History and humanities

Mojon’s manual of medicine. A cartoon book for daily clinical life. Mojon D. Berlin: Springer, 2009 (xii + 128 pp, $42.45). ISBN 978 3 540 68559 3. And now for something completely different . . . Daniel Mojon, a Swiss professor of ophthalmology, started his “other” career as a cartoonist while attending (boring) medical school lectures. According to a preliminary page of his unique manual of medicine — which is really a cartoon book for daily clinical life — he was most probably infected with a very rare strain of Streptococcus cartoonaurius during a microbiological laboratory course. The Manual has over 100 black-and-white cartoons divided among 13 chapters, which cover 10 medical specialties as well as congresses, the financial aspects of medicine and research. Some are based on what some might call “sick” jokes, which can be readily appreciated by most of us — particularly those who are not, themselves, the butt. For example, with respect to choice of career: “I became a pathologist because I kept turning up late to emergencies . . .” and “With your superficial character I would become a dermatologist”. Most could be considered more than a little sarcastic and a few, like the one depicted here, are simply delightful. After graduation, Mojon’s cartooning career apparently persisted only because he kept being confronted with uninteresting meetings and conferences. In fact, he has become so well known that colleagues in need of sleep avoid sitting close to him due to the loud laughter of neighbouring attendees — perhaps something to keep in mind if you are thinking of taking this book along with you to a meeting or two.

Ann T Gregory

Objectives: To identify the incidence of self-reported harmful adverse events in the health care of community-dwelling adults, and to examine attitudes about safety in the health system.Design: Cross-sectional, population-based survey.Participants and setting: Analysis of data from 3522 adults participating in Stage 2 of the North West Adelaide Health Study, who were surveyed in 2004 and 2005.Main outcome measures: Self-reported adverse events causing harm in the past year; attitudes to safety in health care, including adequacy of current measures for preventing adverse events, and the effect of groups like patients themselves, doctors and governments on patient safety.Results: The annual incidence of self-reported harmful adverse events was 4.2%. The main types were medication error (45.5%) and misdiagnosis or wrong treatment (25.6%). Multiple logistic regression showed that self-reported harmful adverse events were more likely in people who had been hospitalised in the past 12 months (odds ratio [OR], 2.5; 95% CI, 1.9–3.4), those who had low annual income (< $12 000), those who completed higher education to the level of Bachelor degree or higher (OR, 3.0; 95% CI, 1.0–9.4), and those who had some level of dissatisfaction with their recent health care; and less likely in those more risk-averse rather than those with a tendency to risk-taking behaviour (OR, 0.6; 95% CI, 0.4–0.9). People were more likely to believe that individual health care professionals had a positive effect on safety than professional groups or government, and that more resources were the key to improving the safety of health care.Conclusion: We found an incidence of self-reported harmful adverse events that was significantly lower than that found by a 2002 Australian survey (4.2% v 6.5%; P = 0.009). Better communication to help patients acquire more realistic risk perception may help reduce harm. Better communication could also increase public advocacy for systems improvement in safety to counter persisting community beliefs that individual action alone can redress the situation.

Robert J Adams MD, FRACP · Graeme Tucker BSc · Kay Price RN, MA, PhD · Catherine L Hill MB BS, BS(Epid), FRACP · Sarah L Appleton BSc · David H Wilson BEd, MPH, PhD · Anne W Taylor MPH, PhD · Richard E Ruffin MB BS, MD, FRACP

To the Editor: Controlled breathing is a fundamental principle of marksmanship. I describe an effect of viral lower respiratory tract infection on small arms training that was unexpectedly prolonged. The patient (myself) had abrupt onset of respiratory infection, 1 day after a marksmanship training session on an electronic firing range. During the session, I obtained satisfactory scores from several firing positions (best score, 66 mm grouping for five shots and 126 mm grouping for 20 shots, at 200 m, prone firing position). The illness progressed rapidly from a non-specific prodrome to a flu-like illness with fever, malaise, muscle aches, lethargy, slowed cognition, cough, sore throat, rhinorrhoea, persistent lacrimation and a 24-hour period of prostration. Recovery began after 48 hours, allowing a return to light work at 72 hours and full working duties by Day 7. On Day 14, during another marksmanship training session, my accuracy was severely decreased. I failed to obtain satisfactory scores in any position because of persistent erratic breathing and occasional involuntary coughing (best score, 235 mm grouping for 20 shots at 200 m). Spirometry later that day showed a reduced peak flow rate (310 L/min) (see Box). Serological tests were negative for IgG and IgA for all respiratory agents assessed. Nasal swabs were positive for parainfluenza virus type 3 by polymerase chain reaction testing. Involuntary coughing, particularly towards the end of the day, and decreased exercise tolerance persisted for a further 2 weeks, by which time peak flow had increased to 500 L/min. A third marksmanship session the week afterwards showed an improvement in scores, but they were still worse than those obtained pre-infection. Notably, grouping deteriorated rapidly after the first series of 20 shots, and could not be regained even after short rests. Replay of the recorded laser beam pattern for the session indicated that the breathing pattern remained erratic, although peak flow had risen further to 550 L/min. In the aftermath of the First World War, the joint head of Germany’s forces, Ludendorff, claimed that the failure of his 1918 spring offensive was ultimately caused by epidemic influenza.1 The epidemic affected German troops later than the allied forces, in June 1918. By July 1918, there were an estimated 500 000 German influenza casualties. Ludendorff’s initial successes were a result of new, highly mobile type infantry tactics — the forerunner of today’s “fire and movement” — which require physical fitness, stealth and accuracy of rifle fire. My case demonstrates that the tactical consequences of a viral lower respiratory infection can last much longer than medically explicit morbidity. Prolonged effects in my case included persistent involuntary cough, loss of exercise tolerance and loss of marksmanship, weeks after the initial acute illness. Ludendorff’s claim may be not so far off the mark. Marksmanship scores* and peak flow rates over time after onset of a respiratory tract infection * Lower scores for shot grouping indicate better marksmanship (shots are more closely grouped).

Timothy J J Inglis

Fred Schwarz, an Australian medical doctor-turned-political activist, died on 24 January 2009 in Camden, New South Wales. The fourth of 11 children, Fred was born in Brisbane on 15 January 1913. After graduating with a science degree in 1933, he worked as a school teacher, then returned to university to study arts and medicine. While a medical student at the University of Queensland, he continued to work as a teacher at night, and also preached to the Christian Revelers, a body he founded to emphasise the joy of Christian service. As a new graduate in 1944, Fred led an approach to the Queensland Industrial Court, seeking better conditions for first-year medical graduates in public hospitals. The case was ably presented by him and “Mickey” Whyte, later Professor H M Whyte of the John Curtin School of Medical Research, Canberra. The Court awarded residents an increase in salary from £200 to £350 a year and a limit to their hours of work. Although this industrial action seemed scandalous to older doctors at the time, it is clear that every graduate of an Australian medical school since then owes a debt of gratitude to Fred. Fred moved to Sydney in 1946 to take over a medical practice in North Strathfield. The practice grew to become one of the busiest in Sydney’s western suburbs. As an extension of his strong Christian beliefs, Fred developed a deep concern about the atheistic values and ambitions of the communist states. In 1955, he closed his medical practice and moved to the United States to work full-time for the Christian Anti-Communism Crusade, an organisation he had established in Iowa in 1953 (at the request of evangelist Billy Graham) to spread information about the nature, aims and methods of communism. He conducted lectures, seminars and debates, and wrote a book, You can trust a communist (to be a communist), which sold over a million copies. He also published regular newsletters and conducted week-long anti-communism schools. He opposed communism not for political or economic reasons, but because of its attitude to God and man. Another of his books, Beating the unbeatable foe, is both an autobiography and the story of his crusade. Of special interest is a letter to him and his wife from Ronald Reagan, who said, “Fred, you’re to be commended for your tireless dedication in trying to ensure the protection of freedom and human rights”. In 1996, Fred returned to Sydney, moving a few years later to Camden. He died of cerebrovascular disease at the age of 96 years. Consistent with his contrarian wit, he attributed his longevity to his complete lack of exercise, his high-stress lifestyle and his high-fat, high-salt, high-sugar diet. He is survived by his wife Lillian and children John (a general practitioner), Rosemary (a psychiatrist) and David (an airline pilot).

Derek H Meyers

A skeleton alleged to be that of Johann Sebastian Bach (1685–1750) was exhumed from a graveyard in Leipzig, Germany, in 1894, but its authenticity is not established. In 1895, anatomist Wilhelm His concluded from his examination of the skeleton and reconstruction of the face that it most likely belonged to Bach. In 1949, surgeon Wolfgang Rosenthal noticed exostoses on the skeleton and on x-rays of 11 living organists and proposed a condition, Organistenkrankheit, which he interpreted as evidence that the skeleton was Bach’s. However, our critical assessment of the remains analysis raises doubts: the localisation of the grave was dubious, and the methods used by His to reconstruct the face are controversial. Also, our study of the pelvic x-rays of 12 living professional organists failed to find evidence for the existence of Organistenkrankheit. We believe it is unlikely that the skeleton is that of Bach; techniques such as DNA analysis might help resolve the question but, to date, church authorities have not approved their use on the skeleton.

Richard H C Zegers MD, PhD · Mario Maas MD, PhD · A (Ton) G Koopman PhD · George J R Maat MD, PhD

Women pay more than men for health insurance in the United States. Much, much more. This issue might be hard for Australians, covered by Medicare and community-rated private health insurance, to understand. Women’s health floods the media in New York City, and you can learn a lot from the information provided — newspaper articles, television programs and advertisements. Pharmaceutical companies are allowed to advertise drugs on television, hospitals advertise in the newspapers, and doctors advertise on the subway. Women are prominent in ads for antihistamines, antidepressants, analgesics and heartburn treatment. Even the ads for Viagra, Cialis and Levitra are filled with smiling, contented women. I regularly read the New York Times. (What else would a university academic read while living in New York City?) The Times has had several recent articles detailing the problems women have with health insurance. One of these articles1 suggests that women insured with individual policies from health insurance companies pay between 22% and 49% more than men for the same policy. The data come from the companies’ websites. You might think it’s because women get pregnant. Many US health insurance policies specifically exclude maternity care or charge a significant extra fee for it. But, even excluding maternity care, health insurance is more expensive for women. The insurance companies argue this is based on actuarial data. Women go to the doctor more than men; they take more medication and are more likely to have regular check-ups than men; they have illnesses caused by pregnancy (some policies cover complications of pregnancy but not pregnancy itself); and they go to doctors for regular reproductive care (contraception, Pap smears, mammography). A quote by Mr Bykerk, a former executive of Mutual of Omaha, starkly demonstrates the differences in the US and Australian approaches to health care and health insurance: “If maternity care is included as a benefit, it drives up rates for everybody, making the whole policy less affordable”.1 In Australia, in terms of health care, we are all in it together. In the US, the land of opportunity and free enterprise, you are on your own. However, the US is not monolithic. In some states (New York included) it is illegal to have sex-based individual health insurance premiums, and insurance obtained through an employer is not sex-based. We must be very careful in Australia not to mimic this very negative aspect of the US health care system. It turns out that the same type of actuarial arguments were used to justify race-based insurance premiums in the US many years ago. There are many effects of this insurance system. Today I learnt, much to my surprise, while watching one of my 500 channels of cable TV, that uninsured women cannot get mammographic screening for breast cancer unless they pay. I’m not sure why this aspect of the US health care system surprised me more than other features. Just because it’s in the public interest to reduce the risk of morbidity and mortality from breast cancer doesn’t mean that the public here thinks the government should pay for it. Most of the people I speak to have similar views: “You should be responsible for your own health care and make provision”, “Why should the government pay for you?”, and “I don’t want the government interfering in my health care”. This is from the people I deal with here — educated, urban, slightly left-leaning academic folk. I’m not sure what the rest must think. St Vincent’s is my local hospital. On the TV news I learnt that it offers free mammographic screening for women without insurance. Unfortunately, they do only 250 of these mammograms a year because someone has to pay and, despite fundraising, 250 is all they can afford. This project was started by an uninsured woman who had breast cancer diagnosed by mammography, for which she had to pay out of pocket. The perceptive among you will instantly be wondering how she paid for her treatment. Answer: she got married 3 weeks after diagnosis and was therefore covered by her husband’s group plan! This would not happen in Australia, although of course we have Medicare and the public hospital system available for those without insurance. A major strength of the Medicare and BreastScreen programs in Australia is the ability to pursue such public health screening activities. Indeed, this is one of the best features of the Australian health care system, and you might say it is the role of a civilised society to provide this. On the other hand, one of the strengths of the US health care system as it relates to women is its massive commitment to research, both publicly funded and privately funded, and the rapidity with which new treatments are introduced and paid for. Studies such as the Women’s Health Initiative trial of hormone replacement therapy2 could have been done nowhere else. Although the results were negative, they clarified a very important women’s health issue. The funding available for breast cancer research in the US is staggering by Australian standards. Speaking as one who has done research (though not on breast cancer) for 25 years, the feeling that there is never enough research funding is deeply ingrained in me. Here in the US, the best cancer treatments in the world are available and almost all are developed here — it’s just that they’re not available to everyone. Although there are many aspects of the US health care system that Australians would not wish to imitate, we can learn from the US about the importance of adequate research funding for women’s health. We need to find better ways of increasing both public and private money for this purpose. As for the cable TV, I must admit I have 500 channels in Melbourne as well. I am busier at home and can’t make comparisons, but we do seem to follow the US in our TV programming. In which case, I have seen the future and it is bleak.

Jeffrey D Zajac MB BS, FRACP, PhD

Friendly bosses, fair working conditions and positive specialty training prospects down under It is said that there is many a true word spoken in jest, and I’m beginning to understand why. In the United Kingdom, it is joked that once a doctor has worked in Australia, there is no turning back. The reasons may seem obvious — the famous relaxed Australian attitudes, escaping the stresses of the National Health Service (NHS), a temperate climate . . . but those are only the tip of the iceberg. I am now 10 months into my Australian adventure, and it is time to take stock of the differences between the two systems of medicine. Why is practising down under so attractive to us Poms? Back in August 2007, I was concluding my first year as a newly qualified doctor at a highly esteemed teaching hospital in Leeds in Yorkshire. Twelve months earlier, as a less sleep-deprived medical student, I had spent 2 months in Sydney on my medical elective at a central teaching hospital. The experience left a lasting impression, and as I stared blearily out of the window into the Yorkshire drizzle, I realised I was fated to return. Australia was to be my foreign sabbatical — a new medical experience separating my “foundation training” (intern and resident years). So here I am with my “year” rapidly running out, only to have applied for and successfully secured a further resident year at the same Sydney hospital. This will be accredited in the UK as the completion of my foundation training, which leaves me with a difficult decision. By January 2009, should I stay or should I go? The bread and butter of my resident job in Australia doesn’t differ much from what it would be in the UK. However, the terms and conditions are considerably different; paid overtime — an alien concept in the NHS that I find encourages better care and fosters goodwill within the workforce. This brings me to the effective use of time. I cannot begin to calculate how many hours in the UK are dedicated to the art (or is it skill?) of sexing up ultrasound requests or begging for computed tomography scans from radiologists who are desperately busy and whose services are overstretched. The system in Australia is more organised, with more staff and better access to resources. This cuts out the telephone histrionics and means that, in some hospitals, imaging can be performed and reported on the same day. Hierarchy comes into the equation as well. Consultants in the UK still resemble those in “Doctor in the House”, dressed in dark suits and followed by a quaking entourage of house officer, senior house officer and registrar. In Australia, the style is less formal but no less effective. I am on first-name terms with my boss, and am encouraged to seek advice, day or night. This is a refreshing change from the strict, intimidating chain of command back home. I cannot neglect to mention the impact on the morale of British junior doctors of the newly devised Modernising Medical Careers (MMC) scheme, and the fallout it has generated. MMC was heralded as the educationally sound way of training junior doctors and enabling them to secure training posts that would lead to consultancies. Major flaws in the Medical Training Application Service (MTAS — the area of MMC dedicated to the national appointment of junior doctors to specialised training) were uncovered last year. Criticism has focused on the system’s online technical problems, the marking and weighting of applications and the lack of training posts. Fear of unemployment is high, with government figures citing 32 000 applicants for 23 000 posts.1 The British media have been uncharacteristically sympathetic to the plight of doctors applying to the MTAS, playing on the public fear of hospitals devoid of doctors who have all emigrated to Australia as a result of a “shambolic” recruitment process. “Remedy”, an opposition group set up by doctors, reflected this fear by renaming MTAS “Moving To Australia Soon”. By May 2007, the MTAS was unceremoniously shelved after protests from the medical community, which provoked an independent inquiry. These are still unsettling times for junior doctors. It appears Australia prides itself on an open and systematic process for appointing junior doctors to training programs.2 However, there is a growing shortage of training positions as the numbers of Australian and foreign graduates increase. A similar situation may be faced in this country if the medical community does not learn from the UK’s mistakes. Australia must be wary of the blurring of political and professional agendas when it comes to allowing the government to instrumentalise the process by which junior doctors are trained. In February 2008, the British Home Office ended its tradition of allowing doctors from Australia and other Commonwealth countries to benefit from training in the NHS.3 This medical “iron curtain” has been drawn in response to the bottleneck of home-grown and foreign graduates competing for limited positions. I hope Australia won’t make the decision to follow Britain into the realms of curtailing training opportunities for foreign graduates. It breeds disillusionment and cuts short invaluable experience gained only by immersing oneself in a different medical system. Who knows what the future holds for me? At the moment I am more than happy working in Australia, with friendly bosses, fair working conditions and positive specialty training prospects.

Sarah C Armstrong MB ChB

Like most children, I had heroes, and the heroes I chose have in certain ways shaped my life. The first was fighter pilot Douglas Bader, who lost both legs in an aircraft crash but talked his way back into the Royal Air Force and became one of its most decorated pilots in World War II. I knew his life story by heart because, as a small child, I had polio and spent much of my childhood unable to walk, so I read instead. My second hero was cricketer Don Bradman. Being flat on my back in splints over a period of years, I spent a lot of time listening to the wireless and grew very fond of cricket. Bradman retired very shortly after I was born, so I never saw him play. What was important to me was that not only was Bradman the best, he was Australian. My other great hero just happened to be a woman, the scientist Marie Curie. But she was a hero not because she was a woman, wife and mother, but rather, because she triumphed over poverty and adversity to become one of the world’s greatest scientists. So, from quite early on, I was fiercely Australian, fascinated by the notion of research, determined that handicap was a challenge rather than an impediment, and very familiar with the inside of hospitals. And so I studied medicine at the University of Melbourne (Box 1). HospitalsMy residency at the Royal Melbourne Hospital (RMH) shaped the rest of my career. I worked at the RMH with some outstanding physicians, including Jock Frew, Ken Fairley, Tom Hurley and Margaret Henderson. But the most important influence was a term spent in the Clinical Research Unit affiliated with the Walter and Eliza Hall Institute of Medical Research and headed by Ian Mackay, who encouraged me to think about research. At this time (1968–1971), the RMH Residency (the living quarters for resident medical officers) was a lot of fun and the work ethic and sense of responsibility for patients extraordinarily strong. If you had a problem, you simply rang the Residency and a resident would come and help, whether he or she was on duty or not. None of us ever had enough sleep. Life outside work and study presumably went on (I do remember watching the landing on the moon), but those junior years were when I most enjoyed medicine. My membership exam for the Royal Australasian College of Physicians (RACP) was held in Adelaide. At the party afterwards, Jim Lawrence suggested that, as I was thinking of becoming a nephrologist, I spend a year at the Queen Elizabeth Hospital (QEH), where he was Head of the Renal Unit (Box 2). At the time, the QEH had the only renal unit in Adelaide, and we looked after all nephrology patients in South Australia and the Northern Territory, as well as Broken Hill in New South Wales. I have a vivid memory of a young man with post-obstructive polyuria who passed 50 L of urine daily (thought to be a world record!) and our efforts to keep him hydrated and in electrolyte balance. He made the sleepless nights worthwhile. Thanks to an RACP scholarship, I then spent a year in France at Hôpital Tenon from 1973 to 1974 (Box 3) working with Liliane Morel-Maroger, a renal immunopathologist. While there, I became enamoured of French language and culture, particularly cinema and opera — Placido Domingo was the tenor-in-residence at the Paris Opera that year. My stay in Paris was followed by a year in London at Guy’s Hospital (Box 4) with Stewart Cameron, again working in immunopathology. I took full advantage of the theatre, ballet and opera, Glyndebourne, the Chelsea Flower Show and the tennis at Wimbledon, and came back to Australia with great reluctance. By then, in the mid 70s, feeling I was well trained in renal medicine but less so in medical science, I decided to pursue a doctorate at the Howard Florey Institute (directly opposite the RMH), opting to work on blood pressure — particularly on mechanisms of adrenocorticotropic hormone (ACTH) hypertension in sheep. My PhD supervisor John Coghlan was a splendid mentor who encouraged me to become involved with the Australian Society for Medical Research. Eventually I became the Society’s first woman president. It was the beginning of a lifelong interest in research policy. A couple of years later, I was back at the RMH as an outpatient physician (with Ken Fairley) and nephrologist (with Priscilla Kincaid-Smith).1 The unit Priscilla had built from scratch was rightly regarded as a leading international centre, with a huge and very varied clinical load. I continued to do research at the Florey, while at the same time developing a rat model of ACTH hypertension at the hospital and, more importantly, beginning work on glucocorticoid hypertension in humans. Over the years, we were able to disprove the perceived wisdom that glucocorticoids raise blood pressure through salt and water retention and to show that the mechanism actually relates to nitric oxide deficiency and excess reactive oxygen species. This had major implications for the design of synthetic glucocorticoids for clinical practice. Further, we assembled evidence implicating glucocorticoid abnormalities in some forms of essential and renal hypertension, suggesting a broader role for steroids in raising blood pressure. This work was recognised by the Smith Kline & French Award of the International Society of Hypertension in 1984. I rarely found my gender to be a problem in medicine. My peers judged people on whether they were good doctors rather than other criteria, and I was lucky in that my own professional colleagues tended to be generous about giving women a go. One example stands out. When I was pregnant with my daughter Emma (now making movies in Hollywood), the Medical Officers Award did not contain any provision for maternity leave and so all I had was a couple of weeks of annual leave. This was balanced by the fact that my male colleagues at the RMH Renal Unit were all very supportive, both during and after my pregnancy. When I returned as a new mother, they took turns, over a period of 6 months or more, to do all my night and weekend work. One highlight of these years was a short sabbatical at the Medical Research Council Blood Pressure Unit at the Western Infirmary in Glasgow. It was a highly productive few months that set up a number of lifelong friendships and collaborations. I did physiological studies on glucocorticoid effects in normal subjects (or more correctly, staff of the Unit). This involved putting in cannulae and starting infusions around midnight. I used to rug up against the Glasgow sleet and snow and follow the blood stains into Casualty, the rest of the place presumably being closed for security reasons. After putting in the drips, I would doze for a few hours on a trolley until the experiment proper began, around 4:00 am. The Scots were enormously hospitable and I managed to road-test a variety of single malts. The only downside was the rugby. Watching Scotland v Ireland in January at Murrayfield, with all the excitement of kicking for touch in the mud, made me wish I was back in sunny Australia watching Mark Ella. My view of the dismal game was shared by my host, who kept standing up and yelling futilely at both sides to “run the ball”. University of New South WalesIn 1991, I joined the University of NSW (UNSW) as Professor of Medicine at St George Hospital in Sydney. It turned out that I was the first woman to be appointed Head of a department of medicine in Australia. I started out thinking that the main task was to recruit good people, and finished by thinking it was almost the only task — if you get that right, other things follow. These were very enjoyable years in which we worked to promote a research culture in the hospital. One particular highlight was the establishment of a successful renal transplant program. At this time, again with strong support from my male colleagues at UNSW and St George Hospital, I became the first woman to chair the Medical Research Committee of the National Health and Medical Research Council (NHMRC). I enjoyed enormously the chance to help shape the nature and extent of the national research agenda and my first glimpses of how policies were formulated in practice. Funding for research was increased and the biomedical and public health efforts were reintegrated. We instituted a variety of changes to better match research funding schemes to the overall national research strategy. A particular highlight was the development of partnerships with other funding bodies, notably Juvenile Diabetes International and the Wellcome Trust. Australians gained about 20 years’ life expectancy in the course of the 20th century, and about half of that is estimated to be a consequence of research.2 Research is absolutely fundamental to health care and, in an ideal world, would be fundamental to health policy. Department of HealthWhile chairing the Medical Research Committee of the NHMRC (1994–1997), I spent a considerable amount of time in Canberra, and when I stepped down from that position I was approached about another role, as Commonwealth Chief Medical Officer (CMO). I became the first woman to be CMO. In the event, I very much enjoyed the job and enjoyed living in Canberra. The Australian Capital Territory combines all the advantages of city and bush life and is very different from the mythical location regularly featured in the media in the eastern states. Having signed the “Official Secrets Act”, I am not at liberty to reveal the really interesting bits about my time in the Department of Health, but I did learn very quickly to admire the professionalism and work ethic of the Australian Public Service. In all my jobs I have worked with smart people, and certainly doctors work hard, but the quality that sets a good bureaucrat apart is not just intelligence and hard work, but also excellent judgement. Certainly, in stark contrast to the perceived wisdom outside Canberra, the work ethic was strong and the workload immense. One morning early on in my term, the Department of Health Secretary, Andrew Podger, drove me to our Senate Estimates hearings. On the way I chatted about my plans for the afternoon. He seemed to think my afternoon would be spent in Estimates, so I showed him my program where it said “Senate Estimates 9–11”. He smiled slightly and explained that the finishing time was 11:00 pm, not am! The particular barrow I chose to push during my term as CMO was evidence-informed policy, a counterpoint for the bureaucratic interest in evidence-based medicine. The work was extremely varied. As CMO I had executive responsibility for two divisions (the Office of NHMRC and the Public Health Division) and for all medical professional matters. I was one of the three members of the Vos Committee, commissioned by the Treasurer to determine how the Goods and Services Tax (GST) would apply to health, education, religion and, surprisingly, used cars. I was later publicly reviled for determining that tampons were a sanitary product (thus attracting the GST), not a medical device, and people doing feminist studies still send me angry letters. I chaired a committee for Defence and Veterans’ Affairs on the health effects of the deseal/reseal program in F-111 aircraft, which meant climbing over one at the Royal Australian Air Force (RAAF) base at Amberley to see for myself and left me with a great respect for the RAAF. I chaired an interdepartmental committee on quarantine and another on biotechnology. A tangible outcome from the former was the blending of two forms (customs and immigration) into one, to the delight of many arriving travellers. We promoted a reform agenda at the World Health Assembly and contributed to major policy initiatives relating to the National Health Priorities, quality and safety, and medical research. The theme for me was promoting consistent use of research and evidence to assist policy development. The Pharmaceutical Benefits Advisory Committee had long been regarded as a world leader in the use of evidence for rational prescribing, and the Medical Services Advisory Committee was set up to introduce a similar evidence base into provision of medical services. However, it was less clear that the same rigour was being applied to developing new policies in other areas. Health policy questions are influenced by the political context, particularly health system financing, local culture, community values, and history and geography. Realistically, the best we can hope for is that policy is informed by research and evidence. Policymakers often look for evidence to justify policies developed on other grounds, rather than using evidence to develop policy. As one former state Chief Health Officer put it, “we want evidence-informed policy, but what politicians want is policy-informed evidence”. Some years ago, the satirical magazine Punch (now sadly extinct) ran a competition for the most misleading advice to foreigners. A number of entries, as you might expect, gave misleading advice on how to behave at the cricket, most of which unhappily has come to pass, but the winning entry said “Try the famous echo in the British Museum reading room”. Misleading advice has even more serious consequences in health care and health policy. An example is the advice to parents, from Dr Spock and others, to sleep babies on their stomachs, on the basis of zero evidence, when this in fact increased sudden infant death syndrome. Not all health policy development requires systematic review of the available evidence: for example, equity of access and universal health coverage are self-evidently desirable policies. The difficulty, of course, is that we all want access, quality and affordability. In practice, we can pick any two. John Curtin School of Medical Research (JCSMR)I was very ambivalent about leaving the Department of Health, having thoroughly enjoyed my time there, but, given my background and interests, the Directorship of JCSMR was an offer I could not refuse. It had an outstanding reputation for medical science. The old JCSMR building was very extensive. I spent my first week wandering around meeting people and then discovered I had entirely missed one wing. Armed with directions, I made my way into the previously undiscovered lab and held out my hand to a woman in a white coat, saying “Hello, Judith Whitworth”. “No”, she said, and went back to work. At my interview, I was clear that the School needed to join the national competitive grant scheme, to engage further with the Australian medical research community, to design and build contemporary laboratories, to re-engage with clinicians, and to attract a medical school to Canberra. Before I took up the job as JCSMR’s first female director, I was given a copy of Machiavelli’s The prince. His 15th century view may be politically incorrect, but it contains insights that are as true now as then. The one maxim that stood out for me was that, in trying to effect change, you will have lukewarm support, at best, from those who will benefit and vigorous opposition from those who will not. Another aphorism I took to heart was variously ascribed to Edith Cavell and Harry Truman: you can do anything as long as you don’t care who gets the credit. In the event, these things have come to pass and, more importantly, the School has continued to make cutting-edge and important discoveries. International HealthDuring my stint as CMO in the Department of Health, one of my tasks was to take the Australian delegation to the World Health Assembly in Geneva (Box 5). On the first occasion, I had only recently joined the Department of Health and was still very “wet behind the ears”. Happily, the team (from Health, AusAID and Foreign Affairs) were all highly skilled, and my main tasks were sitting behind the flag, making interventions from prepared briefs and eating and drinking for Australia. At one point in the debate, a question came up about quarantine. I was hazy on our position and so, in the best bureaucratic tradition, I tried to pass the buck, asking our people who was in charge of human quarantine. “You are!”, they said in unison. Weakly I asked what it meant and one junior officer helped me out, explaining that I had the power to close the borders but I couldn’t pat the sniffer dogs, because they belonged to another department. We used the vehicle of the annual Australian speech to the World Health Assembly to advocate for research on health practice and health policy. At that time, despite some very notable World Health Organization research successes, there was little evidence of a strong research culture within the organisation, or of a valuing of research by member states at the Assembly. Perhaps as a consequence of these interventions, I was invited to chair a consultation on the role of the WHO’s Advisory Committee on Health Research (ACHR) and then to join the Committee. I am now in my second term as Chair, the first woman and first Australian to hold that position. The role of the Committee is to provide the Director-General with advice in relation to research. The ACHR is committed to a leadership role for WHO in the use of evidence from research to inform decisions about prevention, practice or policy in health and to bridge the “know–do gap” (ie, turn knowledge into action). The research culture in the WHO has changed substantially in the past decade. Established programs such as TDR (Tropical Diseases Research) and HRP (the Human Reproduction Programme) continue to perform strongly, but strength has also been built in health systems research (Alliance for Health Policy and Systems Research). One very promising initiative is EVIPNet (the Evidence-Informed Policy Network), which seeks to promote the systematic use of health research evidence in policy making, focusing on low-and middle-income countries and promoting partnerships at country level between researchers, policymakers and civil society. Also in the present decade, WHO ethics and guidelines review committees have been instituted and a clinical trials registry established. A code of conduct for research is being developed. Most excitingly, WHO is developing a research strategy that looks both to position the organisation as a standard setter and to use its stewardship role and convening power to promote and foster research relevant to the needs of low- and middle-income countries. Currently, I also co-chair the WHO/International Society of Hypertension Liaison Committee. The 1999 guidelines on hypertension3 have been cited over 2000 times, and the 2003 statement updating those guidelines in key areas4 has been cited over 400 times. ConclusionMy life in medicine has been fortunate. I have moved from a focus on individual patients to populations and policy, and from medical research to research for health. Medicine has been good to me. And my philosophy: today’s research is tomorrow’s prevention, practice and policy. 1 Graduation, University of Melbourne, 1967 2 Queen Elizabeth Hospital Renal Unit, Adelaide, 1972 Back row (L–R): Graham Rowe, David Miller, Napier Thomson, Bim Biswas. Front row (L–R): Judith Whitworth, Jim Lawrence, Geoff Burfield. 3 Hôpital Tenon, Paris, 1973 4 Guy’s Hospital, London, 1975 5 Addressing the World Health Assembly, Geneva, 1998

Judith A Whitworth FTSE, DSc, MD, PhD, BS, FRACP

The 21 August 1937 issue of the Medical Journal of Australia contained two articles on a hitherto unknown disease affecting abattoir workers and farmers — Q fever (with the “Q” standing for query). The first of these was by Edward Holbrook Derrick, Director of the Laboratory of Microbiology and Pathology, Queensland Health Department, Brisbane, and comprised his meticulous clinical descriptions and subsequent experiments to isolate the causative organism.1 During his research, Derrick sought the help of Frank Macfarlane Burnet, and the second article by Burnet and Mavis Freeman from the Walter and Eliza Hall Institute of Medical Research in Melbourne described their identification of the causative agent.2 Research breakthroughs frequently involve scientific collaboration, and attributing credit for the results of such collaborations can be difficult. In the light of some new information about Derrick’s experiments, I believe that he may not have received sufficient credit for his contribution to the discovery of the organism responsible for Q fever. When the MJA articles were published, Q fever appeared to be a disease localised to a small area of south-eastern Queensland. However, within a decade or so, it was shown to be of worldwide significance. Edward Derrick’s laboratory notes rediscovered Edward Derrick in his laboratory in 1937 taking rectal temperatures of guinea pigs. The guinea pigs were housed in second-hand battery jars, with two to a jar. In January 1994, I was asked by Professor L W Powell, Director of the Queensland Institute of Medical Research, to examine some cardboard boxes containing books and papers packed by Derrick before he died in 1976, to see whether there was anything important that should be kept. The boxes contained out-of-date textbooks, letters, photographs, notes of experiments and other memorabilia. One small package wrapped in newspaper contained an old exercise book cover, 13.2 × 21.2 cm, in which there were seven files of brown paper. Each file was stapled with a split-staple in the top left-hand corner, and on the top right-hand corner they were labelled Q1 to Q7 and they were in numerical order. Further examination of these notes revealed that they were laboratory notes comprising case histories and the results of guinea pig experiments. Correlation with Derrick’s MJA article of 1937 revealed that they were the laboratory notes relating to seven of the nine patients on which the article was based, and it was apparent that these notes had not been read by previous biographers. (A more detailed account of my findings, together with more than 300 digital images of the original documents, has been lodged in the Library of the Queensland Institute of Medical Research, and the Herston Medical Library, Brisbane.) Who was Edward Derrick?When Derrick was appointed to the position of Director of the Queensland Health Department Laboratory of Microbiology and Pathology in Brisbane in mid 1935, his previous experience included a year at the Walter and Eliza Hall Institute of Medical Research in Melbourne as a cancer research scholar in 1921 and a year as a pathology assistant at London Hospital in 1923. In the intervening period, he had survived a bout of tuberculosis and worked mostly as a country general practitioner in Australia. The laboratory he was in charge of was primitive even by standards of the time. It had a small staff of four, none of whom had tertiary qualifications. However, as Box 1 shows, Derrick’s appointment as Director of this laboratory was the beginning of a long and distinguished career as a research scientist and administrator. It was only a month after his appointment that Derrick was asked to investigate the cause of an obscure fever affecting meatworkers in a Brisbane abattoir processing dairy cattle (workers at a nearby abattoir processing steers for the international market had not been affected). He immediately set to work questioning the clinicians who had been treating the patients. Edward Derrick’s Q fever investigationsThe patients Derrick described in his MJA article presented between September 1935 and November 1936. Five were abattoir workers, another two were dairy farmers, and another worked in sewage construction. By examining the patients almost daily, and visiting some of them at their place of work, Derrick was able to make meticulous descriptions of their illnesses. He began by excluding other known causes of fever common in coastal Queensland. His working hypothesis was that it was likely to be a rickettsial infection, although it differed from the known rickettsias in that the patients did not have a skin rash or a positive Weil–Felix reaction. To isolate the causative organism, he began inoculating guinea pigs with patients’ acute-phase blood and urine samples with the aplomb of an experienced researcher. The inoculated guinea pigs became febrile and developed enlarged spleens, and he recorded their febrile response. His studies were done during the Depression, which explains Derrick’s use of second-hand battery jars (the casing of early batteries), and his method of recording his laboratory results on the cheapest paper available. Some extracts from the laboratory notes I discovered are described and illustrated in Box 2. He transmitted the infection serially in guinea pigs, investigated its properties in relation to heat, cold, and filterability, and studied the effect of dilution on its potency. He showed, by challenge and cross challenge, that the “strains” isolated from different patients were the same. This led to the development of a diagnostic test, albeit a cumbersome one, based on guinea pig immunity. Derrick also tried to identify the source of the infection and the manner of its transmission to patients. He visited Patient 3, a dairy farmer, at his farm where he looked for ticks or sick animals. He inoculated milk and cream (both raw and diluted) from the dairy into guinea pigs (they died from sepsis, but did not develop fever). He thought the infection might be transmitted by a biting vector, because he could only transmit it from one guinea pig to another by injection of infected liver and spleen. He attempted to infect other laboratory animals, mice and a few rabbits, without success, and rats with limited success. Overall, the results were compatible with Derrick’s hypothesis that a rickettsia-like organism, rather that a virus, was responsible for Q fever. Collaboration with Frank Macfarlane BurnetAt this stage, Derrick sent material from his patients and his guinea pig experiments to Frank Macfarlane Burnet at the Walter and Eliza Hall Institute of Medical Research in Melbourne. Burnet was one of the most prominent medical researchers in Australia at that time, and he already had an international reputation. Derrick was an unknown researcher working in an obscure peripheral laboratory, and he needed assistance from someone with an up-to-date, well staffed laboratory who had scientific support in the international arena. At a follow-up of Patient 5 on 17 September 1936, Derrick took a blood sample and sent half the serum to Burnet. Burnet’s laboratory notes (courtesy of Mr Gavan McCarthy, Director, Australian Science and Technology Heritage Centre, University of Melbourne) on 1 October 1936 read “abattoirs fever apparently successful early passage but now appears to have been lost”.3 On 5 October 1936, Derrick sent serum from Patient 7 to Burnet, and on 12 October he sent spleen and kidney from guinea pig D6 (Patient 7). Burnet’s laboratory notes on 30 November 1936 read “Abattoirs fever. Virus grown consistently. No spirochaetes or rickettsia seen”. After studying Derrick’s notes and drawings (see Box 2), I have wondered whether this comment could be interpreted as the report of a “consultant” to a “referring doctor” who has asked, “Could you please examine this material. I think that it contains a living organism. I have looked for many organisms, but I think it is likely to be a rickettsia”. (I could not find any correspondence that might shed light on this speculation either in Derrick’s or in Burnet’s papers that refer to this period of time.) On 1 January 1937 after further testing on D6 material, Burnet recorded, “Abattoirs fever: positive transmission to rats and mice. Enlargement of liver and spleen. In a rather variable proportion of mice numerous rickettsia seen. Sub inoculation to guinea pigs gives typical fever with immunity. Rickettsia seen.” In later communications, Burnet said that on this day he was confident that he had positively identified the organism causing Q fever. Interestingly, Burnet sent samples of D6 material to Rolla Dyer, head of the Rickettsia section at the National Institutes of Health in Washington, DC,4 and it was this strain that made it possible to show that it was identical to the organism that Herald Cox from Rocky Mountain Laboratory, Montana, USA, had isolated from ticks. Box 3 gives a summary of the current understanding of Q fever. A self-effacing scientistWe may never know whether Derrick should have received more recognition for his part in the identification of a rickettsia-like organism as the cause of Q fever. We do know that Derrick was responsible for having the organism named Rickettsia burneti5 (later changed to Coxiella burnetii as a result of Herald Cox’s contribution), and it is interesting to speculate as to why he did not ask for his own name to be included. Derrick was known for his retiring and self-deprecating nature, so it is quite possible that he shrank from taking the credit. He also knew (or guessed) that he had to act quickly to get a name in print because the group from Montana was about to publish its results on the “Nine Mile agent” in ticks. Rather than entering an argument with the more forceful Burnet, he may have decided to name it after him so that the answer would be a quick “yes” to his suggestion. It is interesting that Q or Query fever still bears the name given to it by Derrick when he was investigating its cause, and strangely it is a disease that continues to puzzle researchers. However, there has been a proposal for a name change. A seminar presentation in French, published in 1951, argued strongly that Q fever should be renamed Derrick–Burnet fever,6 and a Google search reveals that the use of this name is not uncommon. I would support this name change. 1 Edward Holbrook Derrick, CBE, MB BS, MD (1898–1976) 1921–23: Sir John Grice cancer research scholar, Walter and Eliza Hall Institute of Medical Research, Melbourne. Pathology assistant, London Hospital 1924: Contracted tuberculosis and, abandoning plans to become a medical missionary, returned to Australia to fight the disease (his brother had died of TB), hoping the climate would be curative 1925–34: Locum general practitioner, mostly in small country towns in the eastern states of Australia. With his health restored, he began private practice in Brisbane in 1934 1935–46: Director of the Laboratory of Microbiology and Pathology, Queensland Health Department, Brisbane. Conducted the first research on Q fever, collaborating with Frank Macfarlane Burnet to identify the causative organism. Studied other infectious diseases in Queensland, being the first to isolate Leptospira pomona. Suggested the establishment of a research institute to focus on Queensland diseases, and chaired an advisory committee that set up the Queensland Institute of Medical Research (QIMR) 1947–66: Deputy Director, QIMR, and in 1961 became Director. Continued investigations of leptospirosis and scrub typhus, and set up a virology unit. Conducted studies on asthma incidence 1966–73: Director of the Queensland Asthma Foundation’s Research Bureau Awards include: CBE; the Commonwealth Department of Health’s Cilento Medal (shared with Burnet); Britannica Australia Award for Medicine; Medal of the Australian and New Zealand Association for the Advancement of Science; Honorary Doctorate of Science (University of Queensland) Publications: Almost half of his 128 scientific publications were published in the Medical Journal of Australia, which also published a Festschrift issue in his honour in 1967 Source: Doherty RL. Derrick, Edward Holbrook. Australian dictionary of biography. Vol 13. Melbourne: Melbourne University Press: 620-621. 2 What Edward Derrick’s laboratory notes revealed 3 Q fever Q fever is a zoonosis, the causative organism Coxiella burnetii occurring worldwide (except in New Zealand) in mammals, birds and ticks. C. burnetii is an obligate intracellular organism, first classified as a rickettsia. Recent studies and genome sequencing suggest that it is a γ-Proteobacteria, order Legionellales, but with characteristics in common with bacteria in the genus Rickettsia. Q fever infection in humans may be asymptomatic; or it may cause an acute illness (usually a flu-like illness, pneumonia, or hepatitis), or a potentially fatal chronic illness (predominantly endocarditis). C. burnetii is disseminated mostly as aerosols or fomites from animals, particularly parturient animals. It is highly infectious, affecting abattoir workers and farmers, as well as researchers and laboratory technicians. Australia is the only country with a Q fever vaccine. C. burnetii also forms spores (0.2 × 0.5 μm) that resist heat and desiccation, and persist for long periods.

Robin A Cooke MD, FRCPA, FRCPath

In the early 1970s, the Burns Unit at the Royal Children’s Hospital in Melbourne was suddenly faced with the management of a number of children presenting with extensive full-thickness burn injuries. This prompted a renewal of interest in the use of fresh pigskin as a temporary cover for burn wounds. While early debridement and split skin autografts offer the best form of wound coverage, this approach is limited in massive burns by the lack of donor sites available to obtain split skin for grafting. The aim of temporary cover of burns sites with pigskin is to reduce excessive fluid loss, act as a barrier against burns wound sepsis, protect the wound from mechanical trauma, and help control pain. Plans to obtain pigskin were made with some degree of urgency. The State Research Farm at Werribee agreed to supply a pig to the hospital, on a weekly basis, for harvesting of a large split skin graft taken from one side of its body. This would be performed under anaesthesia by a member of the surgical staff. We were also informed that these were valuable “pathogen free” pigs and were to be returned alive and intact (minus, of course, the split skin from their side) to the research farm after the procedure. All that was needed to complete the plan was an anaesthetist. I was selected for the task not on the basis of any experience, skill or knowledge, but primarily because of my junior status within the Department of Anaesthesia. In addition, it seemed that all the other members of the Department had suddenly developed an intense interest in vegetarianism, animal rights, Judaism or any other cause they could find that would preclude them being selected. Having no knowledge of pig anaesthesia, I consulted what literature I could find on the subject and gleaned the following: Pigs can never be considered fully fasted for anaesthesia. They always have a potentially “full stomach”, with its attendant risk of vomiting and aspiration under anaesthesia. If fasted in an enclosure, they will eat their faeces if hungry. After all, they are pigs. Pigs have excellent veins in their ears, suitable for cannulation and intravenous induction of anaesthesia. A clear airway may be difficult to maintain in a pig. Manoeuvres such as chin-lift and jaw-thrust are problematic, and endotracheal intubation is made difficult by the airway taking an acute, almost 90° turn just beyond the vocal cords. There was limited information on how pigs react to anaesthetic agents commonly used in humans. Two points were of concern: Pigs are susceptible to malignant hyperthermia, not only in association with anaesthetic agents but even with significant exercise and stress. Landrace pigs are particularly susceptible to stress, and risk becoming “roast pork” if sufficiently stressed. Pigs are much more sensitive than humans to non-depolarising muscle-relaxant drugs. These drugs need to be titrated carefully to avoid the need for prolonged positive-pressure ventilation. Armed with this knowledge, I prepared an anaesthetic machine, some intravenous equipment, drugs, masks and intubating equipment in the animal laboratory operating room. This room was on the first floor at the rear of the hospital and it was here, on the first morning, that I nervously awaited the arrival of the attendants with my first “patient’’. When they failed to arrive in the operating room and I was called to go to the goods delivery laneway at the back of the hospital, it suddenly became apparent to me that my role was to be larger than I had anticipated. In the laneway was a panel van and beside it were the driver and his assistant, both anxious to get my signature for the delivery of a pig. I peered into the back of the panel van and was confronted by my first view of my patient — a snorting, smelly, very grubby pig with an excess of oral and nasal secretions and weighing about 100 kg. His aggressive stance and demeanour indicated clearly that there would be no cooperation with any medical procedure. My approach to pig anaesthesia required a hurried revision. There was no way this pig was going to proffer me one of his ears, with its excellent veins, and allow me to establish intravenous access and then administer drugs to render him more compliant. The only possibility was to somehow get the pig to turn round and present his buttocks to me at the open window at the back of the panel van. Sweet talking and cajoling failed, but shoving and prodding finally got the buttocks within range and I prepared for action. Using a stabbing motion, reserved for intramuscular injections into violent and uncooperative adults, I plunged a hypodermic needle deep into the nearest buttock and emptied my preloaded syringe of 1 g ketamine — hopefully into a gluteal muscle — before quickly moving to a safe distance away. The pig was angered by this assault, but the ketamine soon took effect and he fell on his side, adopting an air of sweet repose, although snoring loudly, indicating some degree of airway obstruction. Much haste was now required. Four able bodies, myself included, quickly lifted the unconscious pig out of the panel van and placed him on a sheet on the ground. He was then rapidly hosed down before being transferred to a clean sheet. By lifting the sheet at each corner, we carried our snoring pig hurriedly into the hospital. The noisy, obstructed, breathing pattern intensified as we ascended the stairs to the animal laboratory. Appalled at the thought of having to assist breathing en route with mouth-to-snout ventilation, we quickened our pace. I was greatly relieved to finally get the pig onto the operating table, where I was able to deliver 100% oxygen via a conical face mask, suction the nose and pharynx, and thus restore a clear airway. I deepened the anaesthesia by adding halothane to the oxygen delivered from the anaesthetic machine and then placed a large intravenous cannula into one of the pig’s superb ear veins. I then attempted to intubate the trachea. This proved very difficult, and after multiple attempts I finally succeeded by using a malleable wire and then passing a cuffed endotracheal tube over the wire. My greatest fear throughout the procedure was that the pig would develop malignant hyperthermia. The thought of my patient becoming roast pork kept me nervously vigilant. The skin harvesting went well, and after emergence from anaesthesia the pig was transferred, in a somewhat dazed state, uneventfully back into the panel van and home to Werribee. Flushed with success and now armed with a proven approach, we prepared for the next pig to arrive the following week. On its arrival in the back of the panel van, I was confronted with a new pig and a new problem relayed to me by the lone driver. En route to the hospital from Werribee and passing through Footscray, the driver’s assistant noted that the pig was trying to climb out of the open window at the back of the panel van. The van was stopped and the driver and his assistant attempted to push the now almost fully extruded pig back into the panel van. Unfortunately, the pig fell out onto the ground, injuring the leg of the assistant driver, and then escaped into suburban Footscray. The assistant was taken to a local hospital while the driver, with help from some local council workers, eventually got the pig back into the van and finally to my care. In response to this incident, the State Research Farm sternly warned us they would send no more pigs unless we sedated them before departure to ensure the health and safety of the driver, his assistant, the panel van and the pig. How best to sedate a pig for a journey across Melbourne in a panel van? Clinical pharmacology was in its infancy in the 1970s, and conclusions drawn from human studies and applied to animals were risky. What was needed was a drug that would calm the pig and take away its desire to escape but not sedate excessively. At that time there was much interest in the anaesthetic literature in the drug droperidol. Droperidol had been used to treat severe agitation in psychotic patients. It was said to produce marked tranquillisation and sedation, allay apprehension and provide a state of mental detachment and indifference while maintaining a state of reflex alertness. Just what we wanted in our pigs! However, there had been some disturbing reports of the drug causing a state likened to a “locked-in syndrome”, with marked inner turmoil experienced by the patient despite the external appearance of calm. There was no time for trials, and we reasoned that, if the pig did indeed feel locked in, this would make unruly behaviour even less likely. Droperidol was in fact given on only one occasion: 10 mg intramuscularly 30 minutes before departure to the hospital. The pig arrived calm and awake, even tranquil. We, however, remained apprehensive, being unsure what this pig was really thinking. We anaesthetised three pigs in total and the harvested skin was used as temporary skin cover to good effect. It was said that the children’s appetites improved, even to the extent that one child reportedly “would now eat almost anything”. This is, of course, purely anecdotal and I find it difficult to attribute this observation to the nature of the temporary skin cover used. Soon after these three successful anaesthetics, a Surgical Research Fellow arrived at the hospital keen to start a research project on oesophageal atresia, using piglets as an animal model. Unfortunately, being now regarded as the pig anaesthesia expert in the hospital, I once again found myself seconded to the animal laboratory to anaesthetise pigs. These, however, were piglets, weighing only about 8 kg each, and were much less of a challenge. In fact, it soon became almost a pleasure to anaesthetise these happy little piglets. They were small enough for me to carry to the operating theatre in my arms. If they squealed or struggled, which usually occurred only when I started to anaesthetise them, they would immediately become quiet if, with one hand, I held them upside down by their hind legs. Then with my other hand I would place the anaesthetic mask over their snout and anaesthesia induction would take place calmly. The induction was so calm and smooth I have at times been tempted to try this technique on uncooperative small children. As with adult pigs, intravenous cannula placement in the ears was easy and endotracheal intubation difficult. I anaesthetised 10 piglets in total, with only one untoward event: one piglet had a short episode of profound hypoxaemia and appeared to have a somewhat “cerebral” grunt for the first 24 hours after surgery, but then reverted to behaving in a normal piggy way. The research study on the piglets did not produce any breakthroughs in surgical practice, but did demonstrate that pericardium is probably not a suitable material to bridge the gap in the oesophagus when repairing oesophageal atresia. There was very little science in my pig anaesthesia experience either, except for one important observation that sadly remains little known even today. I discovered that when piglets were adequately anaesthetised (ie, did not respond to surgical stimulation), their curled tails became straight. I took it on myself to call this the “Mullins sign”, with the hope of making a name for myself in the paediatric porcine anaesthesia literature. But despite quite brazen self-promotion of this sign over the past 30 years, the Mullins sign has failed to receive due recognition. With the acceptance of this article for publication by the MJA, I can now say with a mixture of pride and humility that the Mullins sign is finally “in the literature”.

Geoffrey C Mullins MB BS, FANZCA

On the eve of the fourth anniversary of the Boxing Day Tsunami, I could not help but reflect on the moment that this catastrophic event reignited my childhood vocational passion in the exact location where it had originated — Matara, Sri Lanka. A sense of anguish grips my weary soul For as a young child, my vision seemed clear But in my youth, soured was my lofty goal To vanquish my poor sick brethren from fear Left my island home for a richer land Forgot the advice of a nun so stern Exams and selfish ambition to hand My heart grew heavy, my mind started to churn Then disaster on a scale unseen before Waves of destruction strike my island home Trying to save kindred from death so raw I was transformed by the human spirit shown Then I heard a familiar angelic sound Twas my nun asking, had I my purpose found?

Suran Fernando MB BS, PhD, FRACP

As a first-year doctor working in a hospital, I have been chastised many times by grimacing patients in pyjamas about how I “don’t know how it feels” or that I’m “just doing this to torture them”. The second accusation is close to the truth for patients who abuse the public hospital system to get free drugs, hot showers, clean sheets and nurses to harass. The first accusation, however, has recently been laid to rest. I now patrol the wards and intervene with impunity. I have been dealt the great trump card of suffering and have been blessed, you might say, with the get-out-of-jail-free card of sympathy. I have done what very few men have ever done. I have given birth! — albeit to a 4.0 × 2.5 mm piece of calcium salt. Early one morning, I awoke with a strange urge to urinate, but had difficulty doing so. It wasn’t that I couldn’t get anything out — it was more that it hurt to get it out. I kept starting and stopping and wondering what in Zeus’ name was going on. Although the problem plagued me all day, I decided that I didn’t need to consult a doctor. I would diagnose myself. I made a mental checklist of symptoms. Urgency? Check. Burning? Check. Difficulty initiating a stream? Check. I felt like a pharmaceutical ad. I thought I had a urinary tract infection. Unfortunately, as I didn’t talk to a doctor, no one reminded me that urinary tract infections are incredibly rare in men and usually indicate cancer or some other form of horrible co-disease. So my prescription was to drink a lot of water and “borrow” some antibiotics from the emergency department (ED). (This is why hospitals don’t trust doctors to handle and dispense medications and instead leave that up to the nurses.) That night, during my shift in the ED, my symptoms continued and I became well aquainted with the toilets. I had just finished with a patient and sent him home when I sat down and felt a horrible ache in my left lower back. It was as if a body builder had ploughed his hand into my side, grabbed my kidney and squeezed it like a fresh tomato. Sweat broke out across my forehead. I got up and went to the bathroom, hoping somehow that it would relieve the pain. Alas! . . . nothing. Staggering back to a chair, I flopped into it ungracefully and, putting on a brave face, told my supervisor I had a pain in the back. Feeding a doctor a symptom is a wonderful thing. It’s like feeding a trained circus dog a biscuit. The symptom immediately unlocked an automatic pathway in her brain and, like a good doctor, she quickly rattled through a series of classic screening questions: Have you ever had back problems? Have you had this pain before? How would you describe the pain? How would you score the pain out of 10, with 10 being the worst pain you can imagine and zero being no pain? On and on she went. I answered as best as I could, but that hand in my back was squeezing tighter and tighter and I could feel my stomach contemplating sending my dinner back to where it came from. At some point, my supervisor’s visual system interrupted her brain. She stopped asking questions and, with a quizzical look, observed: “You’re sweating”. I nodded. “I feel like I’m going to vomit”, I gurgled. Fortunately, a nurse walked past and instantly diagnosed me as sick. She took my arm, led me to a bed and handed me one of the large cups used in the ED for catching stomach contents. I had always despised these cups. They embody all that’s wrong with letting non-medical people have input into how a hospital is run. Some bean counter must have found them on sale after a milk bar went out of business. He must have thought himself very clever for scoring thousands of cups on the cheap. However, I’m sure they cost the hospital more than they save. The logo on the side taunts ill patients with “SLURP, SLURP!” in bubbly pink and blue lettering. Luckily, I knew to avoid making eye contact with the cup. Lying down calmed my stomach enough for the nurse to roll me over for a shot of an antiemetic. For a while, I felt a bit better and thought things might work out, but unfortunately, the pain wouldn’t let me relax. I was sure that the body builder squeezing my kidney had noted my recent drug use and injected some steroids into his own rear. A few minutes went by and the pain escalated from crushing to nuclear. I broke down and staggered to my feet to tell the nurse that I wanted to cross the line and become a patient. This was a poorly conceived plan. Standing up immediately pushed my stomach into reverse and I promptly filled the SLURP! cup. Luckily, the nurse saw this, and, holding a fresh cup, rushed over like a widow with a coaster trying to protect her antique furniture from a foaming beer bottle. During a long period of mind-numbing pain, the nurse probed me for the usual patient demographics and produced what is known in the biz as a “large-bore needle”. The questions were quick and in themselves painless. However, the needle was less so. She missed my giant forearm veins twice. I thought I had always been nice to that nurse, but looking back through the haze of pain, I really can’t remember which nurse it was. There are a few who simply hate all doctors. Or maybe she resented having to put that first needle in my butt. So, I guess I could have deserved it. Fantastically, on the third attempt to get a vein . . . success! and with it . . . sweet, sweet morphine. When frail, elderly ladies who subsist on toast and ginger ale come into the ED with broken hips, we give them 1 mg morphine at a time, and 5–8 mg turns them into giggling school girls. When an average-sized man comes in after a knife fight, we give him 2.5 mg morphine at a time, and after about 15 mg he has to be fished off the ceiling with a broom. During my stay in the ED, they gave me 5 mg morphine at a time and it took 10 doses to make me feel human again. Apparently, that body builder had built up a tolerance by injecting more than just steroids. After being pumped with 50 mg morphine plus various other analgesics and antiemetics, I was finally able to relax. As I failed to diagnose, I had a kidney stone. It was not a fun night for me waiting for that rock to work its way through my narrow plumbing. But, as I was a “VIP” (ie, doctor), I received a couple of perks. First, I was put up in the sexual assault room, which comes equipped with its own ensuite bathroom and total privacy. When I pushed the nurse call button, she showed up immediately with morphine in hand. Well, I passed the stone completely a couple of days later and, although the pain returned occasionally during that time, it was nothing like the first attack. Overall, it was quite an experience and I learned a few things. For instance, I learned that, contrary to common belief, kidney stones are much worse when they are higher up. I was still in a pleasant, early morning stupor when I heard the unmistakable “ping” in the toilet bowl. I shook my head and thought “that was too easy”. I had expected to be balled up on a cold, tiled floor, screaming for the afterlife, as I gave birth to my little rock monster. Furthermore, all that time staring up at a white ceiling in a morphine-induced stupor had got me thinking. It’s a rough gig being a hospital patient, and I wasn’t even offered the food. About 10% of all people who enter a hospital never come out. So, I was lucky . . . this time. But I have to enter that hospital multiple times a week. So the next time you’re in the hospital and some fresh-faced doctor is inflicting a little pain on you in the name of improving your health, just think, that doctor may be me . . . and I do know how you feel! I also live in constant fear that, at any time, another illegitimate child may some day return to reduce me to tears.

Keiran K Tuck MB BS(Hons)

Well chosen artworks in the doctor’s waiting room can be an unwritten prescription for peace “Your blood pressure is up today” is a not uncommon doctor-to-patient line. If it’s a one-off reading — and as long as it’s not dangerously high — a general practitioner will usually take into account that the patient is somewhat stressed just by being there. Well meaning as they may be, posters in the doctor’s waiting room with urgent calls for immunisation against some threatened pandemic can start the blood pressure rising. The notorious poster showing an aorta being squeezed of a white, fatty substance is enough to make us bring up the porridge we had that morning. Recently, while waiting for someone in a colonoscopy area, I had little choice but to read a poster on the many diseases of the colon. It was not consoling by any means and would be better suited in a medical student’s study. Being an artist, it might be thought that I’m a little biased about what should hang on walls, but I speak from experience too. It’s nearly 20 years since my father-in-law died in a hospice. A memory that has stuck with me over the years was the comfort I found in a Monet print in the corridor just outside his hospice room. It was a painting that the soul could enter into and, for a few moments, escape the heaviness of his impending departure. More or less, that’s the good a painting can do in a waiting room. The healing process can begin in the mind, and where better to start than before a patient even says hello to the doctor. Artworks on the waiting room walls, whether prints or originals, are places that we can walk into and feel becalmed. Better still are paintings of local places such as beaches that are likely to strike a chord and evoke happy memories. Having appropriate works of art on your walls is, in effect, an unwritten prescription for peace for those who enter your doors. Indeed, why not go the extra mile by printing up miniatures of the paintings (with the artist’s permission) and handing one to patients as they leave, or sending it with any correspondence? This will reinforce the pleasant experience of the waiting room, which might then spread among their peers. Your surgery is but a few well chosen works of art away from being a much more enjoyable place for patients and staff. The Bluff (Mike Barr) Dune path, Victor Harbor (Mike Barr)

Mike Barr

Round the red lamp. Arthur Conan Doyle. Robert J L Darby, editor. Chicago: Valancourt Books, 2007 (xxiv + 320 pp). ISBN 0 9792332 7 5. Certainly not in the 1890s, or at least, not with any sense of realism. Better known for his Sherlock Holmes series, Conan Doyle shocked Victorian England with his collection of short stories about medical matters, with its graphic descriptions of diseases and medical disasters, and a somewhat jaundiced view of his own medical profession. This was a view that did not sit well with the romanticised image of doctors at the time. From a modern physician’s perspective, this collection offers some intriguing insights: a wide range of physician and surgeon capabilities and personalities remain unchanged. Further, our view of our colleagues of 110 years ago may well be close to Conan Doyle’s. I found fascinating their knowledge, or lack thereof, of aetiology, diagnosis and management of diseases. Medicine practised day to day was notable, such as the preponderance of home visit-based practice, surgery as a spectator sport, and the lack of regulation or accountability (yes, quackery was even more widespread then than it is now!). The stories themselves vary quite a deal in subject, length and quality. The better of them draw complex characters (both doctors and patients), discuss difficult social and medical issues, and do not pull punches. Others are overly sentimental and simplistic, venturing back to the more traditional territory of medical fiction of that century. This patchiness would draw me to conclude this collection is more fascinating as a piece of medical history than as a work of great fiction. Yet there are some very entertaining stories that will resonate long after they are read, and may well cause a medical reader to reflect on what is the true role of the doctor. Who knows, I might start doing more home visits!

James A Best

As the Christmas holiday season approaches, many MJA readers may be feeling uncertain about the future. Will doctors be replaced by nurse practitioners, help lines and computers? Will we outlive our dwindling superannuation stashes? Will the Wallabies ever beat the All Blacks? In such times of uncertainty, humour can be a blessed refuge, which might explain the deluge of entries for this year’s Christmas Competition. Never before have we been forced to be so selective. Of course, the idea that you can clown around and still be a serious person is not new. If we all lived according to Nietzsche’s pronouncement that ... we should consider every day lost on which we have not danced at least once. And we should call every truth false which was not accompanied by at least one laugh we would probably have a lot more fun (as long as we ignored most of the other things he said). Some of this year’s entrants, such as Nair, who thinks the call for the medical profession to emulate the aviation industry might have gone too far (→ Flying and medicine: mutual lessons), and Young et al, who have put continuous positive airway pressure machines to a novel but thoroughly ridiculous use, obviously adhere to this philosophy (→ Blowin’ a blizzard in Brissie). Others, such as Kitzing and McCormack, remind us that too much frivolity where pressurised air is concerned can be dangerous (→ Pneumoperitoneum: a non-surgical cause), as can multi-tasking while tossing back festive fare (Buchholz and Rudan, “Foreign body inhalation: a nut in the tree”). As a research journal, we always look forward to your quirky studies, and this year’s entries did not disappoint. Bolland et al have failed to demonstrate a selection advantage to male-pattern baldness (who says medical journals don’t publish negative studies?) (→ Does degree of baldness influence vitamin D status?), and Barnett et al have demonstrated, with the aid of a multicoloured six-legged “spider”, that the odds of being discharged alive from a London hospital’s intensive care unit on the weekend are not good. (→ Hospitals are dangerous places) Uncertainty can also create opportunities for serious creative reflection. The devastation of the Boxing Day tsunami in his homeland caused Fernando to question whether he had fulfilled his true purpose in life (→ A sonnet to a doctor’s epiphany); Barr challenges the need for alarmist messages in doctors’ waiting rooms and suggests we replace them with carefully chosen artworks (→ The positive power of paintings); and Whitehall reflects on the extraordinary lengths he and his team went to in order to cushion the grief of a dead baby’s parents — and the miraculously unexpected outcome (→ No ticket for a corpse). Of course, situational humour is the bread and butter of the Christmas Competition. We enjoyed conjuring a mental image of Miller’s paediatric patient being restrained by a “bear” (→ Occasional assistance needed for general practice) and Tuck’s painful tale of self-diagnostic uncertainty (→ Kid stone: a tale of valour and writhing agony). The yearly ritual of the secret ballot revealed, however, that our favourite story by far was that of Geoffrey Mullins’ experience with porcine anaesthesia in a teaching hospital, which wins the written part of the competition (→ Pigs, burns and curly tails). We learned a great deal from this story, and are proud to be the first journal in the world to publish the Mullins sign, the use of which we hope will spare many piglets from awareness under anaesthesia. The winner in the image category is Neil Sharma, whose patient’s eye ultrasound demonstrated more than he bargained for (→ Baby in the eye?). It is Christmas after all and, Nietzsche aside, nobody can resist the appeal of a baby in a manger. Each winner will receive an Australian-themed hamper to enliven their Christmas celebrations. A final thought for troubled times: Uncertainty and mystery are energies of life. Don’t let them scare you unduly, for they keep boredom at bay and spark creativity. Robert I Fitzhenry If the pundits are correct, we can expect even more wonderful entries for next year’s competition. Now there’s something to look forward to! Dr Ruth Armstrong, MJA

Ruth Armstrong

The humanities offer tools for wise application of biomedical knowledge and promotion of humane medical care Writing in the New York Times, columnist David Brooks recently described a “distinct brand of social misfits” in “fields like law, medicine or politics, where a person’s identity is defined by career rank”.1 He fears that their childhoods may have been spent in domestic “achievatrons” that ensured their academic success but compromised their interpersonal skills. Brooks believes that American society produces a disproportionate number of people with a “rank-link imbalance”, which he described as “the social skills required to improve their social rank, but none of the social skills that lead to genuine bonding”. These people have opinions about everything and “treat their conversational partners the way the Nazis treated Poland. They crush initial resistance, and the onslaught of accumulated narcissism is finally too much to bear”.1 It is hard to know whether Australia has a disproportionate number of “misfits” in law, medicine or politics, but if this is the case, Brooks suggests that they are the people most likely to force their way to the top of their career ladder and make life miserable for the rest of us. One way of producing doctors (or lawyers or politicians) with a capacity for genuine bonding might be to broaden their education.2 However, physician and writer Rafael Campo argues that “no one has proven that injecting the humanities in any form into medical settings translates to more humane physicians or better cared-for patients”.3 Campo’s use of the word “injecting” is telling; it conveys a sense of the humanities as something foreign to medicine. To appreciate whether the humanities are indeed foreign to medicine, try to imagine a health care facility in which no ethical issues are explored, no lessons have been learnt from the past, no cultural awareness is displayed, no written words (other than technical communications) appear, and no books, films, television programs, plays or concerts are discussed by patients or staff. Imagine that there are no artworks, no music and no other aesthetically pleasing elements. Although some of our hospitals are admittedly run down, the products of the arts and humanities are nevertheless all around us. Two recent Australian examples illustrate why we need to draw on the humanities in health care. The first is the front cover of the 19 May 2008 issue of this Journal, which depicts the phrase “Sorry, the first step” spelt out in candles in front of Parliament House.4 Many doctors are indeed sorry that biomedical solutions to Indigenous health problems have been confounded by ignorance concerning Indigenous history and culture.5 Fortunately, the Indigenous Health Curriculum Framework prepared for the Committee of Deans of Australian Medical Schools gives priority to topics such as culture, self and diversity, Indigenous history and society, and models of health service delivery.6 All of these areas draw on knowledge and insights from the humanities. The arts also offer teaching resources that provide for better cultural understanding. Recent examples include the film Ten canoes, which imaginatively recreates the world of the Yolngu people; Kate Grenville’s novel The secret river, and Doris (Garimara) Pilkington’s book Follow the rabbit-proof fence and its subsequent film adaptation; and plays Murras, Coordah and The keepers, which explore the impact of government policies of forced removal. Such resources communicate and educate by being emotionally engaging. The second example relates to quality and safety in health care. Among the competencies outlined in the National Patient Safety Education Framework are communication skills, teamwork, leadership, honesty and respect.7 The intellectual foundations for these competencies lie in the medical humanities, in particular psychology, sociology, philosophy and ethics as applied to medical practice. Biomedicine puts at our disposal the tools for safe, effective health care; the humanities explore their wise application in practice. Certain educational approaches accommodate the humanities better than others.8 Problem-based learning and its variants engage students’ emotions by giving each patient a story. However, problem-based learning is easily subverted by ignoring or parodying the human, experiential features of clinical problems. Privileging biomedical subjects over the humanities quickly alerts students to what counts as knowledge.3 A good medical curriculum provides time and resources for emotional engagement, reflection, and independent, self-directed learning — qualities that characterise what is best about the study of the humanities.9 The human experience of illness is most powerfully conveyed to students by those who have first-hand knowledge. It can be supplemented by poems, novels and films that faithfully represent that experience: Iris, A beautiful mind and The sea inside (which explore dementia, schizophrenia and quadriplegia, respectively) are recent examples. The Medical Humanities website of New York University provides an extensive database of resources on literature, arts and medicine.10 In the United States, the Accreditation Council for Graduate Medical Education has identified compassionate patient care and professionalism among six required competencies for residents, which training programs must assess.11 It has been suggested that the humanities, and specifically bioethics, could contribute to resident education.12 However, it has been argued that time and effort would be better spent in humanising the US health care system itself.13 The humanities cannot make people behave well. The late John Eisenberg, Director of the Agency for Healthcare Research and Quality in the US, has shown that doctors respond to many different influences.14 Well intentioned educational interventions will not produce more humane doctors if their role models’ behaviour suggests that it is better to do well than to do good. Medical facilities are moral worlds15 in which humane behaviour is elicited by being treated humanely,16 both in medical schools and in clinical settings.17 The humanities provide insight into why people (including patients, doctors and politicians) behave as they do and have done in the past. Equipping students with such insight is a necessary but not a sufficient strategy in the never-ending battle with the rank-link misfits.

J Jill Gordon MPsychMed, PhD, FRACGP

Trachoma: a blinding scourge from the bronze age to the twenty-first century. Hugh R Taylor. Melbourne: Haddington Press, 2008 (282 pp). ISBN 978 09757695 9 1. Why would a substantial scholarly work devoted solely to trachoma be published in Australia? For two good reasons: firstly, trachoma, a disease of poverty and poor countries, is still found in Australia. Secondly, it is written by a world renowned trachoma expert, the University of Melbourne’s Professor Hugh Taylor. Taylor’s passion is evident in this comprehensive review of trachoma from antiquity to the present, a scientific work of great detail and scope. Copies and extracts of documents, photographs and images, both from the author’s own collection and from sometimes obscure sources, support the text. Many of the photos were taken by Professor Taylor during his extensive field studies in Africa, Mexico and Australia, as well as in his laboratory studies. To this extent, the book provides a record of Taylor’s many years in the field and in the laboratory, his work ranging from vaccine development to simple, practical but effective means of eliminating trachoma in children at risk. Taylor draws our attention to the fact that the establishment in the 19th century of many now-famous ophthalmic hospitals was due to the trachoma epidemic in Europe, and even in Australia. He describes how improved living conditions in Europe and much of Australia at the beginning of the 20th century led to the almost total disappearance of trachoma. There is a clear exposition of why trachoma still exists in some remote areas of Australia, offering evidence of control measures and, importantly, evidence for advocacy to policymakers so that they may make evidence-based decisions on the subject. This book is an invaluable reference work for medical researchers, providing an in-depth knowledge of the subject. For public health planners, sections on the prevalence and natural history of the disease, with proven interventions detailed, will be invaluable. Students will find that this work covers much of what they need to know about a disease all but eliminated, yet which still persists in pockets of disadvantaged areas around the world.

Jill E Keeffe

The anatomist. A true story of Gray’s anatomy. Bill Hayes. Melbourne: Scribe Publishing, 2008 (xix + 250 pp). ISBN 978 1 921215 89 6. This is a terrific read, even if the idea of slicing into a cadaver makes you queasy. Hayes is the author of two previous books, Sleep demons, an account of insomnia, and Five quarts, on blood. If The anatomist is anything to go by, then these earlier books are certainly worth reading (I’ve already ordered them). Hayes’ book on blood is particularly poignant, as his long-term partner was HIV-positive and died shortly before the present book was completed. To write The anatomist, Hayes undertook human dissection as an active observer in the medical school at the University of California in San Francisco. I got a bit lost with the student characters, but the anatomy side of things is vivid — I learned several tips even though I’ve been teaching the subject for over 30 years. The account of Gray’s life is sketchy, but that’s because so little is known of the man. He died, horribly, of smallpox, aged only 34 (or 36 — even his birth date is uncertain). Much more interesting is the very detailed picture of Henry Vandyke Carter, Gray’s impoverished yet gifted young colleague who did the illustrations for the book for a paltry one-off sum of 150 pounds (Gray received the same sum for every thousand copies sold — a deal that would eventually benefit four generations of his descendants). Hayes managed to unearth a huge cache of Carter’s letters and diaries. The artist was a sombre man, perhaps even clinically depressed at times, but typically Victorian in his attitudes and self-criticism. He rose above the grind of illustrating Gray’s anatomy and went on to a successful career as a doctor specialising in tropical diseases in India. Although I personally find his illustrations rather gloomy, they are still hugely informative. The book is extremely well researched and has an excellent bibliography.

James M Cummins

Death investigation and the coroner’s inquest. Ian Freckleton, David Ranson. Melbourne: Oxford University Press, 2006 (iix + 929 pp). ISBN 978 0 195507003. Death investigation and the coroner’s inquest is an impressive text written by two highly qualified and acknowledged experts in their respective fields. International in scope, the book manages to bridge the gap between legal and standard forensic pathology texts, providing significant information about coronial systems in Australasia, and how forensic practice and the law interact in this forum. The text is set out in a number of well constructed and easily accessed chapters. One useful and quite fascinating section that sets the scene for the rest of the text deals with the history of the coronial system in England, and subsequently in the colonies, with examples of inquests dealing with the Kelly Gang and the Eureka Stockade. Particularly useful information is provided on the similarities of and differences between coronial systems among the states of Australia and also those of nearby Pacific neighbours, including New Zealand, Papua New Guinea and Fiji. Death-scene investigation is tackled from a number of perspectives, with cross-jurisdictional comparisons of systems in Europe, North America, Asia and the Pacific providing a useful overview not readily available in other texts. The various roles of forensic practitioners in evaluating death scenes are succinctly outlined, with an analysis of not only the medical aspects of postmortem examinations, but also a review of the legal and cultural issues associated with body and tissue retention and handling. A review is provided of the variety of techniques that may be used to identify human remains, with a clear demonstration of how computer-assisted photofit images may improve upon original material. The discussion of international disaster victim identification is comprehensive and timely. Helpful advice is given for doctors who may be called to give expert evidence, and the analysis of the process of inquests is extremely useful. Finally, the review of the strengths and weaknesses of the coronial system, and its likely future, provides a suitable end for the text. This excellent and reasonably priced book certainly fills a niche in the market and will be of use to all lawyers and doctors who are involved in the coronial process.

Roger W Byard

For William Bronson, MD Sudden growling of a truck broke the stillness of Sunday morning, sent a flotilla of pigeons skyward over rooftops, air filled with their cooing. These were neighbourhoods that smelled of grapes trellised above front doors, where kids played stickball in the streets. We waited in the double-parked Caddie, Mother in the front seat, silently reading the paper, my brother and I playing Old Maid while Father walked up stone steps of homes guarded by concrete lions, black bag in hand. Seven days a week he worked, disregarding the biblical injunction, but Sunday afternoons, he was ours — leading us through halls of dinosaurs, by wildebeests in dioramas of the African veldt and trips to the Bronx Zoo — tigers brooding their captivity, the penguin house, and wild pony rides.

Richard A Bronson

Objective: To investigate the first reported cases of strongyloidiasis in the Solomon Islands, and to establish whether this disease poses a risk to personnel of the Regional Assistance Mission to Solomon Islands (RAMSI).Design, setting and participants: Retrospective review of the pathology database of the RAMSI Medical Facility in Honiara, Solomon Islands, for the period 1 July 2006 – 30 September 2007.Main outcome measures: Number and clinical features of confirmed cases of Strongyloides stercoralis infestation, as diagnosed by serological tests or faecal microscopy.Results: Fourteen confirmed cases of strongyloidiasis in previously healthy RAMSI participants were identified. Of 13 patients with notes available, symptoms documented at presentation included epigastric pain (10 patients), diarrhoea (7) and urticaria (4). Clinical disease in all patients responded to oral antihelminthic therapy (albendazole or ivermectin).Conclusions: Strongyloidiasis is endemic in the Solomon Islands and a risk for RAMSI personnel. Australian medical professionals should be aware of this potentially fatal and lifelong infestation, particularly the importance of an occupation history, appropriate diagnostic tests, effective treatment and adequate follow-up to document cure. We recommend implementation of a postdeployment screening program for strongyloidiasis.

David A Pattison MB BS · Richard Speare MB BS, PhD, FAFPHM

The following is an extract from a highly commended essay in the Dr Ross Ingram Memorial Essay Competition Ali had the arms of a fisherman, the legs of a sailor, for so long a time he lived from the riches of the sea. Working from sunrise to sunset on the turn of tides with hooks and lines and nets he made his living. Once he was a young man, now he is an old man, but his eyes shine bright when he talks about the sea and he caught with his hands, the fish that fed the islands. Ali Drummond is a young man when he talks about the sea. — Old men and the sea from the album Island way, by Seaman Dan, Karl Neuenfeldt and Kyana-Lili Neuenfeldt Pearson (2005) Left to right: Samantha Faulkner, Ali Drummond and Vicky Duff (Samantha’s mother) at the book launch of Life B’long Ali Drummond: a life in the Torres Strait. What began as a half-finished open letter to the Prime Minister about Aboriginal and Torres Strait Islander health and an attempt at my personal reflections ended with this story about my grandfather. I thought to myself, “Why go global and try to cover everything when you can go local and talk about something you know enough about to write convincingly and from the heart?”. The other plus is that it is a good news story — a success story. It is something that we can all use and learn from, one way or another. Therefore, the following words I present are a mere snapshot about the life of my grandfather, Ali Drummond. Who is Ali Drummond you ask? He is a 90-year-old Aboriginal man who was born on Thursday Island and lived there for most of his life. Yes, 90 years old, which is quite a feat, considering that most Aboriginal and Torres Strait Islander people have a life expectancy of about 17 years less than the non-Indigenous population. He has led a full and active life. He worked in the Torres Strait as a pearl shell diver both pre- and post-World War II. During World War II he worked with the Civilian Construction Corporation building dams, gun emplacements, forts and repairing roads. He witnessed the bombings by the Japanese on Horn Island. He then went on to cut cane by hand in Far North Queensland, and later returned to Thursday Island and worked on the wharfs. Life b’long Ali Drummond: a life in the Torres Strait, by Samantha Faulkner with Ali Drummond, is published by Aboriginal Studies Press and available for purchase at http://www.aiatsis.gov.au/aboriginal_studies_press/ find_a_book/biography__and__autobiography/ life_blong_ali_drummond and all good bookstores. (Canberra: ASP, 2007 [140pp, $24.95]. ISBN 978 0 85575 556 0.) My grandfather is an ordinary person, a quiet achiever. He was awarded the Civilian Service Medal 1939–1945, 1998 NAIDOC Sportsperson of the Year Award for his achievements in lawn bowls (at the age of 80 years), and a Senior Australian Achiever of the Year Award in 1999. These good stories are important to tell and share with our family and community. Stories of resilience and strength are important for us all to celebrate our continued survival.

Samantha Faulkner

Failure to atone. The true story of a jungle surgeon in Vietnam. Allen Hassan. Sacramento: Failure to Atone Press, 2006 (272 pp). ISBN 978 0 9776049 0 6. Dr Hassan’s background is remarkable. He was a United States Marine Sergeant who qualified in veterinary medicine before becoming a doctor and serving two terms as a civilian in Vietnam, later completing a degree in law. From this unique perspective he presents disturbing insights and images of the Vietnam War. His clinical volunteer work was in the battered province of Quang Tri in mid 1968, and the experience completely altered Hassan’s life. The core of the book is a harrowing episode — the massacre of 40 infants, all shot in the head, apparently by his own Marine Corps — and his efforts to get to the truth behind this tragedy. Several of the 774 doctors despatched by the American Medical Association’s Volunteer Physicians for Vietnam have contributed stories from their own tours of duty. Also acknowledged is the work of civilian teams from other countries, including Australia and New Zealand, and there is praise for the US medical corpsmen who, of necessity, undertook major clinical responsibilities. Surgical triumphs and disasters, atrocities on both sides and the despair of embittered servicemen are all recounted, but it is the bigger picture that haunts Hassan’s conscience: the courage and dignity of the Vietnamese people; the death and destruction wrought by futile bombardment of innocent civilians; the failure of aid programs to concentrate more on preventive medicine, public health and training; and guilt that his country is making the same mistakes in Iraq. The book is well bound, with an arresting full-colour dust jacket. Within, unfortunately, the photographs are mediocre and the text poorly edited, uneven and repetitious. Nevertheless, it should be read, not least for such accounts as the mutilated soldiers kept in Vietnam to avoid lowering morale back home, and sinister activities by the CIA. Scarcely believable, but sadly convincing.

Marshall Barr

Sleep disorders: a clinical textbook. Antonio Ambrogetti, Michael J Hensley, Leslie G Olson, editors. London: Quay Books, 2006 (xiii + 561 pp). ISBN 1 85642 237 2 The Australian sleep disorders community has contributed disproportionately to the world body of knowledge about the science and measurement of sleep, and the treatment of sleep disordered breathing, including non-respiratory aspects. Ambrogetti, Hensley, and Olson have produced a comprehensive yet very readable clinical textbook with significant contributions from many Australian authors, who also carry international reputations. At over 500 pages, in contrast to its daunting look, this book is eminently readable, aimed at anyone interested in sleep medicine. The first main component looks at the scientific knowledge of sleep, including neuroana-tomy and chronobiology, followed by the clinical application of sleep medicine, with a grounding in the basics of polysomnography. The second component is a tour through the clinical treatments of sleep disordered breathing, with interesting chapters on sleep disorders in children, medications, and ventilation. The book is very well set out, with numerous break-out boxes highlighting important messages, illustrations and case discussions. The chapters and topics are well marked and easily accessed, and there are appendices with explanations and resource materials. Interesting areas explored include sleep and other conditions such as pregnancy, and various common medications used for depression and anxiety. The development of sleep in children, and abnormalities, are well represented. Useful as a reference book or as an introduction for those interested in sleep medicine, this is a comprehensive, basic clinical textbook without the daunting content of commonly quoted reference books. It could easily be picked up by medical students and trainees in sleep medicine, and would sit well in a sleep clinic or laboratory, as a good example of the depth of Australian expertise in this area.

Peter Solin

Introduction to telemedicine. 2nd ed. Richard Wootton, John Craig, Victor Patterson, editors. London: Royal Society of Medicine Press, 2006 (xii + 206 pp). ISBN 1 85315 677 9. Telemedicine is a health service intervention involving the remote communication of information for clinical care. Now in its second edition, this revised text meets a growing need for a straightforward overview of telemedicine. Rather than presenting telemedicine as the application of a specific technology, the authors are explicit about the health service dimension, the types of services, and the building blocks required — indeed most useful for an audience of health care workers considering telemedicine. The structure of the first edition has been maintained. Each chapter comes from well known practitioners of the discipline, and the editors have done an excellent job of linking all the material within the text. Telemedicine set-ups for a range of clinical settings are well illustrated. The need for a practical problem-driven approach to implementing telemedicine is a common thread. In this respect, the book is balanced in its assessment of telemedicine. In keeping with the initial chapters (with detailed steps for designing a service and the barriers to implementation), readers would have been greatly assisted by a list of evaluation questions for each stage of implementation and the key questions for developing a mature, sustainable service. As the book itself acknowledges, the patchy diffusion of telemedicine is not well understood. Perhaps one area that could have been explored further is the sociotechnical dimension of information and communications interventions pertaining to the social and organisational issues which determine success. This is no criticism of the book but rather the discipline itself, which is still not mature enough to provide evidence about which particular models of telemedicine work in specific settings and why. Introduction to telemedicine does, however, do what it sets out to do. It is pragmatic and even-handed, and the reader comes away with an appreciation of the realities of integrating telemedicine with routine care.

Farah Magrabi