim: “to bring together current knowledge of the whiplash condition that will allow all stakeholders involved in the management of patients with whiplash, from clinicians to policy makers, to gain greater understanding of this condition”. Whiplash research is important, as up to 50% of people with this condition do not recover fully and up to 30% remain moderately to severely disabled. The editors of this book, Michele Sterling (associate professor of physiotherapy) and Justin Kenardy (professor of psychology), are both from the University of Queensland, and have both made significant contributions to the university’s Centre of Clinical Research Excellence in Spinal Pain, Injury and Health. They are well positioned, therefore, to comment on contemporary work in their fields, particularly as considerable research concerning whiplash arises from their institution. They have also attracted contributors from a spectrum of disciplines including neurosurgery, psychology, physiotherapy, rehabilitation, epidemiology, engineering, economics and law. The book comprehensively elucidates contemporary research, particularly in the fields of physiotherapy and psychology. However, as it observes, there is little or no evidence to guide the clinician who is managing the whiplash patient. There is virtually no evidence that confirms a link between symptoms and pathology, and there is also very little established evidence-based management. The chapters on law, compensation and insurance are worthwhile reading for medical practitioners involved in the medicolegal aspects of whiplash. A series of case studies is also included. The book is recommended for scientists involved in physical and psychological rehabilitation research into whiplash. It confirms the paucity of evidence related to the whiplash construct. However, it does not assist the clinician who is interested in providing evidence-based whiplash management.

David G Vivian

The integrated medical curriculum . Raja C Bandaranayake. London: Radcliff Publishing, 2011 (xvii + 128 pp, $43.50). ISBN 9781846195105. THIS MAY BE a timely addition to medical school bookshelves, as so many new medical schools are engaged in curriculum development. Written by a respected Australian medical educator, the book promotes an integrated approach, and then attempts a comprehensive coverage of issues concerning design, implementation, assessment and evaluation, and blending theory with practice. The strength of the book lies in the international experience of the author who has, among other things, worked as a senior academic at the University of New South Wales in Sydney and the Arabian Gulf University in Bahrain. The final two chapters are the most valuable, where this experience is used to describe common pitfalls, and four case studies highlight the lessons learned from well intentioned, but not always successful, attempts to redesign a medical curriculum. However, the case studies are not analysed in great depth and appear almost as a postscript. It may have been better, as in a problem-based curriculum, to present case studies as the lead-in to each chapter, with the analysis combining theory and practice to demonstrate lessons learned about integration. Other strengths of the book are: the commentary on integrated vs integrating curricula, a perceptive issue (Chapter 1); the brief but accessible history of curriculum integration (Chapter 2); the discussion on the advantages and disadvantages of integration (Chapter 5); and the list of evaluation questions to consider (Chapter 7). The major weakness of the book is the relatively scant presentation of a theoretical basis for integration, and methods for achieving, assessing and evaluating integrated learning. Some recent research literature is also not cited, particularly in integrated and workplace-based assessment and evaluation methods. Further, little is said about qualitative evaluation, which may be the stronger approach to exploring how learners perceive and gain from different curriculum approaches. The material is probably of more value to less experienced educators, who should be able to follow the links to the literature and expand their reading. I would suggest that readers work backwards from the final two chapters to the earlier discussions of emerging issues.

Richard B Hays

Mackay and Burnet’s Autoimmune diseases, published in 1962, marked the beginning of autoimmunity as a clinical science and led to the future acceptance of the existence of autoimmunity. While there is still controversy regarding the mechanisms of autoimmunity, the authors’ insightful hypothesis based on clonal selection theory and the emergence of “forbidden clones”, due to somatic mutations, is still current, with recent evidence giving further credence to this hypothesis. We salute Mackay and Burnet on the 50th anniversary of this seminal publication. It is particularly pleasing that it has an iconic Australian origin.

Peter J Roberts-Thomson MD, DPhil(Oxon) · Michael W Jackson BSc, PhD · Thomas P Gordon FRACP, FRCPA, PhD

An elderly lady with an interesting clinical history Sydney Hospital, Australia’s oldest hospital, celebrated its anniversary at its present site on Sunday 30 October 2011, 200 years after New South Wales Governor Lachlan Macquarie laid its foundation stone. On Saturday 29 October, many current and former staff, patients, and other people interested in an integral part of Australia’s and Sydney’s history attended an open day and historical exhibition. The story of Sydney Hospital parallels that of Sydney itself — founded in makeshift circumstances to treat convicts, initially dependent on questionable dealings between commerce and government, but eventually establishing itself as a general hospital, serving and supporting a busy and vigorously growing colony and city. Over time, it has moved into providing a somewhat eclectic mix of specialist medical services to both the local Sydney community and New South Wales. Sydney Hospital was founded in 1788 alongside the initial settlement at Sydney Cove. In this case, “founded” meant a series of tents were pitched at the settlement for the medical treatment of convicts and settlers; they were only later complemented by prefabricated buildings brought from Britain by the Second Fleet. In stark contrast to later 19th century, more orderly, attempts at planning for civic improvement and social order, Sydney Hospital simply grew outside of its tents and temporary structures at the harbour foreshore to occupy whatever surrounding buildings were available to meet burgeoning demand.1 A “public–private partnership”, or a rum deal?In 1810, Lachlan Macquarie decided that something had to be done to found a permanent site for the colony’s hospital. The modestly named Macquarie Street was constructed to transport the necessary construction material from the harbour to the hospital site.1 This road was to become a major element of the city plan, eventually featuring almost all of New South Wales’ administrative and governing institutions — which it still does today to a large degree. The building of the hospital turned out to be the genesis of a substantial part of Sydney’s city centre and civic life. The construction of the hospital (which the British government refused to fund) only occurred as a result of Macquarie agreeing to a tender put forward by businessmen Garnham Blaxcell and Alexander Riley in conjunction with the colony’s acting principal surgeon D’Arcy Wentworth. These three individuals — all with an admirable diversification of commercial interests — intended that Macquarie’s need for a permanent colony hospital would be financially lucrative for them. They agreed to build the hospital in exchange for being granted convict labour and a monopoly importation licence for 45 000 gallons (about 200 000 L) of rum.1 As a result of this “public–private partnership”, the “Rum Hospital” — the nickname given by the population, in the Australian tradition of calling a spade a spade — was born. Officially named the Sydney Infirmary, it was eventually called Sydney Hospital from 1881. It was given the Bank of New South Wales’ first account number (00001) — Wentworth owned shares in the bank — and still has this account number, with what is now named Westpac Bank. The building was overly large for the time, prompting questions as to how to use it. It housed not only the wards for convict patients and the surgeons’ quarters, but also, at various times, the Royal Mint, the Legislative Council, the Supreme Court and the Sydney Dispensary, which looked after those who were free but poor, for whom the government had no responsibility.2 It had structural defects from the start, and the centre of the building eventually had to be demolished and rebuilt in the late 1800s. The last of the defects were only uncovered and remedied in a thoroughgoing restoration in the 1980s. Nevertheless, the hospital as an institution survived and expanded. Florence Nightingale, in response to written appeals from the politician and later New South Wales premier Henry Parkes, sent out from Britain her protégé Lucy Osburn and five other nurses (the “Nightingale Nurses”) to establish Australia’s first nursing school on site.3 This was housed in the Nightingale Wing, which opened in 1869 and is the oldest of the existing buildings on the site. Firsts in research and health careSydney hospital has been the site of a number of firsts in medical care in Australia. It hosted the first operation under general anaesthetic (a leg amputation under chloroform) and the first postmortem examination (which appears not to be the same patient). Its staff performed the first x-ray, the first blood transfusion, the first frozen section histopathology, and the first radiotherapy treatment (with radium) in Australia. It was also the place in Australia where a number of specialised surgical procedures were done for the first time — abdominal aortic aneurysm repair, liver transplantation and corrective surgery for cryptophthalmos (this also a world first) being among them. Medical research started with the arrival of the First Fleet. Principal surgeon Dennis Considen investigated the therapeutic properties of native flora, especially eucalyptus.4 However, Australia’s first medical research institute — the Kanematsu Memorial Institute of Pathology — came into being at Sydney Hospital much later, in 1933. The institute was set up with funds from a company that had been founded in 1889 by Fusajiro Kanematsu, the first Japanese merchant to trade with Australia (its Japanese name was not dropped during World War II, underlining Kanematsu’s respected status).5 John Eccles and Bernard Katz worked there in its early days, performing research into the electrophysiological properties of neuromuscular junctions,5 and later separately won Nobel Prizes for Medicine for research into synapse physiology. The hospital and its specialtiesSydney Hospital was also the first in Australia to establish a number of specialised medical units within a hospital — including coronary care, renal, leukaemia, colorectal and melanoma units. The first-ever specialty unit at the hospital, established in 1878, accommodated the “eye beds”. This unit was relocated to Millers Point and then to Woolloomooloo, developing into the Sydney Eye Hospital, which then returned to the original Sydney Hospital site in 1996. It is now the largest eye hospital in the southern hemisphere, providing specialised tertiary and quaternary referral ophthalmological services. The hand surgery unit, still in existence, was the first of its kind in Australia. The Nightingale Wing moved on from being a centre for nurse education to accommodate the Sydney Sexual Health Centre, New South Wales’ largest sexual health service (initially the “Blue Light Clinic”, which treated local sailors). In 1987, the hospital established off-site primary care services in sexual health and HIV medicine at the Kirketon Road Centre in Kings Cross. Sydney Hospital has undergone a long, varied and often haphazard evolution, from tending to scurvied convicts in a tent, to being the first medical institution to bring new kinds of medical care to Sydney and Australia, and to its current role as a provider of a number of specialist services. At the same time, it is the Sydney central business district’s “local hospital”. The founding of the, at the time, grandiose building by Macquarie 200 years ago, predicated on the rum trade, was the catalyst for the establishment of many aspects of health care in New South Wales and Australia. It is an institution deserving of a toast — nowadays, not necessarily with rum — by doctors in Australia. Sydney Hospital on Macquarie Street, circa 1930s Ward 7, Sydney Hospital, circa 1930s Operating theatre, Sydney Hospital, circa 1930s New South Wales Premier Barry O’Farrell views the exhibition, Sydney Hospital: 200 years of care with exhibition curator Jennifer Sanders during the Sydney Hospital Bicentenary Community Open Day

Astika K Kappagoda BA(Hons), MB BS, PhD

Deadly healthcare. James Dunbar, Prasuna Reddy, Stephen May. Brisbane: Australian Academic Press, 2011 (194 pp, $34.95). ISBN 9781921513756. This is a compelling read. Dr Jayant Patel arrived at Queensland’s Bundaberg Hospital on April Fools’ Day 2003 and, in the words of former Federal Health Minister Michael Wooldridge, “walked into an environment tailor-made for disaster to occur”. In June 2010, he was sentenced to seven years’ imprisonment for manslaughter and grievous bodily harm involving four patients operated on in Bundaberg. An appeal was dismissed. The authors of this well documented account are eminently qualified to tell the tale — Professor Dunbar teaches clinical governance and risk management at Flinders University in Adelaide, Professor Reddy is a health and organisational psychologist at Flinders and Stephen May is a former psychologist and journalist. As they explain, Patel was far from being the only one at fault. The authors carefully examine the bureaucratic structures and attitudes in existence in Queensland Health, and the personal and professional failings of particular administrative staff at the Queensland Medical Board and the hospital that led to Patel — whose registration as a specialist surgeon was restricted in two US states — being appointed as director of surgery at Bundaberg. They find that the hospital was “fiscally driven”, and Patel’s ability to perform large numbers of operations benefited the budget and completely overrode concerns about patient outcomes. The gulf between management and clinicians is neatly encapsulated in the story of an administrator telling a senior Bundaberg clinician concerned about Patel’s activities: “You have to understand that this is a business.” To which the doctor replied: “That’s where the problem is, you see. I think it’s a hospital.” The efforts of this clinician and many other staff, patients and relatives to achieve justice are well described, as are the findings of the numerous formal inquiries and the details of Patel’s trial. Patel’s earlier life and medical training have been meticulously researched and the authors have attempted to give a balanced view, pointing out that many of the 1000 patients he operated on at Bundaberg benefited from his surgery. Had the proper checks and balances been in place, the negative outcomes might never have occurred. Has the Queensland public health system learnt from the Patel case? Sadly, the authors conclude that it has not — their final sentence warns that a case like Patel’s “could be happening right now in your own modern overburdened healthcare system”.

Caroline M de Costa

Deadly healthcare. James Dunbar, Prasuna Reddy, Stephen May. Brisbane: Australian Academic Press, 2011 (194 pp, $34.95). ISBN 9781921513756. This account of the lead-up to the 2010 trial of Jayant Patel — dubbed “Dr Death” by the media — is excellent, which is not surprising considering Professors Dunbar and Reddy’s background in health services implementation research at Deakin University, Victoria. Unfortunately, the same can’t be said for the authors’ coverage of the real impact of the Patel case on health regulation in Australia. The Australian Health Practitioner Regulation Agency (AHPRA) is mentioned only to record its establishment in July 2010. Missing is any reference to the Health Practitioner Regulation National Law Act (enacted in Queensland in 2009 and in the other states in 2010), which came into existence before the AHPRA and started to make it extremely difficult for a similar situation to occur today. The reader is left with the impression that little has changed and similar tragedies could occur today. But while there are no guarantees that a rogue doctor can no longer be appointed, regulation has changed radically since then. Today, complaints from doctors and the community are not so much about the cursory checking of international medical graduates’ qualifications but about the AHPRA requiring too much information. Patient safety is an explicit principle underpinning the National Health Practitioner Regulation Law, which created the Medical Board of Australia and the AHPRA. The authors fail to mention the new mandatory reporting laws that require health professionals to report those who place the health and safety of patients at risk. However, the facts about the Patel case provided in this book should be interesting for those new to regulation and clinical governance.

Merrilyn Walton

A new twist to an old Christmas problem In the past three decades of medical practice, there has been an increasing prevalence of a peculiarly Australian seasonal syndrome. The condition appears to affect a large segment of the population, and it appears that doctors may be particularly vulnerable. Symptoms usually commence in October, and escalate during November. They include irritability, anxiety and a feeling of dread, sometimes precipitated by hearing certain choral music. Typical behaviours include the purchasing of inordinate quantities of food, or standing in an apparently dissociated trance-like state in front of Christmas card stands. During December, there may be lavish preparation of seasonally inappropriate dishes and consumption of large amounts of alcohol. In the advanced stages there is extreme fatigue and emotional lability. Sufferers describe feelings of overwhelming competing responsibilities, particularly if they are parents. They feel they have to provide presents and joy, and cope with the end of the academic year; they feel obliged to attend multiple functions, including break-ups for school and parties for work. Some describe feelings of shock when they realise their children have finished school for the year. On top of this there is preparation for the long summer holiday, with packing up and cancellation of milk and newspapers. Bizarre behaviours include assembling and disassembling Christmas trees in short periods of time, or wandering around a garden with a hose, tearfully farewelling plants. A forme fruste of the syndrome is an urge to make cakes or puddings. Signs of this variant include large quantities of dried fruit sitting on the kitchen bench for weeks. This appears to be a form of compensatory behaviour, particularly in mothers, in an effort to regain control. The illness seems to be less severe in the northern hemisphere; parents there can concentrate solely on Christmas, because end-of-school festivities happen in June. Additionally, in North America, the Thanksgiving festival relieves the pressure of Christmas celebrations. In Australia, the symptoms often continue to increase until the Christmas dinner, when the combination of high ambient temperatures and certain ingredients can precipitate a crisis. Observational studies suggest that medical practitioners can be particularly severely affected. Doctors report additional pressures during this period, including hundreds of patients needing urgent appointments before Christmas, and describe the atmosphere in their clinical practices as one of “impending Armageddon”. These behaviours appear to be compensatory responses to a syndrome first described in an 1843 publication of Dickens.1 In this case report, the sufferer, ES, is described as “a squeezing, wrenching, grasping, scraping, clutching, covetous old sinner”; a miserly, usurious wretch. Most, if not all, affected individuals are aware of this paper, and express a strong desire to avoid being likened to ES. A contemporary reinterpretation of the original article is warranted. ES suffered multiple losses as a child and young man, including the loss of both parents and a sister, and a rejection by his fiancée. His “Bah, humbug!” was an expression of emotional deprivation. Despite this, ES responded to the cognitive behavioural therapy interventions administered by the Spirits of Christmas. In fact, ES became humane and kind, and gave a salary raise to his needy employee, Bob Cratchit. ES did not, however, overcompensate with manic forms of indiscriminate gift-giving, nor did he become profligate with food and wine. ES actually remained totally abstinent from alcohol of all sorts, and he subsequently became happy, and “as good a friend, as good a master, and as good a man, as the good old city knew, or any other good old city, town, or borough, in the good old world”. It is therefore recommended that sufferers of this syndrome emulate, rather than avoid, Scrooge-like behaviour, and that they be good friends, good masters and good men and women not just at Christmas, but all year round; and be generous to those who need it most. “Bah, humbug!” may be just the remedy for the humbug syndrome.

Katrina J R Watson MB BS, FRACP, MPH

In February 2011, Cyclone Yasi was bearing down on the Queensland coast near Cairns. People living in coastal suburbs and towns from Cairns to Townsville were given orders to evacuate their homes, airlines put on extra flights to help people evacuate, and Queensland Health made the decision to evacuate Cairns hospitals for the first time in history. Cairns Base Hospital was established in 1884 on the waterfront overlooking the Coral Sea. The hospital’s location leaves it vulnerable to cyclones, tsunamis and storm surges. Based on the Bureau of Meteorology’s cyclone tracking model,1 Yasi’s landfall was predicted to coincide with high tide, which put hospital staff and patients at risk of inundation by a 5-metre storm surge. On Tuesday 1 February, more than 250 patients from Cairns Base Hospital and the nearby Cairns Private Hospital were airlifted to Brisbane hospitals in what is believed to be Queensland’s largest mass medical evacuation and the largest hospital evacuation ever undertaken in Australia. A timeline of events is summarised in the Box. Seven pregnant women, 16 babies, eight intensive care patients, 18 mental health patients and more than 60 dialysis patients were among those evacuated. General medical patients, the parents of evacuated children, medical escorts and carers were also airlifted to Brisbane. Many patients were transferred to regional hospitals or discharged home if considered safe to do so. Australian Defence Force personnel with 11 medivac-equipped C-130 Hercules aircraft, the Royal Flying Doctor Service, CareFlight, the Queensland Government Air Wing, and several commercial airlines (Qantas, Alliance Airlines and JetStar) were involved with the evacuation. A convoy of ambulances transported patients to Cairns Airport, from where they were flown to Brisbane. Another convoy of ambulances in Brisbane took arriving patients to a number of hospitals. By 3 am on Wednesday 2 February, the Cairns Base Hospital emergency department was eerily empty. The hospital was closed at 9 am that day. A temporary emergency medical facility, staffed by doctors and nurses, was set up at an indoor basketball stadium at the Fretwell Park Sporting Complex, about 10 km inland. By 4 am on Wednesday, Yasi intensified into a Category 5 cyclone, with a storm front 650 km wide, sustained wind speed of 205 km/h, and wind gusts of 285 km/h.1 Its forecast track had veered slightly southward away from Cairns. Yasi crossed the coast in the early hours of Thursday morning, and the northern Queensland towns of Innisfail, Tully, Mission Beach and Cardwell bore the brunt of one of the most powerful cyclones in Australia’s history. Four women gave birth during Cyclone Yasi. One baby was born at Fretwell Park under a soccer net covered with a bed sheet for privacy, and another at an emergency shelter. The other two babies were born at Innisfail Hospital. Cairns Base Hospital reopened at 12 pm on Thursday 3 February with limited services until staffing levels returned to normal. Some staff were unaware the hospital had reopened and others were unable to reach the hospital because of flooded and blocked roads. The Fretwell Park emergency medical facility closed at 4 pm the same day. Parts of Cairns were without power for several days after the cyclone, and roads leading south were impassable due to floodwaters. Trucks carrying essential food and supplies were unable to reach Cairns to restock supermarket shelves that had been stripped bare before the cyclone. Doctors and nurses who organised the evacuation of patients did an amazing job under extreme pressure, as did those who staffed the emergency medical facility while the cyclone raged around them. No patients died as a result of the evacuation. Eventually all evacuated patients were returned to Cairns, although this took several weeks and was stressful for patients and their families. The evacuation posed enormous logistical challenges in terms of medical records, medications and equipment required. Continuity of care for acutely unwell patients, including those receiving dialysis or in coronary care, intensive care and mental health units, was extremely complex, and it is a tribute to the dedication of the staff at the respective hospitals that there were no major adverse outcomes. Pre-emptive evacuations of hospitals are rare events, occurring just three times in the United States since 2005.2-4 Detailed analyses of the evacuation process are underway and will improve our ability to respond to future disasters. Timeline of events in evacuation of Cairns hospitals due to Cyclone Yasi, 2011 Date and time Event 29 January Tropical low identified north-west of Fiji, tracking westward 30 January 10 pm Low intensified into a cyclone, named Yasi, located north of Vanuatu 31 January 10 am Yasi intensified into a Category 2 cyclone 4 pm Yasi upgraded to a Category 3 cyclone, still maintaining a westward track 1 February Queensland Chief Health Officer makes decision to evacuate Cairns Base Hospital and Cairns Private Hospital 7 pm Yasi upgraded to a Category 4 cyclone, moving west-south-west and accelerating towards tropical Queensland coast 10 pm Patients airlifted from Cairns hospitals to Brisbane 2 February 3 am First patients arrive in Brisbane 4 am Yasi upgraded to a Category 5 cyclone, maintaining a west-south-west movement 9 am Cairns Base Hospital closes and temporary emergency medical facility opens at Fretwell Park Sporting Complex 10 am Airport, university, schools and businesses in Cairns closed 12 pm Last Cairns patients (four special-care babies) arrive in Brisbane 3 February 12–1 am Cyclone Yasi crosses the coast near Mission Beach 12 pm Cairns Base Hospital reopens 4 pm Fretwell Park emergency medical facility closes 16 February 40 Cairns patients still in Brisbane hospitals 19 February 29 Cairns patients still in Brisbane hospitals Cyclone Yasi approaching the Queensland coast, 1 February 2011, 5.30 pm (satellite image originally processed by the Bureau of Meteorology from the Geostationary Meteorological Satellite MTSAT-2 operated by the Japan Meteorological Agency).

Cindy E Woods BEd(Hons) · Donna Goodman BPsych, PhD · Jane Mills MN, MEd, PhD · Kim Usher MNSt, PhD, FRCNA · William J H McBride FRACP, FRCPA, PhD

During a time of war, the federal government passed the National Fitness Act 1941 to improve the fitness of the youth of Australia and better prepare them for roles in the armed services and industry. Implementation of the National Fitness Act made federal funds available at a local level through state-based national fitness councils, which coordinated promotional campaigns, programs, education and infrastructure for physical fitness, with volunteers undertaking most of the work. Specifically focused on children and youth, national fitness councils supported the provision of children’s playgrounds, youth clubs and school camping programs, as well as the development of physical education in schools and its teaching and research in universities. By the time the Act was repealed in 1994, fitness had become associated with leisure and recreation rather than being seen as equipping people for everyday life and work. The emergence of the Australian National Preventive Health Agency Act 2010 offers the opportunity to reflect on synergies with its historic precedent.

Julie A Collins BArch, PhD · Peter Lekkas BPty, MPty

Many years ago, I rescued from destruction a unique 120-year-old leprosy register of the colony of New South Wales (Box 1). This register commenced in 1891 and continued after federation under NSW legislation.1,2 With 101 double pages, patient details were entered into 12 columns, in clearly legible copperplate handwriting (Box 2). As leprosy notification was compulsory, entries were a provisional diagnosis. Patients were subsequently examined by specialists, sometimes chaperoned by police. The diagnosis was entered into the register. If the patient had leprosy, warrants were issued for their detention at the Coast Hospital lazaret at Little Bay in Sydney. For many, this was a sentence of life imprisonment as there was no effective treatment. Some absconded only to be returned by the constabulary. Patients were treated compassionately, being allowed to keep pets, grow vegetables, and to fish. Chinese patients were even given a liberal allowance of opium.3 In the first four decades, to 1931, 290 patients were entered in the register; 224 of these (77.2%) had leprosy (other diagnoses included beri-beri, “cretinism”, eczema, gangrene, hemiplegia, psoriasis and, frequently, syphilis). Of those with leprosy, 203 were men and 21 were women, one of whom was a nun. “Nationality”, where recorded, showed the highest prevalences of leprosy among Australian or European patients (79 [35%]), Chinese patients (66 [30%]) and Pacific Islanders (22 [10%]). Only three (1%) were Aboriginal, corroborating the fact that leprosy was not endemic before European settlement. Other patients were from Ceylon, Egypt, India, Syria, the United States and Zanzibar. In the fifth decade (1934), the hospital was renamed the Prince Henry Hospital of Sydney. Subsequently, with the advent of sulfones, patients could be rendered non-infectious within 12 months and be discharged on treatment (with regular reviews) rather than remain incarcerated. Many were readmitted, probably because their compliance with treatment lapsed. The last entry in the register was made in 1950, 59 years after its commencement. There was no confidentiality coding as there is now with HIV-AIDS registers. Nowadays, leprosy is rare in Australia and immigrants are screened;4 globally, there is a decreasing trend in new cases, with the World Health Organization reporting about half a million in 2003 falling to about a quarter of a million in 2009.5

Peter Christopher

Sexually transmitted infections. 3rd ed. David Barlow. New York: Oxford University Press, 2011 (134 pp, $29.95). ISBN 9780199595655. This slim book was first published in 1979 and this is its third edition. It is squarely aimed at the consumer who has an interest in sexually transmitted infections (STIs) — including HIV infection — and attempts to give “the facts” about these infections while dispelling myths and giving practical advice about diagnoses and treatments. The information presented is succinct and generally up to date, although the section on HIV and its treatments is already a little dated given the incredibly rapid changes that occur in this dynamic field of medicine. The 13 chapters deal with common and less common STIs such as gonorrhoea, non-specific urethritis (including Chlamydia trachomatis and Mycoplasma genitalium), genital herpes, genital warts, syphilis, “tropical” infections, viral hepatitis and HIV/AIDS. In addition, there is a chapter on “Understanding your results”, which grapples with the complexities of epidemiology, ascertainment bias and sensitivity and specificity. The author’s writings on these topics are generally quite comprehensible, although it is unlikely that many lay readers will grasp the subtleties involved in interpreting all test results after reading this chapter — lord knows, many physicians have difficulties grasping these complexities! The tone of the book is generally witty, though the avuncular style can grate somewhat at times. Moreover, the book is aimed at people living in the United Kingdom and may not be of much relevance to those outside the UK. References to general practitioners referring on for most STI problems (when the majority of Australian GPs will diagnose and treat the common conditions very competently without needing to refer to specialists), “GUM” clinics and “lavatory seats” mark the book as very British indeed. Oddly, the humorous cartoons scattered throughout the chapters feature men with a surfeit of hair (including some very retro sideburns) and a predilection for flared trousers, firmly placing the decade of their drawing as the 1970s — they look very dated in 2011. Lastly, the first line of chapter 1 didn’t enamour me to the book, either, claiming that “The UK is one of three countries, with Ireland and Malta, which recognise management of sexually transmitted infections (STIs) as a separate medical specialty”. I suspect the author has overlooked Australia and New Zealand and our longstanding Chapter of Sexual Health Medicine in this claim.

Darren B Russell

Fast facts: chronic and cancer pain. 2nd ed. Michael J Cousins, Rollin M Gallagher. Oxford: Health Press, 2011 (167 pp, $25.00). ISBN 97819059832859. Australian Michael Cousins and American Rollin Gallagher are both internationally recognised pain medicine physicians, active in research, teaching and clinical work. Which is why, when my review copy of their book arrived in the post, I was surprised to find it to be so small. It made me recall Mark Twain’s famous comment: “I wrote you a long letter because I did not have the time to write a short one”, and hoped that the necessary time and thought had gone into this little handbook. I was not disappointed. The book explains the new insights into the physiology of persistent pain in a simple fashion. It is well illustrated and provides an up-to-date guide to various treatments. The chapters cover trigeminal neuralgia, complex regional pain syndrome, diabetic and post-herpetic neuropathic pain, central pain, musculoskeletal pain, visceral pain and headache. It is ideally suited to all medical practitioners treating pain including hospital medical officers, general practitioners and various medical specialists. It would also be useful to nurses, allied health clinicians, teachers and medical trainees. The book is balanced in its viewpoint, emphasising the multifactorial nature of persistent pain conditions, and that treatments require both medical as well as restorative approaches to physical function and psychological aspects. The chapter on cancer pain is well done. It offers a good overall summary of pathophysiology of cancer pain and the complications of therapy associated with pain. It summarises pharmacological, non-pharmacological and interventional strategies to manage cancer pain very succinctly. However, it comprises only a small section of the book and fails to cover palliative care or the existential nature of cancer pain and suffering. The introduction reminds readers that “regardless of specialty, clinicians will see patients with persistent pain”. I agree with this statement and, in my opinion, there is a need for concise texts about pain. The authors have definitely tapped into this need with this book.

Carolyn A Arnold