History and humanities

Virtue ethics and professional roles. Justin Oakley, Dean Cocking. Melbourne: Cambridge University Press, 2002 (xii + 188 pp). ISBN 0 521 79305 X. Authors Oakley and Cocking have spent the past ten years reflecting on which moral theory enables professionals to pursue their work ethically. In this book they offer an incisive argument for selecting virtue ethics over two commonly applied rivals — utilitarianism and Kantianism. The authors believe that this virtue-based model has the advantage of being both theoretical and practical. The novice moral philosopher is given a brief guide to the origins and variants of virtue ethics. We are introduced to the Aristotelian view that a specific set of character traits is needed in order to live a "flourishing life". We are also told that to live the good life we need to acquire phronesis — practical wisdom. The authors then add their own concept of the "regulative ideal" to the Aristotelian argument. People are guided by a "regulative ideal" when they have "internalised a certain conception of correctness or excellence in such a way that they are able to adjust their motivation and conduct so that it conforms — or at least does not conflict — with that standard". The idea is aligned to Aristotle's practical wisdom in that it encompasses an appreciation of what constitutes the general good. The book describes how virtue ethics and the "regulative ideal" apply to medical practice and links the concept of a "flourishing life" to the goals of the medical profession. Consideration is given to what constitutes desirable virtues in a doctor and what character traits enable them to achieve the goal of enhancing health and corresponding human "flourishing". The authors settle on a familiar catalogue of virtues: a deep capacity for compassion, truthfulness, trustworthiness, courage, humility and a consistent inclination to act justly. Does the book convince the reader of the benefits of virtue ethics for the professions? Many would support the view that inculcating and promoting certain character traits in doctors would enable them to make a more positive contribution to their patients and patients’ families — but is this a sufficient basis for good practice? Does virtue ethics provide the means to disentangle the myriad moral dilemmas that doctors encounter in their day-to-day practice? Does virtue-based ethics sort out complex issues like euthanasia, abortion, gene therapy, involuntary hospitalisation, respecting confidences, allocating resources, and many other quandaries? All theories have their limitations. Ultimately, we may find common ground between various theories and achieve an integrative view where their advantages are harnessed. Sidney BlochProfessor of Psychiatry University of Melbourne, VIC

Sidney Bloch

On 11 September 2002, at the age of 45, Tim McArdle was killed in a road accident while cycling. Tim was the third of seven children, a son of the late Frank McArdle, formerly a general practitioner in Ballarat, Victoria, and mother Patricia, a nurse and nurse educator. Born on 30 September 1956 in Ballarat, he was educated at Villa Maria and St Patrick's College, Ballarat. Tim was an outgoing, humorous and playful person who loved people. From an early age, his many talents and formidable intellectual qualities were evident. He gained a place at Monash University Medical School in 1974 and completed the medical course with seemingly effortless ease, graduating among the top 10 students in his year. Tim worked at Prince Henry's Hospital, Melbourne, the Royal Children's Hospital and the Queen Victoria Medical Centre, where he obtained a diploma in obstetrics and gynaecology. He then spent a year in Cohuna, in northern Victoria, working in a typical rural general practice, before returning to Melbourne to run the Moorabbin Hospital Emergency Department for a year. In 1987, Tim was invited to Warragul, in south-eastern Victoria, where he decided to join an established practice because of the congeniality of the colleagues and the "grass tennis courts". It was in Warragul that his medical and personal skills blossomed and he developed a love for the local community. He had the good fortune to enter a happy and thriving medical practice, working with colleagues with whom he established wonderful personal and professional friendships. Tim's own practice focused on maternal and child health, but over the years he branched out into other areas. Tim's interest in community medicine inspired him to write a weekly local newspaper column on health issues for 15 years, under the by-line of "Dr Kev". In more recent years, he chaired a regular session on health issues on ABC Regional Radio. In 2000, he spent five weeks as a volunteer medical practitioner in East Timor. Tim loved sport, including tennis, golf, cross-country skiing and horse-racing, which for him were a source of relaxation and comradeship. He was also a natural musician and inveterate performer. He supported himself at university playing piano in restaurants and bars, and later played for 12 years with a group of medical friends in a local Warragul band called "The Fabulous Beatroots". Tim appeared particularly happy and content in the company of his partner Robyn during the last year before his death. His sudden and tragic death leaves a huge gap in rural medical services and is an enduring loss to his mother, siblings and many friends.

Peter McArdle

John Simpson Kirkpatrick, generally known as "Simpson", is one of the most famous Anzacs of the Gallipoli campaign.1-3 From the Gallipoli landing on 25 April 1915 until his death 25 days later, Simpson and his donkey retrieved perhaps 300 casualties from the battlefield. He did this work independently, sometimes in disregard of orders, and frequently with a disregard for danger that kept the onlooking soldiers in the trenches enthralled as they watched him moving calmly to rescue wounded soldiers while under direct fire from the enemy. He is often thought of as the quintessential larrikin Anzac, although he was born in England and only spent four years in Australia before enlisting in the Australian Army Medical Corps in 1914. Simpson's childhood was spent in Tyneside, United Kingdom, where his selfless military service is also well remembered. Early childhood John Kirkpatrick was born on 6 July 1892 in a newly-built4 three-roomed terrace tenement at 10 South Eldon Street, in the Tyne Dock area of South Shields.5 He was the son of Robert Kirkpatrick (c.1845–1909), a merchant navy seaman, and a domestic housekeeper, Sarah Simpson (c.1856–1933).6 Kirkpatrick had three surviving elder sisters and one elder brother. Census records reveal that their mother was sometimes away, and help with the care of the children in 1892 was provided by a domestic live-in servant, Ettie Crozier, aged 15 years.5 His younger sister Annie (born 10 November 1884) wrote to John and sent him cigarettes when he was working as a ship's stoker on Australian coastal traders and subsequently at Gallipoli.2 It is known from Kirkpatrick's surviving letters that food was not plentiful in his family, and the neighbourhood was poor.2 There was no social welfare. In one letter dated 31 May 1911 he replies to his mother's plan to become a shopkeeper in Edward Street, South Shields: A short life of Simpson 1892 John Simpson Kirkpatrick ("Simpson") born at 10 Eldon Street, Tyne Dock, South Shields, UK. 1898–1905 Attended school. 1906–1908 Worked as a milk-float boy. 1908–1909 Volunteer coastal-defence gunner with the 4th Durham (Howitzer) Battery of the 4th Northumbrian County of Durham Brigade, Royal Field Artillery. 1909–1914 Went to sea. Worked as a stoker and engine room greaser, mostly on Australian coastal shipping vessels. 1914 Enlisted in the Australian Army Medical Corps on 24 August, 20 days after Britain declared war on Germany. 1915 Landed at Anzac Cove on 25 April as a stretcher bearer with 3 Australian Field Ambulance. An undisciplined soldier, Simpson worked alone with donkeys he found in camp. He retrieved 200–300 men before he was killed by machinegun fire on 19 May — his 25th day of active service. I am very much afraid that you are in the wrong district ... for the people round there would rob "Old Nick" himself if he gave "Tick" [ie, credit] and I suppose you will know that there is no hope unless you give the good old "Tick". I wasn't four years going round with the milk without finding out a little of there [sic] weak points. Robert Kirkpatrick and his family moved frequently, perhaps because of difficulties paying the rent. John Kirkpatrick lived in at least five homes, and possibly six or more, during the first 16 years of his life. His father was frequently at sea, until he was injured in 1904, thereafter remaining at home as an invalid until his death in 1909 when John was 17 years old.2 The boy's entire childhood was spent in working-class streets. Census data from 1891 lists the occupation of the Kirkpatricks' neighbours as sailor, boilersmith, dressmaker, blacksmith, steam-engine fitter and iron moulder;5 in 1901 the neighbours were a shipyard plater, shipyard labourer, boilersmith and draper's assistant.7 The local society in which he grew up was dominated by shipbuilding and its industries, the Tyne River and the sea beyond. Schooling Kirkpatrick began school, aged six years, at the Barnes Road Infants' School in 1898. Surviving archives record that the school was crowded; in 1904 (four years after Kirkpatrick had left) it was closed for some weeks because 40 of the 509 pupils had measles, mumps, whooping cough or diphtheria. Kirkpatrick's initial two years of education included a curriculum of "reading, recitation, writing, arithmetic, singing and drawing".8 In July 1900, about the time of his eighth birthday, Kirkpatrick transferred to the South Shields Barnes Road Boys' School, where he remained a pupil until 19 June 1903.9 His attendance was exemplary, and he was absent for only one day throughout the school year of 1900–1901.10 He learned to read and write fluently at school. He was a prolific letter-writer in his later teenage years, although his punctuation and spelling were somewhat deficient. In 1903 he transferred to Mortimer Road Council School, where he completed his formal education in 1905 immediately before his thirteenth birthday. Tyneside children, contemporaries of John Simpson Kirkpatrick, playing in the street at the beginning of the 20th century. Epidemics of diphtheria, measles, scarlet fever, whooping cough and mumps swept through the Tyneside estates. (Photograph courtesy of the Ward Philipson Group, Gateshead, UK.) After Kirkpatrick's death at Anzac Cove, two memorial bursaries were instituted at Mortimer Road School, but these were abandoned in the 1960s. A building at the school was also named the Kirkpatrick House Block. The building was subsequently demolished in 1990. Of Kirkpatrick's surviving correspondence, nothing remains that refers to his childhood. Information from his sister Annie suggests that he had a typical Tyneside boyhood.2 The young Jack "played cricket using wickets chalked on a brick wall". He kept rabbits and "was an ordinary boy with little relish for scholarship but delighted in pranks and games and an occasional escapade". He played in the environs of the Gutt leading to Tyne Dock. The "Gutt" was an inlet with stone paving sloping down into the water to facilitate coal-loading. It was a scene of constant activity between people, animals, goods and the water of the Tyne. He attended weekly Sunday School at St Mary's Church (now demolished). Teenage years The terrace of John Williamson Street, Tyne Dock, South Shields, UK, built about 1889. Simpson lived briefly at number 360, far right. Kirkpatrick left school before his 13th birthday, and was employed as a milk-float boy. His sister Annie wrote later: 2 Jack had a dappled grey pony [which pulled the milk float] with which he became close friends. His devotion to "Andrew", to whom he talked like a human, was known to everybody on the milk rounds. Like many local teenage boys, Kirkpatrick volunteered to train at weekends as a coastal defence gunner in the Royal Field Artillery.11 He served in the Howitzer Battery at South Shields and trained nearby at Trow Lea and attended annual Volunteer Camp at Fleetwood in Lancashire, with his volunteer colleagues. It is probable that this was the first time, at 17 years of age, that he had journeyed beyond Tyneside. After his father's death in 1909, Kirkpatrick left Tyneside to go to sea. His second ship, the SS Yeddo, brought him to Australia via South America. He then worked for four years, mostly at sea, as a stoker and as an engine-room greaser on Australian coastal shipping vessels. He tried cane cutting and horse-mounted stock work in north Queensland, each for a period of about one week, but found the overwhelming heat and humidity intolerable. Life-saving influences? John Kirkpatrick spent the first 16 years of his life in South Shields, Tyneside. It was here that the life boat was invented by Greathead and Wouldhave in 1789. A second lifeboat, the "Tyne", managed by the Tyne Lifeboat Institution, was said to have saved 1028 lives between 1833 and 1894. It was then placed on public display in Ocean Road, South Shields, close to where Simpson grew up. The painting, "A wreck off the South Pier, South Shields, 1861", by John Scott, shows the "Tyne" in action. The painting has been on display in the South Shields Museum and Art Gallery since the late 19th century. (Reproduced courtesy of Tyne and Wear Museums.) During this time Kirkpatrick was leading a knockabout life. He jumped ship when it suited him, and, as his letters to his mother showed,2 enjoyed a drunken brawl with his fellows. This medallion showing Simpson and his donkey is presented annually by the Returned and Services League to an outstanding Australian "for exceptional service to the Australian community demonstrating compassion, endurance and dedication". (Photograph courtesy of Dr Robert Pearce.) At the outbreak of war in 1914, he was one of the first to enlist (on 25 August 1914) at Perth, in 3 Australian Field Ambulance. His physical strength and fitness (of which he was very proud) were ideally suited to his Anzac duties as a stretcher-bearer in the Australian Army Medical Corps. On a number of occasions he rescued two wounded soldiers simultaneously. His gregarious "Geordie" personality stamped him as a "character" among his fellow soldiers at Gallipoli. He has been described variously as "original, forthright, fearless, ingenious and generous hearted"; and as "witty, cracking jokes, happily lazy at times, careless of dress, a friendly chap and one who was a 'handful' to ... his Section Sergeant".2 Simpson's lasting fame arises from just 25 days of active service. What made him such a hero? The record we have cannot quite unfold the enigmatic "incalculable personal factor" which Lord Moran felt was "the essence of courage".12 "Simpson" on the web Simpson and his donkey (John Simpson Kirkpatrick). Australian War Memorial. <http://www.awm.gov.au/encyclopedia/simpson.htm> Simpson and his donkey. Convict Creations. Com — The hidden story of Australia's missing links. <http://www.convictcreations.com/history/simpson.htm> John Simpson Kirkpatrick. July 6, 1892 – May 19, 1915. Anzac House Youth Hostel. <http://www.anzachouse.com/simpson.shtml> Stretcher bearers. Digger history: an unofficial history of the Australian Armed Services. <http://www.diggerhistory.info/pages-nurses/stretcher.htm>

John H Pearn MD, PhD, FRACP · David Gardner-Medwin MD, FRCP

In January 2002, 12 European Union countries introduced a new common currency, the euro, which soon afterwards displaced the national currencies of the member states. With that historical act, along with the loss of monetary individuality, we lost an unusual "document" of medical history: the Greek 10 000-drachma note. The front of this banknote shows George Papanicolaou, the "father" of exfoliative cytology (Box, A). Born in Kymi, Greece, in 1883, he studied medicine in Athens and graduated with honours. After emigration to the United States in 1913, he began to study the ovarian cycle in animals (and later in humans), using vaginal smears. He identified the female sexual cycle and, in 1928, presented his results of "possible diagnosis of certain conditions, especially malignancy" by vaginal smear. Through his studies, he became aware that "carcinoma of the fundus and carcinoma of the cervix are to some extent exfoliative lesions, in the sense that cells at the free surface of the growth tend to be dislodged and subsequently find their way into the vagina". In 1941, he presented the method of taking and staining vaginal smears and described the cellular appearance in carcinoma of the uterus. His method was validated and adopted worldwide as the "Papanicolaou test". Papanicolaou died in Miami, Florida, in 1962. Nowadays, cervical cancer, once the most lethal of gynaecological carcinomas, is rare in Western countries, but still the first cause of death among women in most developing countries, where few women receive Pap smears. The reverse side of the banknote shows the god of healing, Asklepios (also called Asclepius or Aesculapius), who lived around 1200 BC in Thessaly, Greece (Box, B). In Greek mythology he was the son of Apollo and the nymph Koronis (Coronis, Cronis). Apollo entrusted the education of Asklepios to the centaur Chiron, who taught him how to treat wounds and how to use herbs for healing. Zeus, who was afraid that Asklepios's great healing powers might render all men immortal and thus challenge the power of the gods, killed Asklepios with a thunderbolt. (Another version of the myth relates that Asklepios was made immortal.) The symbol of Asklepios is the staff with a serpent coiled around it. Besides being mystical and symbolic animals, sacred snakes played an important role in healing rituals. Current biological knowledge suggests that growth factors, which are present in the saliva of certain snakes, may have stimulated healing processes at the site of wounds. The historic 10 000-drachma note A. The front of the 10 000-drachma note, showing George Papanicolaou (1883–1962), with his microscope and famous Atlas of exfoliative cytology, published in 1954. B. The reverse side of the 10 000-drachma note, showing Asklepios, the god of healing, with his symbol, the staff with a serpent coiled around it. Beside him, a healing scene depicts a sacred snake licking or biting the right shoulder of a sleeping patient.

Theodor Tirilomis MD FETCS · Stella Malliarou MD

Whether it was his unusual culinary flair or the way he discovered his profession, there was nothing conventional about Vernon Richard Keep. Born in Harrow, UK, on 22 July 1927, Vernon had set his sights on being a naval engineer. Joining the Royal Navy in 1944, he spent four years as Chief Stoker aboard the Duke of York and various Australian warships, until pulmonary tuberculosis cut short his naval ambitions. Twelve months of being laid up in various sanatoria kindled Vernon's interest in bacteriology and sowed the seeds of his medical career. On release, he was advised that he would need a medical degree if he wanted to be a bacteriologist. Upon matriculating, Vernon enrolled in Middlesex Hospital Medical School, London, in 1949. Recurring TB meant a protracted study period, and he graduated in 1957. After various training posts in medicine, surgery, casualty and urology, he settled on the emerging field of anaesthesia. Training included thoracic surgical anaesthesia at the Brook Hospital, London, and plastic and faciomaxillary surgical anaesthesia at the Queen Victoria Hospital, East Grinstead. His pioneering work included opening one of the world's first intensive care units at Middlesex Hospital. Disenchanted with the British National Health Service, Vernon migrated with his young family to Perth, Western Australia, in 1962. On arrival, he briefly held the position of Staff Anaesthetist at Royal Perth Hospital before being appointed the first Director of Anaesthesia at Fremantle Hospital. It was during his tenure at Fremantle that he formulated the Civil Disaster Plan for the busy port city. Improvements in anaesthetics led him to experiment with the concept of rapid-recovery day surgery, and he opened the first custom-designed clinic, Kaleeya House, in 1968. Interest was so great that, in 1974, the first purpose-built outpatient hospital in Australia, Kaleeya Hospital, was opened in East Fremantle. As Chairman of the Board, he oversaw the finer details, such as the selection of lime-green paint and psychedelic bed linen. In 1980, Vernon and his wife Lyn retired to their farm, "Lanark Park", in Wokalup, for some "peace and quiet". But retirement proved short-lived, and he took up various medical positions around the Harvey area until ill health forced him into hospital in October 2002. From his ward on the ninth floor of Fremantle Hospital, Vernon was reassured to see his old surgery, Kaleeya House, and the Medical Library at Fremantle Hospital, which he had founded nearly 40 years previously. He died on 4 January 2003 from pneumonia complicated by TB damage and emphysema. He is survived by three sons and three grandchildren.

Matthew J Keep

Communication for health care. Catherine A Berglund, Deborah C Saltman (editors). Melbourne: Oxford University Press, 2002 ($44.95, xiv + 257 pp). ISBN 0 19 551298 7. “What do others think of you as a communicator?” This book invites readers to explore their habitual communication styles, and to consider whether they are appropriate for clinical care. Most of the 18 chapters by 18 authors call for demanding self-awareness. Readers are drawn into examining their personal realities. Participants follow the path of a series of workshops supplemented by brief but succinct informal summaries. Most chapters provide activity boxes, simple categorisation models and exercises for evaluation. Frequent examples connect concepts raised to the realities of patients and their situations. Facets of techniques, personality, habits and assumptions that can help to clarify “What’s the right thing to do?” are learned. Readers can expect to gain insights into their own performance, as well as a set of frameworks and tools they can use with their students, their colleagues, their patients and their families, and even with their own children and spouse. Chapter cross-references help to maintain coherence across a range of topics that are not limited to interpersonal conversation. Subjects include information searching using libraries and informatics, writing and reporting, and working with the media. All the material is up to date, very practical, useful and readable at all levels, from the lay person to experienced practitioner. Ken CoxEmeritus Professor of Surgery Hunters Hill, NSW

Ken Cox

Although many 19th-century misconceptions about the foreskin have been dispelled since it was shown that infantile phimosis was not an abnormality, the ideas that ritual or religious circumcision arose as a hygiene measure, and that circumcision makes no difference to sexual response, have persisted. The first idea should be dismissed as a myth and the second has been seriously questioned by modern research. Owsei Temkin, renowned medical historian, has written: ". . . we are all apt to accept a historical myth where we cannot rely on historical knowledge. Where history is lacking, mythology takes its place, and those who disdain history are among the foremost victims of mythology."1 This is most certainly true when we consider male circumcision. Although much progress has been made since 1949 in dispelling 19th-century myths about the male foreskin (for example, that infantile phimosis was a pathological abnormality; that circumcised men were immune to syphilis; that the foreskin was a "cesspool"; and that circumcised boys did not masturbate), others have proved more persistent. Among these are the idea that ritual circumcision, as practised by certain tribal peoples, arose as a hygiene measure; and the assertion that the removal of the foreskin makes no difference to sexual function. There is no evidence that customary circumcision originated as a hygiene measure. Many primitive cultures carried out a variety of mutilating procedures on different parts of the body, including the genitals of both boys and girls, but the reasons for these practices are obscure and contested. These cultures also practised cannibalism, human sacrifice, infanticide, widow-burial, foot-binding and other traditions not endorsed today. Conflicting theories have been advanced to account for the rise of ritual operations on the male and female genitals, among which are the following: 2 a propitiatory sacrifice or sign of submission to a deity (probably a milder form of a ritual which began as human sacrifice); an offering to the god or goddess of fertility to ensure children; a mark of tribal identification; a rite of passage from childhood to adult responsibility; an attempt to emphasise feminine or masculine characteristics in girls and boys by removing the parts of the genitals (clitoris and foreskin) believed to resemble the genitals of the opposite sex; and a means of humiliating and marking defeated enemies and slaves. The only point of agreement among proponents of the various theories is that promoting good health had nothing to do with it. In the days before aseptic surgery, any cutting of flesh was the least hygienic thing anybody could do, carrying a high risk of bleeding, infection and death. None of the ancient cultures which traditionally practised circumcision have claimed that the ritual was introduced as a hygiene measure: African tribes, Arabs, Jews, Muslims and Aboriginals explain it differently, but divine command, tribal identification, social role, respect for ancestors and promotion of chastity figure prominently.3 It was only in the late 19th century, when mass circumcision was being introduced for "health" reasons, that doctors sought legitimacy for the new procedure by claiming continuity with the distant past and reinterpreting its origins in terms of their own hygiene agenda.4,5 Although the policy statement recently issued by the Royal Australian College of Physicians reaffirms earlier statements that there is no medical indication for routine circumcision, it does suggest that tribal circumcision arose as a hygiene measure in desert environments, and it is disappointingly silent on the significance and role of the foreskin itself as a normal and prominent part of the male genitals.6 Despite the assertion of most contemporary advocates of circumcision that circumcision makes no difference to sexual response, there is a vast medical literature on the significance of the foreskin. In the Graeco-Roman world doctors considered the foreskin so important that they devised treatments to lengthen those which did not provide generous coverage of the glans.7 During the Renaissance and 18th century the centrality of the foreskin to male sexual function and the pleasure of both partners was recognised by anatomists Berengario da Carpi, Gabriello Fallopio and William Harvey, in popular sex manuals like Aristotle's master-piece,2,8 and by physicians like John Hunter, who also appreciated the importance of the foreskin in providing the slack tissue needed to accommodate an erection.9 In the 19th century the role of the foreskin in erotic sensation was well understood by physicians who wanted to cut it off precisely because they considered it the major factor leading boys to masturbation. The Victorian physician and venereologist William Acton (1814–1875) damned it as "a source of serious mischief",10 and most of his contemporaries concurred.11 Both opponents and supporters of circumcision agreed that the significant role the foreskin played in sexual response was the main reason why it should be either left in place or removed. William Hammond, a Professor of Mind in New York in the late 19th century, commented that "circumcision, when performed in early life, generally lessens the voluptuous sensations of sexual intercourse",12 and both he and Acton considered the foreskin necessary for optimal sexual function, especially in old age. Jonathan Hutchinson, English surgeon and pathologist (1828–1913), and many others, thought this was the main reason why it should be excised.13,14 In the 1970s, a United States physician who had himself circumcised was so pleased with the result that he wrote an article urging everybody else to have it done, but even he acknowledged the loss of sexual sensation: "The change in sensation during intercourse a few weeks later was surprising. The sharp pleasurable sensation was noticeably lessened, as it is when topical anaesthetics are used to delay ejaculation. . . The overpowering erotic sensation has been dulled, and with it some of the immediate pleasurable sensation. Initial excitement has decreased. . . [When fully erect the penis presents] a smooth shaft with a piston-in-cylinder-like action during coition. Friction and therefore sensation are diminished."15 It is difficult to put numbers on so subjective an experience as sexual satisfaction, but contemporary Canadian researchers who have identified the complex innervation of the penis, the ridged bands and the frenular delta16,17 have provided physiological confirmation of the 18th-century folklore that a man's foreskin was "the best of your property".18

Robert J L Darby PhD

To the Editor: Van Der Weyden has asked a provocative question about the relevance of what he calls "medicine's homage to health".1 In so doing, he pays his own homage to a world where boundaries are sharp and healing becomes reduced to a matter of applying "bioscience to matters of mind and body". While I daresay many editors of biomedical journals would share his view, he is only highlighting an age-old tension. Indeed, Crookshank wrote in 1926 about the Ancient Greek schools of Cos and Cnidus, and of their debate about doctrines of the natural/descriptive and the conventional/academic approaches to medical knowledge.2 The Coans promoted the importance of the influence of the individual and society on the presentation of illness, and managed illness holistically with regimens oriented towards the needs of the individual, while the Cnidans oriented their practice around the distinctions between diseases, treating specific diseases with specific remedies.3 These differing approaches to illness and disease highlight the conflict between cybernetic and linear thought which has underpinned medical history ever since. It is rarely understood that the linear doctrine of biomedicine has only become dominant in the last century or so. Medicine's isolation from contemporary scientific thought explains our long delay in confronting the challenges of systems thinking — challenges that the basic and applied sciences took on in the early years of the 20th century.4 Our contemporary error is in assuming that the accumulation of data that passes for modern medical knowledge is sufficient to deal with the tasks of medicine. The disquiet expressed by Van Der Weyden is only a symptom of the continuing inability of a mechanistic view of medicine to deal with caring for patients in the real world.

Grant M Russell

Self-experimentation in Australia is alive and well Many advances in modern medicine owe a great deal to human experimentation. Indeed, much of biomedical research is irrelevant to mainstream medicine unless its clinical utility is established through human experimentation, for, as observed by the English essayist Alexander Pope, "the proper study of mankind is man."1 Today the circumstances and conduct of human experimentation are painstakingly policed by ethics committees, but even such strict surveillance cannot guarantee safety: "because experiments with humans are voyages into the unknown, an element of risk is always involved; the potential for death, injury, or illness can be reduced, but it can not be eliminated."2 It is this very uncertainty that presents a dilemma for researchers. Sir George Pickering, past Regius Professor of Medicine at Oxford, delineated this quandary: "The experimenter has one golden rule to guide him . . . Is he prepared to submit himself to the procedure? If he is, and if the experiment is actually carried out on him, then it is probably justifiable. If he is not, then [it] should not be done."2 In short, the researcher should be the guinea pig. Risk-laden stories of researchers being guinea pigs abound in medicine's heritage. They include that of John Hunter, the 18th-century English anatomist and surgeon, who allegedly inoculated himself with venereal pus. The symptoms of gonorrhoea and primary syphilis were soon apparent and during the last 15 years of his life he was plagued by a legacy of angina pectoris presumably due to tertiary syphilis.2,3 Other celebrated accounts include that of Werner Forssmann, who, in the 1920s, catheterised his heart with ureteric tubes. This risk-laden technique lay fallow until the 1940s, when Cournand and Richards in the United States refined and employed it in ground-breaking work in cardiorespiratory physiology. In 1956, all three were awarded the Nobel Prize in Medicine or Physiology.2 In the 1950s the enthusiasm for self-experimentation within the Department of Internal Medicine at Washington University, St Louis, earned it the name the "Kamikaze School of Medicine".2 Bill Harrington, a young researcher, courted death from cerebral haemorrhage with profound thrombocytopenia after being infused with plasma from a patient with idiopathic thrombocytopenic purpura (ITP).2 A fellow researcher, Tom Brittingham III, repeatedly injected himself with leukaemic white cells in an attempt to produce white-cell antibodies. He almost killed himself when he had an anaphylactoid reaction accompanied by profound hypotension and severe pulmonary oedema after being infused with plasma from a patient with aplastic anaemia.2 Nonetheless, these unsettling self-experiments established the immune basis of ITP and white-cell-associated transfusion reactions. Harrington's work inspired Jan Dausset of Paris to pursue research into the immunology of ITP and white cells, which culminated in his being awarded the 1980 Nobel Prize for demonstrating human leukocyte antigen (HLA; the transplantation antigen) in white cells.2 Australian researchers have also succumbed to the human guinea pig syndrome. In 1951, as the first wave of myxomatosis raced along the Murray River, its arrival in Mildura coincided with an outbreak of Murray Valley encephalitis in the surrounding district. The public was gripped by fear that the myxoma virus was responsible for the outbreak of encephalitis. This fear reached such heights that the chairman of Mildura Base Hospital challenged R G Casey, the Minister responsible for the Commonwealth Scientific and Industrial Research Organisation (CSIRO), and Sir Frank Macfarlane Burnet, Director of the Walter and Eliza Hall Institute (WEHI), to test the harmlessness of the myxoma virus on themselves! Spurred on by intense media pressure, Macfarlane Burnet, Frank Fenner (Professor of Microbiology at the John Curtin School of Medicine, but working at WEHI) and Ian Clunies Ross (Director of the CSIRO) inoculated themselves with enough myxoma virus to kill 100–1000 rabbits. All three suffered no harm, and in true political style this fact was made public by Casey through an announcement in Federal Parliament.4 The culture of the Kamikaze School of Medicine was further manifest when Australian clinical researchers performed radiolabelled platelet studies on themselves,5 or underwent unpleasant bone marrow aspirations to procure marrow cells for drug studies.6,7 Finally, the experiments of Barry Marshall, who ingested Helicobacter pylori,8 are now legend in medicine. His self-experiments eventually turned prevailing concepts of peptic ulcer causation and treatment on their head. Now, in the new millennium, the report in this issue of the Journal by Landmann and Prociv attests that self-experimentation in Australia is alive and well. In a series of self-experiments these investigators have shown that dog hookworm (Ancylostoma caninum) infection causing symptomatic eosinophilic enteritis is more likely to enter the body orally than percutaneously.9 What drives researchers to be their own guinea pigs? Lawrence Altman, in his delightful book Who goes first? The story of self-experimentation in medicine, proposes a number of motivating factors.2 These include reliability (researchers being more likely to adhere compulsively to the research protocol), dependability (for observations and detecting problems with design), a spirit of adventure, first-hand experience, self-protection, convenience (avoiding the frustrations of recruiting and being involved in the nuances of informed consent) and experience (when the experiments involve risk, the experience of the researcher is important and many will risk exposing themselves rather than others). However, self-experiments are subject to criticism.2 Potential problems include loss of objectivity, cumulative exposure to risks and comorbidities in the self-researcher (including self-experimentation suicide), but particularly the inherent limitations of a research design focusing on a single subject.10 Despite all this, researchers who enlist as guinea pigs will continue to grace medical research. Modern research is increasingly complex, with sophisticated designs and statistics, bewildering technology and the added burden of the close monitoring of projects by ethics committees. This impersonal and mechanistic culture is far removed from the humanistic and romantic spirit of adventure embodied in altruistic self-experimentation. As long as human research is informed by the premise that "because we were venturing into the unknown . . . a man is entitled to risk his own life. He is not entitled to risk somebody else's",2 researchers as guinea pigs will always be with us.

Martin B Van Der Weyden MD, FRACP, FRCPA

Timothy Murrell was the Foundation Professor of Community Medicine at the University of Adelaide, a position he held from 1975 to 1994. A seventh-generation Australian, born in Adelaide on 8 April 1933, he was educated at St Peter's College and the University of Adelaide Medical School, graduating in 1958. After a year as Resident Medical Officer at the Queen Elizabeth Hospital in Adelaide, Tim worked with the Commonwealth Department of Territories from 1960 to 1964 as a District Medical Officer. Stationed in New Guinea at Goroka, Wabag and Kundiawa, he investigated the aetiology and epidemiology of pigbel, a gangrenous intestinal disease that predominantly affected children in the highlands. His survey, case work and reports led to measures that significantly reduced mortality from the effects of the disease and ultimately enabled the development of a vaccine. This formed the substance of his MD thesis in 1966. From 1965 to 1966, Tim was a lecturer at the University of Adelaide Faculty of Medicine, after which he spent two years studying under an Australian Nuffield Fellowship at the General Practice Research Unit at Guy's Hospital, London. On returning to Adelaide, he pioneered teaching general practices as well as general practice teaching units in Highbury and at Modbury Hospital. He introduced community medicine to the undergraduate curriculum, integrating general practice with public health and the teaching of doctor–patient communication. Tim regarded himself as a "human ecologist". Accordingly, his publications on sudden infant death syndrome, multiple sclerosis, Dupuytren's contracture and breast cancer stemmed from his lateral thinking on observations of his general practice patients. In 1978, he received the WHO Staff Society Medal for his pioneering work on pigbel, and in 1992 was awarded a Visiting Fellowship at Corpus Christi College, Cambridge. His publications, career and personal papers can be viewed in the manuscript section of the National Library of Australia, Canberra ("Papers of Timothy Murrell, MS 9304"). Tim was very involved with his extended family, as well as various charities, schools, sports and gardening. He was thrilled to learn that he was to be made a Member of the Order of Australia in the 2002 Queen's Birthday Honours List, only to die suddenly from the sequelae of a heart attack on 15 August, a few weeks before the ceremony. Tim is survived by his wife Patricia and children David, George, Thomas and Melinda.

Dedee Blackburn Murrell MA BMBCh FAAD · Robert G Moorhead FRACGP DipCM

"Operation Bali Assist" was the name given to the Australian Defence Force (ADF) evacuation of injured Australians and foreign nationals after the Bali terrorist bombing on 12 October 2002. The operation involved the triage, stabilisation and evacuation of 66 critically ill patients from Bali to Darwin over 21 hours. Subsequently, the patients were stabilised in Royal Darwin Hospital (RDH) and then, under direction of Emergency Management Australia (EMA), transferred to various centres in Australia. The Royal Australian Air Force (RAAF) transported 35 patients in four separate missions and the operation involved 50 medical staff. Deployment ADF reservists sent in a Hercules C-130 13 October 2002, 0700 EST: The RAAF was tasked by Headquarters Air Command to send a Hercules C-130 transport aircraft to Bali for medical evacuation of Australians injured in an explosion the previous night. The initial information suggested that up to five patients might be seriously injured, possibly more. The medical team assembled at the RAAF's No. 3 Combat Support Hospital at Richmond Air Force Base, NSW, and prepared equipment to be loaded on the aircraft. This included equipment to transport two intubated and ventilated patients, 20 NATO litters (canvas stretchers in a standard size to fit any aircraft) for other patients, four units of locally sourced blood, and other items essential for an aeromedical evacuation (AME) in a military aircraft. 13 October 2002, 1530 CST: The aircraft arrived in Darwin and the AME team, which included one medical officer, three critical care nurses and three medical assistants, was advised that in Bali there were 15 very seriously injured and 20 seriously injured patients. The team was joined by two Army Reserve specialists (a surgeon and intensivist from RDH), another Air Force medical officer and nurse from RAAF Darwin, and extra equipment to allow the surgeon to perform operations as required. By this stage, a second aircraft was en route to Darwin from Richmond Air Force Base to assist in the evacuation. Phase 1: AME Bali to Darwin, 1930 13 October 2002 to 1400 14 October 2002Denpasar Airport, 13 October 2002, 1930 CST: The first RAAF aircraft arrived in Bali. The initial plan was to assess patients waiting at the airport and load these for the return flight. However, on landing we were informed that five casualties had just left on a private Learjet to Perth and that the most seriously injured people were at Sanglah Hospital (more than 40 minutes away by road). The medical team then split, leaving a medical officer and two medical assistants to prepare an Aeromedical Staging Facility (ASF), while the remainder went to Sanglah Hospital to manage the triage, resuscitation and movement of patients to the ASF. Three satellite phones were distributed to the medical officers to allow communication on the ground and to relay medical information and casualty estimates to Headquarters Air Command in Australia. Denpasar Aeromedical Staging Facility The ASF was situated in the airfield fire section in a hangar housing fire trucks and appliances. This provided shelter, light, electricity, places to hang IV lines, vehicle access, and direct access to the tarmac where RAAF Hercules C-130 aircraft would unload supplies and load patients. What greeted the medical team at Sanglah Hospital was something they will never forget. The hospital was overwhelmed with injured Australians with severe burn, blast and shrapnel wounds. There were two critical patients: one was a man with 80%–90% burns who was being ventilated by an Australian paramedic from Darwin on holiday; the other had extensive burns and had had a laparotomy for shrapnel wounds to the abdomen. Denpasar Airport, 13 October 2002, 2230 CST: The first aircraft had to leave for Darwin because of aircrew duty limits (the crew's duty time had already been extended twice). On board the RAAF Hercules C-130 were 15 patients: two critical and 13 relatively stable. One and a half hours into the flight, one critical patient died, despite aggressive attempts at resuscitation. The others thankfully remained stable and on arrival in Darwin were transferred to RDH. Denpasar Airport, 14 October 2002, 0130: At the ASF in Bali, casualties were pouring in, with up to 30 patients on the hangar floor being stabilised and operated on by medical staff and volunteers. The patients were mostly young, quiet and stoical. There were no complaints or unreasonable demands; on the contrary, most were concerned for their mates. Casualty management at Denpasar Denpasar Airport, 14 October 2002, 0430 CST: The second C-130 departed for Darwin with 22 patients on board (two in intensive care and ventilated, six in a serious condition). Denpasar Airport, 14 October 2002, 0600 CST: A third C-130 arrived with three anaesthetists, extra nursing staff and supplies. It was closely followed by a fourth C-130 carrying an AME team and two anaesthetists. The newly arrived staff were most welcome, and increased the capacity to stabilise patients before flight. Soon after, a fifth C-130 arrived with four more AME members and further supplies. Airway and circulation assessments, femoral lines, venous cutdowns — a gritty but surreal scene on the floor of a concrete fire hangar in tropical heat, ringed by anxious friends, relatives and interested Balinese emergency service personnel. Denpasar Airport, 14 October 2002, 0830 CST: The third aircraft was loaded with 16 patients (most critical patients last on – first off) and departed. The fourth C-130 was not far behind, carrying 11 patients and all remaining medical personnel who had been on the ground since the beginning of the evacuation. Left behind were 11 medical personnel, but no patients. The team resupplied and cleaned the ASF and consulate, and two medical personnel left the airport to check that no injured Australian or foreign national had been left behind in the hospitals or hotels. In the Denpasar Airport civilian terminal, large numbers of tourists evacuated by Qantas were checked for injuries requiring potential AME. Over the next few hours, only two more patients arrived at the ASF (one with three surfboards!). Denpasar Airport, 14 October 2002, 1400 CST: The fifth C-130 departed with all medical personnel, two patients and a small number of uninjured Australians (and three surfboards). Sixty-six patients were evacuated out of Bali in 21 hours using five Hercules C-130 aircraft and 34 Australian permanent and reserve military medical staff. An ASF was established to allow for stabilisation, resuscitation and field surgery to the injured people awaiting transport on military aircraft. Importantly, the medical staff were able to communicate through satellite phone to military headquarters to allow appropriate medical staff and supplies to be brought to the ASF and to coordinate the evacuation. Civilian retrieval companies, including Qantas, complemented the evacuation. Phase 2: AME Darwin to various major burns units, 2400 13 October 2002 to 1700 15 October 2002 Sydney: awaiting the arrival of patients from Darwin. The strategic AME component of Operation Bali Assist began while the first phase was ending. Civilian retrieval organisations (Royal Flying Doctor Service, Medical Emergency Adult Retrieval Service, CareFlight, and Retrieval Team Royal Adelaide Hospital) had flown to Darwin and began to transport ventilated patients to various hospitals throughout the country. This activity continued into the night of Monday. We focus on the ADF activities. Darwin, 14 October 2002, 1300 CST: The initial directive from Air Command was that there would be two strategic AMEs: one to Perth and the other to Brisbane, then Sydney and Melbourne. However, this soon changed, with the news that RDH and EMA had requested four strategic AMEs that evening: to Perth; to Adelaide then Melbourne; to Brisbane; and to Sydney. These were to be conducted in quick succession and would require a high level of logistical and personnel support. Darwin, 14 October 2002, 1600 CST: The first meeting was held with the staff from the RDH to determine the numbers of patients to be transferred to each of the capital cities, the priority of the patients, and how these patients were to be transported. A difficulty at this meeting was that patient priorities were still changing because of ongoing resuscitation and initial surgery. However, it was resolved that only the AME to Perth would transport ventilated patients; the other AME would not do so unless necessary. At the meeting, a rough patient manifest was determined for the AME to Perth. This included 12 patients, with burn surface areas between 5% and 40% and with varying degrees of blast and shrapnel injury. Two of the 12 patients were intubated and ventilated. It was decided that the most efficient means of transferring patients from RDH to the C-130 Hercules was by the RAAF ambulance bus. This bus is capable of carrying patients on NATO stretchers and can allow for transfer of a large number of patients. Volunteer crews from RAAF Darwin were responsible for loading and unloading the bus and aircraft under the direction of medical personnel. Darwin, 15 October 2002, 0150 CST: The first of the AMEs departed Darwin. The six-hour flight to Perth was uneventful until two hours out from Perth, when a ventilated patient suffered a cardiac arrest. Resuscitation efforts by the staff on board were successful. All patients were eventually transferred to Royal Perth Hospital. Darwin, 15 October 2002, 0305 CST: The second AME departed for Adelaide. On this flight were six patients with burn areas ranging from 15% to 50%, two patients with shrapnel injury, and two family members. None of the patients had been previously intubated and ventilated, but there was concern that one patient might have needed ventilatory support during flight. Also on this flight were three members of the Royal Adelaide Hospital retrieval team who had been working for the previous 24 hours. All patients were transferred to their destination medical facilities without incident. Darwin, 15 October 2002, 0530 CST: The third AME (seven patients with various blast, burn and shrapnel injuries) departed for Brisbane. By that stage of the operation, medical supplies and medications were beginning to run low and equipment issues began to appear. A late request from RDH to transfer a ventilated patient was accommodated; however, when reviewed, the patient was deemed to be too unstable for the four-hour mission to Brisbane. The medical staff on this flight consisted of two RAAF Specialist Reserve anaesthetists, one Navy Reserve anaesthetist and one Army Reserve anaesthetist, all proceeding home following the first phase of the operation. Without these Reserve personnel, the mission would not have been conducted. All members of the team remaining in Darwin were beginning to show obvious signs of fatigue by the time the third AME departed. The fourth AME was delayed while patients were prepared, and did not depart Darwin until about 1100 CST on Tuesday. On board the final flight were the bulk of the initial crew from RAAF Base Richmond who had mobilised initially, additional Reserve specialists and a CareFlight member who had been stranded in Darwin. Eight patients with various areas of burns and two family members were transferred on this flight. In all, 35 patients were transferred to the four capital cities over 16 hours on Tuesday, 15 October 2002. Crews that had been pushed to the limits of fatigue, having been working for an average of 34 hours with only broken sleep, undertook this feat and continued to provide optimal care for their patients until the work was completed. The second phase of Operation Bali Assist enabled the load to be shared among burns units across Australia. It ensured that most patients would be treated in their home State and it allowed the RDH the ability to cope with the numbers of injured patients for the time necessary to conduct vital resuscitation before resources became stretched. DiscussionA terrorist act causing large numbers of critically injured Australians in a country where the provision of medical services differs from our own provided unprecedented challenges. This tragedy required a response not previously conducted by Australia. Burns required prompt resuscitation and expert surgical management. It was recognised that the best response for these victims was to bring them safely to Australia and then to specialist burns units around the country. Military and civilian agencies, their planners and operators worked seamlessly to meet this challenge. No single agency could have conducted the whole operation. The tragedy focused the resources of the nation to give the best outcome for injured Australians. The AME had unique problems. There were large numbers of critically injured patients, necessitating large numbers of Specialist Reserve support, significant quantities of oxygen, IV fluids, blood products, drugs (morphine, ketamine, midazolam, muscle relaxants, antibiotics and Tet Tox) and critical care equipment (oxylog, Propaq monitors, etc). In the short response time, these were sourced from ADF facilities in Sydney and Darwin, and local hospitals in Sydney, Darwin and Adelaide. Each C-130 aircraft arriving in Bali brought more supplies, until the surplus allowed some excess fluids to be sent to Sanglah Hospital on our departure from Denpasar. The prompt response and support of ADF Specialist Reserve allowed expert medical care to be projected with this operation. As always, they provided experienced clinical judgement, procedural skills and support to the permanent medical force. The RAAF has identified areas for future improvement to maximise the capability we can project. These mainly focus around critical care equipment update, and training and alliances with civilian critical care services. Operation Bali Assist was successful because of the united and dedicated response of all people involved. So often in tragedy, individuals and organisations exceed normal expectations; this was no different. The ADF, EMA, the Department of Foreign Affairs and Trade, RDH, burns units around Australia and the Australian public were all crucial to the best outcomes for the victims of terrorism in Bali. With this operation comes the responsibility to ensure Australia's capability to react to such tragedies is enhanced. The possibility of future acts of terrorism ensures its maintenance.

Gregory V Hampson MB BS · Steven P Cook MB BS · Steven R Frederiksen MB BS

Left to right: Professor John Tyrer with three of his "disciples" — Mervyn Eadie, myself and Bryan Emmerson — taken in 1999 when I retired as Director of QIMR. As I reflect on my professional career, the one word that repeatedly springs to mind is "mentorship". I have been fortunate in having had truly remarkable mentors at several key points in my career. Family firstThe first was my father, who, while not university educated, was an intelligent man who ran the family printing business. His professional contacts convinced him of the importance of a sound education for his only son, and when I declared an interest in Medicine and Law he suggested that the two in combination would be very useful. I chose Medicine — in part, because I was intrigued by our family illnesses and surmised that an insight into them would be of benefit to the whole family. This, of course, proved correct. Throughout my school and university years, my mother suffered from post-encephalitic parkinsonism. This placed a great burden on my younger sister, who undertook the family's domestic responsibilities when still in high school. My father died during my fourth year of medical studies and my mother soon after my graduation. Local heroesMy next influential mentor was Frank Garlick, a perspicacious surgeon at the Royal Brisbane Hospital (RBH). It was he who, in 1956, detected a spark of enthusiasm for inquiry and research in a young medical student and so encouraged me to pursue my then interest in malignant melanoma. My dissertation (published in Trephine, the annual magazine of The University of Queensland's Medical Students Society) won the prize for the best research project by an undergraduate student at the university's medical school, and this experience kindled my life-long interest in medical research. After Garlick came John Tyrer, who had not long been appointed to the first full-time chair of medicine at The University of Queensland based at the RBH. Tyrer steadily built a strong department of medicine, having had the foresight to create several "temporary clinical lectureships". These positions were filled by aspiring medical registrars who had successfully negotiated the hurdle of membership of the Royal Australasian College of Physicians, and provided them with the opportunity to combine clinical responsibilities with research — usually towards an MD thesis. It is interesting to reflect on the number of people who spent their formative years being nurtured in such positions who subsequently went on to become academic leaders in Australia. They include Bryan Emmerson (rheumatologist, professor of medicine and head of the department, based at the Princess Alexandra Hospital, Brisbane, 1985–1994) and Mervyn Eadie (neurologist, professor of medicine and head of department at Royal Brisbane Hospital, 1994–1997), to name but two. I greatly lament the fact that, during the 1980s, these positions were abolished progressively as increasing financial constraints affected the university. It was as a temporary clinical lecturer that I found myself fascinated when I realised that four young women with haemochromatosis were from the same family. The literature at that time indicated that the disease was rare in women, especially premenopausal women, and that it was usually due to excess alcohol consumption. These women were all teetotallers, firing up my interest in challenging the existing dogma. Encouraged by Tyrer and his deputy, Martin Lloyd, I undertook a systematic study of iron metabolism in families of patients with haemochromatosis and families of patients with alcoholic cirrhosis.1 This, together with some rather tedious animal studies in iron-loaded rabbits, eventually led to a successful MD thesis and several publications, one of which occasioned an editorial in The Lancet.2 But, more importantly, these achievements provided me an opportunity to work with the doyenne of liver disease, Professor (later Dame) Sheila Sherlock — again following overtures made by John Tyrer on my behalf. International influenceMuch has been written about Sheila Sherlock and her enduring influence on aspiring hepatologists from many countries, including the many obituaries published following her death last year.3,4 In 1965, I was just one of some 20 research fellows — from countries far and wide, including the USA, South Africa and Asia — working in her unit, located in wooden huts up on the roof of the Royal Free Hospital in Gray's Inn Road, London. Sheila took a sincere personal interest in each of us and our careers. Given my published work in haemochromatosis and iron metabolism, Sheila resolved that I should "broaden horizons". She suggested I tackle the topical subject of bilirubin metabolism and Gilbert's syndrome with Barbara Billing, who had recently joined the unit as its only basic scientist. It was an enjoyable and productive association that added new information on haemolysis and Gilbert's syndrome, which Sheila quickly put into clinical perspective.5 Barbara Billing herself was also an excellent mentor and taught me a great deal about laboratory research. Like other fellows in the unit, I was not only exposed to the whole repertoire of liver disease, but also Sheila Sherlock's brilliant clinical acumen and lucid thought processes. Sherlock made a particular effort to train her fellows to present their work at meetings clearly without notes, and set an example by always rehearsing her own major lectures and speeches with staff members and research fellows. Her clarity of communication was legendary. She would convert an amateurish first draft into a manuscript promptly accepted by the New England Journal of Medicine — without revision! She exposed us to "the big names". I felt privileged to be sent to Caroli's unit in Paris to lecture on our work (Caroli, the famous French hepatologist, is noted for Caroli's disease, a congenital cystic dilatation of the intrahepatic bile ducts and associated disorders). Most of her fellows had similar experiences. My subsequent international training, some years later, was equally important but different and complementary. In 1972–1973, Kurt Isselbacher — at that time chief of gastroenterology at Massachusetts General Hospital (MGH) and Harvard Medical School — introduced me to North American academic medicine and laboratory science. Kurt was yet another active mentor, involving me in giving lectures to Harvard medical students, presenting medical grand rounds at MGH, and a harrowing experience as discussant at one of the weekly clinicopathological conferences, published, as usual, in the New England Journal of Medicine.6 The case was one of cholestasis and cholangitis in a man with alpha-1-antitrypsin deficiency. He also recruited me as a contributor to Harrison's Textbook of Medicine, a unique opportunity. I have continued to contribute to each subsequent edition of the book as author of the chapter on haemochromatosis.7 In 1978, a sabbatical at the Rigshospitalet in Copenhagen with Niels Tygstrup — renowned for his extensive work on quantitative tests of liver function — broadened my horizons once again. His unit had strong expertise and interest in basic immunology as it applied to the liver, adding a further dimension to my perspective of international hepatology. Back in AustraliaIn 1966, I had been fortunate in securing a senior lectureship in the department of medicine at The University of Queensland and the Royal Brisbane Hospital. The next vacancy did not occur until eight years later! The department had been progressively strengthened by Tyrer, and was arguably the most productive department in the biological sciences and medicine faculties at the university. With my two inspired colleagues, June Halliday and Graham Cooksley, I established the first academic liver unit in Australia, which, over the years, attracted numerous scholars, both science-based and medical, each adding stimulus and challenge. These scholars included, among others: Geoff Farrell, head of the Storr Liver Unit in Sydney; Mark Bassett, gastroenterologist and associate professor, the Canberra Hospital and Clinical School; Keith Tolman, head of gastroenterology at Utah Medical School, Salt Lake City; and Paul Adams, an international authority on haemochromatosis, from Ontario, Canada. Our research focus was, of course, on haemochromatosis and iron metabolism, with our original research contributions opening doors to both the International Association for the Study of the Liver and the biennial meetings on iron metabolism. Fortunately, these international meetings were held in alternate years. Graham Cooksley later extended our research repertoire to include the immunology of liver disease and then viral hepatitis. Our combination of two physician scientists with a full-time NHMRC-funded basic scientist proved a successful formula. We were awarded an NHMRC program grant (iron metabolism and liver disease) in 1982 that was renewed at every subsequent quinquennial review until it was incorporated into the block grant for the Queensland Institute of Medical Research in 1998 (see below). During this period, I was privileged to be elected President of the International Association for the Study of the Liver. We hosted the World Congress of Iron Metabolism twice: in 1989, in Brisbane, and in 2001, in Cairns; we also hosted the Biennial Scientific Meeting of the International Association for the Study of the Liver in 1990 on the Gold Coast. The Queensland Institute of Medical ResearchLeft to right: Graham Cooksley, myself, June Halliday and John Tyrer — in 1982, at the announcement of the NHMRC Program Grant. In 1988, I undertook my last sabbatical at the Queensland Institute of Medical Research (QIMR). This experience allowed me to become acquainted with the Institute's staff and science and successfully apply, in 1989, to become its Director. The 10 years that followed are now history, but I still find it interesting to reflect on the developments that occurred at QIMR during that time. My predecessor, Chev Kidson, had made significant advances by linking the Institute with The University of Queensland (rather than the State health department) by recruiting some high quality staff, and by securing funding from the Queensland government for a new purpose-built 11-storey institute — the Bancroft Centre. The Centre was opened by the then State Premier, Wayne Goss, in 1991. This new facility allowed a fivefold expansion of the Institute, achieved smoothly over the next five years. Queenslanders were recruited back from overseas, including Graham Kay, who established QIMR's transgenic facilities. Others came from the southern Australian States, notably Anne Kelso and Andrew Boyd among those recruited from the Walter and Eliza Hall Institute, with the assistance and strong support of Sir Gustav Nossal. The Liver Unit — myself, June Halliday and Graham Cooksley and some 25 staff — moved en bloc into the Bancroft Centre (Graham as Director of the Clinical Research Centre of the Royal Brisbane Hospital Foundation, which was also situated in the building). It soon became apparent that the expanding Institute would benefit from independent peer review. In 1994, with the strong support of Judy Whitworth, then chair of the research committee of the National Health and Medical Research Council (NHMRC), I was able to put together a formidable review committee. Chaired by Keith Peters, chairman of the department of medicine at Cambridge University, UK, and including Peter Doherty (then professor of immunology at St Jude's Hospital for Children, Memphis, Tennessee), Bob Williamson (then professor of biochemistry, St Mary's Hospital, London), the committee included three Australians. Professors Fiona Stanley (the Institute for Child Health, Western Australia), Richard Smallwood (professor of medicine, the Austin and Repatriation Hospital, Melbourne) and Ashley Dunn (the Ludwig Institute, Melbourne) were all nominated by the NHMRC. A week-long in-depth review by this committee made a huge impact on the strategy and further research directions adopted by the Institute. I also believe that this committee influenced the NHMRC with respect to block funding. Its last term of reference, clearly the most challenging, was to address whether QIMR should apply for block funding. After deliberation, the committee concluded that, "in the Australian context", QIMR should indeed apply to the NHMRC for block funding. However, it was also clear that the largely international committee saw significant disadvantages in block funding. Keith Peters conveyed these sentiments, at the time, to Judy Whitworth. Interestingly, since 1998, NMHRC block funding has been progressively abolished and the program and project funding system restructured. As a result, total NHMRC funding to the QIMR (including program grants, project grants and fellowships) has increased from $6.0 million in 1998 to $7.82 million in 2002 — an increase of about 30%. The "White Knight"By 1996, the "new" Bancroft Centre was fully occupied and we dreamed of new ways to expand the Institute. All were futile until, in 1998, the fortuitous juxtaposition of two "once-in-a-lifetime" events enabled us to realise our dream. Firstly, we were approached, anonymously, by a US organisation — which we later found out was Atlantic Philanthropies in New York — after they had conducted an independent assessment of the Institute. After protracted discussion with their Dublin-based consultant, two visits by him, and submission of a detailed business plan, we were advised that their board would support our "dream", with a donation of $20 million, conditional on our raising the remaining $35 million required within six months! Of course, this proved a difficult challenge, but with the bipartisan support of the Queensland government ($20 million), the assistance of the Leukaemia Foundation ($5 million) and the QIMR Trust ($10 million) the target was achieved. The second fortuitous event was the concomitant rebuilding of the Royal Brisbane Hospital and the Royal Women's Hospital, which released space for a new building close to the Bancroft Centre. State authorities graciously provided the space to QIMR and the new 10-storey Comprehensive Cancer Research Centre was completed in 2001. Soon afterwards, Mr Clive Berghofer (a Queensland grazier and real estate developer) generously donated $5 million for the naming rights for 10 years — a rare occurrence in Australian science! A special feature of the development has been the inclusion of a clinical trials centre occupied and administered by QPharm, a newly established independent company that conducts phase I clinical trials of new compounds. State authorities have also granted QIMR the former Queensland Radium Institute (QRI) building, available from 2004, which lies between the old and new QIMR buildings. Thus, when fully developed, the new QIMR will occupy three buildings and have a total staff of over a thousand. A new eraThe new Queensland Institute of Medical Research (QIMR) (left), incorporating the Bancroft Centre, and the Clive Berghofer Comprehensive Cancer Research Centre, with the former Queensland Radium Institute building in between. From 2004, QIMR will comprise all three buildings. In 2002, on retiring from the QIMR, I was invited to become the Director of Research at the redeveloped Royal Brisbane and Royal Women's Hospital — in some respects, a position more challenging than Director of QIMR! While I continue to enjoy some clinical practice and teaching, the challenge to stimulate research in the hospital environment is formidable. For decades, the RBH has been the flagship of Queensland's hospital health and medical research effort, but financial stringencies of recent years have indeed taken their toll. While Australian medical research institutes have increased in size and number over the past 10 years, university departments, and particularly our teaching hospitals, have found it increasingly difficult to fund research. Moreover, with ever-increasing clinical demands, less time for research and uncertain career paths, I believe young graduates are now discouraged from embarking on clinical research or a career in research or academia. Although this is, to some extent, a global problem, it is so particularly in Australia, where, for example, in contrast to Canada and the USA, there is a very significant difference between stipends for research fellows as opposed to those in clinical posts. I sincerely hope that current efforts by the NHMRC and others to boost clinical research, such as with the introduction of NHMRC practitioner fellowships and the NHMRC Centres of Clinical Excellence Program, will be successful. Thus, I am delighted that the potential gap between basic and clinical research has been bridged at QIMR. The Institute's present Director, Michael Good (with an international reputation in the immunology of infectious diseases), and Deputy Director, Adèle Green (an internationally acclaimed epidemiologist), are both medically qualified scientists; as well, several of the research staff have clinical appointments at the Royal Brisbane Hospital. The Institute's research portfolio now spans the full spectrum, from fundamental molecular research to clinical translational research and clinical trials and, more recently, a research program in Indigenous health. ConstanciesNone of my contributions would have been possible without the devotion and enduring support over 42 years of my wife, Margaret (née Ingram), herself a University of Queensland graduate in education. Margaret has not only raised and nurtured five children, fostering their university education (in medicine, education, psychology, environmental science and music), but has also taken them around the world during my extensive years of training and study leave. Also, it should be apparent that I feel and have always felt passionately about two themes — the importance of mentorship in medicine and biomedical science, and bridging basic science and clinical medicine (from the bench to the bedside and back) to produce clinically relevant research. It is because young researchers were inspired by their mentors that clinical science, and indeed clinical medicine, have become what they are today, and this needs to continue. The importance of this practice has been enunciated well by Dean William Welch, of Johns Hopkins fame, who wrote: Let us not forget that a university or a medical college may have large endowments, palatial buildings, modern laboratories, and still the breath of life may not be in it. The vitalising principle is in the men (and women) — both teachers and students — who work within its walls. Without this element of life, this bond between teacher and taught, these things are but outward pomp and show. But let these greater opportunities receive the breath of life from the inspiration of great teachers and they then become the mighty instrument of higher education and scientific progress.8

Lawrie W Powell AC, FTSE, MD, PhD, FRACP, FRCP, FRCPT

Disobedience, in the eyes of anyone who had read history, is man’s original virtue. It is through disobedience that progress has been made — Oscar Wilde, 1881 The invitation to contribute this piece to the Journal was disconcerting. I told the Editor I felt previous contributors to the Power of One series were all distinguished retirees. What was he trying to tell me? I have just turned 51, but it seems some believe I have been around forever and should write a retrospective piece. Sinking smokingRecently, I was leaked a staff training CD-ROM from British American Tobacco (Australia). Five senior executives sat in front of the camera blubbing about the inexorable fall in smoking rates and how, as the plug had been pulled, this could only get worse. As the remaining water drained from the pool, they tried to inspire their staff by talking up hopes of snatching profit from brands that smokers were inspired to believe were at the luxury end of the market. Luxurious carcinogens! It was desperate stuff, but heartening all the same. In the early 1960s, nearly 60% of men and 30% of women in Australia smoked.1 Today, daily smoking by adults has fallen to under 20% for the first time,2 and shows no signs of having bottomed out. In NSW, lung cancer in men has been falling for 18 years and female lung cancer has stopped rising.3 National death rates from coronary heart disease fell by 59% in men and 55% in women between 1980–2000, in large part because of changes in risk factors like smoking.4 Along with vaccine uptake, the fall in the road toll and arresting the HIV/AIDS epidemic, the fall in the smoking rate is one of the major public health achievements of the past 40 years. Innocents sometimes introduce me as "the person" who is responsible for the revolution in the way smoking is now regarded. This nonsense derives from their youth, mixed with thoughts of David and Goliath — as if a single individual could ever be said to be responsible for turning around something as complex as community and political perceptions of smoking. The metaphor of being pecked to death by ducks provides a more apposite description of the way things work in public health. Strategic pecks that irritate and distract gradually build to a point where those under attack — in this case, the tobacco industry — develop a debilitating siege mentality. While the public appetite for dragon-slayer mythology demands there should be individuals who stand over public health carcasses, many, often unsung, people have oxygenated the huge changes achieved in smoking in Australia. MOP UP and BUGA UPA BUGA UP refacing, circa 1983. Today, smokers huddle in doorways and excuse themselves from meetings. To smoke with equanimity is increasingly to wear a badge of immaturity, low education or resigned addiction. Thirty years ago, it was very different. The tobacco industry had infected smokers with the thought that they had a monopoly on all that was interesting, convivial and sensual. Epidemiological revelations rather ruined all that; but it was advocacy that ensured the translation and transition of epidemiologists' conclusions into policy and law reform. In the late 1970s, I was bored witless in my first job as a community health educator, employed by the NSW Health Commission. While I gave interminable Rotary Club talks to half-sozzled businessmen about the "drug problem", tobacco advertising adorned every conceivable public space. Drug pushers were very publicly jailed while tobacco industry executives were quietly knighted. So, in 1978, with a few colleagues, I formed MOP UP — Movement Opposed to the Promotion of Unhealthy Products. We put out a precocious press release and in the next week were covered by the Sydney Morning Herald as "the latest pebble in the shoe of sin industries".5 We engineered the removal of Paul Hogan from the Winfield advertising campaign;6 "MOP UP's slingshot cuts down the advertising ogre" read one headline. MOP UP re-energised the debate about tobacco advertising that Nigel Gray (then head of the Anti-Cancer Council of Victoria) and Cotter Harvey (founder of the Australian Council on Smoking and Health) had started in the 1960s. At our first meeting — held in the lecture theatre of the Sydney morgue in Camperdown — someone stood up and declared, impatiently, that our political letter-writing plans were pathetic and that, if we had guts, we would take more direct action. BUGA UP, the graffiti movement, was born and over the next eight years revolutionised ordinary people's understanding of the politics of tobacco control.7 My modest involvement was to take ongoing responsibility for the billboard on a shopfront directly opposite the entrance to News Ltd, but my admiration for the dozens of courageous people who risked much over a decade of civil disobedience is boundless. We held a 20-year reunion in October this year. (For a powerpoint collection of BUGA UP's 'greatest hits' see http://tc.bmjjournals.com/cgi/content/full/11/3/DC1). Truth in advertising: the German brand West shows a smoking Olympic athlete "lighting the fire" of a stick-figure woman in front of Australia's Uluru, about the time of the 2000 Sydney Olympics. When I first started in tobacco control, people at parties would occasionally give me wide berth as a probable teetotal morals crusader who would soon move to turn the music down and pluck sweets from children's mouths. MOP UP, and especially BUGA UP, changed all that. Understanding that the tobacco industry is a pariah of the corporate world rapidly became a litmus test for a whole set of values about the abhorrence of putting profit above all else. Today, one never hears a tobacco industry executive in the media. As my colleague Stan Glantz, professor of medicine at the University of California, San Francisco, has said: "They are like cockroaches; they spread disease and don't like to be seen in the light." No respectable politician would now ever risk public association with these executives, and this change in business community status has facilitated the incremental adoption of a legislative program that puts Australia in the forefront of nations trying to reduce tobacco's health toll. Getting the message outThose heady days and my first degree in media sociology gave me a taste for the nature of news values. They blooded me for a career where I have tried to translate epidemiologists' conclusions into discourses that gel with community concerns, and then needed to truncate them into soundbite-length summations if they were to have any hope of making the news. I have always had enormous respect for the power of the news media to influence the way that communities think about issues. My honours thesis on imagery in advertising for psychotropic drugs in medical journals was tabled into the Senate Hansard by Peter Baume in 1979.8 That lit a fire within me: there were ways in which academic work could climb out of its (mostly) cosseted sanctuary and thus get to influence political debates. A luxurious Sunday for me is an undistracted day of writing. Since 1976, I have published over 370 original articles, editorials, letters and commentaries in peer-reviewed journals and another 105 in throwaways. I have written 10 books and large reports. A few of these have become citation classics in my field,9-11 but if I was to nominate my most influential writing without hesitation I would name some of my 93 newspaper opinion pieces, my 130 letters to newspapers or some of my extended radio and TV interviews during critical periods of advocacy for change, like the tumultuous period of advocacy required after the Port Arthur gun massacre in 1996. Years of watching my citation rate splutter upward and 11 years of editing an international journal (Tobacco Control) have taught me that scholarship, for all its importance, exists in intellectual backwaters and rarely influences practice, public or political opinion. Colleagues boast of a paper being cited a few hundred times or of speaking to 5000 people at an international conference. In my opinion, a gloves-off opinion piece in a morning newspaper, followed by a round of interviews on breakfast radio, on the day that a vital public health political decision is to be made will be read, and often discussed, by incomparably more people than a journal's readership. Outside agentAdvocacy, by its nature, involves contested debates — there are always losers when change occurs; so often, they are determined to resist change, and angry when it happens. Public health advocacy often requires pushing governments to act and being critical of inaction. This can brand advocates as troublemakers, with all that can go along with that. I have known David Hill, now the director of the Anti-Cancer Council of Victoria, since 1978 and count him as a close friend. A few years ago, when I was feeling a little disconsolate at being plainly excluded from some key national committees appointed by a minister for health whom I had occasionally criticised, David counselled me to consider that every cause needs different people to work "inside and outside the political tent". He said that those on the inside greatly appreciated that someone with my judgement and determination was outside helping keep policy agendas alive that would otherwise be at risk of neglect, being largely off-limits to those working on government committees. Magnificent mentorsMayer mailI count three mentors in my life. Henry Mayer (1919–1991), Professor of Political Theory at the University of Sydney, invited me to lunch after reading an analysis I wrote of the use of sexually seductive imagery in a doctor-directed advertisement for a bronchodilator.12 Henry was a Renaissance man who read everything from impenetrable European psychoanalytic theory to debates about radio bandwidths. From that day on, seldom a week passed in the next decade when a bulging packet of eclectic pages torn from his astonishing reading habits did not arrive in the mail. "Read this", he'd have scribbled. To this day, I am compelled to open my mail and email before anything else, so exciting were the contents of the material he often sent me. I found out later that Henry was in the same habit with dozens of other people he favoured. My imagination owes him an enormous debt. Godfather GrayNigel Gray, then head of the Anti Cancer Council of Victoria, invited me to go with him to Papua New Guinea in 1983 to help convince the government to ban tobacco advertising. It did, although the law remains poorly enforced. Nigel quickly burst any preconceptions I had about senior, venerable figures in medicine being aloof, arrogant and irrelevant. Besides being great fun, Nigel has an appetite for energetic people who, like him, were prepared to stay for the long haul, always searching for opportunities to reignite concern about tobacco industry actions or complacency in government. He taught me that public health's successes tend to creep along almost imperceptibly and about the importance of setting 10–20-year windows on achievement. He remains the godfather of tobacco control advocacy for many of us.13 "Fearless" LeederStephen Leeder, then head of Community Medicine at Westmead Hospital, asked me to work with him in 1986 and has been a major influence ever since. While he has written some of the most articulate public health policy analyses, and cuts the mustard with most powerbrokers, it is his incandescent humanity that sets him apart for me as one of Australia's most inspirational figures in public health. Affectionately known to many of us as "Fearless" Leeder, Steve's writing and speeches drip with his values. Working with Steve for 16 years has exposed me not just to his intellect, but to his unerring encouragement of others. Whenever I have had moments of doubt about writing what I think and upsetting someone powerful, he has seldom hesitated to say simply, "You must say this . . . if you won't, who will?". He's been a wonderful role model. Citizen ChapmanWinner of the Lung Slayer Award. This portrait, of a 34-year-old man with emphysema, was a rejected entry in the 1984 John Player Portrait Award, National Portrait Gallery, London. An alternative exhibition was held on the footpath outside the gallery (that's me holding the painting). Most days I pinch myself in disbelief that I get paid to do what I would gladly do for nothing as a citizen. My 20 years (1982–2002) as a director and chair of the Australian Consumers' Association (Choice magazine) count as an experience I value enormously. I have swapped tactics with some of the most tenacious exponents of rat-cunning advocacy that you could ever hope to meet. Today, I have seven researchers working with me on a critical history of the tobacco industry as revealed through their internal documents (see http://tobacco.health.usyd.edu.au/). Each day, I see their growing incredulity at what they are discovering and the way this translates into passion about carrying on this work, using scholarship as an instrument of shame that drives policy change. The other day we found an item that read "Australia is a laboratory for the global anti-smoking network. Both anti-smoking policies and the individuals who promote them are exported from Australia and stimulate anti-smoking activities worldwide."14 It's been a huge privilege to be a part of that.

Simon Chapman PhD

The death of a friend solved a centuries-old, oft-fatal mystery My doctrine is produced in order to banish the terror from lying-in hospitals, to preserve the wife to the husband, and the mother to the child... — Ignaz Semmelweis, 1861 Today, a very large proportion of women giving birth receive antibiotics, potent and sometimes in combination, during their accouchement. Routine prophylaxis is widely accepted for caesarean sections, which account for 20%–25% of deliveries.1 Of course, any pregnant woman presenting with an obvious infection will automatically receive an antibiotic. Further, so will most pregnant women with membranes ruptured for any length of time, either before or after labour begins, and any woman in labour with a raised temperature. There is also a more relaxed approach to many former midwifery routines — for example, the abandoning of masks and gowns and the admission of several support people to the delivery scene — which could diminish both younger obstetricians' and midwives' appreciation of the potentially deadly risk of puerperal infection. However, until relatively recently in developed countries, and still in many developing countries, puerperal sepsis was and is a killer.2 Fatal feverImmediately postnatally, the placental site is a large open wound — easily invaded by ascending bacteria. For thousands of years, it was recognised that puerperal women were at risk of a fever that could be fatal. The Hippocratic writings contain references to childbed fever, as do some Hindu texts dating back to 1500 bc.3 Moreover, the potential for birth attendants to initiate such infections seems to have been comprehended by some of the ancient writers, including the Greek physician Soranus, and the Hindus, since advice on hygiene for birth attendants was offered.3,4 Triptych showing the Hôtel Dieu in Paris, about ad 1500. The comparatively well patients (on the right) were separated from the very ill (on the left). Note there were always two patients to a bed. Nevertheless, in ancient and medieval times, mortality from puerperal sepsis was apparently relatively low, as women generally gave birth at home. Peculiar to the puerperium?The 17th century saw the establishment of "lying-in" hospitals in many European cities. While these institutions were, in some ways, an advance — in particular, by relieving obstructed labour with forceps or intrauterine manipulation — the crowding of patients, frequent vaginal examinations and the use of contaminated instruments, dressings and bedlinen spread infection in an era when there was no knowledge of antisepsis. The first recorded epidemic of puerperal fever occurred at the Hôtel Dieu in Paris in 1646. Subsequently, maternity hospitals all over Europe and North America reported intermittent outbreaks, and even between epidemics the death rate from sepsis reached one woman in four or five of those giving birth.5 Numerous bizarre theories as to the cause of childbed fever were expounded — among them that it was due to a "miasma", or the labouring woman's disturbed state of mind, or mechanical pressure from the distended uterus. Certainly, childbed fever was universally regarded as a condition peculiar to women in labour.6 Sepsis suspectedContagion as the basis for childbed fever was first suspected by a number of British physicians in the late 18th and early 19th centuries.7 The name of Thomas Watson, Professor of Medicine at King's College Hospital, London, is not well known, but in 1842 he wrote: "Wherever puerperal fever is rife, or when a practitioner has attended any one instance of it, he should use most diligent ablution." Watson recommended handwashing with chlorine solution and changes of clothing for obstetric attendants — everything, he said, "to prevent the practitioner becoming a vehicle of contagion and death between one patient and another." Unfortunately, Watson's advice seems to have been largely ignored by obstetric practitioners of the time — the contagion theory is completely absent from contemporary obstetric texts.7 Oliver Wendell Holmes Across the Atlantic, in Boston, Dr Oliver Wendell Holmes — pathologist, physician and president of the Boston Society for Medical Improvement — developed an interest in the condition after two related cases were presented to his society. A physician and a medical student both died of septicaemia after performing an autopsy on a woman who died of puerperal fever. Holmes read the existing literature, and became convinced that the condition was highly contagious, and that doctors, nurses and midwives were the active agents of its spread. He began to speak and write on the subject, and in 1843 published his classic essay The Contagiousness of Puerperal Fever.8-10 The essay contains eight rules for the obstetrician, which included not only handwashing and changes of clothing, but also the avoidance of autopsies if obstetric cases were being managed. Holmes' conclusions were ridiculed by many of his prominent contemporaries. For example, Charles Meigs, a well-known obstetrician, was incensed at the suggestion he may himself be transmitting disease. "Doctors," he said, "are gentlemen, and gentlemen's hands are clean."10 Connection comprehendedMeanwhile, in Vienna, Dr Ignaz Semmelweis, a native of Hungary, was beginning a life-long obsession with finding the cause of, and preventing, puerperal fever. However, knowing no English, and far from North America, Semmelweis was unaware of the work of Holmes. Ignaz Semmelweis In 1844, Semmelweis was appointed assistant lecturer in the First Obstetric Division of the Vienna Lying-In Hospital, the division in which medical students received their training. He was appalled by the division's high mortality rate from puerperal fever — 16% of all women giving birth in the years 1841–1843. In contrast, in the Second Division, where midwives or midwifery students did the deliveries, the mortality rate from the fever was much lower, at about 2%. Semmelweis also noted that puerperal sepsis was rare in women who gave birth before arriving at the hospital.6,11 Over the next few years, Semmelweis studied and rejected numerous hypotheses. He did note that medical students and doctors from the First Division performed autopsies each morning on women who had died in the hospital the previous day and that midwives were not required to perform such autopsies. However, he did not immediately appreciate the connection between the two observations.6,11 In March 1847, Jakob Kolletschka — professor of forensic pathology, colleague and friend of Semmelweis — died of septicaemia after sustaining an accidental wound to the hand during an autopsy. On reading the report of Kolletschka's autopsy, Semmelweis was struck by the similarity of the pathological findings to those of women who had died of puerperal fever. He later wrote: "Suddenly a thought crossed my mind: childbed fever and the death of Professor Kolletschka were one and the same. His sepsis and childbed fever must originate from the same source . . . the fingers and hands of students and doctors, soiled by recent dissections, carry those death-dealing cadavers' poisons into the genital organs of women in childbirth . . .".6,11,12 Semmelweis began experimenting with various cleansing agents and, from May 1847, ordered that all doctors and students working in the First Division wash their hands in chlorinated lime solution before starting ward work, and later before each vaginal examination. The results were extraordinary — the mortality rate from puerperal fever in the division fell from 18% in May 1847 to less than 3% in June–November of the same year.11 Doctrine dismissedLike Holmes, Semmelweis found that his conclusions did not receive immediate acclaim from his colleagues and superiors. Indeed, he was treated with scepticism and ridicule by many in the Viennese and wider European medical establishments, including his own professor, Johann Klein. In 1849, Semmelweis' contract with the Lying-In Hospital was not renewed and he returned to Hungary, joining the University of Pest. He presented his findings to the Medical Society of Vienna in 1850. They were not well received, other opponents at that time including the famous pathologist Rudolph Virchow and the prominent obstetrician Friedrich Scanzoni. Semmelweis did not publish his observations until 1861; again, they were greeted dismissively. Embittered, Semmelweis wrote a series of "open letters" to his former professors, accusing them — rightly, as it turned out — of being "medical Neros" and "murderers".11,12 Sadly, his last years were affected by depression and mental disturbance. In July 1865, he was committed to a psychiatric institution in Vienna, and died there two weeks later — ironically, probably from septicaemia following a cut to a finger.3,6 Acceptance of antisepsisParadoxically, within a few years of his death, Semmelweis' doctrine began to be accepted by the wider medical community. In 1874, Billroth demonstrated streptococci in pus from wound infections, and in 1879 Louis Pasteur identified the haemolytic streptococcus in the blood of a woman with puerperal sepsis.3 Joseph Lister, learning of Pasteur's work and germ theory, began to apply antiseptic principles to the practice of surgery, with a dramatic fall in postoperative deaths from infection. As with Semmelweis', Lister's ideas were also greeted with scepticism and it took nearly 30 years for "Listerism" to be universally accepted by medical practitioners.13 By the end of the 19th century, the need for obstetric asepsis was well appreciated. An authoritative text of 1905 gives detailed instructions for the personal hygiene of physicians and nurses attending confinements and instructions on the performance of internal examinations. The importance of "inculcating in the student the principles of obstetrical cleanliness, mechanical and chemical" is emphasised. The need for meticulous antiseptic care during operative vaginal deliveries and manipulations — more frequent then than now — is reiterated.14 Australian medical practitioners were apparently quick to follow the lead of their overseas colleagues in the application of hygienic measures in obstetrics, and of self-regulation when puerperal fever occurred in their practices. Most stopped attending midwifery cases for a time after one or two deaths among their patients.15 Surprisingly though, despite the new understanding of the importance of antisepsis, puerperal sepsis still occurred frequently in developed countries in which figures were kept. It appears the principles of antisepsis were not universally applied. In England and Wales, in the period 1870 to 1890, the maternal death rate in hospital births was around 1 : 20, of which about 40% were due to infection. In the United States, in the 1890s, 20 000 women a year died in childbirth.14,16,17 In New South Wales, in 1894–1896, among confinements of married women, both at home and in hospital, the government statistician found a death rate of 1 : 148, and he commented on the negligence of medical men in filling the certificates required by law. Up to that point, causes of death had been supposedly accurately recorded for more than 40 years, but, in fact, the puerperal nature of fatal infections in women was frequently omitted.14,15 Globally, the most common and most feared infecting organism at the time was the Group A haemolytic streptococcus, whose virulence appears to have diminished in recent years, possibly due to improved socioeconomic conditions and the use of antibiotics. Normally found on the skin, in the nose and throat, and in the vagina, as well as in skin lesions, the streptococcus was introduced into the genital tract during examinations and deliveries. Lacerations, blood loss and exhaustion from prolonged labour increased the possibility of postpartum infection. Staphylococci, gonococci, coliforms and other bowel flora, as well as anaerobes, were less likely culprits, but have assumed greater importance in recent years, as have Group B streptococci.3,7,15 Debating deliveriesIn Australia overall, as elsewhere overseas, the maternal mortality rate (MMR) actually remained steady from 1900 until the late 1930s (5.95 per 1000 women delivered in 1903; 5.13 in 1933). Among developed nations, the United States had the highest MMR and the Netherlands and Scandinavia the lowest, although there were some individual hospitals with remarkably low rates, including the Rotunda in Dublin, Ireland, and Crown Street Women's Hospital in Sydney, Australia.15,17 Causes of the continuing fatal role of puerperal sepsis were widely debated. The medical profession tended to blame untrained midwives, and moved towards their training and registration, which was achieved by the 1930s. Some attributed the rates of sepsis to high levels of interference in labour and delivery, especially forceps deliveries. In Australia, the "lodge" system of practice — whereby families purchased medical services through lodge or friendly society membership — was held to blame. Busy general practitioners contracted under this system were allegedly likely to try to conduct confinements hurriedly.15-17 There were moves both to increase instruction in obstetrics for general practitioners and to encourage specialist obstetricians to do deliveries.15 Antibiotic arsenalAfter 1935, the situation improved rapidly in developed countries. Early that year "a startling therapeutic success" was announced by Domagk in Germany — the prevention of septicaemia in mice experimentally infected with streptococci after the administration of prontosil, a sulfonamide dye.18 In June 1936, Colebrook and Kenny, in a landmark paper, reported their success in treating established puerperal sepsis in women using prontosil — the death rate in apparently similar cases dropped from around 27% to 8%. Colebrook and Kenny wrote (cautiously): ". . . the very low death rate, taken together with the spectacular remission of fever and symptoms observed in so many of the cases, does suggest that the drug has exerted a beneficial effect".18 History was to prove them correct, and in 1939 Domagk was awarded the Nobel Prize in Medicine and Physiology for his work. Prontosil and other sulfonamides were followed by penicillin, to which streptococci causing puerperal sepsis still remain sensitive, and the arsenal of antibiotics used for all other forms of postpartum fever today.3,19 Today, in Australia, deaths from puerperal sepsis are extraordinarily rare (the MMR is currently about 0.1 per 1000 births).2 However, infection and fever are not rare, and the microbes causing them are omnipresent. In caring for pregnant women, especially the many who have some intervention in labour or delivery, we would be wise to reflect that it is only the use of increasingly complex antibiotic regimens which prevents a return to "the terror of the lying-in hospitals".

Caroline M De Costa FRANZCOG, FRCOG

As the United States' unsettling rise to hegemony illustrates, the world becomes a more dangerous place when the balance of power is altered. What is true for geopolitics is true for medicine. I have a simple proposal for restoring the balance of power between the junior medical staff and their consultants and registrars. It relies on the well-proven theory of deterrence. It is the intern's equivalent of a submarine filled with nuclear missiles cruising off the coastal shelf of the registrar's continent. The system works this way. At the welcome and orientation to the hospital for the new interns, the last presentation is by a well-respected intern from the previous year. Ten shiny laminated cards are handed to the shiny new interns and they are instructed in their use. They are admonished to hoard these resources, to use them sparingly and effectively. A few weeks later the morning ward round is drawing to a close. Twenty-five patients have been seen, and seven consultations, two MRIs, a bone scan and a partridge in a pear tree have been generated for the unfortunate but uncomplaining intern. However, at last a line is crossed. A patient who had surgery the night before is rolling around in bed complaining about pain in his knee. He has a urinary catheter because he suffers from prostatism and has produced 20 mL of urine an hour from his generously sized ex-meat packer frame. One can easily see from the foot of the bed that he is as dry as a chip. The two drains appearing from under his bandages are full. The orthopaedic registrar looks at the pulse oximeter and notes a mild tachycardia. The terrible words are uttered: "We'd better get a cardiology consult . . ." (at least his expression is hangdog). This is the time to act. The intern pulls out his wallet and deals the "Get your own damn consult!" card. The registrar accepts it with consternation. He is compelled by the laws of decency and tradition to proceed. Dutifully, he calls the cardiology registrar between cases. He is greeted with the derision such an unnecessary consultation deserves. A hefty dose of humble pie is consumed. A couple of weeks later the temptation arises for another dodgy consultation; this time, some minor basal atelectasis. Noting the oxygen saturation of 94%, the registrar turns to his intern and starts to open his mouth. The intern reaches for his wallet; the mouth is shut; the submarine descends from launch depth and the balance of power is restored.

Richard D Lawson

Background: In 1889, Brown-Séquard, aged 72, reported dramatic rejuvenating effects after self-administering testicular extracts of dogs and guinea-pigs. His report resulted in widespread use of testicular extracts throughout Europe and North America for several decades. More recently, the male ageing process has been attributed to partial androgen deficiency, or "andropause", and testosterone treatment is claimed to improve well-being in middle-aged and elderly men.Design: We prepared extracts from five dog testes using Brown-Séquard's methods and assayed testosterone concentrations.Results: Testosterone concentrations were four orders of magnitude less than that required for a biological effect.Conclusions: Our study illustrates the marked placebo response that can be evoked by androgen treatment. It cautions against the empirical use of testosterone treatment for older men, unless a diagnosis of hypogonadism has been substantiated.

Andrea J Cussons MB BS · John P Walsh FRACP, PhD · Chotoo I Bhagat MD, FRCPA · Stephen J Fletcher MSc, Dip CB

Objective: To describe the effect of physicians' dress on patient confidence and trust.Design: A prospective crossover trial involving physicians dressed in "respectable" versus "retro" attire.Setting: A general medicine ward at a tertiary hospital.Participants: 12 male general physicians and 1680 patients.Main outcome measures: Patient trust and confidence as measured by a questionnaire mailed after hospital discharge.Results: Formal attire was correlated with higher patient confidence and trust. Nose rings were particularly deleterious to patients' reported trust and confidence. A minimum threshold of two items of formal attire (dress pants, dress shirt, tie, or white coat) were necessary to inspire a reasonable amount of confidence; this is the NND (number needed to dress).Conclusions: We highlight the need for more research into the effects of physician dress, and coin the term "evidence-based dressing".

Balakrishnan R Nair FRACP, FRCP · Stephen R Mears DipIM · Karen I Hitchcock BA · John R Attia MD, MSc, PhD, FRCP(C)

The Olympic Games should be the pinnacle of sporting achievement, a showcase of the highest athleticism that can be reached by men and women. However, at present, it is estimated that only about 50% of sportspeople take advantage of the performance-enhancing medications developed through the wonders of modern science. This pharmacological nihilism is disappointing. If our best unmedicated athletes can achieve similar performances to those whose performances are pharmacologically enhanced, then how much better might they do with the benefit of modern medical science? What is needed is a level playing field. A fertilised one. We propose that, in future, no athlete should be allowed to compete in the Olympic Games without making maximum use of the miracles of modern medicaments and designer drugs. The Games could then be renamed the Pharmacological Olympic Games. The sponsorship possibilities are infinite. Rules of performanceAll performing athletes will be required to have drug tests at the start and end of competition. Those refusing to provide samples of blood and urine will not be allowed to compete. Any athlete whose samples test negative for performance-enhancing drugs will be sent home in disgrace. Performance-enhancing drugsThe accepted reference work for the sporting pharmacopoeia is MIMS-Sportif. Track and fieldHomoeopathic principles have always dictated that one treats a fever with hot medicines, and a cold with cold ones. Obviously, one can only expect to improve speed with speed. Amphetamines are de rigueur for the ambitious track-and-field athlete. The walkers, however, may prefer to take Slow K. A wide range of uppers is available for the high jump and the high hurdles, and long-acting uppers for the long jump. Cyclists should avoid catching herpes at all costs, because acyclovir can seriously impair their performance. Anti-inflammatories, such as the non-steroidal anti-inflammatory drugs, can help cure a slipped discus. In the poolDivers may benefit from downers, while antibiotics can help any divers suffering from diverticulitis. A new range of stroke medication is available for swimmers. Water polo players will benefit from the new water polio vaccine. The regattaThe COX-2 inhibitors have proved popular among rowers, particularly the coxless pairs. Soccer, tennis, handball, volleyballTestosterone is the drug of choice to improve ball control. Demonstration sportsDemonstration sports are sports favoured by the host country that may become a regular fixture in future Olympics. A demonstration sport with exciting pharmacoathletic possibilities is the dramatic Irish sport of hurling, which can be spectacularly enhanced by the judicious use of ipecacuanha. New developments on the horizonWeight-lifters have found that the new SSRI antidepressants have given them a real lift. Beach volleyball has received a boost from Sandoz, who are adding to Sandoglobulin and Sandomigran with a new drug, Sandobikini. ConclusionThe Pharmacological Olympic Games will showcase the best of what medicine and sport have to offer when the aggressive therapeutics of the heroic physician are harmoniously combined with the ruthless competitiveness of the world-class athlete. Let the Games begin!

David Isaacs · Dominic Fitzgerald

The sun filtered in as he cradled his chin in the palm of his long-serving hand, as he relived the days of his work in the haze way outback in our Great Southern Land. It seems too much to ask, but he's stuck to his task for the span of five decades or so; but his heart it is yearning, his stomach is churning, and he feels it's now high time to go. Ten years have passed by since he first wondered why there was no-one to answer his call — his practice for sale, but there lies a tale — he's just waited and waited, that's all. Will anyone follow his work on the morrow? Have our med schools dried up like Lake Eyre? For each greying carthorse, let's renew the workforce and steer our old docs from despair!

Andrew Beattie

To the Editor: In 1995 and 1998 I was fortunate enough to have extended leave of several weeks. On both occasions, when I averaged out the weight of mail, excluding newspapers, waiting for me on my return, it came to about 7 kg per month. I wanted to determine the volume of communication I received in 2002, but: a substantial amount of my mail is now electronic; I no longer have extended holidays; mail cannot be now left unopened and unattended. It is opened by a trusted colleague, scanned into our patients' medical records and the originals left out for me to see on my return; being away would lead to a decrease in the mail I received; weighing individual mail articles would be a tedious test of sanity. So, I logged my mail for four weeks from 13 July until 9 July 2002. I have included neither mail addressed to me at home (which is now minimal and consists mainly of household bills and private correspondence) nor newspapers. A summary is shown in the Box; I have the individual log if anyone is interested. So, how to measure the communication load of a general practitioner? I have weighed it and counted it, but it was not practical to determine how long it took to read. This is because reading it necessitates acting on it, whether this means writing a reply, incorporating it into a patient's history or recalling a patient to order further tests. This communication load on GPs is significant and is a further indication of the complexity of our discipline. The weight of this load has significance for those wishing to communicate with GPs. Anything longer than a page runs a risk of joining the rapidly enlarging pile next to the GP's desk of material that must be read at the first opportunity. Anything else is condemned to the round filing receptacle under the desk. Correspondence received in four weeks 814 emails (62 individually addressed; 752 undirected from various mail groups). 451 individual pathology results downloaded by computer. 181 letters (147 individually addressed; 76 standard-sized letters, undirected, from various organisations; 58 oversized letters, undirected, from various organisations). 8 journals (4 subscribed; 4 unsubscribed). 8 broadsheets. 8 items of other mail, including books and packages of documents, weighing a total of about 3 kg. 112 faxes. Grand total: 1574 individual pieces of communication per month

Christopher D Hogan

One of my poppy plants always sets its buds in pairs, with a stem formation reminiscent of some human anatomy. If its seedlings set true, I may have a new botanical variety: Papaver orchidiformis, var. vasa deferentia.

Alan Moskwa

The only real firefighter in this group was the person taking the photograph, which shows emergency physicians and anaesthetists undertaking breathing apparatus training at the NSW Fire Brigade's "Hot Cell" training centre. Most aren't watching the fire, but one has just noticed it spalling along the ceiling above them.

Antony Nocera

Torsion of the vermiform appendix was first reported by Payne1 in 1918 and remains something of a curiosity, with only 19 further cases reported, 12 in paediatric patients.2,3 Anatomical variations (eg, long mesoappendix), appendiceal tumours and strenuous physical exercise such as calisthenics were suggested to predispose to torsion.4,5 Reported clinical presentations were indistinguishable from acute appendicitis.4 Our patient, a 44-year-old woman, suddenly developed severe abdominal pain while walking, which was unrelieved by narcotic analgesics. Abdominal palpation revealed acute tenderness suprapubically and in the right iliac fossa. Surgical exploration via the standard McBurney incision revealed a dilated gangrenous appendix twisted 360 degrees anticlockwise at its base, as shown in the operative photograph. Histopathological examination of the appendix revealed a cystadenoma close to its distal end. The patient made an uncomplicated recovery after appendicectomy. First report "On Monday, March 13, 1916, while travelling in a train, [the patient] was seized with sudden pain in the epigastrium after lunch. She vomited several times, but the pain continued and was of a colicky nature. At midnight the pain suddenly shifted to the right iliac fossa and became continuous. The following day a doctor was called in; he ordered enemata, and three were given, with very copious results. On the 15th I saw the patient and operated the same evening. On opening the abdomen through the right rectus incision, the appendix was found pointing downwards and slightly outwards in the right iliac fossa. It was quite free except for a slight recent adhesion from the extreme tip to the iliac fossa. On examination it was found to be twisted, and it took three complete turns to unravel it . . . The appendix distal to the narrowing caused by the twisting was gangrenous, and the meso-appendix dark and swollen. The appendix was removed, and the abdomen drained through the original incision. The temperature and pulse became normal on the third day, and the patient made an uneventful recovery. Remarks. — The appendix was 21/2 in. long and contained faecal material. It seems most probable that the previous attacks were due to a 'constipated appendix,' and that the torsion resulted from irregular peristaltic movements on the part of the appendix itself." — Br J Surg 1918; 6: 327

Amy L Moten · Randal S Williams

The Macarthur Ambulatory Care Service has developed a successful program for delivery of intravenous antibiotics at home to provide an alternative to hospitalisation. Although most patients are housebound, some have returned to their usual occupation during treatment, without adverse outcomes. This 57-year-old poultry farmer, referred by a respiratory physician for treatment of community-acquired lobar pneumonia, was receiving intravenous ceftriaxone 1 g daily. For his final dose, the nurse was directed across the farmyard to a large shed, where he was feeding his chickens.

Nicholas P Collins MB BS, FRACGP · Bradley Warner BHlth, RN · Stephen F Wilson FRACGP, FAFRM

One of my most amusing cases concerned two young fellows who had spent a day on the town doing some considerable celebrating. To prepare for more of the same that night one of them decided to clean his teeth. In the course of this procedure he managed to swallow his toothbrush. I was unbelieving when first I heard this story, but, despite his inebriation, the patient was obviously distressed, so oesophagoscopy was indicated. A toothbrush was removed from the upper oesophagus. My relieved patient, hearing my name, said he was used to consulting Dr Beer regularly, and thought that more beer was sure to help him.

Neville Beer