History and humanities

With the expansion of the Second World War into the Pacific in 1941, and due to the deleterious impact of malarial infection on fighting capacity, the Australian Army devoted significant resources to new research into the prevention and treatment of malaria between 1943 and 1945 by forming the Land Headquarters Medical Research Unit in Cairns, Queensland. The documentation of this research became a significant subject for leading Australian artist Nora Heysen, when she was commissioned as the first female war artist by the Australian War Memorial in 1943.

Cherie L Prosser BSc, MA(Art History) · Ian A Clark BVSc, PhD, DSc

Issues relating to voluntary euthanasia that are currently being debated by Australian society are distinctly different from those encountered by battlefield doctors. Doctors in war undertake to treat those affected by conflict; their participation in euthanasia challenges the profession’s definition of “duty of care”. Euthanasia must be distinguished from “triage” and medical withdrawal of care (which are decided within a medical facility where, although resources may be limited, comfort care can be provided in the face of treatment futility). Battlefield euthanasia is a decision made, often immediately after hostile action, in the face of apparently overwhelming injuries; there is often limited availability of pain relief, support systems or palliation that would be available in a civilian environment. The battlefield situation is further complicated by issues of personal danger, the immediacy of decision making and difficulties with distinguishing civilians from combatants. Regardless of the circumstances on a battlefield, doctors, whether they are civilians or members of a defence force, are subject to the laws of armed conflict, the special provisions of the Geneva Conventions and the ethical codes of the medical profession.

Susan J Neuhaus CSC, PhD, FRACS

Gwen Fleming was born in Taree, New South Wales, on 9 June 1916, the third of John and Caroline Lusby’s six children. She graduated in medicine from the University of Sydney in 1939, just in time to answer the call to military service. Appointed to the rank of Captain, Gwen worked at Yaralla Military Hospital at Concord (“They called me ‘Sir’, during the war”). In 1945, she became the first woman major in the Royal Australian Army Medical Corps and was subsequently appointed Officer Commanding Medical Company. In 1945, Gwen was one of the first women admitted as a Member of the Royal Australasian College of Physicians and, in 1973, she was admitted as a Fellow. She married the brilliant young surgeon Justin Fleming, a Flight Lieutenant in the Royal Australian Air Force, in 1946. Justin was awarded an Oxford Nuffield Medical Fellowship to the University of Oxford, and they took up residence at the Radcliffe Infirmary. In 1950, they returned to Sydney to raise what became a family of six children. The children flourished in an environment where a love of cricket, theatre, art, music and literature was encouraged. Gwen and Justin wanted happiness for their children, not duty from them. The family motto was animo toto laborate (“no half jobs”). After Justin’s death in 1974, Gwen became the family breadwinner. She joined Dr Brian McEwen in his Macquarie Street practice and took a teaching position at St Vincent’s Hospital in Sydney, a demanding regime that she continued until she was 77 years of age. Her patients and students were struck by her calm, clear approach which elucidated both the detail and the big picture. Gwen was innately altruistic and held a firm Christian belief that God travelled through human action. Among the gifts that she brought to medicine were clarity of judgement, patience of manner and accuracy of diagnosis. To her, gaining the trust of the patient was part of the healing. In her last weeks, Gwen suffered from severe angina and a subsequent heart attack, and passed away on 18 January 2011. She is survived by her sister, Sr Elizabeth Lusby OP, and children Margaret, Paul, Justin, Judith and Peter — another son, James, died in 1999.

Justin Fleming

The MJA bids a fond farewell to its Editor of 16 years When Martin B Van Der Weyden, 11th Editor of the Medical Journal of Australia, retired a few weeks ago, it was the end of a remarkable chapter in the Journal’s history. Sixteen years earlier, in his first message as Editor to the Journal’s readership,1 Martin had promised to oversee the MJA’s return to relevance for the medical profession and the abolition of its sometime reputation as the “Blue Comic”. He achieved this, and more, taking the Journal to a new level, not just for readers but among its international peers. Martin rose from humble beginnings, as the third of seven children of postwar Dutch immigrants, to become a prodigious researcher and a leader in his specialty of haematology, before taking on the editorship of the Journal, one of the most influential positions in Australian medicine. As Editor, Martin raised the profile of the MJA locally and internationally to make it one of the key drivers of change in Australian medical practice. He significantly improved the academic calibre of the MJA’s content; broadened its reach, relevance and readership; and presided over the biggest change in the Journal’s 97-year history with the embrace of electronic publishing. Martin’s intelligence and diligence took him from a migrant camp at Bathurst when he was 8 years old and a “good Catholic school” in Wollongong, where his family settled (near the steelworks, the employment mecca for migrant workers), to win a bursary at age 12 to attend Holy Cross College in Ryde as a boarder, and then a Commonwealth scholarship to study medicine at the University of Sydney. He graduated MB BS in 1966 and spent his early postgraduate years at Sydney Hospital, supported as a medical registrar by a Penfold family scholarship. Martin trained in clinical medicine and pathology, obtaining Membership of the Royal Australasian College of Physicians (RACP) in 1969 (and Fellowship of the RACP in 1974), and moved to the Alfred Hospital and Monash University in Melbourne to take up a position as Research Fellow in Clinical Haematology with the late Professor Barry Firkin (a position made possible by a scholarship from the Alfred Hospital Research Fund). In 1972, Martin was awarded a Merck Sharp & Dohme International Fellowship in Clinical Pharmacology to work with Professor Bill Kelley in the Division of Rheumatic and Genetic Diseases at the Duke University Medical Center in Durham, North Carolina. While at Duke, a further scholarship from the United States National Science Foundation allowed him to contribute to major work in the delineation of the effect of adenosine deaminase deficiency in patients with severe combined immunodeficiency. He quickly gained a reputation at Duke for his prodigious output and quirkiness. Many remember him as the “mad” Aussie who wandered into a ward one snowy morning, totally oblivious to the fact that he was on fire! Lost in thought, he had plunged his briar pipe into his overcoat pocket while it was still smouldering. Despite offers of positions at the US National Institutes of Health and at US medical schools, Martin returned to Australia in 1975 on yet another scholarship, as a National Health and Medical Research Fellow at the Alfred Hospital and Monash University. Having been supported by scholarships for most of his life, Martin finally got his first full-time paid job in 1977, when he became a Senior Lecturer in Medicine at Monash University. He graduated MD from Monash in 1978, and became a Fellow of the Royal College of Pathologists of Australasia in 1980. His clinical and research interests encompassed aspects of haematology, immunology, marrow transplantation, and haematological oncology. In 1981, Martin was awarded the RACP’s prestigious Eric Susman Prize for research into purine and pyrimidine enzyme activities in haematological malignancies. He was appointed Professor of Haematology at Monash University in 1985 and Director of the Department of Haematology at the Alfred Hospital. From 1985 to 1987, Martin served as President of the Haematology Society of Australia and New Zealand, presiding over the International Convention of Haematologists held at the Sydney Opera House. In 1989, he became Chairman of the Division of Investigative Medicine, and then Chief of Investigative Medicine Services to the Alfred group of hospitals in 1993. During this time he squeezed in a voluntary position as Haematology Subeditor for the Australian and New Zealand Journal of Medicine and a short, intensive stint at Harvard Business School in 1994. Working as an administrator during the time of the frenetic dismantling of the Victorian hospital system, Martin’s priorities were always the preservation of first-rate patient care and the provision of quality academic and clinical medical education. In time, the strictures of economic rationalism on medical services were to prove demoralising for the profession as a whole. When the frustrations of seemingly soulless restructuring became overbearing, Martin looked for a new challenge, and found it in the Journal. Though sad to leave Melbourne, his children were overjoyed that he no longer paced the front garden in the dead of night, shrouded in a smoky haze from his much loved Dutch cigarillos. Thus, in 1995, Martin, his wife Merle, and their three children moved back to Sydney. Martin’s medical, scientific, research and administration experience, and his familiarity with the research communities in Melbourne and Sydney, placed him well for taking on the mantle of Editor of Australia’s leading peer-reviewed general medical journal. He quickly stamped his mark on the Journal and earned the respect of the medical community, by following the principles of good communication: clarity, brevity, simplicity and humanity. Martin boosted the quality of the Journal’s articles by increasing the number of editorials and encouraging authors to confront controversial topics; introducing a higher academic standard for research articles in particular (and thus significantly increasing the manuscript rejection rate); and expanding the reach of the Journal to cover health policy and reform, workforce issues, medical politics and medical education. Because many Australian researchers choose to submit their best work to higher profile US or British journals, the MJA suffers from “small country syndrome” in terms of international rankings, but Martin made significant inroads to address this. In 1993, before Martin took over, the MJA languished at 30th (out of about 100) in the ranking of general medical journals; in 2008, it reached an all-time high of 18th, with an impact factor of 3.32. Martin is a clear thinker: decisive, with strong opinions and astute judgement. He is a diligent observer of all things medical, is politically savvy, and is a forthright speaker and writer who abhors “bullshit” and has never toadied to political correctness. At times he would play the classic Editor, making a frenzied string of phone calls to his impressive collection of friends and experts to get to the bottom of a story or current event. But he has never published anything that did not meet his own rigorous academic standards, understanding the value of the MJA’s reputation as an unbiased, accurate source of information. He has a wicked sense of humour and an enduring enthusiasm to challenge people to think outside the square. The same qualities that made Martin an excellent Editor also make him a sought-after speaker and a highly valued guest at meetings and conferences, where he can be relied on to stir up debate, ask the difficult questions and offer insightful and constructive criticism. A year into the job as Editor, Martin also took on the demanding role of Chief Executive Officer (CEO) of AMPCo (the Australasian Medical Publishing Company, which publishes the Journal and the Medical Directory of Australia and manages Australia’s largest commercial medical database). He continued in the dual positions of Editor and CEO for 14 years. He is also a member of the International Committee of Medical Journal Editors, which sets the standards for biomedical publishing, and has recently served as a Director of the Executive Board of the World Association of Medical Editors. Under Martin’s leadership, the Journal was an early adopter of electronic publishing, including an innovative trial of interactive, electronic peer review. By 2001, all Journal content was freely available on the web, remaining free until 2009 when, against his better judgement, some articles became accessible to subscribers only. Technical capacity was always a limiting factor but, last year, the Journal finally launched MJA InSight, an online newsletter for doctors. His own background and self-confessed political left-leaning tendencies made Martin open to some of the more marginalised elements of Australian society, providing those working in prison and refugee health, drugs and alcohol, sexual health, mental health and Indigenous health with a much needed mainstream outlet for their research and commentary (but only if they met the Journal’s high academic standards). Two annual theme issues, one on Indigenous health and another on general practice, were established, and remain of great importance to the target contributors and readers. As Martin matured into the job, he became the heart, soul and, indeed, the face of the Journal. His fortnightly column, “From the Editor’s desk”, was frequently on the MJA’s top 10 website hits list from its inception in 2004 — a tribute to his reputation as an astute observer with a long-range view of Australian health care. Dr Martin Van Der Weyden with portrait by (Dr) Ann Theresa Gregory. Those of us who worked with Martin understand how he was able to achieve so much. Even in his spare time, his mind was never far from the Journal. He would often turn up on a Monday morning, brandishing a book he had just read on medical history or health policy, or an editorial he had written over the weekend. He had a knack for appearing erratic, distracted or even perverse, and then coming up with the exact solution required for the problem at hand. On an initial meeting, he liked to shock with a blunt statement or seeming non sequitur, before revealing his incisive intellect and, ultimately, a humane and surprisingly soft inner core. When congratulated for his work at the Journal, he maintained that his genius had been in assembling a competent team: there was method in his madness — to get the best out of people. In his rare spare time, Martin listens to Bach, Beethoven and Haydn, and is a voracious reader of crime fiction and books of medical miscellany with a philosophical bias. His wife Merle remains a huge source of inspiration and moderation, as does his Catholic faith and his involvement in his local parish. When asked how he would like his tenure at the Journal to be remembered, Martin is typically offbeat. His success may be measured in many ways: the rise of the Journal’s impact factor and standing in the international ranking of journals; an increase in high-quality submissions; a robust presence in the media and in health policy machinations; the respect of medicopolitical, Indigenous and other leaders; and the unswerving loyalty of those who worked for him. Yet, 16 years after he penned that first editorial, he was most proud of one outstanding achievement. Nobody, anywhere, was referring to the MJA as the Blue Comic.

Bronwyn Gaut MB BS, DCH, DA · Ruth M Armstrong BMed · Ann T Gregory MB BS, GradDipPopHealth · Peter C Arnold BSc, MB BCh, BA

In recent years, a phenomenon of “late effects of the Holocaust” has emerged, with impacts on the psychological and physical health of ageing Holocaust survivors. As Holocaust survivors age, they may experience heightened anxiety around normal processes of ageing, worsened post-traumatic stress disorder with cognitive decline, and fear of the medical system. Holocaust survivors are at increased risk of osteoporosis, cardiometabolic disease due to hypothalamic–pituitary–adrenal axis dysfunction, cancer, and sequelae of Nazi medical experiments. From existing medical literature on this topic, practical principles of management are derived to create a framework for sensitive medical management of Holocaust survivors in Australia. The issues discussed are also relevant to the wider geriatric refugee or prisoner-of-war experience.

Elizabeth D Paratz · Benny Katz MB BS, FRACP, FFPMANZCA

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

Thomas H Hurley MD, MB BS, FRACP

EpiphanyRex and John, both Australian neurosurgeons, were attending a conference in Oxford. That high summer day on the deck of the Head of the River relaxed by his ploughman’s lunch and ale Rex looked into the cloudless sky saw several far-off small black dots: maybe Canada geese, if not maybe, he smiled, a replay of the Battle of Britain. Hard to be certain ... But the dots stood still. Rex set down his glass stunned by rapid-fire thoughts of probabilities. “I think”, he said quietly to John “I have secondaries in my brain”. Ten years ago Rex had a melanoma on his back. There were questions then. “One never knows”, his surgeon said. “Are you sure they’re not floaters?” Rex closed each eye in turn. “Positive.” he said. “Migraine aura?” “Never before.” Rex knew the drill. For a decade he had savoured each day freed it from bureaucracy and strife. Fancy him, a wise man from the east receiving this epiphany in Oxford — Oxford, home of Tolkien and other master weavers of fantasy — this clear, prosaic sentence! How ironic that its execution would be inside his head! “I think that we should finish lunch”, Rex said slowly. John touched his arm. Both turned again to their cheese, meat and bread, emptied their glasses and left with the calm they assumed as they emerged from theatre weary with effort, seeking relatives in the waiting room desperate for news of a miracle to confess that it was not within their powers to remove all their loved one’s tumour though they’d tried for hours.

Stephen R Leeder MD, PhD, FRACP

Gallipoli doctors. The Australian doctors at war series volume 1. LtCol Robert Likeman, CSM. Melbourne: Slouch Publications, 2010 (223 pp). ISBN 9780980637335. THIS IS THE FIRST of four volumes by Lieutenant Colonel Robert Likeman recording the history of Australian army doctors in World War I. It covers the Dardanelles Campaign and is a landmark in Australian military medical history. LtCol Likeman is an experienced army medical commander trained in obstetrics and gynaecology, tropical medicine, and remote and rural medicine. He is also an established military medical historian and writes with clarity and elegance. The book is the product of painstaking research using the Australian War Memorial’s nominal roll, the National Archives of Australia’s service records, the Australasian Medical Publishing Company’s library and many other sources of information. It is a comprehensive history of 270 Australian Imperial Force (AIF) medical officers. It includes their pre- and post-campaign career achievements, including Palestine, the Western Front in France, and World War II. Australian doctors who served in the British Army or as Australian infantry officers are also noted. The author’s note and introduction, combined with the first two chapters, provide an excellent summary of the military and medical events that led to Gallipoli. Each chapter has background information on key senior personnel, medical problems and general matters. The medical officers’ personal data are presented on the basis of the order of battle of the Australian and New Zealand Army Corps in the Dardanelles in 1915. Summarised army unit battle histories act as preambles to the medical officer details. An alphabetical list of AIF doctors is provided, as well as a thorough overall index. The end result of this great diligence and superb execution is a well illustrated, encyclopaedic volume that is also of a manageable, compact size. The work is a tour de force of World War I Australian military medical history, and I await the next three volumes with great anticipation.

Peter D Byrne

The Canadian Medical Association Journal recently ran a commentary entitled “Who you calling obese, Doc?”.1 It noted that in most Western nations, obesity, as defined by a body mass index of 30 kg/m2 or higher, has assumed epidemic proportions, and the word, like many others in the medical lexicon, has been absorbed into the vernacular. However, the word “obesity” is weighed down with negative connotations, both personal and social. Because of the capacity of the pejoratives “obese” or “obesity” to stigmatise, people use these words with great care and strip away as much of the implicitly judgemental language as possible by substituting terms such as “a person with obesity” or by suggesting that an individual is “medically obese”. The motivation underpinning such verbal gymnastics is idealistic and laudable, intending to give minimal offence and shifting the focus from the person to the condition. It has become an integral part of the new medical lexicon, removing the bluntness of certain medical terms and replacing them with more politically correct (PC) language. However, this fear of hurting an individual’s sensibilities can drive language into foggy territory. This is as true in medicine as it is in other areas of human endeavour. Dr Sally Satel, psychiatrist and resident scholar at the American Enterprise Institute for Public Policy Research in Washington, DC, has published her thesis on the weakening and dilution of medical language in PC, M. D. How political correctness is corrupting medicine.2 She claims that twisting language to avoid occasioning hurt can sometimes be more insulting than edifying: “You are basically sending the message that people are so fragile that they can’t tolerate reality”. A further example of the handiwork of the PC brigade in medicine is the substitution of the traditional term “patient” with “consumer”, “customer” or “client”. As some wag has noted, in our more socially restrictive past, the term “clients” was notoriously reserved for “customers” of the sex industry! However, to fall back on a well worn cliché: there is nothing new under the sun. Euphemisms have always been embedded in our language as we have habitually sought to cushion our emotional response to taboo subjects, such as these examples noted elsewhere: death (“going to sleep”), pregnancy loss (“born still” or “stillborn”) and menstruation (“time of the month”).1 Moreover, this watering down of language can also be found in everyday medical parlance. We now speak of “cardiac impairment” or “cardiac insufficiency syndrome” instead of “heart failure”. This filtering and twisting of reality through feel-good rhetoric may well come back to haunt us in the long run. Interestingly, political correctness is not the only movement changing the medical vernacular. Another is the corporate world. We witness daily the many ways, subtle and not so subtle, that the incompatible corporate structures of the world of business, with their bureaucratic language and allure of success and fortune, have intruded into the medical world. Indeed, the purist may well claim that the medical world has been traduced by corporatisation and business modelling. Like many other things in medicine, we have lost control of our language. Martin B Van Der Weyden

Martin B Van Der Weyden

“... the current may turn towards the [medical] schools of the great nations of the south ... the Africander, the Australian, or the New Zealander may reach a development before which even ‘the glory that was Greece’ may pale” The influence of Sir William Osler on medicine is still apparent nearly 100 years after his death. Here, I examine what he knew about Australia, which Australians he met and how this enriched their personal and professional lives, and his influence on Australian medicine in general. Sir William’s grandfather, Edward Osler, was the father of Featherstone (William Osler’s father) and brother of Benjamin, whose children scattered to the United States, South Africa and Australia.1 Indeed, Harvey Cushing, the contemporary eminent neurosurgeon and Osler’s biographer, stated that he had met a man of the Australian branch of the Osler family who looked so like William Osler in “figure, stature, gesture, feature, and shape of head ... that he might have passed as a younger brother”.1 William Osler was born on 12 July 1849 in Upper Canada (now Ontario), the eighth of nine children.1 He was educated at church schools, where the Rev W A Johnson introduced him to what became his favourite book, the Religio medici of Sir Thomas Browne, and he searched the surrounding countryside for organisms and fossils to explore with the microscope. He next came under the spell of Dr James Bovell, a friend of Johnson’s and an enthusiastic microscopist, who taught at Osler’s school and practised medicine in Toronto. Bovell’s personality so imprinted itself on Osler that he always wrote “James Bovell” when testing a new pen or doodling.1 After finishing school, Osler initially followed his father into divinity, but switched to medicine at the Toronto School of Medicine. This was followed soon after by his first publication, on the subject of discovering organisms with the microscope, at 19 years of age.2 Two years later, on Bovell’s advice, he went to McGill University in Montreal where he met Dr Robert Palmer Howard, who taught medicine and surgery and stimulated Osler’s interest in pathology and searching the medical literature — interests that remained with him for life.3 The influence of these three men — Johnson, Bovell and Howard — was so great that Osler later dedicated his magnum opus, The principles and practice of medicine, to their memory. After graduating from McGill in 1872, Osler travelled to London and worked with physiologist John Burdon-Sanderson, in whose laboratory he noted the aggregation of platelets (previously thought to be bacteria) in 1873.3 He travelled to Germany where he met Rudolf Virchow, then to Austria where he saw dermatologist Ferdinand von Hebra, pathologist Carl von Rokitansky and others at work. When Osler returned to Montreal in 1874, he worked briefly in general practice until he was appointed Lecturer then Professor of the Institutes of Medicine at McGill University (Box 1). There he set about revitalising medical training by teaching physiology and histology through the use of the microscope (providing microscopes at his own expense). He started a journal club and began referring students to German and French publications. He wrote on the comparative pathology of parasites, smallpox, Addison’s disease, pernicious anaemia and other topics, and used his pathological experience as a foundation for his clinical acumen. There were no Australian associations during this period of his life. Osler’s appointment in 1884 to the Chair of Clinical Medicine at the University of Pennsylvania in Philadelphia was equally bereft of Australian connections, but was important in establishing his stature. He gave the Gulstonian lectures to the Royal College of Physicians of London in 1885, speaking on Malignant endocarditis; he wrote on chorea and cerebral palsy; and he continued “preach[ing] the gospel of clinicopathology, showing equal interest in the dead and living”.3 Osler accepted the position of Professor of the Theory and Practice of Medicine at Johns Hopkins University in Baltimore in 1889, at the age of 40. In 1892, he published his classic textbook, The principles and practice of medicine, and only when this task was complete did Grace Revere Gross (widow of a Philadelphia surgeon) agree to marry him. Their son Edward Revere was born on 28 December 1895. The British Medical Association (BMA) held its annual conference in 1897 in Montreal, and on 1 September, Osler gave an address on British medicine in Greater Britain,4 where he took the opportunity to give an historical account of the influence of British medicine on its colonies. He predicted that a future meeting of the BMA might be held in Australia, where there were few local graduates and most were of “English, Scotch and Irish colleges”. He described the Australian population as “more homogeneous” and “thoroughly British”. Osler had evidently read Australian and New Zealand medical journals, as he was surprised “with the monotonous similarity of the diseases in the antipodes to those of Great Britain and of this continent”, although he noted the frequency of reports “of parasitic affections and snake-bites”, which were unusual in the northern hemisphere. He commented that the medical profession in Australia was not as regulated as elsewhere because of “the absence of the military element” and was disappointed at the state of medical ethics, which he surmised from his reading.5 “In the large Australian cities, differences and dissensions seem lamentably common”, he said, attributing this to the 3- or 4-yearly reappointments in hospitals that involved soliciting votes.4 He quoted Dr Ferdinand Batchelor (Box 2), President of the 1896 Intercolonial Medical Congress, who was critical of the “managers of the hospitals [who] knew little, and at times seemed to care less, about the medical school”.5 Osler was scathing about the situation in Melbourne, described by Batchelor, where the election was in the hands of the “subscribers” and “election tickets were put out, and cards soliciting votes for [doctors] were found in hotels and bars and railway stations and in cabs”.5 He was however optimistic that the current may turn towards the schools of the great nations of the south. Under new and previously unknown conditions, the Africander, the Australian, or the New Zealander may reach a development before which even “the glory that was Greece” may pale.4 In July 1900, Osler travelled to London, where he attended the Royal College of Surgeons centenary celebrations at the hall of Lincoln’s Inn. A young Australian, Dr Henry Newland (Box 3), newly qualified in surgery, was invited to attend and was seated four chairs away from Osler at the banquet.7 On discovering Newland’s interest in neurosurgery, Osler advised him to study under Dr Harvey Cushing in Baltimore, which he did.8,9 Also in 1900, Osler published a monograph, Cancer of the stomach, with his former student Thomas McCrae.10 In the first chapter of the book, they write: Our colleagues in Australasia have demonstrated the same thing. The mortality figures [for cancer of the stomach] for Victoria for the years 1870–84 show an increase at about the same rate as in England ... They cited two Australian journal references,11,12 and continued that a similar trend also occurred in New Zealand, giving references to New Zealand journals.13,14 Osler was appointed Regius Professor of Medicine at Oxford University in 1905, and in 1907 made his usual transatlantic trip to the US. He visited there so regularly that “it had become a saying in Oxford that the Oslers often spent their week-ends in America”.1 On 3 October 1907, he addressed the students at St Mary’s Hospital in London on The reserves of life.15 He stressed that medical training “is in only three subjects — science, art, and the knowledge of men”. Halfway through the lecture, he deviated from his notes to verbally attack St Mary’s bacteriologist and immunologist Sir Almroth Wright (Box 4), saying: Stop your ears with the wise man’s wax against the wiles of that Celtic siren, Sir Almroth, who would abolish Harley Street [London’s centre of private medical practice] and all that it represents. Osler knew that Wright was cynical of clinical methods and clinicians and “ridiculed the crudeness of methods which faced disease armed with knives and drugs ...” Wright believed that “the physician of the future would be an immunisator”.17 Osler was aware of Wright’s sojourn in Sydney and his development of typhoid vaccine, to which he referred in his lecture. In spite of this disagreement, Osler and Wright remained friends, visiting each other at home,16 and Osler urged the use of typhoid vaccination of the troops in World War I.3 In April 1909, while travelling around Europe, Osler was asked to see a sick Australian in Rome, who “suddenly became severely purpuric from haemorrhaging blood vessels, turning plum-colored everywhere except under one patch of skin where he had put a mustard leaf”.3 This man, described by Osler in The Lancet,18 died 15 minutes later. Osler theorised that a reaction involving the capillary wall allowed blood to leak out, which he postulated to be an anaphylactic reaction. Osler was a keen traveller — he went about visiting friends, attending conferences, seeing historical places, and searching for books. This made him sensitive to accents, and he developed the habit of writing about them during his voyages. He carried this manuscript, titled The voice, with him from 1893, making additions as he went and promising an article on the topic for The century magazine, which remained unfinished.19 In his notes, he described a 56-year-old Scotsman who had lived in Australia for about 35 years and “except in a few words, the Scotch had been rubbed off his tongue”. Osler’s own speaking voice was described by his friend, Canadian neurosurgeon Wilder Penfield, thus: “he never had an accent that one could identify”.20 This was perhaps unsurprising in a man who lived for 35 years in Canada, 21 years in the US, and 14 years in England. Golden and colleagues suggest that Osler had “a cultivated speech ... what today might be called mid-Atlantic”.19 In February 1911, Osler was invited by his brother Sir Edmund Boyd Osler to visit Egypt and the Nile Valley. As usual, Osler was able to make a good mix of vacation, history and medicine. He enjoyed the pyramids, the Sphinx, various tombs and the Egyptian museum, and was impressed by the beauty of the mosques. He took time to visit the Kasr El Aini Hospital, where he saw “many things I had read of but had never seen”. Here he also met Dr Frank Madden (Box 5), an Australian surgeon at the hospital.22 Osler was invited to give the Silliman lectures at Yale University to a lay audience in April 1913. He spoke about The evolution of modern medicine, describing how religion and medicine grew out of magic, saying “among native Australians today it is still deliberately cultivated”.23 He was obviously aware of the Aboriginal witchdoctor with the power to heal or kill. Osler’s reading about Australia and awareness of its culture prepared him for meeting Leslie Cowlishaw (Box 6) in 1916, when Cowlishaw was officer-in-charge of invaliding in England. The two quickly struck up a close friendship, as Cowlishaw was already an established collector of medical books and could discuss medical history. Osler was perceptive enough to understand the Australian psyche, labelling Cowlishaw the “bibliophile from the bush”.24 There are six letters from Osler to Cowlishaw in the archives of the Royal Australasian College of Surgeons, mentioning Cowlishaw’s purchasing of books, and thanking Cowlishaw for sending him a book and for correcting an article Osler had written. Osler felt very comfortable with Cowlishaw and offered him hospitality, writing: ... come when you can — give a few days notice as I am much away — stay the night. There are many things in my collection to interest you. (7 March 1916) I am devastated to miss you ... Do come to us direct your next leave. (8 August 1917) In another note, Osler writes: “... come here for a rest and bibliographic browse when you come back — I am struggling with my catalogue ...” Osler’s influence added fuel to the fire of Cowlishaw’s enthusiasm for medical history and book collecting, to the extent that Cowlishaw acquired the biggest collection of rare medical books in Australia, which was sold to the Royal Australasian College of Surgeons after his death in 1943 for the now ridiculously low sum of £2750. Cowlishaw followed Osler’s example of not only collecting but also writing medical history. In Cowlishaw’s address on Some early printed books: their authors and printers, he presented a scholarly account of early printing presses and early medical books, many of which were in his possession.25 Cowlishaw acknowledged Osler’s guidance in this article, quoting him on three occasions. This publication was of sufficient historical merit to be referenced by Thornton in his major reference on the history of medical books and collectors.26 Thornton credits Cowlishaw with the statement that the first book in English on medicine was written in 1485 — quite an honour for an Australian, and one that shows the depth of Cowlishaw’s knowledge. In 1936, Cowlishaw wrote an authoritative account of the first 50 years of medicine in Australia, describing the First Fleet surgeons and giving brief accounts of D’Arcy Wentworth, George Bass, William Redfern (the first Australian medical graduate), Henry Cowper (the first postgraduate diplomate in Australia) and William Bland (the first Australian to publish in The Lancet and author of the first postmortem study to be published in the medical press in Australia).27 He also urged a philanthropist to donate money for a historical medical library, as Osler had done. In the Jackson Lecture of 1937, Cowlishaw gave an excellent account of Galen’s life and experiments.28 In his address to the 1937 meeting of the Australasian Medical Congress, Cowlishaw described how Osler made medical history alive and relevant by including it in his medical lectures, getting students to look up and read to the class the original description of a disease, and by having old books available for browsing.29 He also gave what is arguably the best account of medical historians through the ages, appealed for someone to edit a book of Australian medical history, and urged the teaching of medical history to medical students on a voluntary basis. Osler was not unaware of Australia, as he had relatives living here and had read about the country’s Aboriginal culture, the state of the teaching hospitals, and the role of subscribers in hospital appointments. He read Australian and New Zealand journals in his quest for illness trends, and compared them with those of Europe. He made special mention of treating Australian patients and advised Newland about his career. He enjoyed his meetings with Cowlishaw on book collecting and medical history. The expression “bibliophile from the bush” indicated a good understanding of Australian expressions, perhaps learned from other Australian doctors or patients whom he met; but such meetings have not been recorded. 1 William Osler, October 1881, during his Montreal period Reproduced with permission of the Osler Library, McGill University. 2 Ferdinand Campion Batchelor (1850–1915) Batchelor was born on Norfolk Island, where his father was the Anglican chaplain. He was educated in England, then apprenticed to a medical practitioner in Essex. He later attended Guy’s Hospital Medical School in London, practised in England, then migrated to New Zealand and settled in Dunedin. He started in general practice, before specialising in obstetrics and gynaecology. He was “a man of commanding presence and of a dynamic personality”. He was President of the Intercolonial Medical Congress held in Dunedin in 1896. He served in World War I, at the age of 65 years, and was sent to Egypt but was invalided back to Dunedin, where he died. A Batchelor Memorial Medal was struck to commemorate his contributions to New Zealand medicine.6 3 Henry Simpson Newland (1873–1969) Newland was a University of Adelaide graduate who did his postgraduate surgical training in England and Baltimore (with Harvey Cushing), returning to Adelaide to practise as a surgeon. He enlisted in the Australian Imperial Force in November 1914 and was appointed to the 1st Australian Stationary Hospital on the Greek island of Lemnos. With the closure of that theatre of war, he was sent to England, then France. He operated at the 3rd Australian Casualty Clearing Station in France, where he met Cushing again. Newland returned home to Adelaide, where he had a busy general surgical and neurosurgical practice.7 4 Almroth Wright (1861–1947) Wright graduated in medicine from Trinity College, Dublin, in 1883. He was interested in experimental work and visited pathologist Julius Cohnheim in Leipzig, Germany, and physiologist Michael Foster at Cambridge University. The latter proposed him for the position of demonstrator in physiology at the University of Sydney; Wright took up this appointment, demonstrating from 1889 to 1891. He was known as the “Irish windbag” and clashed with T P Anderson Stuart, the head of the faculty. Wright went on to become the Professor of Bacteriology at St Mary’s Hospital in London. He was against women being given the right to vote, but was instrumental in setting up the Medical Research Council. He described the role of calcium in coagulation, developed typhoid vaccine, and was a founder of immunology. He also taught Alexander Fleming, who discovered penicillin.16 5 Frank Cole Madden (1873–1929) Madden was born in Melbourne and graduated in medicine from Melbourne University in 1893. He worked at the Melbourne Hospital before travelling to London, where he eventually became medical superintendent of the Hospital for Sick Children, Great Ormond Street. He then moved to Cairo, Egypt, where he was a surgeon and teacher at the Kasr El Aini Hospital, and eventually Dean of the Faculty of Medicine at the University of Cairo. He wrote The surgery of Egypt, was interested in tropical surgery and schistosomiasis, and was awarded the Order of the British Empire for his services during World War I. He was a conscientious man, and committed suicide on 26 April 1929, probably as a result of the stress of politics between university, Egyptian and British governments.21 6 Leslie Cowlishaw (1877–1943) Cowlishaw was born into a wealthy family and educated at Sydney Grammar School. He started his book collection in 1906 after graduating in medicine. He worked in general practice in Cooma, New South Wales, where he met and married Jessie Garnock. He enlisted with the Australian Imperial Force in 1914 and served in Egypt and Gallipoli. After the war, he had a general practice in the Sydney suburb of Hornsby, before moving to Lindfield. With Robert Scot Skirving and Herbert Moran, he started the Section of Medical History and Literature of the NSW Branch of the British Medical Association in 1925. He became an honorary lecturer in medical history at the University of Sydney in 1931.24 Leslie Cowlishaw in World War I uniform. Reproduced with permission of the Royal Australasian College of Surgeons.

Milton G Roxanas MB BS, FRANZCP

“I would like an arrangement made with publishing houses in India and Australia to issue special editions of my text-book in those countries ... I have so many friends in both places, many of them men in official and teaching positions that the book would be adopted in the schools — as indeed it has been at Sydney ...” The first part of this article examined the life and medical influences of William Osler (Box 1) in the context of his Australian connections. This second part looks at his encounters with Australians in the final years of his life, and the influence and legacy he left on Australian practitioners and medical practice after his death. In 1918, the Oslers were still grieving the loss of their son Revere in the war the previous year. This catalysed Osler’s decision to bequeath his house to “Christ Church [College, Oxford] as a permanent home for my successors”, in the absence of any progeny.1 On 24 March 1918, Lady Osler wrote to Kate Cushing (Harvey Cushing’s wife): These wonderful pictures have just come from Major Fiaschi from the Australian hospital in Boulogne. He — Fiaschi — was once in Baltimore from Australia as a PG [postgraduate]. Perhaps you remember him — we often see him. He says he has sent some pictures to Dr Cullen ... This implies that when Piero F B Fiaschi (Box 2) worked with Harvey Cushing in Baltimore in the United States, he was introduced to William Osler and that he continued the friendship and visits after Osler went to Oxford.2,4 As the tide of war was turning in 1918, Osler was lecturing Canadian and American medical officers on postgraduate medical courses and preparing them for life after the war. In October of that year, Hugh Cairns (Box 3), an Australian from Adelaide, was introduced to Osler by A L Smith, the master of Balliol College, Oxford. Osler offered Cairns an appointment at the Radcliffe Infirmary for 6 months when he was discharged from the army, and then advised him to work for a Bachelor of Science in surgical pathology at Oxford, and subsequently to prepare for obtaining Fellowship of the Royal College of Surgeons.5 Cairns was a frequent visitor at the Oslers’ house, the “Open Arms”, and on 25 January 1919 was introduced to Harvey Cushing. Cairns attended Osler’s Saturday morning rounds at the Radcliffe Infirmary, which continued until Osler became ill with bronchopneumonia in December. Osler then developed empyema and died on 29 December 1919, at the age of 70 years. Cairns continued to visit Lady Osler, and she recommended him to Cushing for neurosurgical training. During 1926–1927, Cairns spent 12 months with Cushing at the Peter Bent Brigham Hospital in Boston. On his return to London in September 1927, Cairns set up the neurosurgical unit at the London Hospital and was instrumental in persuading Lord Nuffield (who was previously Osler’s car mechanic) to donate money to establish Nuffield chairs at Oxford University. Cairns played a major role in setting up mobile neurosurgical units in World War II,6 and was involved in the early trials of streptomycin and penicillin in treating cerebral infections. He became the first Nuffield Professor of Surgery at Oxford. Cushing’s biography of Osler was published in 1925, and Robert Scot Skirving (Box 4), a senior physician, was chosen to review it.8 After a delightfully thorough review, he ended by quoting a description of Osler from the biography: “He joyed with the joys and wept with the sorrows of the humblest of those who were proud to be his pupils”. Scot Skirving took it upon himself to write a short publication on the life of Osler for the Australian market.9 He praised Osler’s textbook, The principles and practice of medicine, as “absolutely sane, without faddism and with a perfect blending of scientific facts with their practical applications ...” His work was not without error however — for he writes that Osler died at 71 instead of 70 years. A physical connection between Osler and Australia exists in the form of a gavel (Box 5) that was donated to the Royal Australasian College of Physicians in March 1950 by Dr William C Gibson, a Canadian neuroscientist who worked with neurophysiologist John C Eccles in Australia and who had a notice on his office door that said, “If you think medical research is expensive, try disease”.10 This gavel is made from wood saved from Osler’s childhood home, the parsonage at Bond Head, Ontario, Canada. The history of similar gavels has been described and catalogued — it appears that Osler’s nephew, Dr Norman Gwyn, used wood from the Osler home to make paper knives for the family and gavels that he gave to various associations (although the one in the possession of the Royal Australasian College of Physicians is not mentioned).11 Osler’s approach to the practice of medicine was a balanced one, between the bedside clinical, the laboratory, and postmortem pathology. He bought microscopes for his students, performed postmortem examinations himself and was careful with therapeutics. He used to remind his readers of a sensible approach to pathological tests and their importance to the clinical situation. In an editorial accompanying a “Clinching the diagnosis” series in Pathology that posed the question, “what would Osler say today?”,13 James P Isbister (Box 6) concluded by writing, “In the Oslerian sense, it [the series of articles] will be a collection of problem-oriented reviews aimed at bridging the gap between clinical and laboratory medicine”. Written from the pathologist’s point of view, Isbister discussed the various approaches to interpreting pathology results, weighing possibilities and relating them to the clinical picture rather than viewing them in isolation — wise counsel at a time when doctors often spent more time looking at results than talking with the patient. In 1996, Dr Oleg Preda (Box 7) privately printed 500 copies of his book The master-word of Dr William Osler.14 In the preface, he writes: He [Osler] never claimed to have more than modest abilities which he organised and used properly. This knowledge he shared with others and along with the charm of his personality made friends of his colleagues of all ages and in all places. Preda edited many of Osler’s speeches, giving them modern, relevant titles, removing gender-specific language, and adding notes to abide with Osler’s wishes (eg, Osler’s handwritten request on his copy of A way of life to add a Sanskrit poem by the Indian dramatist Kalidasa to any future reprints of the address). He divided the book into a brief history of Osler’s life followed by four sections based on the principles by which he practised medicine and lived his life: (1) “Credo” contained his beliefs and philosophy; (2) “Study” referred to students, libraries and bedside reading; (3) “Work” outlined the need “to do what lies clearly at hand”, and relations among colleagues and nurses; and (4) “History” aimed to connect the past with the present. In this technological era of medicine, Preda’s book added humanity and philosophy to the technical aspects of medicine, and he was modest in printing a small number of copies at his own expense and giving these to friends instead of making them available to a wider audience of doctors and students. In 1999, Professor Michael O’Rourke (Box 8) wrote an editorial in the Medical Journal of Australia titled “William Osler: a model for the 21st century?”.15 The publication mentioned various aspects of Osler’s life and stressed his attitude to medicine, especially his enthusiasm, knowledge and ethics. Osler’s rejection of gossip endeared him to friends and foes, which helped unite the medical profession. O’Rourke referred to notes inside a copy of Cushing’s The life of Sir William Osler (held in the library of the Royal Australasian College of Physicians) in which Robert Scot Skirving wrote that James Linklater Isbister (Box 9) had met Osler twice and that “he [Isbister] was extremely impressed by his character and influence on the young”. O’Rourke reminded us that, “given the explosion of knowledge and the frequent intrusions from phone, facsimiles and email which frustrate our routine and challenge our equanimity”, we need to sit back, reflect and weigh knowledge, commonsense and ethics in our daily practice, as Osler taught and practised. A recently found letter from Osler to D Appleton & Co, publisher of The principles and practice of medicine, dated 18 February 1898, stated: I would like an arrangement made with publishing houses in India and Australia to issue special editions of my text-book in those countries ... I could even add if necessary a short supplement to the special edition dealing more fully with certain affections peculiar to those countries. I have so many friends in both places, many of them men in official and teaching positions that the book would be adopted in the schools — as indeed it has been at Sydney ...17 This led to the eventual release, in 1913, of a special eighth edition of his textbook for Australia, which was used in Australian universities.17 At that time there were three medical schools in Australia (Sydney, Melbourne and Adelaide), with a total enrolment of 957 medical students, while the number of doctors in the country was less than 3000. These numbers were sufficient for Butterworth & Co to publish a special Australian edition made up of American sheets.17 Unfortunately, Osler did not identify who his Australian friends were. Osler was keen for his book to have as wide a market as possible, as he used royalties from its sale to further his own book collecting. Osler’s influence on Australia was similar to that on other countries. The Australian edition of his textbook taught the principles of medicine to a generation of doctors. Those fortunate enough to visit or meet him took pride in the experience and were inspired to practise medicine with high ideals and humanity. His writings and timeless sayings (eg, “take heed to [your] education, and [your] reputation will take care of itself”) are often quoted because they have well articulated wisdom, even in this age of molecular medicine. His cautious attitude to medication (“man has an inborn craving for medicine”) is a constant warning to those practising polypharmacy. He also highlighted the need for continuing medical education by stating “it is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it”. The employment of modern tests, be they chemical, imaging or pathological, do not lessen the need to be wise, well read, experienced, and compassionate towards the patient, in spite of the help given by computers and other technology. Australian doctors, medical teachers and writers continue to look to Osler’s guidance in applying his principles to modern medical practice. 1 Sir William Osler at Oxford, 1908 Reproduced with permission of the Osler Library, McGill University. 2 Piero Francis Bruno Fiaschi (1879–1948) Fiaschi was born in Windsor, New South Wales, second son of Thomas Fiaschi, a medical graduate from Florence, Italy. He graduated in dentistry from the New York College of Dentistry in 1903 and then in medicine from Columbia University in New York in 1905. He worked with Harvey Cushing in Baltimore and met him again in Abbeville, France, during World War I. He served in the Australian Army Medical Corps in Gallipoli, Egypt, France and the United Kingdom from 1914. Fiaschi was a pioneer in using saline for treating hypovolaemic shock in France. He became a urologist and venereologist and was associated with Sydney Hospital. In World War II, he was a medical inspector of prisoner-of-war camps in Australia.2,3 3 Hugh Cairns (1896–1952) Cairns was born in Port Pirie, South Australia. He started studying medicine at the University of Adelaide in 1912 but left to join the Australian Army Medical Corps. He served in Lemnos, Greece, where the Gallipoli casualties were taken. After the withdrawal from Gallipoli, he was repatriated to Adelaide to finish his studies, which he did in 1917. He then re-enlisted with the rank of Captain and went to the 2nd Australian General Hospital at Wimereux, France. In October 1918, he obtained leave to visit his father’s relatives in Scotland, and then used a letter of introduction to visit A L Smith, who in turn introduced him to Sir William Osler. Cairns was so upset at the death of his friend T E Lawrence (of Arabia) in a motorcycle accident in 1935 that he researched and advocated the wearing of crash helmets for motorcyclists. In 1945, he was called to treat the American General Patton, who had fatal spinal injuries from a motor vehicle accident. Cairns wrote on brain abscesses, head injuries, brain tumours, akinetic mutism, and cingulectomy for treating psychosis. He was appointed the first Sims Commonwealth Travelling Professor in 1947–48. He died from lymphoma of the caecum in July 1952.5 4 Robert Scot Skirving (1859–1956) Scot Skirving was born in Scotland, the son of a farmer. He travelled to Adelaide as a sailor on the Tantallon Castle and suffered from beri-beri on the return voyage, which influenced him to enrol in medicine at the University of Edinburgh. He graduated in 1881, in the same year as Thomas Anderson Stuart (the first Professor and Dean of the Faculty of Medicine at the University of Sydney) and Arthur Conan Doyle. He returned to Australia as a ship’s surgeon on the emigrant ship Ellora. After working in Queensland, in 1883 he was appointed medical superintendent of Sydney’s Prince Alfred Hospital (which received its Royal charter in 1902). He also served as honorary physician at that hospital and honorary surgeon at St Vincent’s Hospital. He was a lecturer at the University of Sydney and had a lecture theatre named after him at Royal Prince Alfred Hospital.7 Reproduced with permission of Ann Macintosh, Scot Skirving’s granddaughter. 5 Gavel at the Royal Australasian College of Physicians The inscription on the plate states “Made from wood saved from the birthplace of Sir William Osler after its destruction by fire. Made up by Mr Tom Jamisson. Osler’s cousin, Dr Norman Gwyn, provided the wood. Presented by Dr William Gibson of Canada, 22 March 1950”. Reproduced with permission of the Royal Australasian College of Physicians. 6 James Paton Isbister (1943–) Isbister is the son of two physicians (James and Clair). He graduated from the University of New South Wales in 1968 and, after residency at Prince Henry and Prince of Wales hospitals, specialised in clinical haematology, working at St Vincent’s Hospital in Sydney and the Royal Postgraduate Medical School of London. He was head of the Department of Haematology and Transfusion Medicine at Royal North Shore Hospital for many years and, while there, set up the first blood cell separator (apheresis) unit and first allogeneic bone marrow transplant service in Australia. He is currently Chair of the Advisory Committee of the Australian Red Cross Blood Service. He has written several books and many articles on haematology.12 7 Oleg (Alec) Preda (1941–) Preda was born in Russia. He graduated from the University of Sydney in 1972 and was a resident doctor at Royal Prince Alfred Hospital, Sydney Hospital and Hornsby Hospital in Sydney. He became a Fellow of the Royal Australian College of General Practitioners and was in general practice in the Sydney suburb of Castle Hill. He first became acquainted with Osler when, on expressing a wish to study medicine to the doctor conducting his physical examination before national service, he was urged to read Osler’s The student life. In his second year of medicine, he found Cushing’s biography of Osler in his local library, and reading it left a lasting influence on his life and work. Preda made a pilgrimage to all the places where Osler worked, visiting Toronto, the Wistar Institute in Philadelphia, McGill University and the Osler Library, Johns Hopkins University, and Osler’s house (the “Open Arms”) in Oxford. He viewed Osler’s brain at the Wistar Institute where it is held, and said “sadness came over me as I saw the gaps in the specimen where the greedy had debased this noble relic by cutting out portions of his brain” (Oleg Preda, personal communication). 8 Michael O’Rourke (1937–) O’Rourke graduated from the University of Sydney in 1960 and was a resident at St Vincent’s Hospital, Sydney, proceeding from anaesthetics to physiology and finally cardiology. He worked in the Department of Physiology at Johns Hopkins Hospital, before returning to Australia to become Professor (later Emeritus Professor) of Medicine at the University of New South Wales. His main interest is arterial haemodynamics, and he has written extensively, including several books, on the subject. He was instrumental in showing that arterial vasodilator drugs such as calcium channel blockers and angiotensin-converting enzyme inhibitors are superior to β blockers in treating hypertension. He is a Member of the Order of Australia (AM) and a member of the American Osler Society (Michael O’Rourke, personal communication). 9 James Linklater Thomson Isbister (1870–1936) Isbister was born in Scotland and went to school both there and in Adelaide, before graduating in medicine from the University of Adelaide in 1896. He worked at the Sydney Hospital before starting in general practice in North Sydney in 1898. He became an honorary surgeon and gynaecologist at the Royal North Shore Hospital in Sydney. In 1908, he spent a year travelling to London, Scotland and his ancestral origins in the Hebrides. He must have met Osler during this visit (as noted by Robert Scot Skirving), but there is no mention of this association in any other source. Isbister was described as a reserved, meticulous and saintly man. He was a foundation member of the Royal Australasian College of Surgeons.16 He treated Sister Mary MacKillop at the convent in Mount Street, North Sydney, and was the grandfather of James P Isbister (see Box 6).

Milton G Roxanas MB BS, FRANZCP

Robert “The Prof” Bedford provided medical services in South Australia for over 20 years, despite having no medical qualifications In the early 1980s, a national newspaper ran a feature soliciting nominations for “the most boring town in your state”. The winner for South Australia was the Eyre Peninsula township of Kyancutta. This generated the expected reaction from parochial inhabitants, who came up with a long list of interesting aspects of the district, including the notable and exciting fact that the township straddles the Eyre Highway, that great semitrailer-populated road connecting the west of the Australian continent with the east. Doubtless much of this list was facetious, but Kyancutta does in fact have a fascinating history, however dull it might have seemed by the end of the 20th century. It was the home of one of the earliest inland meteorological reporting stations; it had Australia’s fifth officially recognised aerodrome; and it housed an outstanding and unique natural history museum. All this, and much more, was the work of one man, Robert Bedford, who was known to three or more generations of farming families as “Beddie” and “The Prof”. Thirty or so years ago, when the boring town award arrived, there were still many older people in the central Eyre Peninsula who could recount stories of treatment, operations and consultations by “The Prof”. Once it was known that he had medical skills and was prepared to use them to assist his farming neighbours, he dealt with a never-ending stream of broken bones, dislocations, gunshot wounds, boils, carbuncles, scalds and burns, snakebites and fevers. He is even recorded as having treated burns with skin grafts. So many medical problems came his way that, with the aid of his wife, Hilda, he eventually set up a cottage hospital. The tyranny of distance ensured that he remained the first choice for local medical problems and emergencies, but Bedford was conscious of his limitations, and communicated frequently with nearby practitioners and metropolitan specialists. He referred patients whenever it was practicable; this being a term to be interpreted with regard to the sometimes vast distances involved, the vagaries of the weather, the primitive vehicles traversing equally primitive roads, and a rattly train service whose main function was to transfer wheat and barley, with passengers being of secondary importance. Such conditions meant that the transfer of patients did not occur very frequently in the earlier years. Like many other rural medicos then and now, he had a veterinary practice as well. It might have been assumed that he was medically qualified, even if not of professorial status, but simple enquiries reveal that, though widely consulted for injuries, illnesses and even obstetrics (he is recorded as having successfully delivered 99 infants from 98 confinements), Robert Bedford was not a doctor. Nor was his original name Bedford; he was born Robert Arthur Buddicom and changed his name to Bedford when he left England for Australia in 1914. In some accounts, his departure is described as “hasty”, implying a scandal, but all that could be found to support a scandal was a court case for alleged misrepresentation on a prospectus for a proposed telephone company. It is just as likely that his widely expressed pessimism about the future of England motivated his move. Bedford was born in Shropshire, in 1874, to a landowner family. He was educated at Charterhouse School and was a science scholar at Oxford University, where he qualified with a Bachelor of Arts degree in 1897. After this, he worked in marine biology in Naples, Italy, and then served as a curator of the Plymouth City Museum and Art Gallery, where he founded and edited a journal, Life. From 1906 to the time of his migration, he worked as a demonstrator and lecturer at the London Hospital Medical College (now Barts and The London School of Medicine and Dentistry). He was clearly a talented, cultured and widely educated man when he took up wheat farming in the remote district of South Australia where he was to spend the rest of his incredibly active and productive life. In 1919, he attempted to enrol as a medical student at the University of Adelaide, but he wanted to attend courses at the Royal Adelaide Hospital on his own terms and according to his own timetable. Not surprisingly, this was unacceptable to the medical faculty, and Bedford returned home disappointed, but with as good a collection of up-to-date textbooks purchased in Adelaide as would have graced the shelves of any reputable practitioner of the time. As long as anyone needed him, he was prepared to help, even when a full-time doctor set up practice in the nearby town of Wudinna. In fact, he remained on good terms with that doctor, and they frequently assisted each other and enjoyed games of bridge and musical evenings together with their wives. Farming, operating a flour mill, running a general store and acting as the local doctor and vet should have been enough to occupy anyone; but not so for this restless renaissance man. Radio station 5RB took to the airwaves in 1924, a railway refreshment room was opened in 1925, and in 1928, the Bedford store also became the official post office. In 1929, he decided it was important to set up an inland weather reporting station as an aid for the airlines, which were by then flying across the country from coast to coast. He bought his own barometers and wind gauges, but his observations were so accurate that the Bureau of Meteorology supplied further instruments and set up Kyancutta as an official weather station. His inspiring personality drew in neighbours to help build an all-weather aerodrome, which became an essential refuelling point for east–west flights across the country. In the 1930s, Robert’s interest in aviation was continued by his son, Bill Bedford, who continued to evacuate medical patients from areas as distant as Coober Pedy in the north of South Australia and Cook on the trans-Australia railway line, until an ambulance plane was stationed at Whyalla in 1965. Robert Bedford and one of his fossil fish In 1929, among his many interests and occupations, Bedford opened the Kyancutta Museum and Library to house his personal geological and palaeontological specimens, which he had collected locally and interstate on numerous self-funded trips, as well as specimens sent from collectors elsewhere in Australia. He examined and excavated meteorite craters in southern and central Australia, and published descriptions of these meteorites and tektites, mainly in his own Memoirs of the Kyancutta Museum. In 1939, he sent five specimens of fossil fish collected from early Devonian limestones in New South Wales to the Natural History Museum in London. These specimens formed the basis of an article published by Dr Errol White, then the fossil fish expert at the British Museum, who named one of the newly described fossils Williamsaspis bedfordi in Robert’s honour. Unfortunately, because of wartime disruptions at the Museum, the article was not published until after Bedford’s death. Other fossils on which Bedford worked included the ancient Cambrian archaeocyathid sponges from the Flinders Ranges. Described by his daughter as quietly spoken and peaceable, but capable of flying into a sudden rage, Bedford must have been a difficult man to argue with. The “establishment” certainly did not like him. He engaged in an acrimonious debate on geological matters with Sir Douglas Mawson (Newton Luscombe, personal communication), and the South Australian Museum opposed his admission to the Museums Association of Australia and New Zealand. His action in sending meteorite and fossil specimens to the British Museum may have been a reaction to the ill feeling that existed towards him among local geologists, and it certainly did nothing to ameliorate that antipathy. He was a prolific correspondent with dignitaries, scientists and institutions in Australia and abroad. His mind was constantly active and he involved himself wholeheartedly in local politics and as a member of the Australian Wheatgrowers Federation, for whom he drafted a constitution. He had visions of his little town of Kyancutta becoming a major regional centre, but this was not to be. The weather reporting station continued to function and, now operated by his grandson, is still an official Bureau of Meteorology observation and reporting station. The cottage hospital has long gone, its function being taken over by a hospital at Wudinna, established by the Bush Nursing Society, and which later became the Central Eyre Peninsula Hospital. The museum was closed shortly after World War II and its contents were dispersed. A series of models of his ingenious mechanical inventions ended up as toys for his grandchildren. Some of his medical books have been donated to a project for a museum at the University of Adelaide Medical School, which has still to see the light of day. Robert Arthur Bedford died on 14 February 1951. His contributions to geology and palaeontology have now been recognised by the scientific world, and his museum is named in historical studies. He was well aware of his limitations and did not publish any medical articles, so his legend as a medical practitioner remains only in the memories of those he helped. Such memories are mostly now extinct, but they are still, no doubt, associated with the inherited possessions of his descendants and with the folklore of the region. There is talk of a biography to expand on the memoir published by his daughter, Sylvia Laube, but, until then, this note may serve as a tribute to an amazing man, scientist, inventor, entrepreneur and original thinker, and a well loved bush doctor. He is buried in the Kyancutta cemetery, and his epitaph reads: “He laboured in his sphere as those who live in the delight that work alone can give”.

Michael Sorokin MB BCh, FRCP(Ed)

Mr D Duck presented with a painful neck and underwent cervical facet and foraminal injections under computed tomography control. He looks happy with the result, which proves that interventional radiology is not quackery.

Derrick G Selby · Claudio Coscia

Rock music may be bad for your knees as well as your ears Clinical record In May 2009, a 17-year-old woman in the dance floor audience at a rock concert was performing “air guitar” — a form of dance and movement in which a performer mimes to rock or heavy metal guitar music, commonly requiring enthusiastic jumping and leaping about a “stage”. While performing a manoeuvre involving a jump into the air, she landed awkwardly on her right leg. She noted immediate intense right knee pain with obvious patellar deformity. An ambulance was called, and a dislocation of the right patella was diagnosed. Under methoxyflurane inhalation, ambulance officers reduced the dislocation by manoeuvring the knee into full extension. On arrival at the emergency department, the patient complained of pain “everywhere” in the knee. There was no obvious swelling or deformity of the knee joint. There was tenderness over both the medial and lateral collateral ligaments, with minimal patellar tenderness. She had full painful range of movement. Radiological examination of the knee showed a joint effusion with lateral subluxation of the patella. There was a 2 mm ossicle lateral to the lateral femoral condyle, which may have represented an acute avulsion fragment. A compression bandage was applied, and the patient was discharged with analgesia and crutches, with follow-up to be undertaken with her general practitioner. The patient re-presented to the emergency department 36 hours later with a painful and swollen knee joint. After discussion of treatment options with the patient and her mother, a decision was made to proceed to arthroscopy. At arthroscopic debridement, a tense haemarthrosis was released. A bleeding point was identified at the patellar attachment of the torn medial patellofemoral ligament. A synovectomy of the affected area was performed, and haemostasis of the local bleeding vessel was achieved with diathermy (Box). There was minor chondral damage about the medial patellar facet. Other joint structures were intact and there was no fracture. The patient had an uncomplicated recovery with routine postoperative care. At 3-week review, she was able to walk comfortably unaided. There was minimal effusion and she had a full range of movement. She was prescribed a muscle-strengthening program and referred to a physiotherapist, and she made a full and uneventful recovery. DiscussionDislocation of the patella is an injury more commonly seen in young athletes and usually spontaneously reduces at the time of injury.1 There has been no report in the medical literature of a knee injury sustained during a musical performance. Although the literature describes several maladies attributed to guitar playing, such as wrist injury,2 overuse injury to the digits,3,4 and irritation of the skin secondary to exposure to the instrument’s surface,5-7 there are no reports of an acute physical injury due to guitar playing. There is a single internet report of an acute injury sustained while playing a guitar-like instrument — an avulsion injury of the lateral condyle of the left femur, incurred while playing the video game Guitar Hero.8 An internet search using Google found numerous reports of acute injuries attributed to the performance of air guitar. The Chicago Sun-Times reported an unspecified back injury to the reigning Chicago Region Air Guitar champion,9 while the winner of the United States Air Guitar regional competition in Brooklyn “rocked so hard during a daredevil performance that doctors had to amputate a toe she broke during the gig”.10 There are also reports of a knee injury as a result of jumping from a height during a performance and an ankle injury sustained after jumping from speakers.11 There has even been a report of death due to air guitar — a student in Singapore fell to his death from a building when he was “jumping up and down on the bed placed against an open window while mimicking a rock guitarist”.12 Our case suggests that injuries due to the performance of air guitar are a source of previously unrecognised and unreported morbidity and demonstrates that, even though the instruments used in air guitar are imaginary, the injuries sustained are quite real. Rock music may be bad for your knees as well as your ears. Arthroscopic photograph of the knee joint Diathermy-treated bleeding point within the medial patellofemoral retinaculum (arrow).

Robert J Douglas BA, BAppSc(Dist), BM BS · Jason Ward BM BS, FRACS(Orth)

Objective: Design, setting and participant: A mixed-methods, prospective, descriptive study of unsolicited mail sent directly to a general practice registrar in a private general practice located in rural north Queensland, collected between 1 March and 30 September 2010.Main outcome measures: The amount, by number and weight, of unsolicited mail items, and the proportion of each document read, in total and by category.Results: 196 items of unsolicited mail, weighing 19.85 kg, were received over a period of 7 months. The category with the largest number of mail items was pharmaceutical company correspondence (70; 36%), closely followed by medical tabloids and free journals (67; 34%). Medical tabloids and free journals made up the largest proportion of unsolicited mail by weight (15.49 kg; 78%). Of all 196 items, only 10 (5%) had more than half of their content read.Conclusions: Although small in size, this study suggests that a reduction in unsolicited mail to general practitioners in Australia would have benefits for GPs in terms of time management, environmental benefits, and reduction in frustration levels.

Amanda M Torkington MB BS, BSc · Robyn G Preston BA(DevS)(Hons), MHSc(HealthProm), PGCertDisasRefHlth · David T Brandts-Giesen BHlthSc(Podiatry), GradCertPHResEval

Did you know that when a manuscript is sent out for peer review, experts may elect to provide comments for the editor’s eyes only? Although we have sometimes shaken our heads in frustration when advice given to the editor (“Do not publish!”) does not match that offered to the authors (“A promising report, indeed ...”), thankfully, more often than not, the content is fairly congruent and includes further information that enlightens, entertains or otherwise stimulates us. We feel particularly privileged when contributors share their personal stories. Once again, at Christmas, we’d like to share a few comments that caught our eye this year. From the more sobering to the humorous, we hope you’ll find something thought-provoking among the batch provided. A doctors’ health journal?We all may know that many doctors do not have their own general practitioner. Members of the Journal’s Content Review Committee meet on a monthly basis to discuss, among other things, the most recent issues of the Journal. During one meeting, a participant commented: “The closest many of us [that is, doctors in general] get to seeing a GP is reading the MJA”. Public stationsFrom various submissions, apologies and requests for extensions, we are aware that several of our very valued contributors required medical attention this year. One expert shared this timely experience that was relevant to reviewing a paper related to the practice of medicine: “I recently had to go to the emergency department of a large teaching hospital. The doctors and nurses were kind to me but the place was like Euston Station and my visit there ranks as one of my bad life experiences — and I am medically qualified.” On location“I see you [the MJA] are in Clarence Street [in Sydney]. My parents bought me a bike there for my 17th birthday (1986) and I am ashamed to admit that I still ride it, although it has largely retired (2005), to ride down to check the surf on summer holidays.” Editor’s note: We think this was probably Clarence St Cyclery, founded in 1975. Quality publishing“I’ve written more than I usually do to the authors in the hope this places a bomb under them to write something that is more worthy of the MJA. As it stands, their current version could make it in the Women’s Weekly or page 3 of the Sun. (Probably showing my age with that last line — I guess the Sun doesn’t do Page 3 anymore. Not that I ever looked at Page 3, I only know this from what [name of esteemed professor] tells me ...).” Recipe for success“Thankyou for the opportunity to review this entertaining manuscript. A mix of science, fashion and a tinge of plausibility was evident which is, of course, the basis of many a Cochrane review.” The essential ingredient “I’m wondering whether you’ve had the time (or the inclination) to watch a new reality [cooking] show ... I came across a re-run yesterday when the cricket match was boring me to tears ... For the starter course, they [an amateur chef team] served a risotto of lobster with vanilla and truffle ... You will note [from the website transcript] that no truffles are listed on the [ingredients]. In its place is truffle oil ... I thought the quote of the show was, ‘Where were the truffles?’ ... Well, this in a nutshell, is what’s wrong with [this manuscript]. Where were the truffles?” The MJA looks forward to receiving more of your “truffles”, be they formal or informal, next year and beyond.

Ann T Gregory MB BS, GradCertPopHealth

Registration Good medicos are burning with desire, To take on board advances they require, Devoting leisure moments to pursue Such literature that enters their purview. They front up to hear lectures after work, To bone up on some therapeutic quirk, So expertise and insight may be gained, And professional standards be maintained. Continued education brings rewards, And favour of the state medical boards Without whose benefit good doctors fear They’re likely to be tossed out on their ear. Well, not infrequently, they feel they must, Pursuant to their academic lust, Convene with keen like-minded personnel, At some prestigious convention hotel. They choose a choice location for this spree, Where shopping is most likely duty-free, Then as they doze or contemplate or learn, They plot deductions from their tax return. The program planner usually provides Relief from lectures and relentless slides, Allowing those who feel at all inclined, To swan off on excursions and unwind. Thus one encounters doctors of renown, Who while relaxing let defences down, And herewith is a brief manifesto Of doctors, some of whom you surely know. This resumé of medicos indeed, Should satisfy an all-consuming need, So patients may be able to rejoice, In visiting the doctors of their choice. Herewith in verse maybe for the first time, The healing arts and artists caught in rhyme. Appear on stage to be viewed and discussed, The ones to whom our bodies we entrust. Final session (After Noel Coward’s I went to a marvellous party) For some obscure reason I’m here for the season Of medical rorts, With doctors who venture To convention centre In grand plush resorts. The new qualifiers And old frequent flyers Arrive in their hoards, The healing profession To make an impression, On medical boards. It cost quite a bit But I have to admit It was worth every cent, I’m not a cheapskate And I’m pleased to relate That I’m glad that I went. Yes I went to a lovely convention, A junket, a real jamboree, The doctors turned up to sip and to sup, And much of the noshing was free. Benevolent caring drug houses Fell over each other, what’s more. Such elegant samples they took from their shelves, The drugs into which all the avant-garde delves, And which they agreed to try out on themselves, I couldn’t have loved it more! It was such a super convention, The doctors committed to learn. You know what I mean, The more they could glean, The more they’d be likely to earn. They didn’t need too much note-taking, With printed handouts by the score, Then discounted textbooks were offered for sale, All quite up to date in the latest detail, And others available on the e-mail, I couldn’t have loved it more! It was such a way-out convention, No lawyers or newshounds allowed, Although I admit, When musing a bit, A few had got in with the crowd. You have to watch out for intruders, You need a firm hand at the door, Insurers were handing out membership slips, Detailers were offering quite useful tips, And promised to upgrade old computer chips, I couldn’t have loved it more! It was such a stunning convention, With double projection of slides, Intelligent folk, Enjoying a joke, Occasional funny asides. The visiting firemen were splendid, Imported from somewhere offshore, Presenting their work with a practised aplomb, It’s easy to tell from the accent where from, It had to be either a Yank or a Pom, I couldn’t have loved it more! It was such a friendly convention, The women were out on spree There’s no way of stopping, The ladies when shopping, When everything is duty free. Some menfolk had joined in the outing, When finding some lectures a bore. A sort of wine buff, I examined the range, Of duty-free liquor and some of it strange, And picked up a discounted carton of Grange, I couldn’t have loved it more! It was such a first-rate convention, And nobody wanted to stop, Although one or two, Perhaps me and you, Declared it was over the top. We ambled along to the rostrum, Displaying such esprit de corps, Then off we all went with a friendly handshake, To boast of the hardships that we undertake, And let patients know what we do for their sake, I couldn’t have loved it more!

Leonard Green MRANZCR, FRACR, OAM

Blood on my hands: a surgeon at war. Craig Jurisevic. Melbourne: Wild Dingo Press, 2010 (328 pp). ISBN 9780980757002. This Autobiography is set in Kosovo 1999, in the weeks before North Atlantic Treaty Organization bombing finally forced Serbia to make peace and stop its ethnic cleansing of Kosovars. The author, Craig Jurisevic, a cardiothoracic surgeon from Adelaide, served with the International Medical Corps in Albania. There he kept a journal which, a decade later, he revisited, with the help of writer Robert Hillman, to write this book that describes what he saw and how he felt. As the chapters unfold, it is unnerving to see how the author’s sense of responsibility escalates, not only towards the wounded soldiers and civilians on whom he operates but also to those exposed on the front line without medical support. Jurisevic (his mother’s Slovenian surname) becomes disgusted, angered and eventually consumed by the injustice — the evil of ethnic cleansing and the brutality of its perpetrators, the Serbian militia. It is not only the dreadful injuries that move him, but also the way in which they are inflicted and the manner in which people are executed. He is unable to act the part of a detached foreign doctor, nor tolerate the Albanians who exploit and extort the sick and injured Kosovars — local mafia barons who enrich themselves on the suffering. During the final weeks of the war, Jurisevic serves on the front-line, operates in a cave, and is forced to defend himself against Serbian attacks. This is an extremely well written book, but not one that is just to be enjoyed — it is brutal and honest; shocking but authentic. There is no other like it, and small wonder that it is being adapted for the big screen. Its readership will be much wider than the medical market and it is likely to become a bestseller. The worst comment I can make about its content is that it is all true.

David A K Watters

It may be time to invest more in primary care research, including research on clinical conditions Here is a simple exercise: in the PubMed website (http://www.ncbi.nlm.nih.gov/pubmed), type “The New England Journal of Medicine[Jour] AND Australia[All Fields]”, and you will see that the journal has published about 90 Australian articles since 2000. Scanning through them, you will find that just one includes an Australian general practitioner as an author (Professor John Marley, in 10th author position), for an article describing the large blood pressure trial ANBP2.1 Repeating this exercise for JAMA (the journal of the American Medical Association) yields one Australian GP author in one of 79 Australian papers (Professor Chris Silagy as first author), in an analysis of protocols of published systematic reviews and reports.2 But what should we expect in the way of research from just one discipline — general practice — in one country? Should we conclude that general practice is not a glittering performer among the medical and health disciplines in Australia, or that it is holding its own? On one hand, it could be argued that general practice is not likely to be the area for such revolutionary discoveries as will command attention from the two most-cited medical journals. We could, instead, think of general practice as the final common pathway for best practice, honed in specialty clinical practice and research. On the other hand, general practice could be described as not only an obvious but perhaps even an indispensable place for research in the areas of health services (ways of delivering care better) and clinical research into diseases encountered in primary care. It may even be a place for basic science research. General practice is where about three-quarters of all medical consultations in Australia take place. The gaps between practice and the best evidence are as wide there as anywhere, and our need for information is urgent.3 On the basis of the numbers of clinicians in the discipline who need information, primary care research output should be the highest compared with the other (smaller) disciplines. But this was not the case a decade ago and is still not the case today, although the situation has improved. A 2001 study, using clinician numbers in the discipline as a denominator, showed that research in the area of internal medicine and surgery in Australia was 60–100 times more productive than that of general practice.4 In addition, general practice research is usually published in journals that are considerably less cited than specialty journals (although a citation index is an imperfect way of measuring research quality).5 The stimulus for a surge in Australian primary care research came from an unexpected quarter. In 1989, the proposal to form a register of GPs, championed by the Royal Australian College of General Practitioners (RACGP), was met with opposition from some non-RACGP-aligned GPs and the Australian Medical Association. The Australian Government referred this political hot potato to the Senate Select Committee on Health Legislation and Health Insurance, which took submissions around the country.6 The Committee noted that little information was available about Australian general practice, and made two recommendations. One recommendation approved the proposed GP register (registration then requiring vocational GP training); the other was for a program of evaluative research to be established, the General Practice Evaluation Program (GPEP).7 This was the predecessor of the current Primary Health Care Research Evaluation and Development (PHCRED) program and, between them, these programs have since been the major sources of funding for Australian general practice research.8,9 Early general practice research was over-reliant on surveys and descriptive studies.7 Intervention studies started soon afterwards, although they were bemoaned as still too few and insufficiently rigorous.10 The subject matter for research has been heavily biased towards health services research at the expense of clinical illnesses, as might be expected from the historical origins of the funding.11 The investment has certainly paid off, lifting the average from one to three publications per 1000 Australian GPs per year over the past decade, with physicians now being “only” 50 times more productive than GPs.12 Primary care research has been criticised for being too “soft” (using qualitative rather than quantitative methods), and it may be true that too many nascent researchers think that qualitative research, or even survey research, will be easier than quantitative research; neither is. However, this is to confuse the mode of research with its purpose, that is, to answer the type of question that is being asked. One must use the right tools for the job. For example, questions about interventions need randomised trials; questions about diagnosis need consecutively enrolled cohort studies; and questions about aetiology need case–control studies. But sometimes a question, particularly in relation to implementation of multistranded interventions, can only be answered by using several methods — “mixed methods” research — to allow for some of the complexities of primary care.13 More important is the question of what to research. It may be time to invest more in primary care research on clinical conditions (Box). There is more uncertainty about clinical conditions managed in primary care than about many conditions managed by specialists, and there is much research to conduct. A useful leaf that we, as GP researchers, should take from the specialists’ book is to work more collaboratively with basic science researchers. A good example of a successful collaboration of this sort is a study about the prevalence of whooping cough in children, which has changed the way we think about persistent cough after apparently trivial acute respiratory infections — might it be due to pertussis? In this study, bench-top scientists worked with GP researchers to generate a rapid and reliable diagnostic test for infection with Bordetella pertussis.15 Now is the time for more investment in primary care research — of any kind. Australian primary care research funding 2000–2010: clinical research items compared with total items14 Funding body Total items funded Clinical research items funded Primary Health Care Research Evaluation and Development* 46 0 National Health and Medical Research Council 166 27 Pharmacy Guild 82 0 Total 294 27 * Since 2003.

Christopher B Del Mar MB BChir, FRACGP, MD · Mieke L van Driel MD, PhD

Charles Bridges-Webb was born on 15 October 1934 in Castlemaine, Victoria. A country doctor’s son, he graduated from the University of Melbourne in 1957 and went on to become an international figure in general practice research. Charles commenced his research, which he called “organised curiosity”,1 while a rural general practitioner in Traralgon, in south-eastern Victoria. He was appointed foundation Professor of Community Medicine (later renamed General Practice) at the University of Sydney in 1975, and was Head of Department until his retirement in 1994. Charles was a member of the Royal Australian College of General Practitioners (RACGP) Research Committee for 20 years and an RACGP representative on the National Health and Medical Research Council. He was an inaugural member of the Australian Association of Academic General Practice and its president from 1989 to 1991. Charles was an international leader in the development of morbidity surveys, and his publication on morbidity in general practice2 is one of the most important research publications from Australian general practice, offering an understanding of health and disease in the community. As member (1972–1998) and Chair (1991–1998) of the International Classification Committee of the World Organization of Family Doctors, Charles was a key developer of the International Classification of Primary Care, now the official World Health Organization classification system for primary care. In retirement, Charles was Director of the RACGP research unit and Chair of the Australian General Practice Statistics and Classification Centre (home of the BEACH [Bettering the Evaluation and Care of Health] program). He also spent time enjoying his extensive garden, working as a lay preacher and writing his autobiography.3 In 2002, Charles was made an Officer of the Order of Australia for services to primary health care research and general practice. A quiet, philosophical man, Charles saw the good in everyone and encouraged their strengths. He was notable for his generosity in sharing his talents and time, especially with young researchers, for his loving partnership with his wife Anne, and his ability to balance his extraordinary professional contributions with family life. Charles died in Sydney on 16 June 2010 and is survived by Anne and his four children, Andrew, Ian, David and Kate.

Michael R Kidd · Helena C Britt · Graeme C Miller · Deborah C Saltman

Family history has a role, but who should be responsible for exploring and recording it? The increasing age, number and comorbidities of hospital inpatients has increased the load on emergency departments and necessitated significant redesign, including the introduction of short-stay and medical assessment units. These units are diverse in their casemix, but common factors include higher acuity of illness and expedited discharge. Obtaining a complete history of a patient’s acute illness and longstanding comorbidities, as well as his or her social and psychological issues, represents the ideal standard of care. Obviously, however, there are tensions between providing holistic care and continuity of care to the patient and achieving the rapid turnover required in such units. Genetic markers and tests are increasingly available for an expanding range of conditions. Genetic counselling has moved from specialised clinics into the mainstream practice of many disciplines. The inheritance of disease is rarely a simple algorithm, and these new genetic tools provide complexity rather than clear direction. Relevant guidelines are uncommon outside cancer medicine. Family history is a frequent criterion for determining further genetic testing. For example, the Amsterdam criteria for diagnosis of hereditary non-polyposis colorectal cancer (HNPCC) include a family history of at least three relatives with HNPCC-associated cancer.1 There can be harm in failing to interpret genetic tests correctly, and the complexity of many conditions demands a high level of knowledge. “Genetic literacy” is a term that has been used to describe competence in this area.2 However, it seems unreasonable to expect all doctors to be skilful at all times in eliciting and interpreting the family history and then appropriately counselling and testing each patient. Family history is an older tool than genetic testing and is poorly defined, applied and understood.3 Even now, there is not enough evidence to gauge its reliability and role.4 The family history can aid stratification of a patient’s risk of heritable conditions, and it has diagnostic utility for disorders with classic Mendelian inheritance, but it may be less useful in disorders with multifactorial inheritance or more complex genetic expression. In this issue of the Journal Langlands and colleagues report that family history is not recorded in the case notes of most medical short-stay patients.5 They argue that a family history offers potential health gains for the patient and relatives and suggest that there should be increased focus on this element of the medical history. However, this seems unrealistic in the context of increased workload and time pressures, particularly in a hospital short-stay unit. The acute admission is not an ideal setting for detailed and accurate history taking; patients are usually unwell and access to their family is compromised. The family history recorded is often inaccurate4 or misleading, not only because the level of health literacy among patients is variable but also because familial clustering is not distinguished from heritable disease. The accuracy of reporting of family history is rarely studied, but it has been shown that it can be poor in patients with cancer4 or cardiovascular disease.6 The primary care setting affords better opportunities to explore and record family history and to make adjustments after clarification with relatives. Certain conditions (eg, malignant hyperthermia, Huntington disease) drive consideration of genetic testing of the affected individual and sometimes lead to testing of family members. The counselling required should form part of an ongoing relationship with the patient and family. As Langlands and colleagues state,5 the family history may be a casualty of increasing numbers of acute hospital admissions. Perhaps it is a justifiable casualty in the acute health care environment, as long as information is elicited accurately afterwards. Ideally, a patient should have his or her acute illness diagnosed and managed within the acute admission, with a clear plan then delineated for follow-up, which includes notification of those who will be responsible for doing so. It is important to have a use for any family history information once it is accurately obtained. In future, the acquisition of a family history must embrace the developments in our understanding of genetic disease. Without diminishing the role of specialised genetic units, primary care clinicians and specialists in chronic care will need to assume greater responsibility for exploring family history. Screening assessments can identify those requiring a more comprehensive review. We would argue that, under present circumstances and with doubt hanging over its sensitivity, specificity and effect on health outcomes,3,4 the family history is a justifiable omission from many acute hospital admissions. The concept of holistic care is a noble one and, if we are to work within a new paradigm of shorter hospital inpatient stays, we will need to develop a strategy for preserving this concept. Certain diseases, such as unprovoked venous thromboembolism, should trigger an immediate focus on family history, but a routine family history is best ascertained when people are not acutely unwell. If we are serious about disease prevention and the role of genetics in modern medical management, more guidance is needed in terms of which patient groups will benefit from genetic testing and how any positive results will be managed. An integrated approach should include guidance for screening that is based on a better defined family history that has been obtained in the non-acute setting. This approach requires protocols for disease-specific genetic testing and specialist referrals for further assessment and management. A recent National Institutes of Health conference offers hope in this regard.3

Josephine S Thomas BM BS, FRACGP, FRACP · Campbell H Thompson DPhil, FRACP, MD

It is time to reconsider the clinical benefits arising from family history and start making better use of it A patient’s family history may aid clinical diagnosis and contribute to disease risk assessment and prediction. It frequently yields valuable social history, including information about family support structures and insights into individual beliefs about illness.1 Although taking family history is traditionally regarded as a routine part of the medical history, it is not used in a systematic way in clinical practice. In this issue of the Journal, Langlands and colleagues report the results of an audit in an Australian teaching hospital, which found that nearly three-quarters of patients admitted to a short-stay medical unit had no documentation of family history having been considered as part of the diagnostic assessment.2 A similar situation exists in primary care. Although there are no published comparable data from Australian general practice, a primary care study in the United States found that only 16% of subjects (n = 362) had any record of their family history in their clinical chart, including 15 individuals at high risk of an inherited cancer syndrome.3 Internationally, there is growing recognition that a family medical history can support tailored disease prevention, which may be more effective than existing approaches.4 This is also reflected in the Australian Medicare-funded adult health assessment for people aged 45–49 years at risk of developing chronic disease, which specifically includes assessment of the family history of chronic diseases such as diabetes and cardiovascular disease. Family history can also inform the formulation and weighting of differential diagnoses in presentations for a range of common conditions. The risk of many serious diseases is increased in the presence of a family history of the disorder, representing not only shared genetic factors but also environmental and behavioural exposures. For example, the relative risk of breast cancer is 1.4 times higher for women aged 60 years or older if they have a first-degree relative diagnosed with the disease after the age of 60 years; this risk is more than five times higher for women younger than 40 years with a first-degree relative diagnosed before the age of 40.5 Eleven per cent of women with breast cancer have a first-degree relative with the disease. The relative risk of colorectal cancer for a 50-year-old is increased from around twofold with one affected first-degree relative to almost fourfold in people with at least two affected first-degree relatives.6 About 15%–20% of people with colorectal cancer have an affected first-degree relative. In a US population-based study, 14% of the population had a family history of ischaemic heart disease, but these people accounted for 72% of early ischaemic heart disease and 48% of all cases of the disease.7 A parental history of type 2 diabetes is associated with a relative risk of 2.2 and a lifetime risk of 40%.8 These familial disease risks should be compared with other traditional risk factors that are routinely screened for in general practice. For instance, isolated hypertension is associated with a relative risk of 1.8 for ischaemic heart disease and is present in 14% of men and 5% of women with a coronary event.9 There are effective interventions for primary and secondary prevention of all these common diseases, ranging from disease surveillance to drug treatments and lifestyle management. There is some evidence that having knowledge of a family history of a specific condition is associated with improved uptake of a range of disease-preventive activities for breast, colorectal and skin cancer.10-12 Therefore, it is possible that identifying people with a family history of disease could act as an additional motivator for them to change their lifestyle or participate in disease screening. Why then do clinicians continue to neglect the family history as part of routine diagnostic assessment and disease prevention? The experienced clinician will know that recording a patient’s family history to assess disease risk ideally requires a three-generation pedigree, but this can take up to 30 minutes, which is unrealistic in most clinical settings. However, not all patients require such a detailed assessment. Simple, self-completed family history screening questionnaires could provide an answer. Several of these already exist, but many are disease-specific and few have been formally tested to determine their screening characteristics.13 Clinicians also cite patients’ uncertainty about their family history as a barrier. However, a systematic review of self-reported family history found high positive predictive values for cancer in first-degree relatives (breast, 93%; prostate, 85%; colon, 81%), although information was less accurate about second-degree relatives (breast, 91%; prostate, 80%; colon, 77%).14 Of course, sometimes the patient’s perception of his or her family history can be just as important as the reality in determining the patient’s risk perception, illness beliefs and likely response to medical advice. Better methods of recording family history are also required, particularly as we move towards an electronic health record in Australia. Tailored clinical software is potentially the most effective tool for recording and updating a patient’s family history, although current clinical software systems do not support the creation of pedigrees. Previous trials have demonstrated the capacity of computerised pedigree tools to improve the assessment of disease risk and identify those individuals who may benefit most from seeing a clinical geneticist.15 However, while clinicians continue to ignore the importance of the family history in diagnosis and risk assessment, software companies have little incentive to integrate family history tools into their systems. Raising awareness among consumers is an alternative approach that may drive clinicians to consider family history more often. A family health history campaign run in New South Wales in 2007 resulted in increased community awareness and discussions about family history within families and between patients and their general practitioners.16 While DNA-based disease risk prediction remains to be proven as an effective clinical tool, family history is a simple but potent tool that is available now for disease prevention. Langlands and colleagues audit findings show that this important element of the clinical history is seldom included in routine patient assessments.2 The family history should not be seen as a relic of medical school teaching; it is time to reconsider the clinical benefits arising from family history and start making better use of it in clinical practice.

Jon D Emery MB BCH, FRACGP, DPhil · Fiona M Walter MB BCh, FRCGP, MD · David Ravine MB BS, MD, FRCPath

To the Editor: In the December 2009 issue of the MJA, I came across an interesting article by Dr Paul Zimmet, “A lifetime pursuit of diabetes through chance”.1 This is an account of his impressive achievements in medicine. However, I disagree with the statement that describes his father’s situation in 1930s Poland: “He returned to an unpaid position in the Tarnopol Hospital — unpaid because Jewish doctors could not be ‘officially’ employed in Poland.” I argue that, in Poland at that time, there was no discrimination against national minorities, and this applied to the Jewish minority as well.2 I have done some research on the subject. There were 3.5 million Jewish people in Poland before the war — 10% of the population. According to numerous historical sources, Jewish doctors represented 34% of doctors in Poland in 1938. In the Polish capital, Warszawa, this percentage was 66%. The same sources quote the percentage of lawyers of Jewish origin as 55%.3,4 These numbers are a tribute to the talents and assertiveness of Polish Jews; however, they do not support the statement by Zimmet that I am disputing. In Polish archives, I have discovered statistical documents containing alphabetical lists of all doctors registered in Poland between 1936 and 1938.5 According to these documents, there were two hospitals in Tarnopol at that time: the General Hospital and a Jewish hospital. In the official register of all Polish doctors practising between 1936 and 1938, I have not found the name of Dr Jacob Zimmet. He was not registered as a doctor, and therefore could not legally be employed as a doctor in Tarnopol or any other Polish hospital.

Wladyslaw W Smolilo

In reply: Dr Smolilo has challenged my claim that my father, the late Dr Jacob Zimmet, worked in a hospital in Tarnopol, Poland, and without salary, in the pre-World War II period.1 I am pleased to refute Smolilo’s inaccurate claims. Smolilo argues that “. . . in Poland at that time, there was no discrimination against national minorities, and this applied to the Jewish minority as well”. I accept his statement that there was not an official policy as such. There are, however, ample historical records of discrimination against Jews in many areas.2 Smolilo questions the specific instance relating to my late father. I have a letter in Polish from the Director of the Government Hospital in Tarnopol and its 1939 official translation by the Polish Consul-General in Sydney, copies of which I have provided to the Editor of the Journal. This letter not only confirms my father’s employment from 1935 to 1938, but also the fact that he was not paid. The very fact that Smolilo could not find my father in the official records also stands as confirmation! Clearly, there were many Jewish doctors and other professionals employed in Poland from earlier years who retained their positions during the period from 1935 to 1939. However, even before that time, a quota was imposed on Jewish students and many had to go overseas for medical training.3 On return, like my father, they were unable to find gainful employment and eventually left Poland, many emigrating to Australia. My father provided loving care to many Polish immigrants in his medical practice in South Australia.

Paul Z Zimmet

Konrad Jamrozik was born on 2 May 1955 in Leigh Creek, South Australia. He undertook basic medical training in Adelaide and Hobart, graduating from the University of Tasmania in 1977. After a year as an intern in Hobart, he won a Nuffield Dominion Trust scholarship to study at Oxford University from 1979 to 1982. There, he worked with Sir Richard Peto and the late Sir Richard Doll and produced a doctoral thesis examining strategies for promoting smoking cessation in general practice. In 1983, Konrad lectured in Community Medicine at the University of Papua New Guinea in Port Moresby, where he was also a clinical assistant in the leprosy service. He took up a research fellowship in epidemiology at the University of Western Australia in mid 1984, and was promoted to Professor of Public Health in early 2000. From December that year until September 2004, he held the Chair in Primary Care Epidemiology at Imperial College London. Later in 2004, he moved to Brisbane as Professor of Evidence-based Health Care and Head of the Division of Health Systems, Policy and Practice at the University of Queensland, then in 2007 became Head of the School of Population Health and Clinical Practice at the University of Adelaide. He also held short-term posts at the World Health Organization in Geneva, Harvard Medical School, the National Public Health Institute in Helsinki, Finland, and Jagiellonian University in Krakow, Poland. Konrad had wide research interests including health promotion, the epidemiology and prevention of vascular disease, the design and conduct of randomised-controlled trials, and the translation of evidence into everyday practice. He had a natural talent for teaching and mentorship, helping to produce the next generation of health leaders. He also earned an international profile in the area of tobacco control as a researcher and advocate, and maintained a clinical commitment in medical oncology. He was a prominent life member of the Australian Council on Smoking and Health and a Fellow of the Public Health Association of Australia. In 2009, he was awarded the Nigel Gray Award for his outstanding contribution to tobacco control. Konrad was a dedicated cyclist and a keen rower who competed for Oxford and rowed for pleasure in rivers around Australia and the world. He was an unforgettable, extraordinary, dedicated man, and a loyal and caring friend and colleague with a commitment to excellence and justice. One colleague wrote, “It feels like public health in Australia has lost a limb”. Konrad was diagnosed with advanced sarcoma in 2009 and remarked, in light of his work on cancer, that this placed him within “a tradition of doctors who fall victim to their disease of special interest”. He died in Adelaide on 24 March 2010 and is survived by his wife Lesley and children Euzebiusz, Harriet, Magnus and Aleksander, and his parents Adam and Ruth.

Terry Slevin · Euzebiusz Jamrozik