History and humanities

After abuse. Gita Mammen. Melbourne: ACER Press, 2006 (ix + 139 pp). ISBN 0 86431 405 1. I wish this book had been available when I went to work in a women’s health centre over 20 years ago. Then, I was taken aback to discover how often the experience of childhood sexual abuse underlay many patient presentations. Gita Mammen, a psychiatrist and psychotherapist with a wealth of experience, shares with us her calm, compassionate and elegant approach to working with adult survivors of abuse. Written mainly for primary care counsellors, it is also relevant for general practitioners and specialists. The book is clearly structured, providing an understanding of the social context of abuse and abuse-specific work. Mammen provides insight into the way survivors may present — very useful for the new practitioner and the practitioner who does not yet recognise those survivors among their patients. Her framework emphasises the need to develop a respectful partnership with the client or patient, and she gives careful advice on how to enable a therapeutic relationship. This includes the importance of understanding the dynamics of childhood trauma and how this shapes a person’s current life-coping skills. She outlines a holistic assessment process, best suited to those with long appointments, but still useful within a general practice context. Mammen provides enlightening vignettes to illustrate key points, demonstrating a skilful form of questioning both respectful and supportive of the patient. The book is well laid out and each chapter provides summary boxes of key points, which I found very handy. I would have liked a little more on dealing with patients with somatising disorders and the controversial borderline personality disorder, but I appreciate that this was beyond the parameters of the book. The discussion on memory was similarly tantalising and had me wishing for more. I liked the way Mammen included the focus on balance in regard to therapy and for workers. Her awareness of interpersonal dynamics and her sage advice on avoiding some resultant problems could have saved me from making some beginner’s mistakes 20 years ago. I will read this book again and again.

Lesley R Shorne

To the Editor: After the recent New South Wales parliamentary inquiry into Royal North Shore Hospital, one might ask whether the deliberations will deliver real change to the hospital system. An article in the Lancet draws attention to some adverse outcomes in London hospitals.1 One such case is reported from the evidence and conclusions of the Islington Coroners’ Court into the death of a man as a result of his outpatient management. The report states: The jurors have . . . taken into consideration the large number of patients attending Guy’s Hospital as casual patients, [and] are of the opinion that the skilled supervision is insufficient, and should be increased; but they . . . believe the deceased received all the care and attention which the present arrangement of the hospital affords. The report goes on to discuss the effect of the excessive numbers of patients each house surgeon is expected to manage daily. The writer is of the mind that “the reported cases are now so frequent that something will have to be done”. As for immediate solutions, the report suggests: The officers of hospitals will have to be a little more careful. The committees and governors of hospitals must not impose impracticable quantities of work on one man’s shoulders; they must take steps either to diminish the amount of casual out-patient work, or they must increase the number of competent and qualified persons. The article concludes that “there is another party in these questions who is not entirely free of blame — viz., the public”. The writer supports the public’s right to “express indignation at defective diagnosis and accommodation in hospitals” but implores the public to be more liberal with hospital funding. The conclusions are straight to the point: The committees of hospitals cannot multiply beds and qualified house-surgeons without funds, any more than one can make bricks without straw. And if the maimed and the diseased are not to be denied skilled advice and accommodation at hospitals, or are not to be passed from one hospital to another, the public must be far more liberal in its support of hospitals than it has been. This report was published in the Lancet on 20 August 1881. Has nothing changed?! The public has now relinquished its responsibility for running public hospitals to the state. I hope more permanent solutions to the problem will follow the recent inquiry! As the writer suggested in 1881, “something will have to be done”.

Catherine E Storey

Sick to death. Hedley Thomas. Sydney: Allen & Unwin, 2007 (ix + 427 pp). ISBN 978 1 74114 881 7. Typically, journalists write readable books; even journalism textbooks are easy to follow. So it is with Hedley Thomas’ story of Bundaberg Hospital’s saga with Dr Jayant Patel. The journalist credited with publicly exposing the discredited surgeon (and more importantly, the terrible deficiencies of the Queensland public health system) leads us on a trail of discovery, ineptitude, political chicanery and tragedy. The tragedy lies with the patients who put their trust in both their local hospital and Patel, then Director of Surgery, a trust that was shattered and will take a generation to repair. There is a terrible poignancy in the level of personal harm suffered and documented in the book. The ineptitude is staggering: from the local hospital administration up to the highest levels of Queensland Health. In retrospect, how easy it would have been to avoid much of the scandal by conducting a proper investigation into Patel rather than trying to cover up the truth. Instead, here is a tale which harmed almost everyone who came in contact with it. Thomas chronicles rather than analyses as he exposes how a thriving department of surgery was destroyed by an appalling administrative culture and turned into Patel’s fiefdom. Thomas is mostly, but not always, accurate. He relies a little too much on National Party gossip instead of checking facts. Gastroenterologists would no doubt be astonished to learn that they are the most qualified practitioners to perform oesophagectomies, Patel’s signature procedure. At the end of 427 pages, one has to reflect on whether there are any winners. Many Bundaberg patients are still waiting for compensation, surgical waiting lists are no better, and institutional reform of Queensland Health is still required. Burdensome legislation makes medical registration and quality assurance in Queensland inefficient and insidious. There were no political winners, except, perhaps, the incumbent state government. Plus ça change, plus c’est la même chose...

David Molloy

Charles Halliley Kellaway (1889–1952) was one of the first Australians to make a full-time career of medical research. He built his scientific reputation on studies of snake venoms and anaphylaxis. Under Kellaway’s directorship, the Walter and Eliza Hall Institute gained worldwide acclaim, and he played a critical role in its success between the world wars. His administrative and financial strategies in the era before the National Health and Medical Research Council (NHMRC) helped local medical research weather the Depression and gain a strong foothold by World War II.

Peter G Hobbins BA, BSc(Hons) · Kenneth D Winkel MB BS, PhD, FACTM

Christmas this year will be marked for us by the arrival of our first grandchild, so as a mother and obstetrician I am receiving a steady stream of questions from my daughter on pregnancy-related matters — not the least of which relate to the use of analgesia in labour. At her antenatal classes, the advice has been to draw up a birth plan: warm baths, movement, partner support, and later, possibly, reluctantly, epidural ... But if I do want an epidural, she asks, will it be available even at Christmas? Christmas is also the time for celebrating the birth of Christ — which led me to wonder about the obstetric details of this event. There is little precise information available to us. Luke 2:4-7, though the author was himself a physician, gives but a brief historical account: ... Joseph ... went up ... unto ... Bethlehem ... with Mary his espoused wife, being great with child ... while they were there, the days were accomplished that she should be delivered. And she brought forth her firstborn son, and wrapped him in swaddling clothes, and laid him in a manger ... (All Bible quotations given here are from the King James Version.) Although there was clearly a birth plan, this was heavenly and long-term, rather than a matter of maternal choices. Presumably the delivery was a spontaneous vaginal one, with a cephalic presentation and rapid labour — possibly initiated by the long donkey ride to Bethlehem. There would have been few facilities for intrapartum care in a stable, and, although angels were in evidence, we are not told of the presence of any human support other than Mary’s husband. The third stage of labour was probably uncomplicated — depictions in religious art always show the mother of Jesus as serene postpartum, with no hint of exhaustion or exsanguination. What can be said with certainty is that for the Madonna there was little in the way of pain relief in labour, and that this situation would continue for women in childbirth for nearly two thousand years. Not only was effective medication lacking, women also had to contend with the curse of Eve — a belief that the pain of labour was women’s lot following Eve’s succumbing to temptation and her subsequent banishment from the Garden of Eden. In Genesis 3:16, God declares sternly, “... in sorrow thou shalt bring forth children”. And so, for hundreds of years, women brought forth children with only the support of other women for relief from pain, and many men, particularly clergy, regarded pain in childbirth as evidence of God’s moving in mysterious ways that should not be questioned. The Nativity, by Petrus Christus, circa 1450. Fortunately, all this finally began to change in the middle of the 19th century, thanks largely to Queen Victoria and a remarkable medical practitioner named John Snow. Victoria, mother of nine, has often been depicted as disliking sex (“lie back and think of England!” is frequently attributed to her), but immediately after her marriage in February 1840 she wrote to her Uncle Leopold, King of the Belgians, that she was the “... happiest Being that ever existed”, and within days she conceived her first child, the Princess Royal, born in November that year.1 She was no wimp — despite “all the ennuies” of pregnancy, she worked until close to each birth — but she was not amused by the experience of labour.1 After her first delivery, she remonstrated with Leopold that “men never think ... what a hard task it is for us women to go through this very often”.1 Later, when her eldest daughter was herself married, Victoria wrote to her of the “heavy trials” and “cruel sufferings” that labour entailed,2,3 and commented that: ... the pride of giving life to an immortal soul is very fine ... but I own I cannot enter into that; I think much more of our being like a cow or a dog at such moments; when our poor nature becomes so very animal and unecstatic.2 Nevertheless, her letters show that she adored her “Angel” — her consort, Prince Albert — and was devoted to all her children.1 In London in 1847, Dr John Snow began to experiment with ether, which dentist William Morton had successfully demonstrated as an anaesthetic to an interested Boston audience the previous year.4 Born in 1813 to a poor Yorkshire family and apprenticed at age 14 to a surgeon, Snow later studied medicine at the Hunterian School of Medicine in London.5 He was a vegetarian, a teetotaller and, by his own admission, celibate all his life, devoting his energies entirely to his profession.6 Snow was one of the first to calculate appropriate dosages of ether; he devised his own apparatus for its administration and soon had “the busiest ether practice in London”.6 He was also interested in chloroform, introduced by James Simpson of Edinburgh in 1847 for obstetric and surgical anaesthesia, and he wrote about both drugs.7,8 Simpson, as well as taking a clinical interest in pain relief for childbirth, also confronted the Church’s objections, quoting from Genesis 2:21-22 the story of Eve’s creation from Adam’s rib: ... the Lord God caused a deep sleep to fall upon Adam ... and He took one of his ribs ... and the rib ... made he a woman. Thus, said Simpson to his opponents, did God condone the use of anaesthesia.9 Victoria and Albert initially expressed interest in chloroform for childbirth in 1848. However, the Royal physicians, Dr Charles Locock and Sir James Clark (a man described as “a walking medical calamity”), had grave concerns about the safety of the drug, so the birth in 1850 of Victoria’s seventh child, Prince Arthur, took place without anaesthesia.6 Over the next 3 years, Snow’s reputation as a safe anaesthetist grew, and, in early April 1853, with the arrival of another child imminent, Albert summoned him to Buckingham Palace for a private conversation. Three days later, the Queen commenced labour, and Snow was again called to the Palace. Subsequently he wrote: April 7, 1853 — Administered ... to the Queen in her confinement ... a little chloroform with each pain ... on a folded handkerchief .... Her Majesty expressed great relief from the application [and] appeared very cheerful and well, expressing herself much gratified with the effect ...6 The Queen indeed found chloroform “delightful beyond measure”, and the child, Prince Leopold, was born healthy. The editors of the Lancet, however, were not amused. “Intense astonishment ... has been excited throughout the profession by the rumour that her Majesty during her last labour was placed under the influence of chloroform, an agent which has unquestionably caused instantaneous death in a considerable number of cases”, they thundered.10 The British Medical Journal hit back at its rival, asserting that “when well controlled and supervised, the use of chloroform is safe”, and by the 1860s, using chloroform in both obstetrics and general surgery was standard practice.11 In 1857, at the birth of her last child, Princess Beatrice, the Queen again used chloroform, once more administered by Dr Snow. “Her Majesty is a model patient”, Snow declared, but very properly declined to comment further on his conduct of either case. The Royal approval much enhanced his professional reputation, and chloroform in childbirth became respectable, being referred to as anaesthesia à la reine. The notion of pain relief in labour was here to stay.12 Snow died in 1858, aged just 45, but left an enduring medical legacy not just confined to his contribution to anaesthesia. In 1854, he had investigated an outbreak of cholera in his London neighbourhood of Soho, becoming convinced — well before the germ theory of disease was accepted — that the source could be traced to water from a public pump in Broad Street. He persuaded a sceptical municipality to remove the pump’s handle — whereupon the epidemic abated. He thus made a significant contribution to epidemiology, as well as to the realisation that plagues and epidemics were not, in fact, the work of a wrathful God.6 Chloroform continued to be used in childbirth until the 1970s, joined by narcotics such as pethidine, nitrous oxide–oxygen mixtures, and other self-administered analgesics. Since the 1960s, increasingly sophisticated techniques of epidural analgesia have been developed.5,12 Currently, 90% of Australian women having their first child have some form of pharmacological pain relief in labour.13-15 However, with the growth since the 1980s of a movement critical of the medicalisation of childbirth, opinions on the acceptability of pain relief in labour have become polarised. Now, instead of the doctrine of the divine necessity of pain in labour, we have the view that experiencing pain is a woman’s right, and that accepting analgesia diminishes the experience of childbirth. “The easy availability of analgesia”, says one advocate of this viewpoint, “can reinforce the medical notion that women’s bodies are intrinsically defective”.16 Not so, respond some obstetric anaesthetists — epidurals are “the gold standard ... you can participate in the experience, you can push the baby out, and it takes the pain away”.17 Had it been possible, Queen Victoria would almost certainly have ordered one. So, what advice should I give my daughter? The same that I would give all women. There is no right or wrong way to have a baby, be it in a stable or a tertiary-level hospital — there is just the best way for you. Epidurals are effective and safe, and available even on Christmas Day. Be well informed, keep an open mind, make the decisions that seem right for you at the time, and do not be tempted to regret them later; the most important thing is a healthy baby and a healthy mother. We will welcome our Christmas arrival with joy.

Caroline M de Costa MPH, FRCOG, FRANZCOG

Satirical prints and drawings have been popular for centuries, and politicians and prominent people have been fair game for the barbed pen of the artist. The medical profession has come in for its share of satire, usually in relation to the treatment available and the fees charged In newspapers and periodicals, artistic expressions of political and social events are presented to us daily in various forms, from caricatures of prominent people to line drawings and thumbnail sketches that depict a particular situation. In 18th and 19th century London, such satirical prints were very much in vogue. Satire was the language of the day, and no level of society was spared. Prints were the only pictorial records of life at that time, and the print shops were extremely popular. They provided amusement, but also powerful social and political criticism. In those times, society, politics, and economics were changing rapidly, and scientific knowledge was emerging. Managerial and professional classes were rising in power and status. Tall poppies were there to be cut down, and the caricaturists were always willing to do this with their pens. The first publication in the United Kingdom of Punch, in 1841, and the British version of Vanity Fair, in 1868, saw the emergence of illustrated journalism. Medical treatment in the 18th and 19th centuriesIn the 18th and 19th centuries, medical treatment was harsh and violent, and the cartoonists treated it and its practitioners in the same way.1-5 The aetiology of diseases was unknown, and conditions such as fever, ague (malaria-like acute fever) and gout were personified as monsters or devils. The doctors were depicted as pompous pretenders to fashion, with their wigs, cocked hats and gold-headed canes (Box 1). Physicians prescribed medicines — many ineffective and unpalatable — including emetics, cathartics and clysters (enemas). Being ill was bad enough, but being “physicked” could be even worse. Surgeons lanced, cut, bled and amputated, their skill being judged by their speed. Anaesthetic agents were non-existent until the mid 1800s, and the only relief would have been from opium or alcohol. Therefore, disease and doctors were to be feared. The standing of those practising medicine, in the eyes of the artists and the public, was not high, and disease and death were considered to be the doctor’s constant companions. The humour of the time was “black”. The misfortune of the patients and the attitude of the doctors were material for satire by the artists. William Hogarth (1697–1764) is regarded as the founder of the English form of satirical art. He was not a caricaturist, but is better described as a graphic satirist and moralist. His works are a perfect representation of life in London in the first half of the 18th century, and examples would be such works as The March to Finchley, Southwark Fair and Gin Lane (Box 2). After Hogarth, other British satirists who applied themselves to recording life and events were Thomas Rowlandson (1756–1827), James Gillray (1757–1815) and George Cruikshank (1792–1878), and the period in which they worked has been referred to as the “Golden Age of English caricature”. The social stratification at the time was reflected in the medical profession. The pecking order of those practising medicine would have been: The physicians with degrees from Oxford or Cambridge, who considered themselves to be learned men and above all others. The licentiates who had a qualification from some other university in England or abroad. The surgeons. The apothecaries. The quacks. However, success in the practice of medicine did not always depend on qualifications, but often on patronage and, in the case of the quacks, advertising. Hogarth’s work, A consultation of physicians or The company of undertakers (which he presents as a coat of arms), satirises the standing of the physicians (Box 3). It shows 12 members of the College of Physicians examining a flask of urine. In the escutcheon, he presents three famous quacks of the time, (“Chevalier”) John Taylor the oculist, Sally Mapp the bone setter and Joshua (“Spot”) Ward of “drop and pill” fame. In Hogarth’s opinion, there was little difference, if any, between them. Another Hogarth print, published in 1726, Cunicularii, or the wise men of Godliman in consultation, depicted the story of Mary Tofts. In 1725, Mary Tofts of Godalming had been reported in a Guildford newspaper as having given birth to rabbits, and the doctors believed it! The event even came to the attention of the king, who sent his anatomist–surgeon to investigate and report. Eventually, the situation was found to be a complete fraud, and Mary Tofts confessed. In the drawing, three “surgeons” are pilloried for their gullibility — Mr Howard, the midwife, who first reported the event; Nathaniel St Andre, the royal anatomist–surgeon; and Cyriacus Ahlers, a royal surgeon. It has been suggested that the accoucheur, labelled as the philosopher searching into the depths of things, was Sir Richard Manningham (Box 4). Jealousies and enmity existed among the strata of the medical profession — physicians, surgeons, apothecaries and quacks. These reached the press, and even the law courts, providing more material for the print shops, who would represent them as battles. The cartoon, Siege of Warwick Castle (1767), illustrates a fight between the licentiates and the Fellows of the College of Surgeons (Box 5). The licentiates had invaded the College after having been denied access to a College meeting and dinner at an establishment in Warwick Lane. The president is depicted as a skeleton and the weapons are urinals, clyster pipes and syringes, as well as canes and fists. The licentiates were finally dismissed with the aid of the College fire engine. The physicians also battled with the apothecaries over whether the latter could treat patients. Eventually, this was settled by the court, which found in favour of the apothecaries. All levels despised the quacks. Cruikshank satirised the board of examiners at Surgeons’ Hall in his drawing, The examination of a young surgeon (1811). A fierce-looking examiner asks the candidate to describe the organs of hearing. Of the motley collection of examiners around the table, two are deaf, others are bored or uninterested, another takes snuff, and a skinflint counts his money (Box 6). Patients then, as today, sought cures to their ailments and improvements to their wellbeing in clinics and health centres. Bath was a popular place for the gentry and wealthy to visit to bathe in the hot springs, and to take the air and the waters. There was also a very important social side to the Bath visit, which involved afternoon teas, dinners and balls. Doctors were in abundance and available for consultation. Rowlandson satirised the situation in his series, The comforts of Bath, published in 1798.6 One of the main figures in the series is an elderly obese gentleman with a gouty leg. Cartoons show him being examined by a group of doctors; attending the pump room in his Bath chair; and visiting the marketplace where he appears to critically examine a large fish as well as the lady assistant’s attributes. In another scene titled The gourmets, two gentlemen indulge themselves in the good food and drink that would suggest a contributory factor in the aetiology of their gouty legs and other medical conditions. Another satirical view of the Bath visit was the Bath races. Here, the decrepit visitors race down the slope below the Royal Crescent. Death was also in attendance, and in a couple of cartoons was shown driving a coach drawn by some of the visitors. Lecherous doctors did not escape the artist’s pen. A Rowlandson drawing, Medical dispatch or Doctor Doubledose killing two birds with one stone, shows a portly doctor taking the pulse of a dying crone and at the same time putting an arm around the shoulders of a nubile maid (Box 7). Innovations in medical treatment also provided material for the satirists. One of Gillray’s prints shows Jenner inoculating patients with cowpox exudate. As a consequence of the procedure, the patients have begun to sprout miniature animals from their arms and faces, etc. A drawing by Gillray titled Scientific researches! New discoveries in pneumatics! satirises the effects of air or nitrous oxide treatment in a lecture–demonstration. The subject’s trousers are blown off, while members of the audience show shock and disgust. Death was considered to be the doctor’s constant companion, and the skeleton was used as a symbol. One cartoon (artist unknown) illustrates a doctor carrying a bag of gold, with a skeleton riding on his back (Box 8). The doctor has pointed ears, which might suggest an association with the devil, and in the background, a funeral procession can be seen. Metallic tractors were invented by Elisha Perkins in 1795. These instruments were supposed to produce galvanic electricity and were available (at 5 guineas a set) to cure all conditions. A Gillray cartoon of 1801 shows them being used to treat a brandy-loving patient’s large inflamed nose, with resulting discomfort (Box 9). Boards of public health were established during the 1831–1832 outbreak of cholera in England; the Central Board was in London, and its members were employed on high salaries. (The present-day analogy would be “jobs for the boys”.) Although the board issued statistics, it had no effective measures to deal with the problem, and The Times stated that “Choleraphobia was profitable to the medical profession”. The members of the Central Board of Health were lampooned by the cartoonists, and in one drawing by Cruikshank, four distinguished members, indulging themselves with a sumptuous dinner, drink a toast: “May we preserve our health by bleeding the country” (Box 10). The relationship between contaminated drinking water and cholera had not been appreciated at that time. In London, 130 sewers emptied into the Thames near the site where the Southwark Water Company drew its drinking water. A cartoon by Cruikshank depicted John Edwards, the owner of the company, sitting on a buoy in the filthy Thames while people on the bank called for pure water. It was not until 1854 that John Snow confirmed that the cholera infection was related to the quality of the water. Later 19th centuryIn the latter half of the 19th century, the satire became more sedate and the humour more subtle, a change from the black humour of the earlier years. Because of the advances in medicine, violent treatment such as amputation and other painful procedures were no longer a target. Doctors and patients became the main subjects, the former because of their pretensions to upper-class status and the latter, their gullibility. The doctors’ attire changed to the top hat, morning coat and striped trousers. A cartoon in Punch shows the fashionable patient protesting at the medication prescribed (cod-liver oil) and the fashionable doctor’s solution to the problem (cream and curaçao). In another drawing, the specialist writes a prescription, which the patient can have filled or not — for it would make no difference.7 Diagnostic problems were illustrated, as shown by a few examples from Punch: The specialist physician searching for a diagnosis asks the patient, “What do you drink?” The reply, “Oh, Sir! — thank you Sir . . . I’ll leave it to you, Sir!” The beneficial effect of taking the patient’s temperature and the patient’s comment, “That done me a lot o’ good, Sir!” The doctor makes a diagnosis on the patient’s symptoms of “feeling wretched . . . no interest in anything, have no appetite, can’t sleep”, and his advice is “Why don’t you marry the girl?” Another cartoon (1882) shows an American physician and an English physician in discussion (Box 11). Modern timesBetween the 1940s and the 1990s, Giles in the British Daily Express used members of the “Giles family” to put a humorous aspect on events of the day, medical and otherwise. The foils were usually Grandma and sickly, snivelling Aunty Vera, who always had her handkerchief to her nose and carried her bottle of pills. In Australia in the 1970s, Larry Pickering drew a series of sketches on the activities of the medical profession,8 which included a doctor operating on his hobby antique car assisted by his son in the role of theatre sister, and another rather cynical set published in The Weekend Australian newspaper in 1979 lampooning doctors and their fees (Box 12). Handwriting and fees are perennial subjectsThe handwriting of doctors has always been criticised. A cartoon in Punch shows the annual pharmacists’ competition, in which they are adopting many bizarre positions in their attempts to interpret the writings of members of the British Medical Association. In the 1970s, the Australian cartoonist Larry Pickering produced a drawing on this subject in which a lady, leaving the pharmacy carrying a large purchased teddy-bear, complains to her companion that her doctor’s writing is not getting any better. Fees have been a subject for satire throughout the years. An 18th century drawing shows Dr Gallipot weighing the guinea (at the time a precaution against “light guineas”). Punch had its own examples, such as the specialist surgeon being asked by his colleague, “What did you operate on old Jones for?” “100 pounds.” “But what had he got?” “100 pounds”. Another cartoon, in the 1920s, shows the patient expressing surprise on receiving the bill: “Good Lord, doctor, have I been as near death as that?” Disease and doctors both fair targets for humourHumour and jokes have often been used as a way to deal with adversity, and satirical humour could be described as a form of benign aggression. Disease and death have been mankind’s greatest enemies. Anything that interferes with life and makes it uncomfortable (which could include the doctors and their medicines) falls into a similar category. Being physicked, 250 years ago, was unpleasant, and going to the surgeon a painful and horrible experience. Those unpleasantries have passed but are now replaced by other inconveniences and irritations, such as waiting times for appointments and operations, and complicated and invasive tests and the fees they generate, all of which can act as grist to the mill for the satirist. 1 A Going! A Going! Reproduced with permission of the Museum of the Royal Pharmaceutical Society of Great Britain. 2 Gin Lane Hogarth, 1751 (engraving). 3 A consultation of physicians or The company of undertakers Hogarth, 1736 (engraving). 4 Cunicularii, or the wise men of Godliman in consultation Hogarth, 1726 (engraving). 5 Siege of Warwick Castle Source: George MD. Hogarth to Cruikshank.1 6 The examination of a young surgeon From a print in the library of the Royal College of Surgeons of England. 7 Medical dispatch or Doctor Doubledose killing two birds with one stone Rowlandson, circa 1800. 8 The doctor’s constant companion Anon. From the Stephen Don Print Collection, Royal College of Obstetricians and Gynaecologists 9 Treatment by metallic tractors Gillray, 1801. From the Boston Medical Library. 10 “May we preserve our health” Cruikshank, 1832. From the Manfred Kraemer Collection, Harvard Medical School. 11 An American physician and an English physician in discussion “Now, in Vienna, they’re first-rate at diagnosis; but then, you see, they always make a point of confirming it by a post-mortem!” From Mr. Punch among the doctors.7 12 The Australian medical profession, by Larry Pickering From The Weekend Australian.8

H Reginald Magee FRCS, FRACS, FACS

We seldom identify the holiday season with medical matters, but perhaps we have been remiss in not doing so. Many holiday customs have medical significance — some positive, some negative. Christmas and the following 2 weeks host the highest cardiac and non-cardiac mortality of the major holidays,1 but few people seem to dread the approach of December as a threat to their physical health. On the positive side, some ancient kinds of Christmas gifts turn out to have modern medical applications, while, not so positively, some modern decorations cause a fair degree of morbidity. Here, solely to amuse and pique curiosity, not to provide an exhaustive review, we explore the pharmacology of the first Christmas gifts, as well as the potential benefits and hazards of some modern Christmas decorations. Ancient gifts that keep on giving today The first holiday custom we thought might have a medical application is the giving of Christmas gifts. This apparently originated with the arrival of the Magi, the three wise men, some time around the year 1 CE. Given the apostle Luke’s vocation as a physician, we felt it only fitting to use his biblical account of the three wise men bearing gifts to the baby Jesus. But, alas, his gospel includes no account of this exchange, so we were forced to quote Matthew, a tax collector: “Then they opened their treasure chests and gave him gifts of gold, frankincense and myrrh”.2 Interestingly, all three of these items have modern medical applications. Gold is the most obvious. As sulfhydryl-containing organic gold compounds, it has been used for rheumatoid arthritis and tuberculosis since the early 1920s, although elemental (metallic) gold was used for many centuries before. Elemental gold is largely inert, not reacting to any chemicals it encounters inside the body; however, it can be deposited in the soft tissue of the skin and eye, leading to a condition known as chrysiasis. Unfortunately, the gold deposits are actually an unappealing grey–blue, rather than the metallic gold glow that might be considered festive. Although the use of gold is not as common today as it was in previous years, exposure to modern therapeutic technology, such as the Q-switch laser, or even ultraviolet light, has resulted in chrysiasis many years after gold therapy was discontinued.3 Gold also causes its share of problems when combined with another holiday tradition: ethanol. Case reports indicate that Goldschlager, a liquor that contains gold flakes, has been associated with lichen planus.4 Although frequently having a lacy white pattern, known as Wickham’s striae, lichen planus too is unappealing, rather than festive. The next gift of the Magi, frankincense, has several medical uses. This substance is obtained from trees of the genus Boswellia, by slashing the tree trunk longitudinally and harvesting the liquid released after it has dried to “tears”.5 It has been valued greatly since ancient times, although its mechanism of action has only recently been discovered. Frankincense inhibits leukotriene synthesis via the inhibition of 5-lipoxygenase, but, interestingly, it does not block cyclo-oxygenase or 12-lipoxygenase.6 This mechanism is similar to that of the leukotriene-receptor antagonist, monteleukast, and indeed frankincense has been shown to prevent exacerbations of asthma much more efficiently than placebo in a small study.7 Frankincense also appears to be bacteriostatic and larvicidal, and may yet prove beneficial as an antimicrobial.8 Further, it seems to have activity against skin cancer as an escharotic agent and stimulates apoptosis in colon cancer cells.5 It has also shown some cytotoxic activity against meningioma.5 Finally, myrrh, a secretion of plants of the genus Commiphora,9 is proving to have its own set of medical benefits. It appears to have an analgesic effect through action on opioid receptors.9 It also seems to have antimicrobial activity, and has recently been touted as a highly effective treatment for schistosomiasis in Egypt.10 Myrrh extracts have shown antibacterial activity against common pathogens such as Escherichia coli, Pseudomonas aeruginosa and Staphylococcus aureus.11 On a more practical level, myrrh combined with bee propolis (a hive sealant used as an alternative to beeswax) and, paradoxically, honey has been used to treat wounds in patients with diabetes mellitus, with great success in limited trials.12 Another product of plants of the genus Commiphora, guggulipid, is purported to have a favourable effect on lipids — causing a modest decrease in low-density lipoprotein (LDL) cholesterol concentration, but a profound increase in high-density lipoprotein (HDL) cholesterol.13 However, randomised trials have failed to show this effect.14 Traditional decorationsMistletoe, a plant popular as a decoration around the Christmas holidays, is also finding a myriad of medicinal uses. This tree parasite, thought to have been sacred to the Druids, and blamed for the death of the Norse god Balder, is commonly used as an excuse for stealing a kiss during the Christmas season. But mistletoe does not, to our knowledge, have any aphrodisiac qualities. However, it has been found to inhibit peristalsis, and has been suggested as a treatment for colic.15 A mistletoe extract has shown antihypertensive effects in rats, although safety in humans has not been established.16 Mistletoe extracts also apparently have activity against bladder carcinoma in both mice and rats.17 In humans, mistletoe has been used to treat prostate cancer.18 Modern decorations or dealers of disease?The humble Christmas tree can be a source of disease, as well as providing pleasure. A young man in Molokai, Hawaii, contracted ophthalmomyiasis while unloading a Christmas tree.19 Perhaps the larvicidal effect of frankincense would have been of benefit to him in this situation (as it might be to a herd of reindeer — flying or otherwise — infested by botfly larva). As might be expected, children are not immune from the dangers of Christmas trees. A 2-year-old Canadian child with recurrent pneumonia eventually underwent a thoracotomy and right lower lobectomy for the disorder. The pathology examination revealed a 3 cm by 0.5 cm foreign body resembling the distal branch of an evergreen tree.20 Similarly, a 2-year-old Australian child apparently inhaled an ornament shaped like a Christmas tree, which caused asthma-like symptoms until it was removed laryngoscopically.21 Even artificial trees have been the source of disease. A 44-year-old English woman had a relapse of bird fancier’s lung a long time after she got rid of her fine, feathered friend.22 Apparently, her symptoms were triggered by an artificial Christmas tree that had been her bird’s favourite perch — protein deposits left on the branches were enough to cause the recurrence. Christmas trees have also been — unfairly — blamed for sporotrichosis. It seems that, although Christmas-tree farming has been associated with this disorder, it is actually the sphagnum moss used to wrap the roots of the trees, rather than the trees themselves, that are the culprit.23 Christmas trees are not the only unfairly maligned plant of the Christmas season. Perhaps the most notable medical feature of a common Christmas decorative plant — the poinsettia (Euphorbia pulcherrima) — is actually the lack of any adverse events associated with it. This festive red and green plant is used throughout the United States as both a Christmas gift and a holiday decoration, despite the widespread public notion that it is highly toxic. Recent investigations failed to show any fatalities — and indeed very few adverse events at all — associated with poinsettia ingestion.24 Likewise, that common Christmas plant, holly (Ilex aquifolium), is traditionally thought of as poisonous, but a PubMed search of this genus and species revealed no reports of ill effects associated with traditional European holly. That said, there were also no reports on the safety of European holly ingestion either, so it is probably a dish best avoided. Other members of this species have been shown to have toxic effects when ingested in tea form.25 So, as families and friends gather this Christmas holiday season, they can delight in the fact that most of the decorations in their homes are medically relevant. The traditional biblical gifts of gold, frankincense and myrrh are all doing their part to stamp out disease. The humble tree parasite, mistletoe, despite its toxic nature, has its place in the medical pharmacopoeia. Parents need not fear their toddlers drifting too close to the poinsettia, because the plants are pretty much harmless. On the other hand, they should keep an eye on that Christmas tree . . .

Stuart M Smith MD · B James McCallum MD, FACP

For over two decades, there has been savage conflict in Sri Lanka between a minority group of Tamils who claim traditional rights for land in the north-east and the majority, Sinhalese, government in Colombo. The conflict has consumed tens of thousands of lives, displaced hundreds of thousands, sown agricultural land with mines, laid waste plantations, and stunted a generation of children. It could be argued that the only rule of warfare is the respect each side has for the capacity of the other to terrorise: the desire for self-preservation has tended to restrict the number of civilians being bombed. Nevertheless, human rights organisations have reported over 4000 Tamil deaths in recent months. The conduct and cost of the conflict is obscured by suppression of the press on the government side and lack of access of the press to the other. The Ceasefire Agreement in 2002 between the leaders for Tamil autonomy, the Liberation Tigers of Tamil Eelam, and the government in Colombo, and the effects of the Asian tsunami in 2004 have combined to reduce hostilities and permit greater access to the north-east by foreigners. In this time of relative peace, I visited the region in January and again in May 2005, delivering antibiotics and then ventilators and surgical equipment to hospitals throughout the island, supplied through the generous response of North Queensland to the tsunami. Sri Lanka and southern India Driving north from Colombo to Jaffna, I was struck by the poverty on the Tamil side of the armed border, the lack of facilities in the hospital in Kilinochchi (the administrative centre of the “Tamil” land) and the dilapidation of the tertiary hospital in Jaffna. Only the crowds in the corridors and the patients on the floors obscured the filth on the walls and passageways. Nothing obscured the suffering of apparently half-dead people being carried on bare metal stretchers at perilous angles up and down the stairs, buffeted in the surge. I was struck by the whites of their fingers as they clung to the metal. Nothing prevented the recycling of dengue through unscreened windows from sullage that pooled from broken pipes alongside the wards. One piddling tap leaned vainly against cross-infection in the crowded children’s barn. Why was this hospital so different to the many I had visited in the Sinhalese areas? I later learned of economic sanctions and underfunding by Colombo. I volunteered to return to Sri Lanka in September 2005, originally to work as a paediatrician on the east coast, but diverted by my hosting organisation to work in Kilinochchi for a couple of weeks and teach “some students who had missed out because of the war”. I remembered the needs of Kilinochchi and was willing to comply. About three weeks later, I discovered that my students comprised the medical wing of the “terrorist” Tigers! I met them in a shed whose walls reached halfway to a roof of corrugated iron that creaked in the heat of the sun, then roared with the monsoon rains as the weeks extended to three months, and I swapped tales of sick children for tales of my students’ lives. We began awkwardly. As I entered, there was a sudden scraping of chairs on the concrete floor and then a silent standing to attention. I was further surprised by how many there were — 32 — and their being perhaps a decade older than I had expected. I introduced myself and asked them to sit. There was more scraping of chairs. Now they were sitting stiffly and silently. “Does anyone speak English?” I asked, and began to try to work out what they knew and what they needed. I had no idea I would grow to love them. A home visit by one of the medical students I realised they needed grounding in the old-fashioned approach of taking a history, examining methodically, and making provisional diagnoses and plans of management, though I soon sensed they had had profound experiences in triage and trauma. They had seen a lot of sick children but were thin on theory, so I decided to prolong my stay and start at the beginning. After about two weeks, we had worked our way to the examination of the respiratory system and it was then that I discovered how close my students had been to the acute end of medicine. I invited a man to remove his shirt and a woman to demonstrate her method of examination and was surprised by the divot out of the man’s shoulder. Asking him what had happened, I noticed a similar deformity in the woman’s forearm. Shrapnel and a bullet, they explained, and everyone began to laugh. “Well, who hasn’t been shot?” I asked, and, to my astonishment, only about a third raised their hands. “Didn’t you notice our wooden legs?” someone asked and, adding to my foolishness, three were waggled for my inspection, with the class now in uproar. Who are these people? I wondered, and began the journey of discovery. They comprised the medical wing of the Liberation Tigers of Tamil Eelam and were the remainder of an original group of over 70 who had been chosen from the ranks of the infantry because their commanders had concluded they had the potential to become doctors. The struggle for a Tamil homeland, Tamil Eelam, had entered a violent phase in the late 1980s, and the problem of casualties had originally been solved by taking them in small boats to sympathisers in nearby Tamil Nadu, in India. As the numbers increased and the political situation altered, they were taken to the hospital in Jaffna. But lives and limbs were lost in transportation through jungles or around the coast from distant front lines, and the need for the movement’s own medical wing became obvious. In time, I asked them all why they had joined the Tigers and learned of the deaths and torturing of family members, of schools bombed, of the bodies of neighbours washing ashore, of mobs rampaging against Tamils and of discrimination in education and language. Each one had a saga and each had joined the Tigers because “they spoke less and did more” to protect their race against what they were all convinced was genocide. They had all been trained as infantry, but none had forgotten the speech by their leader, who had asked them to forego fighting for the greater goal of healing their people. Paraphrasing a student’s stories of his experiences The course had started in 1992, with some students needing preparation in maths, chemistry and English because they had not finished high school. Others had graduated in biology from university. The course paralleled the curriculum at Jaffna University but had been interrupted by long periods of service in field hospitals, in public health campaigns against cholera and malaria, in the manning of general hospitals, and by the needs of the tsunami, which had wrecked the north-east coast. The Ceasefire Agreement of 2002 had allowed them to catch up on formal education, but they were lacking a module on paediatrics, when I turned up out of the blue. My 32 students were those who had stayed the course. Others had been unable to resist the call of the armed struggle, some had failed academically, and five had been killed on active duty. It was obvious they needed tuition that emphasised infectious diseases and malnutrition and it was easy to gather cases for presentation from my rounds in the ward and from outpatients. The days began with a lecture or two, then moved to cases, and included examination of the newborn and resuscitation. The poverty in the nursery was painful — mothers used old handkerchiefs for nappies. They had never performed any formal research and were keen to be divided into groups to review perinatal outcomes, nutrition, causes for acute admission, snake bites and emotional effects of the tsunami. We found mothers and children to be wasted and stunted, road accidents to reflect the dangerous driving through the town, snake bites to be handled well, and counselling to be effective for grief. The findings were presented on a special research day, which evolved into an emotional ceremony of graduation. Student treating civilian wounded by artillery fire As the weeks progressed, I learned more of their lives and could not rest until one began to translate short stories he had written about their experiences. We began to meet every night in a small gazebo, sometimes curtained with rain, and went over his stories, line by line, paraphrasing from Tamil and amplifying for a wider audience in English. My mind was fascinated by the stories of medicine, my emotions drawn by their humanity. I learned of the development of the medical wing from first aid to reconstructive surgery, encompassing the triage of mass casualties, blood transfusions on the front lines, and end-to-end anastomoses of arterial wounds with ketamine anaesthesia by torch light under artillery fire that thudded shrapnel into the coconut-trunk walls of their bunker. I learned of organisation and secrecy that could construct a hospital overnight in preparation for a battle in the morning . . . and of my students who had worked and worked until the casualties stopped coming — in their uniforms stiff with blood, on legs that could barely stand and under the sustained threat of sudden death. I could scarcely believe accounts reminiscent of the First World War, and insisted on interviewing all the students mentioned by name, others not mentioned, and particular patients, cross-checking the details. I went to battlefields to see if the layout was as described. It was. Though overgrown by jungle, the bunkers that had contained the operating theatres were still visible, confirmed by half-buried vials of empty medical containers. Mounds of dirt confirmed former protective walls, and abandoned paraphernalia confirmed the fighting. Bones and shredded uniforms confirmed casualties. Why they continued to fight still puzzled me, especially as I visited war cemeteries and pondered the carnage in which over 17 000 Tamil young people have died in the past two decades. Understanding began on the afternoon of 27 November, their equivalent of Anzac Day. My students collected me and, for the first time, I observed them in uniform, making their way through the cemetery, squatting here and there with parents of the dead who had begun to arrive in droves to festoon the graves with garlands and food for their young men and women who “were living on in the spirit of Tamil Eelam”. There were about 3000 graves and soon the cemetery was pulsating with grief. The burning sun sank beneath a row of palms and I anticipated some kind of communal eruption of emotion as candles were lit on the graves and flickered on distorted faces. But there was nothing. No hymns, no chants, no catharsis. Just a speech on the necessity for more sacrifice. Silently, the crowd shuffled away, leaving the garlands and the candles to the moonless night. I began to realise what some people are prepared to endure for freedom. I had a farewell meal with my students before I left and before they were dispersed to look after the population of their Tamil Eelam and the casualties of a war that has escalated. We made speeches, and they presented me with what was clearly a special gift: a Tiger flag (which caused anxiety clearing Customs on the way out). Students operating and giving anaesthesia Private possession of a Tiger flag, I am informed, is not “recklessly supporting a terrorist organisation”, but detectives from the counter-terrorism team of the Australian Federal Police were keen to explore why I stayed in Kilinochchi when I learned the identity of the students. I figured teaching doctors how to resuscitate children was in the interests of the people, whoever controlled them, but wondered if my career had reached a crossroads! Subsequently, I did not mind going over all our overseas phone calls with the police or explaining why my bank had sent money to England (for a course on radiation biology), but I was a bit unnerved by the attention I received from immigration officials when I recently left for New Guinea. Being profoundly Australian, I found it unsettling to be perceived as being on the “other side”! I hear, however, that the Department of Public Prosecutions is not proceeding with my case, which is good news. The bad news is that it is unlikely I will ever be able to return to Sri Lanka, and the needs of the north-east weigh heavily. Tamil friends assure me that publicity for the situation is the greatest help I could offer Sri Lanka. With that in mind, the collection of short stories I paraphrased will be published in the near future.

John S Whitehall FRACP

Before work — getting thereToday I realised that the aim of travelling to work is survival. I need to arrive at work fighting fit and raring to save lives. Most doctors drive to work — on their own, in a four-wheel drive, SUV or large European sedan of sufficient grandeur and engine capacity to illustrate their importance to the rest of humanity, while protecting themselves against the eventuality that they might accidentally run into any of the rest of humanity. Conservation issues like air pollution, noise pollution, consumption of fossil fuel resources, and pedestrian safety are matters of global concern, but apparently do not apply to small, important self-interest groups such as doctors. Once the children have left home, doctors may exchange the four-wheel drive for a two-seater convertible; it is never too late to have a happy adolescence. An advanced sense of political correctness had persuaded me to travel to work by public transport instead. Public transport is nature’s way of introducing you to your fellow human beings with a degree of intimacy normally reserved for other species — say, locusts, termites and wildebeests. Of course, the money I save by not running a car is picked from my pocket on a regular basis. Each journey is an olfactory kaleidoscope of cheap deodorant, pheromones, body odour, and garlic. After each rush-hour journey, I envy lemmings, who can at least look forward to an end to their travels. Today, my bank balance and waistline encouraged me to cycle to work. The purpose of cycling is to make you feel good about yourself and your lifestyle — you are an environmentally friendly urban crusader against pollution. The bonus is that the gridlock of modern city traffic means cycling to work actually saves time. I spent this time donning the protective headwear, luminous protective clothing and protective breathing apparatus that I need to survive cycling to work. The money I save by cycling to work will no doubt be spent on replacing stolen bicycle parts, and chiropractor’s bills. I have discovered that I should aim to arrive at work earlier than my colleagues, so I can glance pointedly at my watch as they arrive. If any of my colleagues consistently arrives before me, I will send them an anonymous note suggesting they get a life. Travelling to work is just part of the rich tapestry that comprises a working physician’s day. At work — the committee meetingI am learning through experience that the aim of a committee meeting is not to commit to anything. The aim of a board meeting is boredom. The seating arrangement at committee meetings appears to be a ritual rooted in deep tradition. You sit flanked by your friends and show them the defamatory cartoons you have drawn, and giggle conspiratorially. You sit opposite your sworn enemies, the subjects of your cartoons, and try to out-stare them. Any attempt to alter the seating arrangement is a Declaration of War. For committee meetings, an interest in conflict is much more important than a conflict of interest. I now know the two operating rules applicable to all committees on which I sit. Rule One is: “Never volunteer for anything”. Rule Two is: “Never become the Secretary”. The Secretary is the only member of a committee who ever does any work. It has become clear that I will never have time to read the meeting agenda in advance. However, I have decided to always bring an impressive manila folder, containing the agenda papers for the meeting later that afternoon, which I can try to read surreptitiously. If the meeting is long enough and I am not too tired, I can also deal with the other papers in my manila folder, including the curriculum vitae of the applicants for the registrar position, the journal articles I should have read for that evening’s journal club, and a sheaf of love letters, which, sadly, I had to write to myself. For meetings of sufficient length, the technique of microsleeps can improve my cerebral function for the remains of the day. For the appropriately named board meetings, a siesta may even be an option. I have found that if I am startled awake by hearing my name mentioned, I should say confidently, “I agree completely”. If I have just inadvertently agreed to chair a sub-committee or, horror of horrors, to be the new Secretary, the solution is to subsequently remember an unfortunate conflict of interest. If a more detailed reply to the question was expected, a long sentence liberally interspersed with terms like “clinical governance”, “mandatory criteria for accreditation”, “quality improvement”, “transparency” and “public accountability” is guaranteed to glaze eyes and end interrogation ... er ... discussion. The third, unwritten, rule of committee meetings is that when the Chair says “Any other business”, this is not a question, but in fact a signal for us to pack up our papers and head for the exit. After work — journal clubI have long known that the aim of a journal club is calories. In order to nourish your brain, you first need to nourish the larger proportion of your body that is not brain. Pharmaceutical company sponsorship improves the nutritional status of the journal club substantially, while also improving the interest of junior staff. Apparently, lavish journal club suppers (or breakfasts or lunches) do not constitute a confiture of interest. I know that the probability of my having to present at journal club is inversely proportional to the number of attendees. However, although a large journal club reduces the frequency of my presentations, it increases my exposure to my colleagues’ presentation foibles. I spent this evening’s journal club noting down the seven recognised stereotypes of journal club presentation: The abstract artist is an advocate of abstract thinking, who never progresses beyond the abstract of a paper. After hearing 12 consecutive abstracts in an hour, I usually feel like using a lump of cement to demonstrate the power of concrete thinking. The anecdotist presents interesting case reports. The evangelist reads long sections of the paper verbatim, in an ecclesiastical monotone or drone usually reserved for sermons and bible readings. The EBV-ologist is not an evangelist, but has nevertheless undergone a religious conversion, as well as a seroconversion, after being infected with EBV (evidence-based virus). The symptoms of EBV infection are both local and systematic: echolalic repetition of the terms “randomised controlled trial”, “meta-analysis” and “What is the level of evidence?”; a mania for searching the literature; and irrational worship of an obscure deity named Archie Cochrane. The reflexologist presents papers on alternative medicine, using a holistic approach that excludes statistics and data. The psychoanalyst interprets the paper from a Freudian perspective, while reclining on a couch. The results may not be statistically significant, but the true significance of the paper depends on the author’s unconscious motives for performing the study, and the author’s relationship with his or her mother. To the psychoanalyst, EBM means expressed breast milk more often than evidence-based medicine. The apologist has forgotten to read the papers and forgotten to organise the supper. My conclusion from this evening is that while the journal club is of anthropological interest, it does not otherwise qualify as further education.

David Isaacs MD, FRACP, FRCPCH · Stephen Isaacs MB BChir, FRCPCH · Dominic A Fitzgerald MB BS, PhD, FRACP

Doctors and paintings. Insights and replenishment for health professionals. John Middleton, Erica Middleton. Oxford: Radcliffe Publishing, 2006 (x + 102 pp). ISBN 978 1 84619 052 0. I wanted to like this book. The idea of a husband British GP educator and wife artist/art historian coauthoring a book about the interface of painting and medicine intrigued me. The structure is also quite novel. It follows four fictional general practitioners starting up a group learning course about painting and medicine, listening in on their discussions in a play-like format. Superimposed on this are two more layers, the first being two other characters walking through an art museum, listening in on and commenting on the group of doctors. Secondly, there is a non-fictional analysis of various famous artists and their works, as well as the art-in-medicine movement. Strangely, the artist co-author includes her own works in the book for analysis, putting herself up against some of the most famous artists in history. All of this in a book under 100 pages long! It did come across as confusing to me; on many occasions, I found myself unaware of who was talking (author or character) or whether I was reading fiction or non-fiction. That said, both authors seem knowledgeable in their respective fields. Analysis of communication techniques, of empathy and listening, and of “patient-centredness” are well discussed and referenced. Philosophical points on the role of the doctor, of death and dying, and even faith suffuse both the fictional and non-fictional sections. Artists as diverse as traditionalists like Rembrandt and Rubens through to modern artists such as Francis Bacon and Mark Rothko are analysed both in terms of how their lives and personalities helped shape their works and in how their philosophy and its expression can influence us as doctors viewing their works. Rather than being printed in the book, the works discussed have web addresses for viewing (except for the coauthor’s work!), I suspect to reduce cost. While interesting in parts, Doctors and paintings may be trying to be too many things. Nevertheless, those with a passion for painting and/or medical philosophy might find it worth a read.

James A Best

To the Editor: I read with interest the recent MJA supplement on spirituality and health. It is interesting to observe the relationship between religious affiliation and life expectancy at birth over the past 100 years using population data supplied by the Australian Bureau of Statistics (Box).1,2 The life expectancy data shown here is for males, but the graph is almost identical for females. While there are many variables in this relationship, they are akin to those chiefly neglected in most of the articles in the supplement. It is easy to see from the graph that, as religious affiliation within the community has declined, life expectancy (a gross surrogate measure of health) has increased. The correlation is very good. Religious affiliation versus life expectancy at birth in Australia1,2* R2 = correlation coefficient. * Lines on graph are lines of best fit.

Robert F Grace

Search for Oz Richard Bronson. New York: Padishah Press, 2006 (102 pp). ISBN 0 9776405 2 3 A 12-year-old girl is playing the violin. The poet asks if she hears the tunes in her head. “No”, she replies, “My fingers know the way, and I follow them”. It’s a measure of how much meaning Richard Bronson’s poems can sustain that this glorious, insouciant piece of “found poetry” (the girl presumably said just this) reads as a brief image of the link between body and mind, the physical and the inspirational. Bronson is an endocrinologist, and this is his first collection of poetry. Some of his work draws directly and successfully on his medical experiences, but most does not. There is a cool intelligence and compassion throughout which one can think of as exemplifying the ideal doctor, but little which fits easily with lazier notions of “medical humanities”. Rather, the driving force is an awareness of cultural heritage. Music and literature are everywhere. The girl, the poet, his late father are all musical, and we learn that Bronson’s library includes Rilke’s magnificent (and fiercely difficult) Duino Elegies and the like. Indeed, two poems are addressed to Hypatia, murdered by Christian fanatics in 5th century Alexandria and one of the first women of learning whose name we know. The destruction of a civilisation which this event symbolises is at the heart of some bleak meditations for a post 9/11 world: The world has come to this no heat, no water, no food, but boxes of books in my basement. The half-dozen love poems with which the volume concludes are serious but occasionally awkward (“a chamber of rules/ where carnal love reigned”), and there are a couple of pieces of whimsy; but Bronson at his best is very much worth reading. (A video log of Bronson reading four of his poems — rather well — is at http://www.poetryvlog.com/rbronson.html, and one of Bronson’s poems was published in the 2 July issue of the Journal [Med J Aust 2007; 187: 46].)

John R Skelton

Many people use prayer, and some studies have shown a positive association between prayer and improved health outcomes. This article explores four possible mechanisms by which prayer may lead to improved health. While acknowledging the efficacy of prayer and recognising the needs of patients, prayer, being a personal spiritual practice, cannot be prescribed, nor should it be used in place of medical care.

Marek Jantos MA · Hosen Kiat MB BS

Australian youth engage in behaviour that threatens their health and wellbeing. National surveys report that about a third of young Australians have tried an illicit drug. High rates of substance use and risky sexual behaviour among young Australians suggest that effective prevention efforts based on empirical evidence need to be expanded. Church-associated organisations are an untapped resource that could be used to improve the health and welfare of young people. We describe eight evidence-based elements to consider in designing strategies to prevent high-risk behaviour in young people.

Gary L Hopkins MD, DrPH · Duane McBride PhD · Helen H Marshak PhD · Kiti Freier PhD · John V Stevens Jr JD · Wendi Kannenberg MPH · James B Weaver III PhD · Stephanie L Sargent Weaver PhD · Peter N Landless MMed, FCP(SA), FACC · Jonathan Duffy BEd, MPH

Providing spiritual care is about tapping into the concept of spirituality: core meaning, deepest life meaning, hope and connectedness. The search for meaning, connectedness and hope becomes more significant as older people are faced with the possibilities of frailty, disability and dementia. Spirituality, ageing and meaning in life can be discussed in the context of an alternative view of “successful ageing”. A model of spiritual tasks in older age can help explain the spiritual dimension and provide a starting point for spiritual assessment.

Elizabeth B MacKinlay PhD · Corinne Trevitt RN, MN, GradDipGerontics

Medicine is a huge opportunity for me, I am serious about making a difference and to work with my community, and now I am learning the skills to be a doctor. I have always had the motivation to follow my journey; this opportunity has allowed me to make the journey real. — Beth Kervin, fourth year medical student Beth is one of the first recipients of a unique scholarship program to boost the number of Aboriginal and Torres Strait Islander students undertaking medical and other health-related degrees at the University of New South Wales (UNSW). She grew up and was educated on Gandangara land in south-western Sydney, but her people are from Guyra in western NSW. Like so many other Indigenous students, Beth is among the first in her family to study at university. She certainly won’t be the last, with her younger brother entering UNSW’s medical school and the Shalom Gamarada Ngiyana Yana scholarship program in 2007. The Shalom Gamarada Ngiyana Yana scholarship program sprang from a chance meeting and conversation between Associate Professor Lisa Jackson Pulver, of the School of Public Health and Community Medicine’s Muru Marri Indigenous Health Unit, and Ms Ilona Lee, President of the Shalom Institute, on National Sorry Day in 2004. Today, the partnership comprises the UNSW’s Shalom College, the Nura Gili Indigenous Programs Unit and the Muru Marri Indigenous Health Unit. The name of the scholarship program reflects this partnership. Shalom is a Hebrew word meaning peace, and the phrase gamarada ngiyani yana in the Eora language is translated literally as “friends-walk-we” or “we walk together as friends”. The scholarship program is funded by the annual Shalom Gamarada Ngiyani Yana Aboriginal art exhibition and sale. The proceeds of the exhibition are used to fund residential scholarships for Aboriginal students on the UNSW campus. Many of the sales at the first two exhibitions (2005 and 2006) were made to private purchasers; however, the program is enthusiastically supported by corporate sponsors and individuals, in the management of the actual event, in purchase of the artworks, and by the provision of named scholarships in honour of relatives, events or organisations. Each scholarship is valued at $15 000 per year and covers academic tuition and full board at Shalom College on the university’s Kensington campus. Each student awarded a scholarship has tenure until they complete their degree. Shalom Gamarada provides on-campus accommodation and meals to students in a city that is arguably the most expensive in the country. In addition, through the sale of their artworks, many of the artists involved in the exhibition are making a deliberate contribution to improvements in Aboriginal health outcomes. The exhibition also hosts a panel discussion of Aboriginal health experts, drawing on the skills and experience of health professionals in the field. “We need Aboriginal doctors to tell us what to do, to provide leadership, guidance and insight in addressing the problems and the causes of the problems Aboriginal people are facing,” said UNSW Professor of General Practice and Director of the Centre for Primary Health Care and Equity UNSW, Professor Mark Harris, during the exhibition’s expert panel discussion in 2006. Perhaps the strongest endorsement came from the exhibition’s Patron, Professor Marie Bashir AC, Governor of New South Wales: “This program is a strong and eloquent contribution to our journey of reconciliation.” The Shalom Gamarada Art Exhibition will take place at: Shalom College, UNSW, Barker St, Kensington 17–22 July 2007, 11 am to 8 pm. Aboriginal Health Forum, 22 July 2007, 4 pm to 6 pm. Email: gamaradaATshalom.edu.au Website: http://www.shalomgamarada.org Artist: Alkawari Dawson. Artist: Rosella Namok, Secret Dance. Artist: Regina Wilson. Artist: Ningurra Napurrula. Artist: Walankura Napanangka. Artist: Charlene Carrington.

Lisa R Jackson Pulver PhD, MPH, GradDipAppEpi

Verbal medicine. Twenty-one contemporary clinician–poets of Australia and New Zealand Tim Metcalf, editor. Canberra: Ginninderra Press, 2006 (148 pp). ISBN 1 74027 369 9 When I sit on medical curriculum advisory committees, I hear that the subjects studied and examined to gain entry to medical courses, and the courses themselves, have become too focused, too narrow, too mechanistic, too concentrated on sciences and biology. I hear that our students lack sufficient exposure to literature and philosophy to cope with the intense emotional impact of the blessing and the curse that is the life of a doctor. I worry that so many colleagues are at risk of emotional burnout. It has been said that there is no greater tragedy than an unexamined life. This book of poems by 21 contemporary Australasian clinician–poets is a delight, but it is no light read. I could not read it all in one sitting as each poem is strong and powerful. Verbal medicine goes a long way towards examining what it means to be a doctor, and how it feels to deal with the joys and sorrows, frustrations and successes of practice. It does not stop there; painfully, ruthlessly, thoroughly, it examines the role of doctor as patient and mortal human being. I believe that more doctors should be encouraged to write poems as a way of examining their own lives, and this book is a great example. The MJA editor took a chance on asking me, as a poet, to review a book on poetry. So I cannot let the opportunity pass without a poem of my own. Why? Why do we write, why do we dare? Do we think that there’s someone there? Have we a message, have we a thought? On a piece of our lives that fortune brought? Why do we write? Do we want to be heard? Or just carve order from the great absurd? To tear a pain from our inside? Or see a terror that no more can hide? To release our anger and give it vent? Until our passion and frustration’s spent? Or play with words and toy with sound? And admire the pretty game we’ve found.

Christopher D Hogan

All patients want good doctors they can trust. Good doctors are competent, respectful, honest, and able to form good relationships with their patients and colleagues. Medical practice is inherently risky. The public, recognising this, believes that in a modern health service the competence and professionalism of all doctors should be a given, not an additional avoidable hazard. Some doctors find this expectation reasonable, others threatening. Good medical practice may be best achieved by professional regulation based on explicit, patient-centred professional standards embedded in medical education, registration and licensure, specialist certification and doctors’ contracts. Effective professional regulation and professionalism should be an integral part of wider quality improvement and quality assurance. The advantages for patients are self-evident, but the trustworthiness, influence and good name of individual doctors and the medical profession collectively would be enhanced if together they were able to show that the house of medicine is being maintained in good order.

Donald H Irvine CBE, MD, FRCGP

Trends in meningococcal disease (MD) over the 20th century in Australia, as in other industrialised countries, have been characterised by epidemics during the two World Wars, a transient rise in incidence in the 1950s followed by endemic disease, and in the 1980s the emergence of a sustained hypersporadic phase. Epidemics occur at times of social upheaval and among marginalised populations, and resolve when living conditions improve. Periodic serogroup A epidemics have been replaced since the 1950s by endemic disease caused mainly by serogroups B and C meningococci. The current hypersporadic plateau in Australia, as in other industrialised countries, is associated with the intercontinental spread of hypervirulent clones of meningococci. The conjugate serogroup C vaccine has reduced the incidence of MD and carriage rates of serogroup C meningococci. However, the vaccine is expensive and its long-term impact on the emergence of non-vaccine strains and on nasopharyngeal microecology is unknown. A rising incidence of MD should not be viewed as the action of a virulent microbe exploiting a vulnerable population, but as the emergence of an “accidental pathogen” from an evolving host–microbial ecology. While it is essential to monitor the impact of vaccines on this ecology, we must find ways that can optimise our coexistence with microbes.

Mahomed S Patel MB BCh, FRACP, FAFPHM

I have had a long and interesting life. I have been doubly fortunate in that most of the rewarding activities came into my life not through my own endeavours but by being presented to me, often quite unexpectedly. My first choice of a career came from seeking vocational guidance while in secondary school. I was advised to become a psychologist. Having no other aspirations, I set off in that direction and, in due course, gained admission to the Faculty of Arts at the University of Sydney, hoping to gain an honours degree in psychology. All went well until my second year — in 1942. By then, the Second World War had become pressing, and I found myself being interviewed by an army recruitment officer. He told me that, with my university background, if I were to join the infantry I might be rapidly promoted. The alternative was radar and coastal artillery. Radar sounded more interesting, and turned out to be very active as well. In 1942 and 1943, the Japanese I class submarines sank 175 000 tons of shipping and drowned some 350 sailors in the waters around Sydney. Our job was to locate the submarines. Things happened quickly. At one stage, Sydney had only one 10 cm radar station and I was for a time the most senior soldier running it. After some time the war moved north. On the wayIn the military, one learns to be a little devious. After 2 years, I manoeuvred myself into the Australian Army Psychology Service and, in time, achieved the rank of Warrant Officer 1st Class. I was doubly fortunate: my immediate senior officers were both learned and helpful — they became Professors of Psychology after the war. Wide experience and expert supervision achieved the curious result that, with no formal qualification, by the end of the war I was performing the duties of the Clinical Psychologist at 114 Australian General Hospital, the principal interservice psychiatric hospital. Here I saw my first battle casualties. To make amends for my training deficiencies, I was given the title “Psychometrist”. Consulting the Oxford dictionary, I discovered that psychometrists had the power of divining — from physical contact with an object — the qualities of any person or thing that had been in contact with it. Although this would indeed have been a very useful talent, I had to acknowledge that I did not possess it, but no one seemed to mind. Working as a psychologist showed me that doctors had most of the professional power. Therefore, I decided to do medicine and become a psychiatrist. On the way through, I discovered that many doctors believed that only those who were unable to make a living in any other branch of medicine, or who were hopelessly dependent on alcohol, became psychiatrists. At that time, the solution was to prove that one was a “real” doctor by acquiring the Membership of the Royal Australasian College of Physicians. For that reason, many psychiatrists in my generation have the hard-won FRACP after their names. The immediate postwar yearsLooking back now, it is interesting to reflect on the medical world in New South Wales 60 years ago. There was one university — the University of Sydney — and its Faculty of Medicine had one Professor of Medicine, one Professor of Surgery and one (part-time) Professor of Psychiatry. Consider their numbers now! There were many roles to be filled. Within a few years, I found myself a Lecturer in Psychiatry in the Faculty of Medicine and a Member of the Board of Studies, Lecturer and Examiner for the degree of Master of Arts in Clinical Psychology in the Faculty of Arts. Additionally, I had become a Member of the Advisory Board of the Institute of Criminology at the University of Sydney. In those days, to be on the teaching staff of three faculties at once was a little unusual. Getting aheadMy entrance into the Australian and New Zealand College of Psychiatrists was atypical. In the 1960s, David Maddison created the College virtually single-handedly. For some time, I had examined with him in clinical psychiatry for the University of Sydney’s Diploma of Psychological Medicine. David Maddison rang me one day and said he wanted me to be a Censor of the College. Having the psychopathology of the only child, it does not occur to me to join things, and I pointed out that I was not a member of the College. David said, “Yes you are”. The next day, I paid my subscription, and a few days later I was in the College, and a Censor. There were many committees to join, and each would have a story to tell if there were more space. Their titles will have to suffice (see Box). The essence of it was that there was much to be done and I did my best to be as active as possible. In 1997, I received the College’s Medal of Honour, an award rarely given. It was awarded not only for my services to the College but also for being an “ambassador” for the College. The Law FoundationIn 1960, David Maddison’s brother, John, was the NSW Attorney-General. He rang me one day and invited me to join the Law Foundation of NSW. It sounded interesting, so I joined, and, in time, I found myself chairing it. This meant chairing a group comprised of the Attorney-General, the Head of the Bar and of the Law Society and one or two other worthies of similar status. It was an interesting experience for a psychiatrist and taught me a lot during my 20-year membership of the Foundation. There was no shortage of problems to be dealt with. Representatives of the articled clerks came to see me, and complained that some of them were receiving little instruction and were instead being used as lowly paid messenger boys. The solution was to set up the College of Law in Sydney, which is still going strong. There were other problems. My experience as a witness had shown me that, while the great body of judicial officers were intelligent and committed to their duties, there were some unfortunate exceptions. For example, in the District Court of NSW, I found myself giving evidence before a judge who did not raise his head from the bench. When finally he lifted it he said, “Bloody bullshit”. The only possible answer was “May it please Your Honour”. He replied, “Thank you, doctor”, and put his head down again. The Chief Justice of the day was manifesting clear evidence of dementia, but no one was doing anything about these and other problems in an important system. I persuaded the Law Foundation to set up the Judicial Commission to deal with such problems, and, from 1997 onwards, gave occasional lectures to the Educational Division of the Commission. Back to the servicesOne Friday afternoon in 1964, Bill Deane-Butcher, from a nearby office, came to talk to me. I knew he was Head of Royal Australian Air Force (RAAF) Reserve Medicine. He said, “We’ll be at war with Indonesia over the weekend. The mirages have gone to Darwin. You have service experience, and we want you in the RAAF this weekend.” And I was. I was on the active Reserve for the next 17 years, with service in Malaya and Vietnam. I became Senior Consultant in Psychiatry to the Director General of Air Force Health Services, with the rank of Group Captain — certainly an improvement on my army career! Once more, I learned a lot about many things and about myself. Vietnam, with its jump mines, left me with an enduring hatred and contempt for those who advise war and bring it about. There is no shortage of such people now. Something newIn the early 1980s, I received another memorable phone call, this time with an unusual invitation. It was the NSW Minister for Corrective Services, asking me if I would like to be a part-time Commissioner of Corrective Services. There had been much trouble in NSW prisons, culminating in the 1978 Report of the Royal Commission into NSW Prisons,1 in which Justice Nagle recommended the creation of such a position. As my work at the RAAF had been settling down and my advancing years made it unwise to fly in very fast highly manoeuvrable aircraft, and as I had never been a Commissioner of Corrective Services before, I could not resist the invitation. It turned out that I had a particular advantage. The common language used in the lower ranks of the army was exactly the same as that spoken by the prisoners. This made my communication with them much easier, since I spoke it as a native. On one occasion, I was in what was then the maximum security wing at Long Bay Gaol, housing 90 prisoners. The prisoners told me that heroin was much cheaper there than it was on the street and that they were all using it. They shared one syringe and one needle, and I was aware that HIV was spreading rapidly in the outside world. I went to the Minister and suggested that we start a methadone program and distribute clean needles and syringes. He was appalled at my suggestion, and when my 1-year term was up, he told me he would not reappoint me. When my job was advertised, I applied for it, was interviewed by the appropriate committee and chosen by it. The Minister did not welcome me, but I stayed for another year to make my point, and then resigned. On another occasion, to achieve a necessary result, I broke the law. During a visit to the NSW female correctional centre at Mulawa, I encountered a woman sitting with her shirt hitched up and her trousers pulled down. She had a single-edged razor blade in her right hand and was cutting deeply into her abdomen, with considerable loss of blood. There was a brief conversation. “That’s not a good thing to be doing, why are you doing that?” “There’s a baby in there and I’m going to get it out.” “Is there any way that I can persuade you to stop?” “If you send me to Rydalmere Psychiatric Hospital, I’ll stop.” In those days it was necessary to get the services of two psychiatrists, each of whom signed a Schedule 3, before a person could be moved from a prison to a psychiatric hospital. Both the Minister for Corrective Services and the Minister for Health were involved. The median time for a transfer under these conditions was about 6 weeks. This seemed excessive in the circumstances, so — unlawfully — I signed a Schedule 2 and sent her off immediately, the bleeding having been staunched. (A Schedule 2 required the signature of only one psychiatrist, but could not legally be used for the transfer of prisoners to a psychiatric hospital.) Soon after this, my good friend, Bill Cramond, who was Head of Mental Health at the time, contacted me and said that the NSW Cabinet wanted to know exactly what I had to say about breaking the law in this way. Part of my reply was unprintable, and the rest was to say that I had the choice of standing before them with a dead woman and a dead baby, or signing the wrong piece of paper. I had chosen to do what I did, and, presented with the same dilemma in the future, I would do the same again. If they did not like it, we would have it out on talkback radio, television and the newspapers. I heard no more. The game went both ways. At one time, we had a former Chief Magistrate and a former Minister for Corrective Services in custodial care for breaking the law! One of the biggest problems with the prison system was that the officers and prisoners had each other stereotyped as villainous creatures, and there was something close to open warfare between the two populations. The 1978 Royal Commission into NSW Prisons noted that, in 1942, there had been a substantial upsurge in prisoner unrest in NSW, “leading to a dramatic increase in breaches of prison discipline. There were several serious assaults on officers.”1 As a result, between 1965 and 1976, prisoners regarded as intractable were sent to a special unit at Grafton. They were welcomed with a “reception biff”, which consisted of a beating about the back, buttocks, shoulders, legs and arms by two or three officers using rubber batons. In 1970, there was a systematic flogging of a large number, if not all, of the prisoners in Bathurst Gaol. In 1974, the prisoners rioted and burned the gaol down. The antipathy that resulted was strong, and our principal task was to break it down and help each side (prisoners and officers) to see the other more as they really were. We started a special unit in which the very “heavy” prisoners (those with power in the prison population social structure) and prison officers mixed freely and enjoyed some pastimes together. To that we added a psychologist and a female governor. In those days, that was something like appointing a woman to head the Anglican and Catholic churches. My greatest day in corrections occurred when, on one occasion, I was sitting in the office of the Governor of the special unit and two heavy prisoners came in and addressed her by her first name. “Isabel, Christmas is coming and we can’t get any boots for Santa Claus. Can you help us?” “You’ll be right, boys. I’ll make sure that you do.” “Thank you, Isabel”, and off they went. This was a long way from the Grafton “biff” to which heavy prisoners had been sent to teach them who was “boss”, as described in the Royal Commission report. More than once, when there was a fierce riot raging in a prison and I was there with my brother Commissioner, Frank Hayes, the heavies reassured us that they would make sure that nothing nasty happened to us — and, indeed, nothing ever did. They recognised that we were trying to be just to both sides. In the end, we had a 6-week strike, with no prison officers working at all. The heavies said there would be no trouble in the gaols, and there was none. This was a significant communication, as their cooperation meant that the administration could run on for many weeks without any prison officers present and that the officers’ strike did nothing but harm their own interests. Other thingsDuring the second half of the 20th century, I had observed that there were many excellent psychiatrists in private practice but that the field had shown little indication of becoming organised, as academic psychiatry and public psychiatry had done. This moved on when I met Paul Ramsay, who then owned a small private hospital I was using. We formed a close and comfortable working relationship that led to the building of the Northside Clinic, a sizeable private psychiatric hospital that was opened in 1973. The psychiatric services were managed by my practice, in which there were some 15 or more psychiatrists and associates. We taught students and were recognised by the University of Sydney as a teaching establishment. We also had registrars, which was of special interest to me, as I had held the first registrar position in psychiatry in Australia in 1956. It was called “psychological medicine” at the time. It all went well, but, by 1999, after one partner had behaved improperly, I decided to concentrate on other things. Protecting the publicThere was another problem that troubled me. In the 1980s, psychiatrist Harry Bailey was practising deep sleep therapy at Chelmsford Private Hospital, Sydney, with a completely unacceptable number of consequent deaths. There were other improprieties as well. I was hearing about this in my consulting room, for it was widely known. There was no sign of the statutory bodies — the coroners, the Health Department, the Medical Board — taking action, even though many of the patients were transferred from Chelmsford to public hospitals and died there. Disturbed by it, I obtained the details of the death of a particular patient, and — supported by a professor of pharmacology and a senior physician — had the relevant information laid before the prosecuting authorities of the day with a charge of manslaughter in mind. Before anything could happen, the patient’s body was shipped overseas, as she came from another country, and the case collapsed. I felt that I could do no more, but then Merrilyn Walton — now Professor Merrilyn Walton — turned up in Sydney to establish the Health Care Complaints Commission. We conferred, and identified 18 deaths that should never have occurred. Dr Bailey was asked for his responses to each of these — seriatim. He suicided and, in his suicide note, blamed me by name for his death. Subsequently, I was an expert attached to the Royal Commission into Deep Sleep Therapy conducted by Justice Slattery. Those who wish to learn more about these matters can consult the Report of the Royal Commission into Deep Sleep Therapy.2 As a consequence of this activity, I was asked to investigate the management of Ward 10B at Townsville Hospital. The ward had been run as a “therapeutic community”, a popular concept decades ago. The essence of it was that an institution of this kind should be run by those in it rather than by the ordinary management team, such as psychiatrists and the like. As might be imagined, chaos reigned, and there was an inquiry to which I became a part-time consultant. I have always done my best to ensure that patients are treated competently and sympathetically. This has led to an interest in euthanasia. The notion that someone dying in agony, unrelieved by palliative care, should be made to go the full distance when they beg for death is repugnant to me. Much more could be said about this. It led to my involvement with a poor fellow in Darwin seeking to terminate his life when no other psychiatrist could be persuaded to become involved in the matter. It was a very public situation. I received both an award and hate mail. And nowIn my eighties, I find myself sitting on the Mental Health Review Tribunal and enjoying it. I have been there since its establishment under the Mental Health Act 1990 (NSW). The only problems are the vagaries of the Act and the traffic encountered in getting to some venues. I have had a good time with excellent friends, family and people to help me. My occupation has been interesting and I am still going strong. Who could ask for more? Awards, appointments and publications Awards Service medals 1939/45 War Medal Australian Service Medal (Second World War) Vietnam Service Medal (Vietnam War) Member, Order of Australia, 1983 Medal of Honour, Royal Australian and New Zealand College of Psychiatrists, 1983 Honorary Life Member, Faculty of Medicine, University of Sydney, 1994 Reserve Forces Decoration, 1996 Gold Star Award, Voluntary Euthanasia Society of New South Wales, 1998 Part-time consultancies Royal Commission into the Use and Effects of Chemical Agents, 1985 On Australian Personnel in Vietnam, 1985 Carter Inquiry into Ward 10B at Townsville Hospital, Queensland, 1990 Royal Commission into Deep Sleep Therapy, NSW, 1990 Adviser to Commission of Inquiry into Workers Compensation Common Law Matters (NSW), 2001 Previous appointments Member, Psychologists’ Registration Board of NSW, 1989–1996 Chair, Board of Practice Standards, Royal Australian and New Zealand College of Psychiatrists, 1990–1997 Chair, Clinical Practice Advisory Committee, Royal Australian and New Zealand College of Psychiatrists, 1990–1997 Chair, Inquiry into Psychosurgery (NSW Government), 1996–1997 Chair, Medical Committee (Poisons Act 1996 [NSW]), 1973–1992 Member, Legal Representation Committee considering the rights and needs of the mentally ill, 1977–1987 Member, Ministerial Advisory Committee inquiring into mental health services in New South Wales, 1987 Consultant Psychiatrist to the Health Insurance Commission, 1989–2005 Visiting professorships and lectureships in Malaysia, New Zealand and all Australian states except the Northern Territory Publications Writing has been one of my pleasures. My first publication was in the school magazine of my intermediate high school — a satirical additional chapter for the book we were obliged to study for the Intermediate Certificate. I am still at it: I have 170 articles in the medical and legal literature, eight chapters in books, and three books to my name. In addition, I edited the journal Modern Medicine for 22 years.

John H T Ellard MB BS, MRACP, DipPsyMed, FRACP, FRANZCP, FRCPsych, MAPsS

Looking back over my life, I am struck by how important chance has been. Chance creates opportunities — and my life has been abundant with opportunities. I have had the rare experience of changing careers several times. I have been associated with the birth of several new organisations and seen them become successful.1 My decision to study medicine was considerably influenced by my father, Kenneth Hetzel, a consultant physician at the Royal Adelaide Hospital, who became Dean of the Faculty of Medicine at the University of Adelaide (1953–1959). A greatly respected clinical teacher with a passionate interest in medical research, he was an inspiration to me.1 I graduated from the University of Adelaide at the end of 1944. Early in my course, I had enlisted in the Royal Australian Air Force, but after being diagnosed with pulmonary tuberculosis in 1945, I was unable to undertake military service. Many of my contemporaries did not return from war service. This left me with a strong desire to make the world a better place! As a student, through membership of the Student Christian Movement, I adopted a Christian commitment. This led me to a holistic medical perspective that I have consolidated with fairly extensive reading in philosophy and theology, with particular reference to the interaction between science and religion.1 My holistic perspective led to an interest in endocrinology, including “stress”. I became aware of the ideas of Hans Selye, who had first recognised the importance of the role of the adrenal cortex in the body’s response to stressful stimuli. This followed the earlier work of Walter Cannon, who established the role of adrenalin. Selye proposed the concept of “diseases of adaptation”, including essential hypertension as the result of “adrenal exhaustion”. I conducted an investigation of the adrenal cortex in hypertensive patients using a bioassay in mice for glucocorticoids (cortisol), which was a considerable challenge. The studies revealed normal adrenal function except in Cushing syndrome.2 There was considerable interest in stress at the time, and I had many requests for reprints! My finding was later confirmed by others. In 1951, I received a Fulbright Research Scholarship and proceeded to the New York Hospital Cornell Medical Center to work as a Research Fellow in Medicine under Professor Harold Wolff. He was leading a systematic study of physiological changes in a variety of organs and systems during different emotional states associated with stressful life experiences. I was assigned to study the endocrine (adrenal, thyroid) and metabolic systems. I believe I was the first to report an increase in cortisone secretion in humans associated with emotional states such as apprehension and exhilaration.3 These changes were accompanied by an increase in metabolic rate and other changes similar to those observed in physical trauma.4 After a period of training in clinical endocrinology at St Thomas’ Hospital in London, I returned to Australia in 1956 to become a Michell Research Scholar in the newly established Department of Medicine at the University of Adelaide under Professor H N Robson, the Foundation Professor of Medicine. In 1959, I was appointed Head of the Department of Medicine at the newly opened Queen Elizabeth Hospital (QEH) at Woodville, first as Reader and then, in 1964, as Michell Professor of Medicine. My point of view in practice, teaching and research was a holistic one embracing the whole person — body, mind and spirit. My clinical teaching also took account of the social environment in relation to the occurrence and management of disease. It involved the health care team and included the hospital chaplain. My clinical teaching paid special attention to the personal and social aspects of a patient’s illness. I emphasised to my students that there is both a “scientific diagnosis” of the mechanism of disease and a “personal diagnosis” of the personal and social situation of the patient, both diagnoses being equally important. My research team at the QEH included graduate students and was particularly focused on the pathogenesis of Graves disease (hyperthyroidism), which was shown to be an autoimmune disease.5 My interest in thyroid disorders led to my involvement (from 1964 to 1972) in studies of severe iodine deficiency in the Papua New Guinea (PNG) highlands in relation to goitre and brain damage (cretinism). Confronting the challenge of trying to improve public health in a developing country had a permanent impact on me. I was a member of the Foundation Council of the new University of Papua New Guinea (1965–1972) and assisted in the establishment of a university medical school from the previous Papuan Medical College, following the model in Fiji.1 The challenge of public health in AustraliaMy interest in public health arose from a number of factors. Firstly, although trained in internal medicine and endocrinology, I had a strong interest in psychosocial aspects of health and disease. This interest became explicit during my 3 years as a Research Fellow in New York studying the relationship between psychosocial stress and physical illness.1 Secondly, my experience in PNG stimulated my interest in the health services of developing countries, particularly when I first clearly recognised the importance of the organisation of health services. I was impressed with the very effective organisation of services in PNG, including the provision of services at village level through the Aid Post Orderly and the organisation at district and regional level, with the result that PNG had a major public health program embracing the whole country. The Director was Roy Scragg, from Adelaide, who provided visionary leadership over 12 years. Finally, Australian Frontier (1963–1972), established by the Australian Council of Churches, provided me with experience of a social mechanism for helping communities develop their own ways of dealing with social problems through promoting human values. Special health problems explored by Australian Frontier included the needs of migrants and Indigenous people, as well as elderly, young, disadvantaged, poor and disabled people — a good introduction to social medicine! In 1967, these experiences together led me to apply for and then be appointed to the Foundation Chair of Social and Preventive Medicine in the new medical school at Monash University, Melbourne. In teaching with a small, dedicated staff, we adopted the “ecological model” of health, which included human biology, environment, lifestyle and health services.1 This involved the discipline of epidemiology. I was particularly interested in bridging the gap between research and action. At Monash University, between 1968 and 1976, we conducted various epidemiological studies related to the rapidly expanding metropolis of Melbourne. We began with studies of suicidal behaviour and the management of traffic casualties. These were followed by studies of the mental health of students, the health and health behaviour of Indigenous people, the reproductive behaviour of Greek migrant women, and more general studies of women’s health.1 All of these projects required epidemiological data. Studies were carried out by a series of research fellows who completed higher degrees with the assistance of Tony Ryan, a Senior Lecturer who had recently had postgraduate training in epidemiology at the Harvard School of Public Health. These studies led at the time to innovations in the provision of community services — such as the Lifeline Service in Melbourne; an Aboriginal Health Service managed by Indigenous people in Alice Springs; interpreter services for Greek and other migrants in Melbourne hospitals; and improved services at the Alfred Hospital emergency department for traffic casualties and victims of self-poisoning. In addition, we developed a Community Health Centre in Prahran, following an earlier health survey that showed the need for both health and social services to be available at one site.6 This was a very hot political potato at the time (1973–1974), in the face of opposition from most of the local general practitioners and an Australian Medical Association resolution condemning me for the initiative! After an uncertain beginning, the centre became well established in meeting the needs of the people of Prahran. I became interested in the challenge of bridging the gap between epidemiological findings and their public health application, with particular reference to road safety campaigns. The first major success in this area was in 1971, when legislation was introduced to make the wearing of seatbelts compulsory. I developed my “wheel” model for the social learning process in relation to seatbelt legislation and then proceeded to apply it to the development of random breath testing (RBT) legislation (Box 1). The process begins with collecting and analysing epidemiological data, then disseminating them in suitable form through the media. This leads to wide public discussion. When a consensus emerges, a plan is designed to tackle the problem that has been defined by the data and the discussion. Political agreement is required before the necessary legislation can be passed. After the legislation has been introduced, the program is implemented and evaluated. Evaluation requires collection of new data, which then provide the basis for the next cycle. I used this model in relation to a series of public health issues.1 1 My “wheel” model, showing the social process involved in public health advancement in relation to blood alcohol levels and random breath testing legislation Much later, I was able to review subsequent data on alcohol consumption, which indicated that up to 1975 there had been a steady increase in national consumption to the level of 10 L per person per year. By 1997, this figure had dropped to 7.6 L. The fall began in 1983, which was after the adoption of RBT in Victoria (1979), South Australia (1981) and New South Wales (1982). There had therefore been a change in drinking behaviour after the introduction of RBT, and this change has persisted. Such a change in Australian drinking habits would not previously have been thought possible! The invitation to give the 1971 Boyer Lectures for the Australian Broadcasting Commission was a big shock! I chose the topic “Life and health in Australia”, which was based on the teaching and research work of the young Monash University department (Box 2).7 The lectures were later expanded into a book, Health and Australian society,8 first published in 1974, with two subsequent editions in 1976 and 1980. The first book of its kind, it was used as a student text for teachers, nurses, social workers, physiotherapists and medical students. I was pleased to discover it was also read by politicians! 2 “Life and health in Australia”, my presentation for the 1971 ABC Boyer Lectures The Boyer Lectures and the book, together with other press coverage of our work, introduced public health and epidemiology to the public in the form of major modern Australian epidemics such as traffic crashes, suicidal behaviour, coronary heart disease and cancer of the lung. In the 1970s, this was new information to the public and caught media attention. Public perceptions of epidemiology have expanded greatly since then, so that the media are now well aware of the discipline in relation to heart disease, cancer, the effects of Agent Orange, infectious diseases and many other problems. This greater public awareness has been very important for public health. Public health nutrition in AustraliaThe redirection of the Animal Nutrition Division of the Commonwealth Scientific and Industrial Research Organisation (CSIRO) to become the Division of Human Nutrition gave me a remarkable opportunity — unprecedented for a medical graduate — when I was appointed Chief and took up my position in 1976. In my plan, I proposed a study of the relationship between diet and “diseases of affluence” (particularly coronary heart disease and cancer) using a multidisciplinary approach involving epidemiology, behavioural science, nutrition, physiology and biochemistry. A staff of 80 enabled me to develop this approach. A book called The LS factor — lifestyle and health, written by Senior Epidemiologist Tony McMichael and myself, described research at the Division over a 10-year period (1976–1985). It covered areas such as diet; diet and cardiovascular disease; diet and cancer; alcohol and tobacco consumption; stress; and the development of preventive services.9 Our book has even been translated into Chinese! Iodine deficiency in PNGOur work in New Guinea, carried out in collaboration with the PNG Public Health Department, raised my awareness of the problem of iodine deficiency. This problem eventually took over my life after I formally retired from the CSIRO at the end of 1985. Combating iodine deficiency has been for me a great personal adventure in international health. It all began in 1963, when I was asked by the Editor of the Medical Journal of Australia to review an article by Terry McCullagh on the use of injections of iodised oil (Lipiodol) in PNG.10 This was new technology proposed to help control the severe goitre problem (Box 3) in remote villages in the highlands where iodised salt (the usual remedy for the problem) could not be easily introduced. An initial controlled trial carried out by McCullagh, at the request of the Director of Public Health, John Gunther, showed that one injection of iodised oil would prevent goitre for up to 3 years.10 However, in 1963, it was not known whether iodine deficiency was present in PNG. 3 Severely iodine-deficient mother and child, Papua New Guinea The mother has a large goitre and the child is also affected. Cretinism in a child can be prevented by correcting iodine deficiency before the onset of pregnancy.1 In due course, our laboratory studies in collaboration with the PNG Public Health Department revealed that there was severe iodine deficiency and that it could be corrected for up to 5 years by a single dose of Lipiodol.11 Apart from the very large and frequent goitres seen in the villagers, there were many severely brain-damaged people who were also deaf-mute and often had a squint and a spastic weakness of the limbs (Box 4). This condition (“cretinism”) was being reported at the time in similar remote mountainous regions of South America, India and China, and had been observed earlier in Europe.12 There was considerable dispute as to whether or not the condition was related to iodine deficiency. It had apparently spontaneously disappeared in various parts of central and southern Europe without any known correction of the iodine deficiency. After we had successfully demonstrated the long duration of the effect of a single iodine injection, I realised that with iodised oil we had the means to carry out a controlled trial (which would not have been possible with iodised salt) to see whether correcting severe iodine deficiency would prevent cretinism. After approval by the PNG Research Advisory Committee, the trial was set up in the Western Highlands north of Mount Hagen. In collaboration with the PNG Public Health Department, we began the trial at the time of the first census in 1966. Families were alternately given injections of iodised oil or saline. Over the next 3 years, follow-up assessments of brain damage in young infants were carried out without knowledge of which injections the mother had received (ie, double-blinded). Particular attention was paid to the motor milestones, such as age of sitting up and walking. Any evidence of deafness reported by the mother was confirmed by a simple tuning-fork test. This critical phase was undertaken double-blind with great skill and dedication by Peter Pharoah, an experienced PNG medical officer who was seconded to this work by the Public Health Department at my request. After more than 3 years of careful and laborious work, involving Pharoah in extensive climbing to reach the mountain villages, the code was broken. There was no doubt that mental retardation (evident in 26 cases in the control group) had been prevented by injection of iodised oil before pregnancy. In six of the seven retarded infants born to mothers treated with iodised oil, the mothers were already obviously pregnant when injected, and there was doubt about the birth date of the seventh infant. 4 A young Papua New Guinean cretin with squint, ataxia and mental deficiency After completion of the study, injections of iodised oil were given to 120 000 people in the highlands, and an iodised salt program was introduced. The report of this work was published in the Lancet13 and was duly accepted as definitive.14 The spontaneous decline in iodine deficiency in Europe has since been attributed to diversification of the diet, associated with economic and social development, and the use of iodine supplements.12 The finding clearly demonstrated, for the first time, that the cretinism observed was the result of fetal iodine deficiency in the first half of pregnancy. The trial also showed the effectiveness of prevention by correction of the deficiency before pregnancy. Unfortunately, although this form of cretinism is preventable, it is not reversible.12 Animal modelsDuring the 1970s, it became apparent to me that there was a great gap between our knowledge of the effects of iodine deficiency on brain development and its application in the developing world. More evidence was needed. One of the factors leading me to take the position at the CSIRO was the possibility of developing an animal model to confirm the effect of iodine deficiency on fetal brain development. This was duly done (for the first time) both in the sheep and the marmoset monkey over the period 1976–1985 by an excellent CSIRO team with past experience of trace element deficiencies in sheep.15 These animal studies indicated the significant effects of iodine deficiency on growth and development. The effects on the brain were part of a spectrum of effects including abortion and stillbirths as well as goitre, brain damage and growth retardation of the fetus. A new concept — the iodine deficiency disordersClearly, a new concept beyond that of “iodine deficiency and goitre” was needed to better reflect the increase in knowledge that had occurred over the preceding 25 years, particularly in relation to brain development. After much pondering and two stimulating visits to China, and with the sympathetic encouragement of colleagues, I proposed the epidemiological concept of “iodine deficiency disorders” (IDDs) to denote all the effects of iodine deficiency on the growth (and especially brain development) of a population that could be totally prevented by correcting the iodine deficiency (Box 5).16 This concept was rapidly adopted internationally — the term was even used in China without translation! My Chinese colleague pointed out that Confucius would have approved of the term, as it referred to the primary cause and would therefore lead to appropriate measures for control! International actionThe announcement by the World Health Organization of the global eradication of smallpox in 1980 encouraged me to raise the possibility of eradicating IDDs with available technology using iodised salt or iodised oil.16 In China (1981–1984) and Indonesia (1976–1981) I had seen the massive nature of the problem of iodine deficiency. The WHO subsequently estimated that there were two billion people at risk in 130 countries and recognised iodine deficiency as the most common preventable cause of brain damage.17 Preventive measures suitable for mass application (use of iodised salt or iodised oil) and simple methods of epidemiological monitoring and surveillance (salt iodine and urine iodine measurements) were available. However, there was great delay in applying existing knowledge on IDDs to preventive programs in areas of need — to the detriment of the many millions in developing countries who were suffering irreversible brain damage due to iodine deficiency. In a report to the United Nations (UN) Nutrition Subcommittee, I stressed my concern about the gap between knowledge and application. To help bridge the gap, I proposed that an expert consultative group of scientists and other public health professionals be established to help develop national IDD control programs in collaboration with the WHO and UNICEF.1 The International Council for Control of Iodine Deficiency DisordersThe decision to establish the International Council for Control of Iodine Deficiency Disorders (ICCIDD) was made in Delhi, India, in March 1985, when I put the proposal to a group of 10 consultants and advisers who were attending a WHO/UNICEF workshop on the control of IDDs in South-East Asia. This was followed by an inaugural meeting, supported by WHO and UNICEF, in Kathmandu, Nepal, in 1986 (Box 6).18 I became Executive Director, and later Chairman, of the ICCIDD. The ICCIDD now consists of a multidisciplinary international expert network of 700 endocrinologists, epidemiologists, nutritionists, public health administrators, technologists, communicators, economists and others from 100 countries, with a majority from developing countries, who are committed to helping national governments and international agencies develop national programs to eliminate IDDs as a public health problem.19 Since 1986, the ICCIDD has held a series of regional meetings with the WHO and UNICEF to foster the development of national control programs. The meetings have been attended by ministry of health representatives from countries in the region. I adapted my social process wheel model (Box 1) to the IDD elimination program.19 Particular importance was given to political will, which had been lacking in the past but had now been mobilised through the UN system, particularly the World Summit for Children, held in 1990. The outcome of the Summit was a declaration signed by 71 heads of state and eventually by 88 other governments. The declaration accepted a series of goals for the better health and education of children throughout the world, including the virtual elimination of IDDs by the year 2000. A report to the 1999 World Health Assembly (WHA) indicated that, of the 130 countries that had a significant IDD public health problem, two-thirds had introduced universal salt iodisation programs. Between 1990 and 1998, the number of countries with salt iodisation programs had increased from 46 to 93.17 However, there is a need to ensure the sustainability of this achievement. This depends on epidemiological surveillance with urine iodine measurements to confirm the absence of iodine deficiency. Sustainable elimination of IDDs is only possible if surveillance continues — recurrence can readily occur, and has indeed occurred.17,19,20 In 2001, the ICCIDD adopted a mandate for the future dedicated to the elimination of iodine deficiency as a cause of brain damage (Box 7).20 At the 2005 WHA, Canada and Australia proposed a resolution requiring countries to report to the WHA on the monitoring of their iodine deficiency elimination programs in 2007 and every 3 years thereafter. The resolution was adopted and provides the necessary political support for future sustainability of the programs. I believe the non-government organisation model is relevant to many other international health problems. A multidisciplinary group of concerned scientists and public health professionals can come together to define a problem and then develop a program designed to solve the problem in collaboration with UN agencies.12,19,20 ConclusionIt has been a great experience to assist in the development of a UN program to eliminate iodine deficiency — the most common preventable cause of brain damage. The program was made possible by targeted research that established the relationship between iodine deficiency and brain damage — research that included epidemiological study in the field in PNG and later studies in animal models. Rapid development of the elimination program was made possible by the effectiveness of introducing iodised salt as a population measure and the application of a simple laboratory method to determine urine iodine levels as a marker for iodine deficiency and to correct any deficiency in populations. A dedicated group of multidisciplinary professionals in the ICCIDD provided the scientific leadership in collaboration with national governments, the WHO and UNICEF, assisted especially by aid programs of Australia, Canada and the World Bank. I have been very fortunate, for more than 50 years, in the people I have been associated with — my family, friends and colleagues have always been a support and inspiration to me. 5 Iodine deficiency disorders by stage of human development16 Fetus Abortions Stillbirths Congenital anomalies Increased perinatal mortality Neurological cretinism (mental deficiency, deaf-mutism, spastic diplegia, squint) Hypothyroid cretinism (dwarfism, mental deficiency) Psychomotor defects Neonate Goitre Hypothyroidism Child and adolescent Goitre Hypothyroidism Impaired mental function Retarded physical development Adult Goitre Hypothyroidism Impaired mental function Iodine-induced hyperthyroidism All ages Increased susceptibility to nuclear radiation 6 Inauguration of the International Council for Control of Iodine Deficiency Disorders (ICCIDD), Kathmandu, Nepal, 1986 L – R: Basil Hetzel, Executive Director (Australia), John Dunn, Secretary (USA), and John Stanbury, Chairman (USA). Inset: the logo adopted by the ICCIDD emphasises the importance of the effects of iodine deficiency on the brain. 7 International Council for Control of Iodine Deficiency Disorders (ICCIDD) mandate, 2001 The vision of the ICCIDD is a world virtually free from iodine deficiency disorders, with national endeavours in each country to maintain optimal iodine nutrition, primarily through universal consumption of iodised salt. The mission of the ICCIDD is to advocate to governments, citizens and development agencies a priority commitment to normal iodine nutrition through a multidisciplinary approach that involves all relevant partners. The ICCIDD believes that country programs must be fully supported nationally for sustained success and will work with all partners and national entities towards that end.

Basil S Hetzel AC, MD, FRCP, FRACP, FFPHM, FAFPHM, FTSE

In an 1823 lecture to medical students on the principles and practice of surgery, London surgeon Sir Astley Cooper raised many issues still discussed among doctors today, including: the importance of studying anatomy; factors leading to what would now be called “adverse events”; and the possible legal consequences of making errors. Cooper stressed the need for open communication between doctors and patients. Cooper practised surgery during a period when old medical guild controls were breaking down and before new professional regulatory bodies had developed. Cooper’s lecture suggests that the important principles that underpin competent, caring professional practice endure today.

William Coote MB BS, FRACGP, BEc

Helicobacter pylori is established as a cause of peptic ulcer (PU). Less well recognised is that an epidemic of PU began around the middle of the 19th century, reached a peak at the turn of the century, and is now on the wane. As the epidemic developed, the risk of PU increased in successive generations throughout life. Then the epidemic diminished in successive generations. The risk of gastric ulcer (GU) was highest in people born around 1885, while the risk of duodenal ulcer (DU) was highest in those born about 10–30 years later. H. pylori infection offers an inadequate explanation of the PU epidemic. Although the epidemic coincided with a major rise in cigarette smoking, PU then declined in spite of an increased incidence of smoking. None of the other possible causes of ulcer (non-steroidal anti-inflammatory drugs, stress or diet) satisfactorily explains the epidemics of GU and DU and their asynchronicity. The best, but inadequate, explanation for the epidemic is the coincidence of the acquisition of a new potent strain of H. pylori in childhood and the uptake of smoking in adult life.

John M Duggan MD, FRACP, FRCP · Anne E Duggan MHP, FRACP, PhD

MondayHe’s a dead man. Balloon pump. Recurrent VTs. Frequent defibs. Still conscious! Stupid wife I hate this rude bitch. No respect for me. No respect for my husband. No respect for his life. I can see it in her eyes TuesdayShe knew what was coming the moment I looked at her. Spoke to her anyway. She knows he’s a dead man. But still refuses to listen Who does she think she is? Telling me what to do. She won’t even give him a chance WednesdayAnother defib. Can’t stand to look at him. Let her watch the defib. See what she’s doing to him. He cried out. Gave her a pointed look She won’t even look at him. Won’t acknowledge him. Won’t acknowledge his right to live. Not even when he cried out ThursdayAnother defib. I wish he’d die He looks worse today. I’m losing him. Why won’t she help him? FridayAnother defib. Cracked it. Took her into my office Another shock. Cracked it. Will give it to her in her office She begged me “I can’t lose him” “What will I do without him?” “My life for 40 years” “Give him his life back” She begged me “I can’t save him” “I can’t shock him any longer” “I can’t hurt him any more” “Give him his dignity” SaturdayShe looks into my eyes. Holds my hand Tells me she can’t save me I already know I squeeze her hand Thank you She looks into my eyes. Holds my hand She’s letting me go I squeeze her hand I love you

Ailin Mohajeri

Generally, a hospital has one Director, but during the filming of several scenes of this year’s blockbuster Superman returns at Thomas Walker Hospital (“Rivendell”) in Sydney, there were two! Equipped with a medical background and psychiatric qualifications, I continued to be responsible for the smooth running of the psychiatric hospital, while Bryan Singer, of X-Men fame, took charge of the movie. In the main, there was no confusion about our identities and roles among hospital staff, patients, actors and film crew, but there were a couple of exceptions. Early in the piece, when entering the hospital gates, I was accosted by one of the film’s security guards. “I’m the Director”, I explained. “And I’m Superman”, replied the disbelieving, portly guard. Another time, my wife visited the hospital to watch a scene being shot and announced on arrival that she was “the Director’s wife”, which floored a second security guard, as Bryan Singer is openly gay. There are differences, of course, between a hospital director and a movie director. In this case, Mr Singer boasted an artistic temperament, an entourage of doting attendants, a wonderfully appointed caravan in which to unwind, and reportedly a $30 million salary for making the film. I offered a milder manner, loyal but not fawning secretarial staff, my office as my sole retreat, and a considerably smaller salary. Although happy with my lot, subconsciously, along with other staff, I craved a part — hero, villain or mere extra — in the movie, but Brandon Routh, Kevin Spacey and co. had these sewn up. Undeterred, I wore a hired Superman outfit under my suit for the duration of the filming and was ever ready to strut my stuff. “I’m the Director and Superman” would surely be hard to top, in one’s medical career and in life.

Garry J Walter MB BS, PhD, FRANZCP