History and humanities

From the 1930s to the 1960s, Royal Newcastle Hospital was the centre for innovation in Australian health care. Many of the innovations were driven by a visionary medical superintendent, Chris McCaffrey, and the staff he appointed. Among the reforms he introduced were: an overarching emphasis on efficiency; the appointment of salaried specialist staff, now widespread; the unit record system for medical records, now universal; a domiciliary care service, now established in most of Australia; and an emphasis on audit and quality studies, now largely abandoned in the form pioneered in Newcastle. These innovations were vigorously opposed by organised medicine and barely tolerated by the health bureaucracy. They are unlikely to be replicated in the current environment where hospitals are run by managers in a culture dominated by budgetary considerations.

John M Duggan AM, MD, FRACP · Peter I A Hendry AO, MB BS, MD(Hon), FRCPA

A ramble along the byways of medical history Scatology — the study of excrement — has long fascinated my co-author and me.1 Nevertheless, until our most recent discovery, even we would have conceded that the most dedicated coprophile would be hard pressed to find a link between dog droppings, medicine and Christmas. At the Nativity, despite the manger’s rural setting, was there a dog, let alone dog droppings, to be seen? Cows, goats, sheep aplenty and a camel or three, but Rover seemed conspicuously absent. Rudolph is a reindeer, not a red setter. And, over those 12 days of Christmas, our True Love trucked in a whole aviary of birds but, for some reason, never a dog a-barking. Perhaps this absence is related to the popular view that dog faeces rate towards the lower end of the general desirability scale. In Australia, many a local authority finds menace in every deposit of dog excrement2 — it seems that dog droppings are deemed a health hazard, despite a distinct lack of scientific evidence. Statistically, on an average walk in the park, you are far more likely to be killed or injured by dog bites,3 broken glass,4 or discarded syringes5 than infected by stepping in dog excrement. Slipping over and fracturing a hip is a potential hazard, but we have failed to find a report of the same; however, there has been a report of a fall involving a slip on puppy urine.6 Imagine our delight to find out — after meandering along little-travelled byways of medical history — that dog excrement has not always been so reviled and that it does have a prior, however slight, association with Christmas. An old surgical text, a pleasant surprise withinA little while ago, we purchased the fourth English edition of Laurence (more properly, Lorenz) Heister’s A general system of surgery, published in London in 1750 (Box 1). It was considered the first truly modern surgical text in the English language,7 and was the greatest surgical text of the 18th century, running to seven German, ten English and three Latin editions as well as being translated into Italian, French and Dutch. Profusely illustrated (by the standard of the day), Heister’s text combined practical surgical technique with sound anatomical knowledge, both of which he had gained by first hand experience. Who were its past owners? Were any of them practising surgeons? Alack, our copy of Heister is pristine in every detail with no markings to indicate prior ownership. Judging by its unsullied pages, this book was never used as an everyday reference by student or surgical practitioner. However, deep within its pages, there is one tantalising clue to suggest that at least one of the unknown previous owners of this book had intended on practising the art of surgery. That clue came in the form of a piece of interposita — that extraneous matter that tends to accumulate within the pages of a book (Box 2). An 18th century visitationThe piece of interposita in question is a single sheet of watermarked paper measuring 8 by 10 inches (255 by 210 mm) (Box 3). On holding the paper up to the light, a large watermark of the Pro Patria (“For the Fatherland”) type can be seen, indicating that the paper itself was probably produced in Holland at some time in the 18th century, but could have been used elsewhere, particularly in the United States.8 Our interposita was folded in four when we found it. On one side, in a series of ruled-off compartments, was a collection of ten recipes, mostly medicinal, neatly hand-written in ink. Its unsoiled nature, the fact that the writing and ink are the same throughout, and that there are no corrections, suggests that the piece was compiled at one sitting from sources already at hand. The intent, we presume, was to create a permanent document for future reference, an aide-mémoire kept for safety and ease of access in the standard surgical reference of the time. But, seemingly both the book and interposita were little used from that day to this. Although the author is unknown, we feel the evidence indicates he was a young, enthusiastic but inexperienced doctor of the later decades of the 18th century. In all probability he had just finished his apprenticeship and was about to embark on a career of his own. An established practitioner would not need recourse to such an aide-mémoire, having already acquired his own favourite nostrums. Our English Heister edition dates from 1750. From the fine, undamaged condition of the interposita, it seems unlikely it would predate this. We believe, most likely, it was made fresh and placed immediately within the edition. Several other pointers lead us to the conclusion that it does not post-date the end of the 18th century. Firstly, the writer routinely employs what is now an archaic form of the letter “s”, known as the long s located at the beginning or in the middle of words, while the modern s form, the short or terminal s, appeared at the end. Secondly, the writer uses what are now obsolete spellings. For example, he spells the word “garlic” with a “k” — garlick. The k had been dropped from English usage by the turn of the 19th century. The Oxford English Dictionary records a usage of the k-less form in 1796 and constantly thereafter. Likewise plaister is an antique variant of plaster. But we have left our strongest evidence till last — the recipes themselves. Amusing the patient while Nature takes its courseIn all, the interposita lists ten recipes — eight medical: Plaister for Cuts or Wounds; Recipe for Eye water; A good recipe for the piles; An infallible recipe for the Dropsy; A cure for an obstinate cough; The famous American recipe for the Rheumatism; Bitters, and Bitters [a second variation]; and two culinary: Recipe for little cakes; and, for a plum pudding. Of course, to our minds, such recipes, in particular that for an “infallible” cure for dropsy, would seem to be nothing but fanciful imagination. But what else could a young and inexperienced practitioner have relied upon at a time when no satisfactory alternatives existed? They are good examples of what Voltaire (1694–1778) described as the art of amusing a patient while Nature takes its course. An “infallible recipe” for dropsy would have to wait upon William Withering’s ground-breaking An account of the foxglove and some of its medical uses, published in Birmingham in 1785. The effect of foxglove was to quickly consign such ineffectual remedies to the dust-bins of history. Our writer noted “the famous American recipe for the Rheumatism” and recorded “£100 has been given for the Recipe”. Would you have paid such a price for a recipe which combined garlic(k) with gum ammoniac (a foetid plant resin) into boluses (large round pills) to be taken twice a day with strong sassafras tea? Both bitters recipes are based on Peruvian bark (genus Cinchona), which was introduced to Europe in 1640; however, the plant which produced it was not known to botanists until 1737.9 But, with Christmas (and dog droppings) uppermost in our minds at the moment, and medicine ever-present, let us turn our specific attention to another recipe in this collection. Dog turd, medicine and ChristmasWe do not refer to the recipe for a plum pudding (although we do think the experience of “one large nutmeg” could well be overpowering, capable of evoking strong emotions, just like dog turd), but rather to that to help haemorrhoids (Box 3). The recipe begins, innocently enough, with oil of red roses,10 a volatile oil obtained from the distillation of the fresh flowers of the Gallica rose, Rosa gallica. Then comes frankincense,9 the ingredient with the ultimate Christmas connection: And when they [the Wise Men] were come into the house, they saw the young child with Mary his mother and fell down, and worshipped him; and when they had opened their treasures, they presented unto him gifts; gold, and frankincense, and myrrh. The Bible, King James version, Matthew 2: 11 Frankincense, otherwise known as olibanum, is the dried resin from trees of the genus Boswellia, known to grow in regions surrounding the Red Sea. It was highly valued particularly for its fragrance, and has been widely traded throughout the Near East for millennia. Topical application of frankincense to the colonic mucosa is reputed to have anti-inflammatory properties, but whether this can withstand rigorous scientific scrutiny is debat-able.11 The surprise appearance of dog turd, coming so soon after frankincense — a substance steeped in Christmas tradition and reverence — would no doubt jar most modern sensitivities to the core. Turd is an Anglo-Saxon word of ancient origin (proto-European), pushed aside from genteel conversation: “not now in polite use” as the Oxford English Dictionary quaintly puts it. Presumably, dog turd was included for the same “cleansing and purifying properties” that made dried “dogs’ dung” (also known as “pure”) desirable for dressing leather in the 19th century.12 However, as dogs do not suffer from haemorrhoids, we are slightly tempted to think it may have some mysterious power to suppress their appearance. The recipe is completed with honey, aloes Socotrine9 and egg yolk.13 In pharmacy, honey finds use as a demulcent which soothes inflamed mucous membranes. All aloes, in general, act as large-bowel stimulants, promoting the transport of material through the bowel lumen. Its inclusion here was probably to expedite bowel emptying. We doubt whether the author appreciated the minutiae of pharmacological niceties within the range of aloes. He probably specified the Socotrine form more because of availability or price. Egg yolk is slightly alkaline and has the virtue of not being readily broken down by acids or other electrolytes. We believe that in this preparation it was used to bind the active ingredients together. On balance, we feel that this recipe — in its day — would have found acceptance as “a good recipe for the piles”, easing the pain and discomfort of this common condition. However, we are not so sure about the desirability of dog turd as a medicinal ingredient today. 1 Frontispiece of Heister’s surgery text 2 A word on interposita Once a book has left the bookshop, been opened and presumably read, extraneous matter tends to accumulate within its pages. Strangely, for such a common occurrence (and as far as we can tell), this matter seems to lack a collective name. Thus, we would like to suggest the name interposita derived from the Latin — think of it as our Christmas gift to the English language. Interposita gets within books for a variety of reasons. For the greater part, it serves as a bookmark. Over our many years of borrowing public library books, we have encountered bus and rail tickets, envelopes, letters (some very personal), shopping lists and receipts, lottery “scratch-it” cards (in our experience, never with an unclaimed prize), photographs, string, rubber bands, hair pins, religious images (quite common), and once a condom wrapper (in a book on retirement planning!). Less frequently, interposita, as in our current report, may be related to the contents of the book itself, such as a newspaper cutting of a review. Among extraneous interposita, tobacco and cigarette ash were once quite common but not so much now. Thus, interposita can be viewed as miniature time capsules reflecting prevailing social attitudes and practices. Once, a doctor donated a carton of old medical texts to our university medicine history library. His wife reclaimed them very quickly. It seems she was in the habit of secreting bank notes within them, on the assumption neither her doctor husband nor anyone else for that matter was likely to consult these outdated tomes. Our local librarian tells me the strangest object found in a returned book was a partial denture — obviously someone really getting their teeth into the subject matter. 3 The interposita with the “recipe for the piles” enlarged

Mervyn D Cobcroft MB BS, FANZCA · Charles Pembroke-Corgi

We can put issues on the agenda, but perhaps not achieve reform For Thomas Wakley, the founder of The Lancet, an important function of his journal was to reform medicine, which he saw as full of incompetence, quackery, corruption, and nepotism. He wanted to reform as well as inform. But can journals reform? Can they lead? Are medical journals important for leadership in medicine? Or is this grandiosity on the part of editors? Aren’t journals there to follow, reflect, and comment rather than to lead? Most editors think that journals can lead Drummond Rennie leading us to the promised land of open peer review. Some years ago, I asked various editors if they could provide me with examples of where journals had shown leadership. All the editors — except one — came up with examples. JAMA had led on promoting a tobacco-free society, preventing nuclear war, drawing attention to the plight of the uninsured in America, promoting the control of violence, and encouraging research into peer review. The New England Journal of Medicine had led by describing and deploring the industrialisation of medicine, encouraging health reform, and drawing attention to the importance of conflict of interest. The BMJ had led on fighting tobacco and improving the standard of statistics in medical journals. The Lancet had led with reducing the risk of nuclear war and encouraging the internationalisation of medicine. The Medical Journal of Australia had led with campaigns on smoking, promoting reform of the World Medical Association, AIDS awareness, Aboriginal health, and traffic safety. The Canadian Medical Association Journal had shown leadership by publishing a highly influential series of articles on critical appraisal of scientific papers. One editor disagreed violentlyThe most interesting response came from Stephen Lock, my mentor and predecessor as Editor of the BMJ. He wrote: Stephen Lock, Editor of the BMJ, 1976–1991. There are no examples of where medical journals have led. Nor is it the journal’s role — which is to provide a forum for debate and to publish checked data. In fact, despite what editors say, I doubt whether any publication has done much leading — for instance, the Socialist landslide in [the British general election in] 1945 was probably due to the WEA [Worker’s Education Association] influence in the forces during the war rather than the Daily Mirror, while Ernest Hart’s [great editor of the BMJ in the 19th century, see below] successes owed more to the BMA parliamentary Bills Committee, and his numerous social contacts, than to the BMJ — and even Robbie Fox’s [great Lancet editor of the 20th century] often cited role in the introduction of the NHS was secondary to Moran’s [Lord Moran, Churchill’s doctor] leadership at the RCP [Royal College of Physicians] and in the Lord’s [House of Lords] debate. Think of the contemporary issues — AIDS, health reform in the USA, and the current NHS debate — and you’ll realise how little influence the journals are having, can have, or should have. What does follow-up tell us?One advantage of having asked editors for examples of leadership several years ago is that it is possible to take a longer term look at whether they were examples of leadership. I deliberately did not define leadership for those editors, but my working definition of leadership by a journal is that it achieves a change that would not otherwise have happened. Ironically, the best two examples of leadership from the list involve Stephen himself. Stephen, together with Drummond Rennie from JAMA and John Bailar, statistical adviser to The New England Journal of Medicine, played a central part in prompting the study of peer review. This process, which is fundamental to all of science not only in deciding which papers to publish but also in the giving of research grants, was largely unstudied until these three urged that it should be. There have now been five international congresses on peer review, and a body of research has been created. This has happened almost entirely within biomedicine, but its results are beginning to percolate into other areas of science. I cannot see that this would have happened without the leadership of Lock, Rennie, Bailar, and their journals. Similarly, the work to improve the quality of statistical reporting was led by Lock and the BMJ, together with other journals. The Lancet published an important series on statistics by Austen Bradford Hill, the BMJ published a series called “Statistics at Square One” (which later as a book sold more than 100 000 copies), and Lock and other editors involved statisticians in the peer review process. Many studies showed that the standard of statistics in medical journals was woeful — it is now better (although still far from perfect). This has an importance way beyond journals themselves. Bad statistics means false conclusions. Doctors and patients were thus being misled. Ernest Hart, Editor of the BMJ, 1867–1898, made use of his extensive social contacts to promote the issue of child protection. Can history furnish examples of journals leading? History can help us with trying to answer the question on whether journals can lead, and I want to examine a campaign of Ernest Hart, Editor of the BMJ from 1867 to 1898.1 Hart was a major public figure in a way that no BMJ editor has been before or since. He was highly controversial, believing that, “An editor needs, and must have, enemies; he can’t do without them. Woe be unto the journalist of whom all men say good things.” Hart tried to lead on many issues, but his most prominent campaign was against “baby farming” — giving infants (often bastards) to carers for money, knowing that the carers neglected and even murdered them. In Hart’s first year as editor, the journal carried a story on the inquest of four children who had all died under the care of the same “nurse”. The journal also published several leading articles on the subject. In 1868, Hart advertised in a newspaper as a father-to-be, offering money for adoption. He received 333 replies and identified Mrs X, who had seven malnourished infants living in her care in dreadful squalor. In the previous 2 years she had registered seven deaths of infants younger than 1 year. Articles in the journal led to questions in parliament. More cases were reported in 1870, and Hart formed with others the Infant Life Protection Society. He was also appointed chairman of the BMA’s Parliamentary Bills Committee in 1872. A bill was drafted and enacted in 1872. It proved to be a weak bill, and a much stronger bill was passed in 1877. The problem was not solved. In 1896, Mrs Dyer of Reading was executed for strangling her charges and throwing them into the Thames. The BMJ published a six-part series on “baby farming and its evils”. The child protection movement grew enormously at this time, and the National Society for the Prevention of Cruelty to Children was founded in 1889. Baby farming: infants (often bastards) were given to ”carers“ who neglected and even murdered them. Peter Bartrip in his history of the BMJ concludes: “The Journal did not singlehandedly cause the Infant Life Protection Act to be passed, but it undoubtedly exerted a powerful influence.”1 We can probably never separate out the role of the journal from broader influences, but journals seem to be good at putting issues onto the professional and public agenda. Evidence from media studies Hugh Clegg, Editor of the BMJ from 1947 to 1965 believed that: “A subject that needs reform should be kept before the public until it demands reform.” The question of whether journals lead or follow is similar to the question of whether the mass media lead or follow, and some in the new discipline of “media studies” have addressed exactly this question. The story of Watergate is often cited as a classic case of the media leading people on what to think. It was in June 1972 that five men broke into the campaign headquarters of the Democratic Party. The incident received extensive publicity from The Washington Post, but initially there was little public interest. Yet the press kept on, and by April 1973, 90% of the American population knew the word “Watergate”. In 1974, President Nixon was forced from office. Did the media depose the president? Clearly they did not do so alone, but they played a crucial role. Maxwell McCombs and Donald Shaw have developed the theory of “agenda setting”.2,3 This means that “We judge as important what the media judge as important.” Bernard Cohen, a political scientist from the University of Wisconsin, puts it this way: “The press may not be successful much of the time in telling people what to think, but it is stunningly successful in telling its readers what to think about.” This chimes with a saying of Hugh Clegg, Editor of the BMJ from 1947 to 1965: “A subject that needs reform should be kept before the public until it demands reform.” McCombs and Shaw analysed the 1968 presidential race between Richard Nixon and Hubert Humphrey to see if they could work out whether the media were leading or reflecting public opinion.2 They looked at nine print and broadcast media used by Chapel Hill residents and ranked stories by position and length. They considered five major issues: foreign policy, law and order, fiscal policy, public welfare, and civil rights. They then looked at how undecided voters ranked these issues, and found that they ranked them exactly the same as the media. The 1968 US Presidential election: Richard Nixon v Hubert Humphrey. But which came first: the media agenda or the voters’ agenda? There have been subsequent studies, and the general finding is that the media interest comes first.3 Later work suggests that agenda setting works best when people are interested in a subject but uncertain about what to think.3 For example, I own a dog and hence am interested in animal experimentation, but I am very uncertain about what the risks and benefits might be. Nobody, as far as I know, has conducted any studies like this with medical journals, but it might be that the findings can be generalised from the mass media to general medical journals. If so, journals can put issues on the agenda and do have some influence on how people think about them — a limited form of leadership. Evidence from campaigningJournals do sometimes consciously set out to lead, to make change happen. At the BMJ I was involved with campaigns to encourage explicit rather than implicit rationing of health care, promote an ethical code that could be used by everybody in health care, and revitalise academic medicine. All produced many fine words but none led to change. This may not be because journals cannot produce change, but because we did not conduct the programs well. The Institute for Healthcare Improvement in the US is running a campaign to reduce unnecessary deaths in hospital, many the result of medical error. The campaign is called the “100 000 lives Campaign”, and its slogan is “Some is not a number. Soon is not a time.” (Box 1). Before launching the campaign, the institute studied political campaigns, and identified six essential features: platform, measurement, communication, field, funds, and values. The start is a clear, scientifically sound, highly developed platform or message. Measurement is essential to know if the campaign is succeeding, and communication must be constant, two-way, and involve many different media. Impact will depend on signing up many people and institutions (creating a field force), and the 100 000 lives Campaign has signed up some 2000 hospitals. Funds are essential, but so are explicit values; the values of the 100 000 lives Campaign include “all in” but “staying on message”. I do not know of a medical journal that has campaigned so carefully, and perhaps a more important question than “Can journals lead?” is “What must they do to make change happen?” ConclusionMy cautious conclusion is that journals can lead, in limited ways (Box 2). They might follow the example of the Institute for Healthcare Improvement and more effectively campaign, but their main contribution may be less to try and achieve precise reform and more to put issues firmly on the agenda. In my years at the BMJ, we tried to lead by promoting evidence-based medicine, encouraging doctors and patients to work in partnership, reminding the rich world constantly of its obligations to the poor world, battling against research misconduct, hastening the flow of information to the developing world, securing the independence of medicine from the pharmaceutical industry, and promoting patient safety. History will judge if we have had any success. 1 The 100 000 lives Campaign A: The campaign poster B: Locations of hospitals in the “100 000 lives Campaign”. 2 A hypothesis on factors that might influence the ability of medical journals to lead One hypothesis, no more, is that journals will be most successful in leading when it is on a topic that is of direct concern to them and where they work together. The successful example shown is the registering of clinical trials. In contrast, the work of the rationing agenda group was not directly concerned with journals and involved only one journal: it failed.

Richard Smith MB ChB, MSc, FRCP

The presumption that fictional characters may have real diseases is nothing new. The description of mental illness is a constant feature in literary criticism, and with increasing frequency, descriptions of physical afflictions suffered by literary characters have been showing up in the medical literature. Various characters have even lent their names to medical syndromes — who doesn’t know that Pickwickian Syndrome derives its name from a character in Charles Dickens’ Pickwick Papers or that the Lilliputian Syndrome derives its name from the land of little people in Jonathon Swift’s Gulliver’s Travels?1 However, characters in children’s literature have been less well examined for physical maladies. Save for a recent article on head trauma in nursery rhymes,2 this area seems largely unexplored. We propose that children’s literature provides a wealth of descriptions of disease states; one only has to look. Consider the following as examples. Winnie the Pooh The tale of Winnie the Pooh, A A Milne’s good-natured but bumbling bear, seems on the surface to be a simple children’s story. However, examining Mr. Milne’s hero in a medical light casts a different shadow — that of a short, heavy-set, polyphagic bear. It is not difficult to appreciate the relative corpulence of Winnie the Pooh. In fact, it is well described. In Chapter 2 of Winnie the Pooh, Pooh becomes lodged firmly in the doorway of his friend Rabbit’s house as a direct result of his generous girth.3 Does he, however, have true truncal obesity? To test this theory, we measured the classic Pooh doll belonging to one of our daughters. The waistline measurement was found to be 37 cm; the hip circumference was 38.5 cm. This gives a waist to hip ratio of 0.96, well over the 0.9 necessary to define abdominal obesity. This got us thinking . . . Could Pooh be an early example of the metabolic syndrome? By World Health Organization criteria, he would also need to have hyperinsulinaemia and hypertension or dyslipidaemia.4 While it is difficult (if not impossible) to measure the fasting plasma glucose level and blood pressure of a fictional character, we do believe that Milne left clues for us to follow. The first is that Pooh is always hungry — the polyphagia of impaired glucose tolerance. The second is the very nature of his food — as everyone knows, honey-coated translated to Latin is mellitus. We think that Winnie the Pooh may be a very appropriate spokesperson for metformin. Humpty DumptyHumpty Dumpty sat on a wall, Humpty Dumpty had a great fall, All the king’s horses and all the king’s men Couldn’t put Humpty together again. So, what caused the massive trauma that apparently befell Humpty Dumpty? The classic image of this character is that of a large egg, which has fallen from a wall. However, the origin of this image is exceedingly unclear. Might it, in fact, be that Humpty Dumpty was actually not an egg, but rather a human with eggshell-like bones? We propose that Mr Dumpty actually suffered from osteopetrosis, a rare disorder characterised by impaired resorption of bone by osteoclasts.5 The resulting bone is exceedingly dense and can, in severe cases, crowd out haematopoietic cells. This results in exceedingly brittle bones, and affected individuals have frequent fractures, not infrequently from “great falls”. Also, with the displacement of the marrow, extramedullary haematopoiesis is common and frequently causes hepatosplenomegaly.5 Is it possible that Mr Dumpty acquired a distended abdomen as a result of organomegaly, producing a torso that was egg-shaped? Furthermore, the resultant anaemia may lead to pallor, causing the skin to assume a colour reminiscent of an eggshell. The possibility that Mr Dumpty represents the first described case of osteopetrosis is high, and should be investigated further. Goldilocks and the three bearsIn this classic tale, Goldilocks happens upon the three bears’ house. She samples all of their food, angrily rejecting their porridge as either too hot or too cold. Then, after finding the perfect bed, she falls into a deep sleep. These are all horribly inappropriate things to do in a stranger’s house. In this story, we appear to have hypersomnia, polyphagia, social disinhibition, and irritability — all strongly characteristic of the Kleine–Levin syndrome.6 This syndrome typically (though not always) occurs in adolescent males, and involves periods of hypersomnia followed by megaphagia. While Goldilocks does not exhibit the hypersexuality frequently associated with this disorder, she does display its characteristic irritability, confusion, and impulsive behaviour. As for the apparent reversal of the sleep–eat phase in this story, it is highly likely that Goldilocks had awoken from sleep immediately before the initiation of the tale. Little Boy BlueLittle Boy Blue, come blow your horn The sheep’s in the meadow, the cow’s in the corn, Where’s the little boy who looks after the sheep? Under the haystack, fast asleep. To conventional thinkers and many a child, this rhyme conjures up an image of a lazy little boy, dressed all in blue catching an ill-timed nap while his chores go unfinished. We suggest an alternative hypothesis. As individuals can change their clothing quite easily, it would be folly to record for posterity a rhyme based upon colour of the the garments of a small child. On the other hand, what if the “blue” represents some intrinsic property of the individual? We propose that Little Boy Blue was actually cyanotic, causing a bluish hue in his skin. Examining the rest of the data available in the rhyme, it would seem likely that Little Boy Blue was born with the rare Taussig–Bing syndrome (a ventricular septal defect located immediately below the pulmonary valve).7 This causes transposition of the great vessels and subsequent pulmonary hypertension. Severe pulmonary hypertension doubtlessly led to shortness of breath and fatigue, necessitating frequent sleep. The act of blowing a horn would undoubtedly decrease venous return by increasing intrathoracic pressure and causing a relative decrement in the forward flow of blood. It is not difficult to imagine that this would be unsettling to anyone with already compromised respiratory function, let alone a small child. Little Boy Blue was not lazy; he merely needed a cardiothoracic surgeon. Modern examplesRaggedy Ann is a well known red-haired character (as is her male counterpart, Raggedy Andy, who must be mentioned for the sake of political correctness). To even the most casual observer, Ms Ann does not appear to be the picture of health. Immediately noticeable is the straight, coarse, red hair surrounding a plump, round face. Further investigation and more careful physical examination reveal in Ms Ann more subtle signs of disease. Vital signs show Ms Ann to be hypothermic (in fact dangerously close to poikilothermic) and underweight. Further dermatological inspection shows her to have extremely dry skin. Neurological evaluation shows some degree of muscle flaccidity and perhaps even atrophy. Given these findings, it seems entirely likely that Ms Ann suffers from protein malnutrition, or more specifically, Kwashiorkor.8 Ms Ann is apathetic about this probable diagnosis (and everything else for that matter), which is also a symptom of the disease. The trend continues. Modern day characters exhibit modern day afflictions. A certain olive-colored, swine-loving amphibian host of a children’s television show appears to be suffering from a variety of maladies. His most striking feature is his greenish hue; but we should not overlook his obvious exophthalmos, absence of a visible nose, hyperkineticism, and loss of coordination. A MEDLINE search gives a possible unifying answer for this constellation of symptoms: exposure to nitromethane. As this chemical is a common synthesis intermediate in agricultural fumigants and biocides, it is likely that this unfort-unate’s pond was exposed. National Toxicology Program studies of toxicology and carcinogenesis related to nitromethane in F344/N rats and B6C3F1 mice show that this chemical can cause hyperactivity and loss of coordination; hepatomegaly; anaemia; increased methaemoglobin concentration; and exophthalmos along with olfactory degeneration.9 This character’s protuberant eyes and lack of nasal structures are self-evident. We postulate that his greenish hue is in fact a combination of anaemia and increased bilirubin level from methaemoglobinaemia, worsened by hepatic dysfunction. His anaemia may be severe enough to cause a peripheral cyanosis, with his jaundice and cyanosis combining to cause a greenish colouration. ConclusionWe believe we have made nothing short of tenuous arguments that nursery rhymes and other popular children’s literature are often thinly veiled references to chronic disease states. We advise physicians to become observant of the literary works that their children and grandchildren enjoy, and, if possible, to subject them to the rigour of evidenced-based medical analysis. This might be an activity that brings the whole family together.

Brown J McCallum MD · Stuart M Smith MD

Making films from bone marrow aspirates is often a challenge for haematologists and oncologists in training (particularly oncologists). This aspirate taken from a child’s ilium ended up looking more like a femur.

Anthony R Herbert MB BS, BMedSc

William Coote Chief Executive Officer, General Practice Education and Training, GPO Box 2914, Canberra, ACT 2601. billcooteATnetspeed.com.au To the Editor: Lightning can strike in the same place twice, or at least untoward medical deaths can. Today, I was looking through the Medical Journal of Australia of 7 July 1928 and was amazed to find the report of a Royal Commission entitled “The fatalities at Bundaberg”.1 It is a tragic story. On 27 January 1928, 21 children received an injection from “an india-rubber capped bottle purporting to contain diphtheria toxin-antitoxin mixture”. Eighteen of these children became ill during the night of 27 January. Eleven died on 28 January, and another child died on 29 January. The Royal Commission found that the bottle had become “contaminated with a pathogenic staphylococcus” when it was being used the previous week. The bottle had been stored at room temperature during the intervening week. The Royal Commissioners made a series of recommendations including “biological products must be distributed in bottles or ampoules of clear glass”, “antiseptics should be included in bottles that might be used on several occasions” and, if this was not possible, bottles “should be used immediately on opening and any remaining product discarded”. One similarity with the current inquiries into Dr Patel’s activities is the complicated and confused lines of responsibility and accountability. The immunisations were administered under a Bundaberg City Council program. The Council was implementing immunisation policies of the Commissioner of Health for Queensland. The injections were given on the Council’s premises by a private doctor on contract to the council. The product was manufactured by the Commonwealth Serum Laboratories in Melbourne and supplied to the council by a private firm in Brisbane.

William Coote

Alfred Grauaug, known to everyone as “Fred” or “Freddy”, will be forever remembered as the pioneer of neonatal medicine in Western Australia. Fred was born in Vienna, Austria, on 11 August 1935, but grew up in Sydney, where he attended Sydney Grammar School and the University of Sydney, graduating in 1960. His postgraduate training included several years at the Royal Alexandra Hospital for Children, Sydney, and the Princess Margaret Hospital, Perth. When he arrived at King Edward Memorial Hospital (KEMH), Perth, in 1968, neonatology was not yet a subspecialty of paediatrics, and babies were cared for in “special nurseries”. Under Fred’s leadership, there was rapid progress to a fully equipped neonatal intensive care unit, which today has become one of the largest and best in the world. Fred was the first Director of the Neonatal Unit at KEMH. He held this position from 1968 to 1997, after which he continued as a neonatologist at KEMH and the nearby St John of God Hospital. His appointment by the University of Western Australia as a Senior Lecturer and subsequently Associate Professor in Neonatology was the first academic appointment in that specialty in the state. He was the first to use ventilators for respiratory problems in premature babies in WA. He established the first neonatal transport system, the first retinopathy of prematurity screening program and the first neonatal intensive care nursing course in Australia. He was a founding member of the Asia and Oceania Perinatal Society, and held positions on state, college and hospital committees. Before he knew of his illness (metastatic adenocarcinoma of the lung), Fred announced that his retirement from KEMH would be on 30 June 2005, two months before his 70th birthday. He would be one of the few intensivists to have continued working full-time in this demanding role at this age. Fred was known for his dedication, vision, energy, drive, determination, resilience and success. Fred valued multidisciplinary and multicultural clinical teams. Although he had a strong commitment to work, he managed to preserve a balance between work and the other aspects of his life. He was passionately involved in the Medical Association for the Prevention of War, of which he was State President for a time. With his wife Heather, he was an active supporter of the arts. Fred died on 13 July 2005. He will be sadly missed by the medical, nursing and other staff of KEMH and St John of God Hospital, by paediatric colleagues around Australia, and by his countless patients and their families. He is survived by Heather and their children David, Richard, Elizabeth, William, Emma, Michael, Alexandra and Sally. Fred’s first wife, Anne, died in 1978.

Karen N Simmer FRACP, FRCPCH · Jeffrey Tompkins FRACP

Bevan Coombes, a distinguished pathologist both in New South Wales and Queensland, died in the company of his family at Southport, Qld, on 18 December 2004, from complications associated with limbic encephalitis. Bevan was born in Sydney on 26 March 1930. He attended Sydney Boys High School and studied medicine at the University of Sydney, graduating in 1955. He did his residency at Sydney Hospital, and in 1962 completed a Diploma in Clinical Pathology. He remained at Sydney Hospital until 1964, by which time he was a Staff Specialist in pathology. In 1964, Bevan embarked on 18 months of investigative study and practice as a Fellow in Pathology at the Memorial Hospital in New York. He was very proud of being the first Australian doctor to have worked there. He became a Fellow of the College of American Pathologists in 1965 and returned to Australia in the same year, where he resumed his pathology career — juggling work, family life and further studies and trying to find time for his favourite pastimes, golf and tennis. From 1966 to 1980, Bevan was a Visiting Medical Officer at Hornsby District Hospital and worked in a partnership with four other doctors. During this time, he was made Senior Pathology Examiner for the Royal Australasian College of Radiologists. In 1980, Bevan moved to Southport, on the Queensland Gold Coast, to take up a position in a small partnership known as Queensland Medical Laboratories (QML). Over the next 22 years, he was influential in the growth and expansion of QML, not only in Queensland but also in New South Wales. He was the main instigator in the formation and operation of the QML practice in country NSW in Tamworth and Armidale. It gave him great pleasure to see the small partnership he had helped grow for over 20 years turn into the largest private medical practice in Australia. In 2002, Bevan decided that after 50 years in medical practice it was time to retire and enjoy the final years of his life travelling and doing the things that such a frantic, demanding and constant career hadn’t allowed him to do. He had always loved sport, and it was only after having a pacemaker fitted (due to heart problems in the early 1990s) and experiencing increasing problems with his knees that he was forced to give up his beloved tennis and, at a later stage, golf. Bevan will be deeply missed by his family and all those who knew him. He was a true gentleman, with an infectious energy for life and learning, who, without question, would go out of his way to help anyone who asked him. In the words of one of his closest friends, Dr Ross Hayes, “he was one of the truly intellectually honest people I have ever met”.

Howard J Coombes · Andrew H Coombes

Vietnam veterans reported a high prevalence of health problems among their partners and children in a 1998 survey. Data about the effect of our veterans’ war service on the health of their families are quite limited. These data are mainly from the Vietnam and Gulf Wars; cover veterans, partners and children independently; and largely focus on the individuals’ medical conditions and risk factors. Australia should develop a broad research strategy that uses a wider definition of health, looks at veterans’ families as a whole, and does so from a range of perspectives, including sociological, life-course and trans-generation perspectives. Preventive research should be emphasised, especially into enhancing resilience of veterans’ families. The use and usefulness of current services should be evaluated, including whether they need to be more family-inclusive.

Hedley G Peach PhD, FFPH

To the Editor: Osteonecrosis of the jaw, recently reported in patients treated with bisphosphonates, may be analogous to the historic occupational disease “phossy jaw”.1,2 Phossy jaw was osteonecrosis of the jaw caused by exposure to white phosphorus during the manufacture of matches. “Lucifer” strike-anywhere matches were first produced in 1833. They were made by dipping the match ends into a mixture containing white phosphorus.3 Workers were exposed to fumes from the white phosphorus during mixing and spreading of the dip material, and dipping, drying and boxing of the matches.3,4 The first case series, comprising 22 cases, was reported in Vienna in 1845.5 About 11% of those exposed developed the disease.5 The average period from first exposure to diagnosis was 5 years.4,5 Occasionally, this period was as short as a few months.5 The mandible and maxilla could be affected, the mandible in 60% of cases (Box).3 Dental decay was considered a prerequisite, and preventive measures included dental surveillance and treatment within the factories.4 In that pre-antibiotic era, phossy jaw was fatal in about 20% of cases, usually because of septicaemia or meningitis.5 Donald Hunter, British doyen of occupational medicine, commented: “It was the most distressing of all the occupational diseases because it was very painful and was accompanied by a foul fetid discharge that made its victims almost unendurable to others. It was obstinate and chronic, the treatment was agonising and the final result was a distressing disfigurement. It was this disfiguring effect plain to every observer that made phosphorus poisoning so notorious and led to determined efforts for its abolition in every civilised land.”5 In 1906, several European countries banned the manufacture and importation of white phosphorus matches at the Berne Convention.4,5 A safe substitute, sesquisulfide, had been discovered by a French chemist and successfully used for manufacture of strike-anywhere matches in 1898.4,6 In the United States, John Andrews published a report in 1910 of 150 cases of phossy jaw from 15 of 16 match factories then in operation.4,6 The Diamond Match Company, which held the American patent rights for sesquisulfide, waived their rights, thereby allowing the entire US match industry to use this alternative.6 Congress then passed the Esch law, which imposed a prohibitive tax on white phosphorus matches and banned their import and export.4,6 Eventually safety matches were developed that used amorphous red phosphorus, which did not have the toxic properties of white phosphorus.5 Phosphorus necrosis of the jaw A Deformity resulting from excision of entire lower jaw in a case of phosphorus necrosis. (Case of Dr John P. Andrews, The Occupational Diseases, W Gilman Thompson, D Appleton & Co, New York, 1914). B Phosphorus necrosis of entire lower jaw excised by Mr McCarthy in 1884 (London Hospital Medical College Museum).

A Michael Donoghue

This year marks the 60th anniversary of the end of World War II. The following poem pays tribute to those who carry the legacy of that war. Thus we seeThe memories of war are embodied forever. I wrote this poem some months after a 65-year-old man consulted me in the mid-1980s complaining of a band of chest pain that two cardiologists had investigated without diagnosis. As a Polish prisoner-of-war in World War II, he had been enslaved in a German coalmine, starved and inadequately clothed. He described to me how, as winter progressed, he and his fellow prisoners would wire the decaying pieces of their clothes together. His shirt was reduced to a band of fabric around the middle of his chest. His current chest pain was in the same anatomical zone as that covered 45 years before by the remnants of his shirt. Thus we see and sew and save the triangular, square or without form, coloured bits of fabric that keep us warm. Thus we see the landscape under snow, “the infected winter of our condition”, and in seeing, know. Thus we sew, as freezing prisoners of war, the remnants of the clothes we wear, Dole. Too rough: thread of repair is not enough to make us whole. Thus we save, as lining for our trap, flotsam rescued from the wave, the storm, from life’s enthralling compromise — worn and wet rags to fill the gap — we have only man’s eyes.

Stephen Leeder AO

e-Communication skills. A guide for primary care. Louise Simpson, Paul Robinson, Mark Fletcher, Rob Wilson, editors. Oxford: Radcliffe Publishing, 2005 (x + 132 pp). ISBN 1 85775 868 4. This short guide to the world of “e-communication” for United Kingdom general practitioners is a departure from the plethora of books on health informatics for primary care services, which tend to focus on detailed descriptions or evaluations of information systems and management. This book attempts something quite different and novel — to provide guidance to health practitioners on how they should use the information tools at their disposal to access information and to communicate with patients and other providers. The editors are from the north-east of England and are known for their contribution to health informatics in British general practice. Their book is designed for a UK audience, but is mostly still of relevance in Australia (although it does not deal with some important tools for e-communication in Australian general practice, such as registers and care plans). e-Communication skills comprises a series of brief chapters which can be read in 15 to 20 minutes each, providing clear take-home messages that are understandable to any clinician. The second chapter notes three key issues identified in a Scottish report on patients’ views: enabling shared decision making, patient and clinician access to evidence-based guidance, and interdisciplinary teamwork. However, the book does not follow this thematic structure. Thus, while many chapters contain very useful ideas or suggestions (such as how to prevent use of the computer from disrupting rapport in the consultation and how to send and receive better emails), it is difficult to identify the key messages from the book as a whole. This is an accessible book which will be of interest to all those involved in facilitating information management and communication within general practice. Despite some limitations, it is worth the read. Mark F HarrisProfessor of General Practice, University of New South Wales, Sydney, NSW

Mark F Harris

Simon J Foote Professor, Senior Principal Research Fellow, and Joint Head, Genetics and Bioinformatics Division, The Walter and Eliza Hall Institute, 1G Royal Parade, Parkville, VIC 3050. footeATwehi.edu.au To the Editor: I am amazed by your assertion in your recent column in the Journal that many clinicians fail to equate advances in basic research to advances in clinical medicine. 1 I would therefore like to make some small contribution to your understanding of the work of Richard Axel and Linda Buck, 2004 Nobel laureates in Physiology or Medicine, 2 and why this was considered worthy of the Nobel Prize. Our understanding of the nervous system is still very primitive, and their almost complete description of the functioning of the odorant system — a small part of the nervous system — has laid down many of the principles pertinent to the more complex fundamentals for understanding neuronal signalling and signal processing. This is essential to an understanding of neurological and psychiatric diseases. The odorant receptors are also G-coupled protein kinases, and this is one of the most frequently targeted groups of compounds for novel small-molecular therapies. If anyone still believes that Nobel Prize-winning science, such as understanding neuronal circuitry, is irrelevant to clinical medicine, they might look at the 2003 recipients for the Nobel Prize in Physiology or Medicine, Paul Lauterbur and Peter Mansfield. They received the award for the discovery of magnetic resonance imaging, which clearly plays a role in “mainstream” medicine.

Simon J Foote

Martin B Van Der Weyden Editor, The Medical Journal of Australia, Locked Bag 3030, Strawberry Hills, NSW 2012. medjaustATampco.com.au In reply: I welcome Foote’s comments, but, to the contrary, I find it entirely credible that many clinicians “fail to equate advances in basic research to advances in clinical medicine.” The reasons are many, but include not only the tortuous language of research,1,2 but also the scepticism that inevitably follows research announcements of “cures” and “breakthroughs”, which prove to be patently premature or just peter out.3 However, I am amazed that Foote appears to have missed the point of my column — the “narrowness of the Nobel awards for physiology or medicine” with their recent predominance of basic research.4 While it must be admitted that the Nobel Prize is increasingly awarded for what is undoubtedly outstanding basic research that has the potential to be of “greatest benefit for mankind”, much of this potential remains unrealised. Indeed, it was the need for recognition of clinical and epidemiological research in the Nobel awards that moved the Lancet, in its Paper of the year 2004, to seek sponsorship for the clinical equivalent of the Lasker and Nobel awards.5 In summary, it is research’s exclusivity, the rise of its false prophets, and the irrelevance of most recent Nobel Awards to everyday practice that fuel disinterest among clinicians.

Martin B Van Der Weyden

A 49-year-old man presented with medial knee pain. Arthroscopy of the knee revealed meniscal fraying and early articular cartilage degeneration (Figure). It was thought that a twisting injury may have had a hand in the matter.

John C Tuffley MB BS, FRACS

Despite recent and largely undeserved adverse publicity, mefloquine remains a useful antimalarial Although malaria causes most suffering among children in the tropics, it should not be forgotten that it remains a major cause of military casualties. In September 2003, about 300 US Marines and support staff were deployed to Liberia, West Africa. Of those troops who spent at least one night ashore, 69 contracted falciparum malaria, an attack rate of 44%.1 Forty-four required evacuation for medical care to Europe or the United States. While none died, several developed cerebral malaria and required mechanical ventilation. Malaria was also common among Australian Defence Force (ADF) personnel deployed to East Timor between 1999 and 2000, with 385 cases reported, an attack rate of 5%.2 Eighty-four per cent of these cases were caused by Plasmodium vivax, which, while not life-threatening, causes significant morbidity. Relapse of P. vivax infection, caused by the re-emergence into the bloodstream of parasites lying dormant in the liver (so-called hypnozoites), was a major problem in this group, with 96 relapses reported despite 2 weeks of primaquine therapy.2 This pattern of infection is frequently observed in patients who contract malaria elsewhere in Asia and the Pacific, as reported by Charles and colleagues in this issue of the Journal.3 Nevertheless, effective chemoprophylaxis is readily available for Australian travellers. The challenge for medical practitioners is to select the most appropriate regimen and then to convince patients to use it. Malaria chemoprophylaxis for areas with chloroquine-resistant malaria* (including the Pacific Islands, South-East Asia, the Indian subcontinent, China, Africa and South America)4 Atovaquone + proguanil 250 mg + 100 mg (child > 40 kg and adult) 1 tablet orally, daily (starting 1 to 2 days before entering, and continuing until 7 days after leaving, malarious area) OR Doxycycline (child > 8 years: 2 mg/kg up to) 100 mg orally, daily (starting 2 days before entering, and continuing until 4 weeks after leaving, malarious area) OR Mefloquine (child 15 to 19 kg: tablet; 20 to 30 kg: tablet; 31 to 40 kg: tablet) 250 mg orally, weekly (starting 2 to 3 weeks before entering, and continuing until 4 weeks after leaving, malarious area). * Whatever chemoprophylaxis is prescribed, patients should be counselled that no prophylaxis is 100% effective, and the importance of mosquito avoidance should be emphasised. Mefloquine as chemoprophylaxisMuch has been written (and broadcast) about the neuropsychiatric side effects of mefloquine. While a number of class actions have been instituted, none has as yet reached resolution. Identifying malaria chemoprophylaxis with any confidence as the cause of major psychiatric illness or behavioural disturbance is problematic,5 even more so during or soon after exposure to an extremely stressful military environment. This issue is illustrated by allegations that mefloquine was responsible for fatal assaults committed by Canadian soldiers in Somalia and British soldiers in Sierra Leone, and that it contributed to the killings of spouses by US soldiers recently returned from Iraq. Similarly, it was alleged that psychiatric morbidity among ADF personnel who had been deployed to East Timor was attributable to mefloquine therapy. While it is reassuring that in this issue of the Journal, Kitchener and colleagues report no excess morbidity among ADF personnel taking mefloquine prophylaxis,6 the issue of tolerability of mefloquine is a real one. A double-blind, randomised controlled trial of malaria chemoprophylaxis comparing mefloquine and atovaquone–proguanil (Malarone [GlaxoSmithKline]) found that 139 of 483 (29%) participants taking mefloquine experienced an adverse neuro-psychiatric side effect, most commonly insomnia or strange or vivid dreams.7 Such side effects were reported in 69 of the 493 (14%) participants taking atovaquone–proguanil. The overall frequency of adverse events was similar in the two groups (71% and 67%, respectively), but the events were sufficiently severe to require discontinuation of the drug in 5% of those taking mefloquine versus 1.2% of those taking atovaquone–proguanil. Assessing tolerance to mefloquine before exposure (as undertaken by the ADF) might identify many of those intolerant of this drug, allowing an alternative agent to be selected. Alternative agents for chemoprophylaxisIn Australia, doxycycline is the most widely prescribed drug for malaria chemoprophylaxis. While its side effects are relatively benign (eg, thrush, photosensitivity and oesophagitis), the challenge is to ensure compliance. Numerous studies have demonstrated that adherence to a daily prophylactic regimen is unsatisfactory, especially among those requiring long-term protection.8 Atovaquone–proguanil is highly effective for chemoprophylaxis, but is costly and, like doxycycline, must be taken daily. There has been a resurgence of interest in primaquine as chemoprophylaxis, a drug generally used to prevent relapse of P. vivax. However, it too must be taken daily for prophylaxis and, like many other old “off-patent” orphan drugs, it is inordinately expensive. Tafenoquine, a much-anticipated drug related to primaquine, is now in phase III clinical trials. After three well-tolerated loading doses, a single monthly dose appears protective.9 However, like primaquine, it can cause severe haemolysis in patients with glucose-6-phosphate dehydrogenase deficiency. Thus, it is necessary to screen for this condition before beginning the drug. New agents for treating malariaAs Davis and colleagues discuss in this issue, artesunate is a highly effective and well tolerated antimalarial agent.10 It belongs to the artemesinin class of drugs derived from the Chinese wormwood plant qinghaosu, and is taken by many expatriates as “emergency standby treatment” at the first sign of fever (unpublished observation). While this practice is effective, particularly when combined with appropriate diagnostic tests, such as the rapid antigen test used in the case reported in this issue by Howden and colleagues,11 it is not without risk. The very short half-life of the active metabolite, dihydroartemesinin, means that any parasites remaining in the blood after a short course of therapy may not be cleared, leading to recurrent parasitaemia.10 Suitable drugs to combine with artesunate include mefloquine, doxycycline (if taken for one week), or, in the few regions where these drugs remain effective, combined pyrimethamine and sulfadoxine.10 Further risks of relying on emergency standby treatment alone include failing to recognise non-classical symptoms of malaria (such as diarrhoea), and exhausting drug supplies through premature self-medication for non-malarial illnesses. Of note, counterfeit artesunate is offered for sale in several Asian countries where pharmaceuticals are unregulated; the only artemisinin derivative available in Australia is artemether in combination with lumefantrine.10 A malaria vaccineAn effective malaria vaccine suitable for non-immune soldiers, travellers and the even larger population of residents of malaria-endemic countries remains a priority. The long-standing search for a vaccine has been invigorated by the creation of the Malaria Vaccine Initiative, a public–private partnership supported by the Bill and Melinda Gates Foundation. The recently published phase II malaria vaccine trial in Mozambique involving this initiative and GlaxoSmithKline Biologicals is an example of the productivity of this partnership.12 While the vaccine produced a statistically significant level of protection (29.9% to 57.7%), it is likely that, for now, doctors will continue to advise mosquito avoidance and to reach for the prescription pad rather than the vaccine refrigerator when preparing patients for trips to malarious areas.

James S McCarthy FRACP, MD

Objectives: To describe the tolerability of mefloquine in Australian soldiers for malaria prophylaxis, including a comparison with doxycycline.Design: Open-label, prospective study and cross-sectional questionnaire and interview.Setting and participants: Two contingents of Australian soldiers, each deployed to East Timor for peacekeeping duties over a 6-month period (April 2001–October 2001 and October 2001–May 2002).Outcome measures: Withdrawals during the study; adverse events relating to mefloquine prophylaxis; willingness to use mefloquine again on deployment.Results: Of 1157 soldiers starting on mefloquine, 75 (6.5%) withdrew because of adverse responses to the drug. There were three serious adverse events of a neuropsychiatric nature, possibly relating to mefloquine. Fifty-seven per cent of soldiers using mefloquine prophylaxis reported at least one adverse event, compared with 56% using doxycycline. The most commonly reported adverse effects of both drugs were sleep disturbance, headache, tiredness and nausea. Of the 968 soldiers still taking mefloquine at the end of their deployments, 94% indicated they would use mefloquine again. Of 388 soldiers taking doxycycline prophylaxis who were deployed with the first mefloquine study contingent, 89% indicated they would use doxycycline again.Conclusions: Mefloquine was generally well tolerated by Australian soldiers and should continue to be used for those intolerant of doxycycline.

Scott J Kitchener MB BS, DrPH, FAFPHM · Peter E Nasveld MB BS, BMedSci(Hons), FACTM · Robin M Gregory BAppSc, MBus · Michael D Edstein MSc, PhD

Bill Young was born in Adelaide on 9 February 1917. After his secondary education at Carey Baptist Grammar School in Melbourne, he worked for the Commonwealth Bank. In 1936, his aunt, Dr Helen Young, herself a Harley Street specialist, wrote offering to support him to study medicine at St Mary’s Hospital, London. Within 3 days, he had paid £30 for his passage and was en route to London. He graduated in medicine from the University of London in 1943. After service in the Royal Navy during World War II, Bill gained a Diploma of Public Health from the University of Manchester in 1947. He returned to Australia in the same year with his wife, Dr Mary Young, and their family. They settled in Hobart, where he and Mary were in general practice together from 1948 to 1987. In addition to full-time general practice, Bill was Medical Officer of Health for both the City of Hobart and the City of Clarence, and was a member of the Medical Council of Tasmania for 34 years, the last three as President. He played a key role in establishing the Medical Benefits Fund, serving on its Council from 1952 to 1987. Bill was a Liberal member of the Tasmanian House of Assembly from 1959 to 1969, including a period as shadow Health Minister. For many years Bill was in the Royal Australian Naval Reserve, retiring in 1972 with the rank of Surgeon Commander. He served in the Korean War and was District Naval Medical Officer in Hobart from 1951 to 1972. Bill was a very good sportsman and excelled in his youth at swimming, water polo and rugby, winning swimming medals at the World University Games and playing rugby for the UK international invitational team, the Barbarians. In Hobart, he contributed his time and skills to a number of community and sporting organisations. Bill was respected by his patients and colleagues as a skilled, compassionate, practical and down-to-earth doctor. He was very gregarious and a wonderful host and derived great pleasure from his large family. A man of great energy and initiative, with exceptional organisational skills, he made a substantial contribution to his profession and to the community. In 1987, he was made a Member of the Order of the British Empire in recognition of his service to the community and to public health. The last years of Bill’s life were devoted to caring for his wife in her final illness. He died in Hobart on 19 November 2003 after a short illness. He is survived by his seven daughters and their families. Judith A Y Straton

Judith A Y Straton

Zelman Freeman Retired Physician, 1/43 New South Head Road, Vaucluse, Sydney, NSW 2030. zelfreeATbigpond.net.au To the Editor: You recently commented on the closure of public hospital common medical dining rooms in the 1960s and 1970s.1 Traditionally, these common rooms were a place where residents and senior medical staff met. The closure of these facilities had more serious consequences than the loss of “breaking bread”, as you quaintly put it. The daily meeting between residents ending their shifts and those starting work allowed discussion about the sickest patients — after the dining room closure, such discussions became much less effective. Helpful comments and advice from senior staff were no longer available. New medical advances and the strengths and weaknesses of the system were previously subjected to keen analysis, but all this medical “shop talk” was lost. More importantly, the closure of medical dining rooms contributed greatly to the loss of hospital esprit de corps, which included a sense of belonging to a worthwhile institution to which most of the medical staff were sincerely dedicated. Medical dining rooms had a century-old history in the main state hospitals. I suspect that their closure had more to do with a Jacobin ideological mindset in health departments rather than being an “efficiency” move. Medical staff were not allowed to put tables together in the new refectory, as to do so might appear elitist. I remember going into the small staff room of my hospital at that time to have afternoon tea — a service provided to both lay and medical staff — only to be told by the medical administrator that “non-recoupable foodstuffs were no longer to be served to the medical staff”. Meanwhile, the cleaners in their room next door were enjoying their hospital biscuits! This was the beginning of the “doctor-bashing” era that only the older members of the public remember, and it is not unreasonable to claim that many of the public hospital problems in patient management stem from the actions of perverse individuals who undermined the cohesive and dedicated work of the medical staff, just as they did when they abolished the distinctive hospital uniforms and badges of the nurses, who had always taken pride in their own hospital traditions. A bland coloured gown was substituted to remind them that they were “health workers”. No wonder there is difficulty in recruiting new staff and building a sense of dedication to such an amorphous service. Administrators need to be reminded that good traditions should not be abolished without mature reflection on the consequences.

Zelman Freeman

William B Molloy Gynaecologist, Suite 10, Level 7, William Bland Centre, 229-231 Macquarie Street, Sydney, NSW 2000. drmolloyATbigpond.com To the Editor: I congratulate you on your column in the 1 November 2004 issue.1 For years, I have stated that it is a problem, not only in the public hospitals, but now creeping into the private hospitals, that there is no private room available for doctors to talk among themselves. This also includes the theatres, where only one room is available for both nurses and doctors, and I think this is a giant mistake. I remember that when I was a young doctor, consultations were arranged over lunch. Doctors talked to each other and everyone knew about the important cases in the hospital. It was a teaching and learning experience. In addition, in the afternoon, after one had finished work and was relaxing over the newspaper, again there was contact between doctors. At St Margaret’s Hospital, where I was the Medical Superintendent for fourteen-and-a-half years, between 1969 and 1984, I fought until the day I left to maintain these rooms. The dining room was lost, but at least there was a room where doctors could gather after they did their morning ward rounds. There was an enormous amount of work done and many opinions proffered in that room, and to this day many doctors tell me how much they miss that experience in the hospital they now attend. Isn’t there someone who can point out that, although the public health system is a shambles at present, we should not allow the private system to go down the same track? Sadly, it appears to be doing just that.

William B Molloy

Peter F Burke Surgeon, PO Box 84, Newborough, VIC 3825. burkeATvic.australis.com.au To the Editor: Somerset Maugham noted, “At a dinner party one should eat wisely but not too well, and talk well but not too wisely”.1 Your recent column lamenting the disappearance of doctors’ dining and common rooms2 precipitated a flood of warm memories of, in my case, St Vincent’s Hospital in Melbourne in the 1960s, 1970s and early 1980s. Now based in the Latrobe Valley, Victoria, I have witnessed first-hand, over almost 20 years, much grievous political and social engineering — the abject failure of the first “privatisation” of a public hospital in Victoria and, in the custom-designed “greenfields” hospital, the near-complete lack of provision of facilities for consultant medical staff, leading to their fleeting meeting in corridors and carparks. It is unlikely that C P Snow had this in mind when he wrote of “corridors of power”.3 Contemporary medical staff are indeed an amorphous lot. The clinical white coat is but a memory, and often the only way to recognise a doctor, usually dressed in a manner that would suggest forthcoming involvement in a “Clean up Australia” gathering, is the fashionably appropriate half-noose stethoscope, which, akin to a saint’s halo, confers immediate status on the bearer. Laennec, who invented the stethoscope in 1819, had surely not foreseen the commercial potential of his epochal invention.

Peter F Burke

Bruce P Waxman Medical Program Director, Surgery Program, Southern Health, PO Box 478, Dandenong, VIC 3125. b.waxmanATsouthernhealth.org.au To the Editor: Your recent experience in a staff cafeteria1 is clearly anecdotal, as are my own. I believe, however, the balance needs to be redressed. There is little point in campaigning for “return of the doctors’ common dining room”, as, at least in the public sector, there are no funds available for this campaign. I have been very impressed with the camaraderie that exists in the staff cafeteria at Dandenong Hospital, Southern Health, because medical care is now a team approach and I have the opportunity to meet with medical students, interns, house medical officers, registrars, nurses and administrators, either over a cup of coffee provided free by the Health Service, or a meal. The staff cafeteria has been a meeting place for the team, engendering a team approach to medical care which, I believe, is appropriate to champion for the future of healthcare delivery in Australia.

Bruce P Waxman

Bruce Griffiths was born in Ballarat on 13 October 1938 and died on 15 October 2004, only a few weeks after being diagnosed with a brain tumour. A son of the late “W R” Griffiths, obstetrician and gynaecologist and former President of Ballarat Base Hospital, Bruce followed in his father’s footsteps. After graduating from the University of Melbourne in 1963, Bruce spent a year as a Resident Medical Officer at Launceston General Hospital in Tasmania. This, together with being born into a rural medical family, convinced him that eventually his career lay outside the capital cities. He left Australia for 4 years to train in the United Kingdom, and became a Fellow of the Royal College of Surgeons of Edinburgh in 1968. He then returned to Launceston for a year before moving to Ballarat, where he practised for more than 20 years. Bruce was a true generalist, holding appointments as a general surgeon at Ballarat Base Hospital and The Queen Elizabeth Centre, while at the same time practising as a general practitioner in the Ballarat Group Practice. He played a significant role in the Professional Staff Group of the Base Hospital. In particular, he was the Group’s chairman in the late 1980s during the planning of the new ward and operating theatre block. Few staff, patients and visitors who walk through the wonderful building today know that they do so only because of the earlier vision and perseverance of people such as Bruce. Bruce resigned from the Ballarat Base Hospital in 1992, but continued to devote his life to the care of rural Australians. After leaving Ballarat, he practised in Derby (WA) and Maryborough (QLD), before joining an Aboriginal health centre in Kempsey (NSW). He was still working at the centre just 5 weeks before his death. When Bruce left Ballarat, the Director of Medical Services wrote at the time that Bruce was owed a debt for the work he did at the Base Hospital over many years. Perhaps it was in part repayment of the debt that, on learning of his illness, friends travelled from Ballarat to his home in NSW to say farewell. Bruce is remembered as a man of few words, but his opinions were always considered and truly held. He loved music, was devoted to his family, and was a familiar figure walking his labrador dogs around Lake Wendouree. Bruce is survived by his wife Wanda and three sons. Hedley G Peach

Hedley G Peach

The Pope, a former state premier, actors and sportspeople can testify that Parkinson’s disease is no discriminator. Alan Nicholson died on 18 October 2004, following his own courageous battle with the disease. He was born on 8 March 1930 in Melbourne. Alan graduated from the University of Melbourne in 1956. After Resident Medical Officer appointments in Melbourne, he trained as a psychiatrist at the Ballarat Mental Hospital, established to relieve overcrowding at the Kew Asylum in Melbourne. He obtained a Diploma in Psychological Medicine in 1961, and in the same year became a member of the Royal College of Psychiatrists of London and a Fellow of the Australian and New Zealand College of Psychiatrists. Alan’s first appointment as a specialist was to the Larundel Psychiatric Hospital in Melbourne, then in 1967 he was appointed to Ballarat Base Hospital, where he continued to work until illness forced him to retire in 1995. When Alan embarked on his career as a psychiatrist in 1959, the practice of psychiatry was a world apart from the way it is practised today. Alan was fortunate to have entered psychiatry in Victoria during the “Daxian” years. This period saw the advent of the Mental Hygiene Authority, later the Mental Health Authority, chaired by Dr Eric Cunningham Dax, and, with it, major changes to the care of people with mental illness and the education and training of the staff who looked after them. Alan played a significant role in the Professional Staff Group of the Ballarat Base Hospital and was the Group’s chairman in the early 1980s. As chairman, Alan oversaw the introduction of a credentials committee for doctors practising at the Base Hospital. This was a new and major influence on the practice of medicine in Ballarat. The smooth introduction of the committee was due to Alan’s stewardship. An example of his foresight and good judgement was his striving for at least a common liaison member, if not a combined committee, between the Base Hospital and St John of God Hospital in the interest of avoiding duplication and promoting the interrelationship of medical practitioners in the city. Alan also played a significant role in the Australian Medical Association and was Honorary Secretary of its Ballarat subdivision for many years. Apart from his medical work, Alan is remembered as an avid and expert collector, particularly of stamps, old banknotes, antiques and wines. He was an enthusiastic member of the Ballarat Wine and Food Society, serving on its committee and as its President and Cellar Master. Alan had the rare honour of being a member of several international wine and food societies. He was also a member and President of the Board of Sovereign Hill, Ballarat’s renowned reproduction of a goldfields township. Alan is survived by his wife Jane and their five children, two of whom are doctors. Hedley G Peach

Hedley G Peach

A national rollout of faecal occult-blood screening, federally funded, is the best approach Bowel cancer is Australia’s commonest internal cancer.1 There is indisputable evidence that population screening with faecal occult-blood testing (FOBT), allowing early detection of cancer and detection and removal of the precursor adenomatous polyp, could save close to 2000 lives each year.2 The federal government is to be commended on its orderly approach to the issue through the Bowel Cancer Screening Pilot Programme (www.cancerscreening.gov.au/bowel/). It is important that this commitment to colorectal cancer screening continues, given also its clear cost-effectiveness.3-6 But who pays? There is no Medicare rebate for almost all screening in Australia, and definitely not for bowel cancer. But what about other methods of screening? Arguments centre on whether we need evidence from meta-analyses of multiple randomised-controlled trials (RCTs) of screening showing mortality reduction before recommending a particular method, or whether less rigorous proof will suffice. Colonoscopy has the highest level of sensitivity and specificity for detection of colorectal neoplasia, but there are no RCTs of screening using colonoscopy, let alone any meta-analyses. Because the FOBT trials have shown a link between a favourable shift in staging and mortality reduction in populations invited to participate in screening, the standard of proof for considering any screening program to be effective can now be the less stringent demonstration of a favourable shift in staging compared with controls. But, without controlled trials, even that information is unavailable for colonoscopy. Colonoscopy is not without risk, with rates of postpolypectomy transfusion requirement, perforation and death being 1 : 500, 1 : 1000, and 1 : 10 000, respectively.7 These complication figures may be too high when applied to the more robust screening population, but they nevertheless underpin the need to be careful before advocating an invasive screening procedure for a healthy population. Flexible sigmoidoscopy is another option, supported by level III evidence and some cost-effectiveness calculations. Controlled trials of flexible sigmoidoscopy are ongoing. So what about computed tomography (CT) colonography (virtual colonoscopy)? Great expectations have been generated by the lack of need for sedation, a low complication rate, short examination time, safety (apart from radiation8), and potential (not yet actual) avoidance of the need for bowel preparation. In the best centres, the sensitivity and specificity for neoplasia detection is equal to conventional colonoscopy, and it is cheaper.9,10 However, once it is positioned beyond its dedicated pioneers, the performance becomes less certain.11 The Royal Australian and New Zealand College of Radiologists has reservations about its widespread implementation for screening (Clinical Associate Professor Richard Mendelson, Colorectal Cancer Reference Group Member, RANZCR, personal communication). For best results, the hardware needs to be advanced (eg, 16-detector spiral scanners), the software optimised (providing three-dimensional endoluminal “fly through” views), scans obtained in supine and prone position, and the radiologists skilled and experienced.12 Conventional colonoscopy is needed to confirm and remove detected lesions (in an Australian study, 27% of participants needed colonoscopy13). Managing the small polyps found by CT colonography, which many would consider an incidental finding of minimal risk, inflates the necessity for colonoscopy both immediately and at follow-up. The chance that two bowel preparations will be required is unpalatable, partly explaining the lack of preference for virtual over actual colonoscopy.14 Having both procedures after one bowel preparation is possible but difficult to organise. Finally, there is not level I, II or even III evidence for cancer mortality reduction or stage shift with CT colonography. Determining an individual’s best screening strategy involves assessing familial and personal risk factors, and age-specific risk for colorectal cancer for the 5- to 10-year period over which colonoscopy affords protection against the risks of screening. FOBT is advocated in average-risk people aged 50–75 years, based on RCT evidence, validating taxpayer funding. Whether the uncertainty (with respect to risks versus benefits) of more invasive screening is acceptable becomes an individual choice. The “What would you do, Doc?” question, which is often personality rather than evidence driven, may tip the balance. In the United States, colorectal cancer screening guidelines emphasise “choice”15 — “Just do something”. Participation in population screening is very important, but whether offering “choice” improves rather than paralyses participation is uncertain. But who pays? There is no Medicare rebate for almost all screening in Australia, and definitely not for bowel cancer. Indeed, the Medicare-rebatable FOBT strategy is inappropriate for screening for colorectal cancer. It specifies a guaiac and an immunochemical test, a combination that has unknown performance characteristics in screening. For average-risk people, there is certainly no Medicare rebate for any of the more invasive endoscopic or CT screening techniques. All this information needs to be considered in the informed-consent process. So what would you do, Doc? A well organised (rather than once-only) screening program is important. A national rollout of faecal occult blood screening, federally funded, is the commendable approach being tested in the pilot program. But beyond or outside that? I would choose one of the two tests (Bayer “Magstream” or Enterix “!nform”) used in the national pilot program — both have adequate performance characteristics for bowel cancer screening — favouring perhaps the Australian “!nform” test because of its associated program of implementation, and ready applicability in general practice.16 Virtual colonoscopy? Not yet, and certainly not until I have identified a neighbourhood CT facility with performance characteristics equal to the best published to date.8 Self-funded colonoscopy? No, and certainly not before my risk for colorectal cancer death over 5–10 years overtakes my risk of serious complications from colonoscopy by an order of magnitude — that is, at age 55–60 years.2 And, for any colonoscopy required in the screening pathway, I would choose a colonoscopist with a good performance “score card” and a licensed centre.

Finlay A Macrae MD, FRACP, FRCP