History and humanities

Henry Oliver Lancaster was born in Sydney on 1 February 1913, but spent his early years in Kempsey, NSW, where his father had a medical practice. His father died when Oliver was almost nine, and he boarded in Kempsey through his primary and West Kempsey Intermediate High School years. After a year studying economics/arts at Sydney University, he enrolled in medicine in 1931 and graduated in 1937. In that year he worked as a Resident Medical Officer at Sydney Hospital, and in 1938 as a pathologist and Senior Medical Officer. Lancaster joined the Australian Imperial Force as a Medical Officer in 1940, and later served as a pathologist in the Middle East and New Guinea. His first two papers (jointly with T E Lowe), on worm infestations in troops, were published in the Medical Journal of Australia in 1944. The same year, a secondment to the Australian New Guinea Administrative Unit awakened his interest in demography and sparked his return to the serious study of mathematics. From 1946 to 1948, while on a temporary appointment to the School of Public Health and Tropical Medicine (SPHTM) (affiliated with Sydney University), he took the opportunity to study advanced mathematics and read the work of the English and American medical statisticians/epidemiologists. In 1948, he left to spend a year as Rockefeller Fellow in Medicine at the London School of Hygiene. After returning to work at the SPHTM, Lancaster was involved with statistical and epidemiological studies of disease in Australia, including diabetes, cancer (notably melanoma and its association with latitude) and tuberculosis. In 1941, the ophthalmologist Norman Gregg had observed that many cases of cataract were the result of maternal rubella in the first month of pregnancy. This was to lead to Lancaster's landmark discovery that "ordinary" rubella infection of pregnant women (rather than a new, highly virulent strain, as Gregg had thought) was linked with congenital deafness of offspring.1 In 1959, Lancaster was appointed to the Foundation Chair of Mathematical Statistics at the University of Sydney, a position he held until his retirement in 1978. He was elected a Fellow of the Australian Academy of Science in 1961, and awarded its Thomas Ranken Lyle Medal for Physics and Mathematics in the same year. He was awarded an MD in 1967, and in his retirement returned to intensive writing in medical statistics. His publications included Expectations of life (1990), a massive study of world mortality, and Quantitative methods in biological and medical sciences. A historical essay (1994). Oliver was made an Officer of the Order of Australia in 1992 for services to science. An account of his career, Some recollections of Henry Oliver Lancaster (1996), edited by his brother Richard, is in the Sydney University archives. He died in Sydney on 2 December 2001 of coronary heart disease.

Eugene Seneta

To the Editor: Your readers might be interested to examine the full story of Dorothy Reed's initial encounter with William Osler,1 and to learn that he later apologised for his initial negative reaction to her expressed intention to enter medical school, and gave her great support. She later said of him: "He was my friend and to me William Osler has always stood for the greatest personality and the soundest medical teaching possible at that time." Some of her unpublished memoirs are included in a book edited by Jill Ker Conway.2

Tony E Seymour

Objective: To describe the genetic basis of various personality traits.Design: Prospective, blinded cohort study comparing questionnaire-reported personality traits with candidate genes for temperament, as revealed by genetic mapping in the Human Genome Project. Non-supervised questionnaires were mailed to MJA subscribers. DNA extracted from newborn screening blood samples of all New South Wales participants was used to perform mutation analysis for candidate personality genes.Setting: Tertiary medical care in New South Wales, 1 April 2000 to 1 April 2001.Participants: Healthcare professionals who admitted to reading the MJA on at least a semi-regular (monthly) basis.Main outcome measures: Correlations between occupation, personality and gene mutations were sought using a LOD score in comparison with a classic Poisson d'avril distribution.Results: Mutations were identified that suggested the existence of genes determining several personality traits. Genes coding for belligerence (bel), charisma (lub), cynicism (dub), housekeeping (vac and uum), lack of personality (dul-1), obsessive-compulsive behaviour (pic-e) and gullibility (suk-r) are described. These were found to be selectively represented in certain members of the healthcare profession.Conclusions: The seven most important healthcare personality genes have now been described for posterity.

Dominic A Fitzgerald PhD, FRACP · David Isaacs MD, FRACP

Ben Haneman's army of friends were greatly shocked to learn that Ben had collapsed in the State Library of New South Wales, was admitted to St Vincent's Hospital, and died the following day, 18 December 2001, without regaining consciousness. His life of service has enriched us all. Ben was born into a Jewish family in Florence, Italy, on 13 February 1923. They migrated to Australia in 1927, where Ben thrived. He attended Canterbury Boys' High School, then entered the University of Sydney's Faculty of Medicine at the age of 15. After graduating in 1944 and completing residencies in Perth, he settled into general practice in Carlton, NSW, in 1947. He became a Member (1960) and Fellow (1971) of the Royal Australasian College of Physicians. Officially, Ben served St George Hospital (as Honorary Medical Officer and then Visiting Medical Officer) from 1947 until 1990, particularly in the field of gastroenterology. His effective service was much longer. He loved teaching, and would take students to Lidcombe Hospital on Sunday mornings to see rare and interesting neurological cases. Naturally, he became St George's first Warden of Students. For many years he contributed a monthly essay to the St George Hospital Post Graduate Medical Bulletin. He was also a regular contributor to RACP News, Australian Doctor and the Jewish press. He became a physician of extraordinary energy, enthusiasm, erudition, generosity, compassion and good humour. Ben gave continuing support to the University of Sydney and University of NSW medical schools. For many years he was Warden of Warrane College (a student residential college) at the University of NSW. Recently, he presented a fascinating discourse on the history of Sydney University's Faculty of Medicine to a large and appreciative audience of fellow graduates. At the time of his death, he was Vice President of the NSW Society of the History of Medicine and President of its national body. Ben had an enormous range of interests. He was a committed Jew and was chairman of the Social Justice Committee of the Jewish Board of Deputies. He had a valuable personal library containing many thousands of volumes, and a highlight of a visit to his home was to share his enjoyment of some recent "find". For over 30 years he was a greatly respected member of the Library Committee of the Royal Australasian College of Physicians. He also had a passion for Spain and its culture. Having learnt Spanish in his youth, he became enamoured of the country and its people. He was an honorary professor for many years at the University of Navarre, and in 1984 the Spanish government appointed him a Knight of the Order of Civil Merit. In 1997, he generously donated to the State Library of NSW 1100 editions of Don Quixote in various languages and a further 1000 books on Cervantes. He became the first Life Member of its Library Society, the Friends' Group, in November 2001. A passionate soul, Ben was truly quixotic himself ("one who strives with lofty enthusiasm for visionary ideals" — Oxford English Dictionary). Generations of students and patients are indebted to him. In 1988, Ben was appointed a Member of the Order of Australia for services to medicine and the Spanish community. He is survived by his sons David and Peter.

George C Wilson AM MB BS FRACP

Steve Hocking was a respected anaesthetist in Perth who died at the age of just 39. He was born on 18 April 1962 and attended primary school at Jolimont in Perth and secondary school at Mentone Grammar School in Melbourne. He graduated in medicine from the University of Western Australia in 1986 and spent his internship and residency at Royal Perth Hospital. On secondment from Royal Perth Hospital, Steve worked in Kalgoorlie as a Resident Medical Officer. While there he took up parachuting, until his fellow RMO broke his ankle participating in the same activity, forcing Steve to do the work of both of them. In 1995 he spent three months in Port Hedland working as Anaesthetic Registrar, and, after obtaining his Fellowship of the Australian and New Zealand College of Anaesthetists in 1996, he spent a year in Pittsburgh, Pennsylvania, as Associate Professor of Anaesthesiology. He returned to Western Australia in 1997, where he worked as a sessional anaesthetist at Royal Perth Hospital before moving solely to private practice. As a doctor and anaesthetist, Steve's focus was always his patient. Woe betide any clipboard-carrying nurse who tried to get in the way of his postoperative analgesia orders. His fierce advocacy and compassion for his patients was perhaps partly a result of having been a surgical patient himself and having experienced a chronic illness. This was always something that he bore privately and without complaint. His attitude to his own illness was to accept it and just get on with life. In the operating theatre he was always calm and precise; the sort of anaesthetist that other doctors would want to be anaesthetised by. He was also funny, but his humour was delivered in a characteristically dry sort of way that people would miss if they didn't know him well. Steve developed metastatic cholangiocarcinoma in October 2000 as a complication of ulcerative colitis, which had been diagnosed when he was only seven years old. He pursued active treatment for as long as this gave him the opportunity to return home to spend more time with his wife Jane and children Oscar and Rupert. He died on 6 October 2001. Steve told his wife that the only regret of his life was his death. He will remain forever young. The measure of Steve's life should not be in its length but in its worth and in the legacy that he leaves. He was a good man.

Robert J Davies MB BS FRACS

The Story of Penicillin that we were taught as children was a simple story of how Alexander Fleming searched in vain for antibacterial agents until Penicillium mould spores drifted through his open laboratory window onto a plate of bacteria and killed them. Realising immediately the potential, he spent many years fighting against a resistant medical establishment and then guided Howard Florey and Ernst Chain to refine and test his great discovery. This myth meets the specifications of the archetypal "quest story", as described by the Russian anthropologist Vladimir Propp.1 The basic quest story seems to be a template in every human culture. It involves heroes who undergo trials or answer riddles, usually with the help of magical or divine intervention (in this case, mould spores drifting through windows). It has been argued2 that the quest story's structure (along with other story structures) is "hardwired" into the human brain, and that such structures evolved, like poetry and music, in human brains as mnemonic aids to help preliterate people store and remember vast quantities of words. Of course, we also have a tendency to rewrite history in a manner that renders it more momentous or more pleasing to the reader or listener. For example, Captain Robert Lewis, copilot of the plane that carried the first atomic bomb, records in his published account of the flight that his words immediately following the explosion were "My God, what have we done?". His exact words, as recalled by the rest of the crew, were "My God, look at that son-of-a-bitch go!".3 Among numerous inconvenient details missing from the penicillin myth is exactly how long the son-of-a-bitch took to get going, who was responsible, and why.4,5 The fact that Florey eschewed publicity while Fleming actively sought it did not help reveal the true story. A BBC film about Fleming, made as late as 1970, still perpetuated the myth, at least in popular culture. Alexander Fleming (1881–1955) in Edinburgh, where he had just been appointed Vice-Chancellor of the University, was received with just cause as a benefactor of humanity. Reproduced with permission from The Illustrated History of Medicine, by Jean-Charles Sournia. Published by Harold Starke. The search for non-toxic antimicrobial chemical agents"We can see further because we stand on the shoulders of giants", Albert Einstein said of Isaac Newton. The "giant" Louis Pasteur allowed the world to see the power of microbes in disease and the ability of the body's antibodies to combat these microbes. The search was then on for antimicrobial chemical agents — but antiseptics were too toxic for anything but surface use on wounds. In Frankfurt, Paul Ehrlich6 (who later won a Nobel Prize for his work on the theory of immunity) began to systematically test substances, searching for the "magic bullet" that could be taken internally, but ended up with little more than a high-risk arsenic-based treatment for syphilis. The resulting mindset was fixed — chemical agents were too toxic for internal use in the human body. Fleming, working in London, had been looking for antibacterial agents in human secretions. His discovery of the enzyme lysozyme (which he regarded as much more important than penicillin) came from an accidental sneeze onto a Petri dish (another divine intervention). He noticed that the area on which he had sneezed subsequently did not grow bacteria. "Noticed" is a key word — Fleming had a genius for taking notice of small, superficially inconsequential effects. Contrary to the myth, Penicillium spores did not fly in through an open window, as the windows of his laboratory were fixed shut. Luckily, Fleming's laboratory work practices were substandard. After stacking uncleaned plates in a corner while he was on holidays, he noticed (that word again) on his return that Penicillium mould had inhibited the growth of staphylococcal cultures. Fleming had little idea what to do with his mould apart from dabbing it on infected wounds. It seems astonishing now that he went so far as to inject his early "mould-broth" into a healthy rabbit, discovering it to be non-toxic, yet failed to take the further step of injecting it into infected rabbits to investigate its therapeutic effect. He then effectively forgot about it for 13 years. What was he thinking? And why, in this instance, did he not take notice? It's easy to see his mistake in retrospect, easy (in the words of author Julian Barnes) "to make the past suck up to the present".7 Fleming was of his time, a victim of the pessimistic mindset against toxic chemical antimicrobials. Ernst Chain at work in his laboratory at Oxford. Keystone (London) The contribution of Howard FloreyHoward Florey, the abrasive Australian who, Robert Menzies said, had more effect upon the welfare of the world than any other Australian, had also been working on lysozyme with his team at Oxford.8 He was a more methodical scientist than Fleming — methodical to the point of obsession — but the psychological imperatives behind this (the "madness in his method") had various origins. Florey suffered from a range of gastrointestinal symptoms, on which he blamed his irritable personality.8 He investigated his own condition by — among other tests — regularly swallowing a rubber tube to extract his stomach contents. The diagnosis was achlorhydria. His famous pinched smile was to hide the erosion of his teeth that resulted from drinking hydrochloric acid. The tests also sparked his interest in saliva and mucus and the antibacterial qualities of lysozyme. An important driving force in the quest for penicillin was Florey's idiosyncratic temperament, with its elements of idealism and obsession. His absorption with his work, and his rather unusual relationship with his wife Ethel, illustrate the power of an idea, or ideal, to sustain passion in the absence of reward. His relationship with Ethel began in his final year of medicine and was continued, in idealised form, by correspondence for five years of separation after he left for England. Even when she later joined him, the couple sometimes preferred to communicate via notes left on the hallway table. Florey worked seven days a week in his laboratory, seldom eating at home, and family holidays were generally spent visiting overseas laboratories. Ethel's involvement in his research was perhaps the one facet of the relationship that worked. She administered and recorded the clinical progress of the first large-scale trial of 187 cases of sepsis. Florey continued to work on lysozyme long after Fleming had abandoned it. Florey had the advantage of the services of a great biochemist, Ernst Chain (a refugee of the Hitler regime), on his team. Chain had purified lysozyme and understood its antibacterial function. Florey and Chain searched the medical literature for other antibacterial substances, and in so doing they rediscovered Fleming's finding of many years before. This was around the time of the discovery of sulfonamides and their minimal toxicity. To Florey, as to many others, this meant the end of the earlier mindset against toxic "magic bullets". He was interested in the fact that staphylococci, while resistant to sulfonamides and lysozyme, were apparently sensitive to the Penicillium mould. Chain was intrigued by the failure of Fleming and others to identify the active ingredient in the penicillin "mould-broth". The background of war in 1939 was a crucial spur to research on antimicrobial agents. Delayed infection (especially staphylococcal infection and gas gangrene) was killing more men than the immediate organ damage caused by shell and bullet wounds. Florey's awareness of this was not without an emotional resonance, as he felt some guilt about not having enlisted in the First World War. World War II provided an impetuous and risk-taking research environment. Resources normally denied could be commandeered, money was freed up, and Florey was able to persuade breweries to ferment mould for the conduct of trials on the battlefields of North Africa. Florey did many things that a modern researcher would be admonished for. He did not patent his work, despite being implored to do so by Chain. The United Kingdom was forced to buy back the technology from the United States for the mass production of penicillin. Florey shunned the media for fear of creating false expectations and had nothing but contempt for their intrusions into his life. He believed that sensational stories about penicillin would create a demand that could not possibly be met. He always stressed the team effort involved (teamwork was an unusual feature of medical research in those days), and claimed that he got more credit than he deserved. As a consequence, he almost left Fleming — seldom out of the limelight by then — to receive the Nobel Prize alone. Howard Florey. Photograph courtesy Dr Joan Gardner, AO. The moral of the storyThe philosopher Richard Rorty has written that "inquiry is never pure ... It is always a matter of getting us something we want".9 The story of the quest for penicillin contains too many complicated semi-heroes to allow itself to be twisted into a myth of the usual impoverished Hollywood dimensions. If there are mythical heroes in scientific research they work in teams — sometimes in teams that are not even aware they are teams, being disconnected in time and place. If a relay team is the closest analogy, the baton is more often tossed into the air in the hope that someone — anyone — will grab it than passed on directly. But, like most archetypal stories, the story of penicillin doesn't lack simple moral lessons. Perhaps the most lasting is the recurring theme of human creativity: how to see what has been hidden in full view all along. The great clinician Sir William Osler wrote of an earlier mindset in 1905: "We may have become more plastic and receptive, but I doubt it; even our generation . . . had a practical demonstration of the slowness of the acceptance of an obvious truth in the long fight for the aseptic treatment of wounds. . . . [It was] a long and grievous battle, as many of us well know who had to contend in hospitals with the opposition of men who could not — not who would not — see the truth . . . "In making knowledge effective we have succeeded where our masters failed. But this last and final stage, always of slow and painful consummation, is evolved directly from truths which cannot be translated into terms intelligible to ordinary minds."10 As the philosopher John Locke wrote, "Truth scarce ever yet carried by vote anywhere at its first appearance. . . . The final struggle for acceptance is the real challenge in achieving knowledge".10 The narrative impulse always seeks to personify that struggle, to dramatise it as a battle between individuals, in black and white — but the truth is much more messy and complex.

Peter D Goldsworthy MB BS · Alexander C McFarlane MB BS (Hons), MD, Dip Psychother, FRANZCP

Chris Silagy was born on 14 September 1960 and educated in Melbourne. He graduated in medicine from the University of Melbourne in 1983 and completed a PhD in epidemiology at Monash University in 1992. After spending two years in Oxford as the Sir Robert Menzies Scholar in Medicine, Chris returned to Australia in 1993, at the age of only 33, to take up the foundation Chair of General Practice at Flinders University. He was actively involved in supporting the development of the Cochrane Collaboration, both in Australia (as Director of the Australasian Cochrane Centre from 1994 to 2001) and internationally (as Chair of the international Steering Group from 1996 to 1998). In February 1999, Chris moved to Melbourne to take up the position of Professor of Public Health and Foundation Director of the Monash Institute of Health Services Research. He had a passionate belief in the need for an evidence-based approach to healthcare and the important role that consumers have within that process. He was a strong public advocate for this approach, reinforced by his personal need for reliable information after he was diagnosed with non-Hodgkin's lymphoma in 1997. Chris spent the last few years of his all-too-short life cramming in as much as he had always done. He was fully involved with his national and international committee work, speaking engagements, and research activities. In 2000, he was appointed to chair the board of the newly established National Institute of Clinical Studies. He was also Deputy Chair of the National Health and Medical Research Council (Health Advisory Committee). Chris also found time to serve the community. For almost 20 years he was actively involved in scouting, holding the posts of Branch Commissioner for Scouts in Victoria and National Commissioner for Youth Program. He managed to combine all these activities with a strong and devoted commitment to his family. He was immensely proud of the achievements of his wife Jane and sons Andrew, Michael, Nicholas and Benjamin. In 2000, he was made an Officer of the Order of Australia for services to medicine, an award of which he was extremely proud. In the end, his battle with lymphoma was lost, but his vision and legacy will live on in many ways. Chris A Silagy* [Postscript: Chris Silagy died on 13 December 2001, at the age of 41. It was his wish that a fund be established in his memory to help continue the work of the Cochrane Collaboration. Donations to the "Monash University Medical Foundation — Chris Silagy Fund" can be forwarded to Monash Institute of Health Services Research, Locked Bag 29, Monash Medical Centre, Clayton, VIC, 3168.] *Self-written obituary.

Christopher A Silagy AO, MB BS, PhD, FRACGP, FAFPHM

Gwen Nash was born in Cairo, Egypt, in 1904, of missionary parents. After World War I the family migrated to Sydney and Gwen studied medicine at Sydney University, where she was one of only seven women in a class of 56. After graduation, she worked at Prince Alfred Hospital, Crown Street Women's Hospital and the Children's Hospital. In 1932 she enrolled at the Melbourne Bible Institute, where she met her husband, Laurence Nash. When they were married in 1933 she followed him to Hong Kong, where she became Director of Women's Medical Services. Gwen returned to Australia at the outbreak of World War II when her husband joined the Royal Australian Navy. During the war Gwen raised three children and continued working in general practice in East Melbourne and at the Freemasons and Queen Victoria hospitals. In 1944 the family moved to Hobart. Gwen worked as a government medical officer, as well as giving regular religious devotional talks for the ABC (the "token woman", she said). It was when the family moved to Melbourne, in 1952, that Gwen started training in psychiatry at Royal Park Psychiatric Hospital under the tutelage of Dr John Cade. She subsequently worked as a psychiatrist at the Alexandria and Malvern clinics and resumed her religious broadcasting. In 1965, after Laurence died suddenly, she moved to Armadale, Victoria. She worked for the Victorian Health Department, including a year as Superintendent of Ararat Psychiatric Hospital and, after this, set up in private practice as a psychiatrist. She served on the Anglican diocese as honorary psychiatrist on the Diocesan Selection Board. Gwen enjoyed retirement in Glen Iris, until a fall resulted in a broken hip. From then she slowly deteriorated and in January 2000 moved to a nursing home, where she died on 4 September 2001, aged nearly 97. Gwen's passions were the well being of her patients, her Christian faith, her family, and a wide circle of friends in Australia and overseas. She was deeply concerned that women have the opportunity to be educated, to have careers and to value their own experience, and she mentored many women professionally and privately. She leaves behind many people whose lives have been enriched by her generosity and her steadfast faith.

Felicity Brown · Barbara Overbury and · Kate Nash

Over the past 50 years, advances in biological and physical science have fuelled an unprecedented expansion of medical knowledge and change in medical practice.1,2 We now have effective treatments for many conditions, including infectious diseases, cardiovascular disease, mental illness, peptic ulceration and diabetes. Advances in surgery and anaesthesia have made these disciplines not only safer, but also bolder. Imaging technology now exposes the most secret recesses of the human body and, with other diagnostic disciplines, threatens to make the art of clinical diagnosis redundant. Technology has revolutionised human reproduction and erased many of its uncertainties. The organisation of the profession has also changed. The Commonwealth Jubilee issue of The Medical Journal of Australia in 1951 chronicled the advances in Australian medical disciplines in the first half of the 20th century. At that time, these disciplines numbered 16 — anaesthesia, child health, clinical pathology, dermatology, general practice, internal medicine, obstetrics and gynaecology, ophthalmology, orthopaedic surgery, otorhinolaryngology, physical medicine, psychiatry, public health, radiology, surgery and urology.3 The kaleidoscope of disciplines in modern medicine now exceeds 50 and this expansion shows no signs of remaining static, as new knowledge and technology further subdivide specialties. Sadly, this mitosis of medical specialties has not led to interconnecting, communicating cells. Instead, specialist and subspecialist "silos" have evolved which serve to contain and isolate. Each specialty has its own body of workers, is sustained by its own agenda, and drives its own research programs, the outcomes of which are discussed at specialist meetings and published in specialist journals. How much does one such silo know about the latest repository in another? To redress the poor external communication of specialist silos, this issue of the Journal features Updates on advances in more than 40 of medicine's current disciplines. We asked Australian doctors to share with us the more significant advances and changes in their disciplines, with three qualifiers: individual contributions were limited to one Journal page to enforce a focus on pertinent issues; contributors were to identify developments which were most likely to remain viable; and advances were to be explored from the perspectives of prevention, diagnosis and intervention. What emerges is a collage of Updates in which the unifying themes are more distinct than the differences. These are: disease prevention is in the ascendancy; clinical medicine is increasingly embracing advances in molecular biology and the attendant implications for prevention and diagnosis; the tools of health informatics are revolutionising clinical decision making — with their capacity to store and analyse vast amounts of information, we can now process anything from nucleotide sequences to clinical evidence; and no discipline is an island, and input from several disciplines made many of these advances possible. What is apparent too is that the doomsday predictions that medicine is on the wane may well be premature. In his epic analysis The rise and fall of modern medicine, James Le Fanu argues that the "golden age" of medicine ended in the 1980s, "when the main pillars of the post-war medical achievements — clinical science, medical chemistry and . . . technological innovation — were in trouble".2 However, the depth and richness of developments outlined in this issue of the Journal support the view that human ingenuity repeatedly confounds predictions that medicine has reached its limits.4 The Updates also highlight problems yet to be solved. The ethical and social implications arising from some uses of new technologies are challenges that face us. The divide between developed and developing countries is alluded to. Resource allocation that is driven by economic and political imperatives places boundaries on what can be achieved. There are pressures to allocate resources that sustain the use of complex technologies and new drugs rather than priorities such as disease prevention programs and population health. That medicine is increasingly isolated into specialist silos is clearly visible in these Updates. Yet, it is equally clear that innovation is not dead unless these silos become even more airtight. On a broader landscape, we live in a world irrevocably changed by the dramatic events of September 11, 2001. The notion that collective values do matter, despite (or perhaps because of) the fact that we live in an unequal, insecure world, has been reiterated by many. We in the medical profession would do well to be driven by a similarly collective and collaborative vision for health. As John Martin, a British Heart Foundation professor of cardiovascular science, recently observed, "a multidisciplinary team is more likely to give rise to non-linear fantasy [or innovation] than a monovalent team".5

Mabel Chew FRACGP, FAChPM · Martin Van Der Weyden

The research enterprise The Menzies Centre for Population Health Research A unique and supportive local population was a vital ingredient in the Centre's success Terence Dwyer MJA 2001; 175: 617-620 Early days: the Tasmanian Infant Health Survey and Sudden Infant Death Syndrome - The post-SIDS era: taking stock - New directions - Genomics - The future - References - Authors' details - - More articles on Psychiatry I ACCEPTED THE CHAIR IN COMMUNITY HEALTH at the University of Tasmania in 1985 with the intention of setting up a research centre that focused on epidemiological research into preventable causes of disease. While I did not know how the centre would be funded, I was certain that Tasmania would be a very competitive site for such research. Already, valuable epidemiological studies on iodine deficiency, hydatid disease and asthma had been conducted in the absence of significant research infrastructure.1 The "Island State" provided a perfect source population for unbiased selection of cases and comparison samples or controls. Further, the land area and population size (around 500 000 people) made follow-up of cohorts relatively easy. Thus, Tasmania had important advantages for the two major strategies used to search for environmental and lifestyle causes of disease — case-control and cohort studies. Funding from the Menzies Foundation came about through the input of three people — Basil Hetzel, then Chief of the Commonwealth Scientific and Industrial Research Organisation Division of Human Nutrition in Adelaide, who had a close association with the Menzies Foundation; Professor Ian Lewis, Dean of the Medical School at the University of Tasmania and a member of the Menzies Foundation Board; and Eric Wigglesworth, the Director of the Foundation. To determine the likely success of such a centre, the Foundation Board held a three-day workshop attended by representatives of State and Federal health departments and the World Health Organization, notable Australians in the field of public health, and distinguished British epidemiologist Sir Richard Doll. History of the Menzies Centre 1987 Workshop ("Towards a Centre for Population Health Research") in Hobart, Tasmania. 1988 Official opening in January. Collection of Tasmanian Infant Health Survey (TIHS) data began (prospective study on Sudden Infant Death Syndrome [SIDS]). 1990 Designated as a World Health Organisation Collaborating Centre for the Prevention of Cardiovascular Diseases. 1991 Provides prospective evidence confirming importance of prone sleeping position as a cause of SIDS (Lancet 1991; 337: 1244-1247). 1992 Evidence that SIDS death rate was falling after a national campaign on infant sleeping position. 1993 Research helps explain how prone position interacts with other factors to increase risk (N Engl J Med 1993; 329: 377-382). 1995 First follow-up of TIHS cohort searching for early life influences on childhood diseases. Shows that the major decline in SIDS deaths from 1991 onwards is the result of changes in infant sleeping position (JAMA 1995; 273: 783-789) 1997 Contract signed with AMRAD pharmaceutical company. Provides funding for Genetic Epidemiology Unit. 1997-2000 Follow-up of the Tasmanian Infant Health Survey cohort into childhood provides important evidence about early life determinants of risk for osteoporosis, blood pressure and asthma (J Clin Endocrinol Metab 1998; 83: 4274-4279; J Bone Miner Res 1999; 14: 146-151; BMJ 1999; 319: 1325-1329; Thorax 1999; 54: 664-669). 2000 Named "Tasmanian Icon" by State Premier. Core funding doubles. Key events Major scientific achievements. Subsequently, the Menzies Foundation Board decided to support the establishment of an epidemiology research centre, to be named the Menzies Centre for Population Health Research. The Foundation then met with the Tasmanian Premier and Minister for Health, who matched the Foundation's initial contribution of $100 000 per year. Early days: the Tasmanian Infant Health Survey and Sudden Infant Death Syndrome Before my departure from Sydney University, I had been reviewing the data on disease distribution in Tasmania. Sudden Infant Death Syndrome (SIDS), with an annual rate in Tasmania twice the national average, stood out. The head of neonatology at the Royal Hobart Hospital, Neville Newman, convinced me that this should be the subject of a major research effort. The cause had not been clearly identified, and epidemiological research had been limited. With helpful input from Geoffrey Berry, Professor of Biostatistics at Sydney University, we planned the first prospective cohort study on this condition. Preliminary work began just before the decision of the Menzies Foundation to support the establishment of the Centre. The epidemiology research group within the Medical School at the University of Tasmania consisted of one epidemiologist, the research fellow Trevor Beard, and limited support staff. Even with the extra $200 000 that the establishment of the new Centre brought, it would not have been realistic to work on a broad front. It was decided that we would focus most of our effort on the new SIDS research program. The next step was to build an appropriately skilled team. We advertised for another epidemiologist and a biostatistician, but it proved very difficult to attract qualified applicants. It seemed that Australian academics were either not interested in living in Tasmania, or were not confident their careers would flourish there. This problem was compensated for by a stroke of good luck when a young Tasmanian medical graduate, Anne-Louise Ponsonby, became our first postgraduate student, working on SIDS. She put an incredible amount of intelligently directed energy into the SIDS program, and together, with financial help from the Australian Rotary Health Research Fund, we were able to develop momentum in the project. In 1988, we initiated the first full data collection for the cohort study — a huge endeavour that involved measurements each year in 1500 infants and their mothers on three occasions in the first three months after birth. That we could get this work under way was pleasing, but we needed to find well-qualified biostatisticians. Given the previous lack of success with advertising in Australia, I decided to use our international network. Sir Richard Doll referred Michael Jones, a young Master of Science graduate from Oxford, who was recruited to our ranks, and then Laura Gibbons, from the University of Massachusetts, joined us. This relatively small and young team of investigators coordinated the conduct, data management and analysis of the SIDS program. They also assisted with less well resourced but developing areas in cancer and cardiovascular disease. In late 1990 evidence was accumulating from case-control studies that prone sleeping position might be a major cause of SIDS, but the research was retrospective, creating concerns that recall bias might explain the findings. We had the only prospective data in the world and were able to show that the association was equally strong prospectively, ruling out recall bias.2 A number of countries, including Australia, launched campaigns to encourage parents not to place babies on their stomachs in the cot, with astonishing results — the death rate from SIDS in Australia fell from 507 in 1990 to 139 in 1998, with similar falls in a number of other countries.3 While our work was not the only important contribution to the understanding of this major cause of SIDS, it provided an important piece of evidence needed for solving the puzzle. Later, in 1993, our team explained why prone sleeping position seemed to exert a different effect in winter than summer and a different effect across countries.4 Then, in 1995, we provided evidence that showed clearly that the fall in deaths could only be attributed to the changes in prevalence of prone sleeping position.5 This success will undoubtedly rank as one of the major contributions of the Centre in the years to come. It also established the organisation as one which, in its special location, could have a significant impact on international medical science. It was the much-needed platform that would underpin future recognition and opportunities. The post-SIDS era: taking stock The death rate from SIDS fell so rapidly after the prone sleeping position campaign that, by late 1991, it was clear there would eventually be insufficient cases occurring annually in Tasmania for epidemiological research (when we started the SIDS program, there had been an average of 27 cases a year for an extended period, and by 1998 there were only three). While this outcome was tremendously gratifying, it was clear that the research money to support our staff of now approximately 20 would dry up unless we repositioned our research program. This was confirmed by the National Health and Medical Research Council (NHMRC) Regional Grants Interview Committee's decision not to recommend refunding of our cohort study for 1992. We went from triumph to a period of considerable adversity. One of our first responses was to tell the Tasmanian public that we needed its financial and moral support. They responded generously. With a major public fundraising appeal, helped greatly by our Board and new Chairman John Tomlinson, and a timely decision by the United States National Institutes of Health, we were able to continue the study long enough to thoroughly evaluate the impact of the prone sleeping intervention campaign. In 1992, I took some time to review where we were going as an organisation and to think about where our future research opportunities might lie. I visited people like Richard Doll in Oxford, who had provided very helpful mentoring since 1987. I also had discussions with Ken Rothman (author of Modern epidemiology6), and Dimitris Trichopoulos at Harvard. These visits confirmed that, if we were to continue to conduct work of global significance, we would have to search even more thoroughly for gaps in knowledge that might be filled by an epidemiological approach. I was also convinced that we would need to develop stronger working relationships with basic scientists if we wished to use epidemiology to understand aetiology. These strategies were challenging, but all our team had learned a great deal from the SIDS research experience. While overseas, I also upgraded my skills in organisation and management by attending a management course in Salzburg, led by Peter Drucker, one of the world's most prominent management theorists. New directions The perspectives gained during my overseas visit were incorporated into planning from 1992 onwards. The major new strategy we decided on was to follow the Tasmanian Infant Health Survey (TIHS) cohort, now numbering 11 000 infants and children. The focus would be to search for links between early life exposures and later disease, using our extensive database of infant measurements that provided information on more than 450 variables measured during the first three months of life. One disease we looked at was asthma, an important disease for which preventable causes had not yet been identified and for which there was a shortage of good epidemiological data. This investigation would be coordinated by Anne-Louise Ponsonby, with help from David Couper, a biostatistician who had joined us from Seattle. We also increased our activity in research on the development in childhood of risk factors for cardiovascular disease and diabetes. Fitting into this theme was the new program started by a recent recruit from the Garvan Institute in Sydney, Graeme Jones (we were finally starting to see interest in work opportunities from well-qualified Australians outside Tasmania). He had a strong track record in osteoporosis in the elderly, and he used that background to focus on the impact of early-life factors on bone density in childhood. Fortuitously, interest in the "Barker hypothesis", which concerns the impact of fetal development on later disease, was gaining momentum. We were well placed to make an important contribution in this field, and our capacity was greatly enhanced by the addition of Ruth Morley, from the Institute of Child Health in London. Supplemented by smaller research efforts in cancer and adult cardiovascular disease, by 1994 we were able to see evidence that the research program was growing again. Between 1994 and 2000, the team was able to attract 17 new NHMRC grants from 38 applications submitted. This overall level of success was built on the tremendous preparedness of the Tasmanian public to be involved in the research. Response rates for case-control studies in this period were about 90% for cases and 80% for controls sampled from the electoral rolls, with comparable figures for cohort follow-up. In addition to our growing research effort we took on an important role in ensuring that knowledge was transferred to countries with less developed research capacity. The World Health Organization designated our institution as a Collaborating Centre for the Prevention of Cardiovascular Disease (CVD) a decade ago. That role has expanded steadily to the point where the Centre is assisting in studies on CVD in countries including Vietnam, Fiji and Samoa, where CVD and diabetes are producing an unexpectedly high disease burden. Genomics For the first seven years (1988-1995) the Centre focused solely on the environmental and lifestyle causes of disease. Meanwhile, others had been using the deep family pedigrees available in Tasmania to search for genetic causes of diseases following a Mendelian pattern of inheritance. Novel genes or linkages were discovered for several conditions, including multiple endocrine neoplasia and Huntington's disease. These successes were based on special features of Tasmania that are replicated in few other locations, namely (i) a population descended largely from identifiable founder families; (ii) comprehensive genealogical records; (iii) a modern healthcare system capable of identifying disease outcomes; (iv) a demonstrated capacity to involve the population in studies; and (v) organisational structures to facilitate the research. In 1995, David Mackey, a Tasmanian medical graduate and ophthalmologist at the Victorian Eye and Ear Hospital, approached us. He was undertaking important work in Tasmania on the more complex genetics of glaucoma. He wanted a base in Tasmania, and the Walter and Eliza Hall Institute, in Melbourne, was seeking a Tasmanian institution to manage new research and development syndicate funds to support his research. We accepted the role and our interest in the use of epidemiology to find genes for human diseases increased. Then, in 1996, the Australian pharmaceutical company AMRAD approached us about increasing its involvement in gene discovery in Tasmania through the Menzies Centre. We agreed, on the condition that the funding would be for a genetic unit that would employ people who could provide intellectual input to the work from a Tasmanian base. AMRAD signed a contract in 1997 for a five-year grant of $2.5 million, and, in 1998, we attracted Tasmanian molecular geneticist Michele Sale to coordinate the work. With financial and other help we were able to very quickly get projects under way in multiple sclerosis and osteoarthritis, and have continued to develop activity with Cerylid, a spin-off from AMRAD formed to operate its discovery arm. The genomics development has also led to an increase in postgraduate student training at the Centre, with five PhD students currently enrolled. The future During the past 12 months there have been several important developments for the Centre, driven by our very committed Board, chaired by Jean Trethewey, and strongly supported by the Dean of the Faculty of Health Science at the University of Tasmania, Allan Carmichael. The Tasmanian Government introduced an "Icons Program", which supports the Tasmanian Symphony Orchestra and our State cricket team. To this list Premier Jim Bacon added the Menzies Centre, with a commitment to provide $500 000 a year to help our organisation develop its capabilities. This, together with a large donation in 2000 from the United States-based Atlantic Philanthropies Inc, has placed us in a previously unimagined position to recruit more staff and drive our research program. To enable us to undertake these future developments with vigour, the University of Tasmania Council has established the Menzies Centre as an independent company limited by guarantee, remaining within the university structure. In 2002, the Centre will become the "Menzies Research Institute". Already, the Centre has grown to support a staff of 60. The new institute is likely to start 2002 with a budget of approximately $5 000 000 that will see staff numbers increase to more than 100, working on both environmental and genetic causes of disease. A major NHMRC grant of $2 290 000 over the next five years will enable us to study a cohort of Australians first measured as schoolchildren in 1985. They will be followed up for the emergence of adult disease, and it is anticipated this will provide the first direct evidence available on the impact of childhood lifestyle and biology on diseases such as coronary heart disease. A collaboration with similar cohorts in the US and Finland has already been established. A new director of the Cohort Studies Unit, Alison Venn, who has a strong background in this research strategy, has been recruited from the Centre for the Study of Mothers' and Children's Health at La Trobe University to coordinate developments. A large adult cohort study in Tasmania, with a focus on exposures that occur closer to the time of disease development, will also commence in 2002. Both studies will benefit from the input of a now-strong biostatistics group of three staff headed by one of our own PhD graduates, Leigh Blizzard. The level of genetic research activity will expand greatly. Tasmania presents opportunities as good as any in the world for gene discovery, and we intend to take up these opportunities. An increasing number of epidemiological studies at the Centre are focused on finding novel genes or validating candidate genes identified through animal or cell studies, or bioinformatic "data mining". This growth in activity reflects the recognition by commercial and government sources of the opportunities here, as well as the developing capacity of our genetic unit. Increasingly, our "environmental" epidemiologists and biostatisticians are developing their interests and skills in genetic research. This has not only led to the more rapid development of a critical mass for projects on gene discovery and validation, but has also opened up the possibility for in-depth investigation of gene-environment interaction. Projects with this focus are already under way in multiple sclerosis. There is great scope for us to contribute in an internationally significant way to the understanding of gene-environment interactions using Tasmania's unique population and our skill base. In the coming decade Australia will be relying more and more on its medical research institutes to maintain its competitive advantage in a knowledge-based global economy. We are confident that the new Menzies Research Institute will be making its contribution. References King H, editor. Epidemiology in Tasmania. Canberra: Brolga Press, 1987. Dwyer T, Ponsonby AL, Newman NM, Gibbons LE. Prospective cohort study of prone sleeping position and sudden infant death syndrome. Lancet 1991; 337: 1244-1247. Australian Bureau of Statistics. Deaths, Australia, 1990, 1998. Canberra: ABS, 1998. (Catalogue no. 3302.0/3303.0.) Ponsonby AL, Dwyer T, Gibbons LE, et al. Factors potentiating the risk of SIDS associated with the prone position. N Engl J Medicine 1993; 329: 377-382. Dwyer T, Ponsonby AL, Blizzard CL, et al. The contribution of changes in the prevalence of prone sleeping position to the decline in SIDS in Tasmania. JAMA 1995; 273: 783-789. Rothman K. Modern epidemiology. Boston: Little John and Co., 1986. Authors' details Menzies Centre for Population Health Research Terence Dwyer, MD, FAFPHM, Director. Reprints will not be available from the author. Correspondence: Professor T Dwyer, Menzies Centre for Population Health Research, 17 Liverpool Street, Hobart, 7000 TAS. t.dwyerATutas.edu.au Make a comment

Terence Dwyer

Christmas offerings Carols in the wind John E Marley, Paula Searle, Nicole L Chamberlain, Deborah R Turnbull and Catherine M Leahy MJA 2001; 175: 656-658 Abstract - Methods - Results - Discussion - Contributions - Competing interests - Acknowledgements - Authors' details - - More articles on Administration and health services Abstract Aim: To compare mood and emotional responses to music played on pipe organs and pipeless (digital) organs. Design: A two-organ (pipe v. digital) crossover study. Setting: St Theodore's Anglican Church, Adelaide. Subjects: 43 non-musician volunteers. Main outcome measures: Changes in mood and emotions measured by the Profile of Mood States. Results: Both instruments produced significant reductions in the emotions commonly experienced during the Christmas season: tension-anxiety, depression-rejection, anger-hostility and fatigue. There were no significant changes for vigour or confusion-bewilderment, and no significant differences between the mood-altering effects of the two instruments. Conclusions: Pipeless organs are as effective as pipe organs in inducing beneficial mood changes. From supermarkets to cathedrals, carols and organs are part of Christmas. Music affects emotions, and listeners agree on the types of emotions experienced.1,2 Listening to music may invoke a range of responses, from a pleasant, relaxed mood to intense emotions aroused on hearing a beautiful musical phrase3 or a children's carol service. Music decreases heart rate, respiratory rate and Profile of Mood States4 scores, indicating relaxation and mood improvement.5 In a US study, a randomised trial of guided imagery and music conducted over 13 weeks, music positively affected mood scores and reduced serum cortisol levels in healthy adults.6 This suggests music may have another important application: treating stressed adults in the pre-Christmas period. Organ music is usually played on the occasion of important life events such as weddings and funerals. For the many people who attend Christmas church services, the experience would be incomplete without the resounding tones of the organ. Associations with tradition, and the instrument's rich tonal range and volume, are part of what gives the organ its ability to produce powerful emotional responses. The sound of a pipe organ is produced from distinct generators (pipes), numbering from tens to thousands. Many pipes work together and their sounds meld in acoustic space. Pipe organs are expensive to install and maintain. In pipeless (digital) organs, sound is synthesised from digital sampling of the tones produced by traditional organ pipes made by famous pipemakers. The sound diffuses from a few loudspeakers and sounds similar to that of a pipe organ. However, signals conveyed to the speakers, and sounds corresponding to many notes, can cause beats with power nodes and antinodes, which may be unpleasant. Electrical beats are different from in-air acoustical beats produced by organ pipes. A greater number of speakers can produce spatialisation similar to the sound produced by pipe organs.7 Comparing natural and emulated orchestral instruments, it has been found that a fundamental property distinguishing natural instrument tones from their emulated counterparts is the presence of two partially independent sources of variability, such as the natural complex harmonics of strings with the resonance patterns of wood. This endows the music of natural generators with richness of texture and enduring interest.8 Organists tend to have strong views about the superiority of pipe organs over pipeless ones. However, most people listening to organs at Christmas are not organists — would their emotional experience be the same whether the sound was produced by a pipe organ or a digital organ? In the spirit of scientific curiosity we set out to explore whether non-musicians experienced similar mood and emotional responses on hearing a digital organ compared with a pipe organ. Would cash-starved parishes be depriving their parishioners of the full Christmas experience if they invested in electronics rather than wind? Methods Participants Healthy volunteers aged 16 years and over were recruited by advertisement from the University of Adelaide and the general community during the pre-Christmas period in 1999. Expert musicians were excluded, as it was thought they might spend the time trying to guess which instrument they were listening to rather than responding to the music itself. The only other exclusions were people with moderate to severe hearing impairment, "tone-deafness" or a known aversion to organ music. A minimum sample size of 30 subjects was needed. A pilot study was conducted by playing a CD of organ music to volunteers to determine the time taken for them to become restless. As a result, 25 minutes of music was chosen for the main study. Study design Our study was carried out at St Theodore's Anglican Church, Adelaide. The design was a crossover study, with subjects randomly allocated to one of two groups. The groups were then randomly allocated to hear either the pipe organ on the first visit, followed by the digital organ on the second, or the digital instrument on the first, followed by the pipe organ on the second. Each group attended at the same time each week (either 6 pm or 7 pm) and listened to only one instrument at each visit. Visits were separated by one week to allow memory of and response to the first instrument to fade. In order to standardise the test conditions, organs of similar size specifications were played in the same building. Subjects were seated at the back of the church facing away from the instruments, so that they were "blind" to which instrument was being played at each session. St Theodore's Church is a large, resonant building with good acoustics, uniform throughout. The same music was used at each test session using similar registrations (for a list of the pieces played, see Box 1). A professional organist who was not familiar with either instrument performed the music, after a standard amount of familiarisation time on each. The instruments used were a pipe organ built by Waters of Adelaide and an Ahlborn Galanti pipeless organ (specification for both organs available from corresponding author on request). Mood scale Before and after each recital, subjects completed the Profile of Mood States.4 This includes 65 adjectives describing feelings and moods, to which participants indicate their response using a five-point scale. The emotions measured are tension-anxiety, depression-rejection, anger-hostility, fatigue, vigour, and confusion-bewilderment. Statistical methods We calculated the differences between pre- and post-listening mood scores and compared the differences between the digital and pipe instruments using t tests (after checking for normal distribution). As carryover effects were found to be not significant, we were able to pool data over the two periods for each instrument. Pre- and post-music mood scores were compared using a one-sample t test for each of the instruments and for both instruments combined. Data were entered and managed in a Microsoft Access database, and the SPSS statistical package was used for all analyses. Ethical approval was given by the University of Adelaide Committee on the Ethics of Human Experimentation. Results Forty-three subjects completed the study, of whom 23 were women (mean age of participants, 39 years; range, 22-71 years). There were no significant demographic differences between the two groups. When the results for both instruments were analysed, either separately or combined, we found that our listeners experienced significant reductions in tension-anxiety, depression-rejection, anger-hostility and fatigue; however, there were no significant changes in scores for vigour or confusion-bewilderment, and no significant differences between mood changes induced by the pipe organ compared with the digital organ (see Box 2). The time at which the music was played did not significantly affect mood scores (data not shown here). Curiously, however, the group that attended at the later time of 7 pm recorded lower vigour scores (mean, -2.1875) after listening to the digital organ, while the 6 pm group had higher vigour scores (mean, 1.1538) after listening to the same instrument (P = 0.024). The 7 pm group showed no change in fatigue scores (mean, 0.0625) after listening to the digital organ, while the 6 pm group had lower fatigue scores (mean, -2.346) after listening to the same instrument (P = 0.041). After completing the last profile at the second session, subjects were asked, without prior warning, to indicate which instrument they thought was being played at that session. Responses were no better than would be expected from random guessing, indicating that subjects could not distinguish between the two types of organ ( κ = 0.009; P = 0.48). Discussion Music played on both pipe and digital organs produced predictable and desirable mood and emotional responses. It may be that greater changes would have been seen had subjects been "pre-stressed" by stressors such as Christmas shopping or finding a parking place in the Christmas rush. We considered it unnecessary to include a control group not exposed to music, as the ability of music to alter mood is well documented. Both instruments proved equally beneficial in reducing the distressing emotions commonly present in the pre-Christmas period. However, our results suggest that feelings of confusion and bewilderment (such as those accompanying present-choosing) are, alas, likely to persist; and, while fatigue may be reduced by listening to music, listeners may not experience increased vigour. The argument that real pipes are essential for non-musicians to experience beneficial mood and emotional responses to music should now be laid to rest. So, while organists may continue to fight to the death on this issue, financially challenged parishes can safely install pipeless organs without jeopardising the Christmas experience for their parishioners or, presumably, their Christmas collections. Organ music can be highly recommended as a good treatment for pre-Christmas mood disorders. Contributions JM (an inept but enthusiastic organist) conceived the study, PS provided organization and administration, DT psychological knowledge, CL musical expertise and NC statistics. Competing interests The Pipeless Pipe Organ Company loaned equipment for the study. Acknowledgements Mark Joyner played the music. Patrick Brislan, of the Elder Conservatorium of Music, University of Adelaide, gave invaluable expert advice. References Gregory A. Cross-cultural differences in perceiving the emotional content of music. 4th International Conference on Music Perception and Cognition. Montreal, Canada: McGill University, 1996. Collier G. Towards a model of music and emotion. 4th International Conference on Music Perception and Cognition. Montreal, Canada: McGill University, 1996. Sloboda J. Music structure and emotional response: some empirical findings. Psychology of Music 1991; 19: 110-120. McNair D, Lorr M, Droppleman L. Profile of Mood States. San Diego, California: EdITS/Educational and Industrial Testing Service, 1971. Chlan L. Psychophysiologic responses of mechanically ventilated patients to music: a pilot study. Am J Crit Care 1995; 4(3): 233-238. McKinney C, Antoni M, Kumar M, et al. Effects of guided imagery and music therapy on mood and cortisol in healthy adults. Health Psychol 1997; 16(4): 390-400. Bazzanella L, Debiasi G. Electronic organ's sound spatialisation with special regard to plenum and tutti perception. 4th International Conference on Music Perception and Cognition. Montreal, Canada: McGill University, 1996. Carterette E, Kendall A. Acoustical analysis of natural and emulated orchestral instrument signals. 4th International Conference on Music Perception and Cognition. Montreal, Canada: McGill University, 1996. Authors' details Department of General Practice, University of Adelaide, Adelaide, SA. John E Marley, MD, FRACGP, Professor of General Practice; Paula Searle, BTeach, BEd, Research Officer; Nicole L Chamberlain, BSc (Hons - Statistics), Statistician; Deborah R Turnbull, PhD, MPsych(Clin), Senior Lecturer; Catherine M Leahy, BA(Hons - Psychology), BMus(Composition), Research Officer. Reprints will not be available from the authors. Correspondence: Professor John E Marley, Department of General Practice, University of Adelaide, Adelaide, SA 5005. john.marleyATadelaide.edu.au Make a comment Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> Fr Peter Thompson playing the pipe organ at St Theodore's Anglican Church, Adelaide (photo courtesy of Wendy Newbury). 1: Music played Trumpet Voluntary (Clarke) Air from the Water Music (Handel) Rondeau from Abdelazar (Purcell) An Old English Melody (Wesley, arranged by Floyd) Canon in D (Pachelbel) Back to text 2: Comparison of mood scores of 43 listeners (determined by the Profile of Mood States4) before and after listening to pipe organ or pipeless organ music (mean differences, with 95% CIs; two-tailed significance) Back to text

John E Marley · Paula Searle · Nicole L Chamberlain · Deborah R Turnbull · Catherine M Leahy

Christmas offering Bloodletting and leeching: instruments of healing or torture? "The danger of a large bleeding is less than the danger of the disease."1 MJA 2001; 175: 665 This aphorism, quoted in a 19th-century medical text, typified the approach of many doctors to disease at that time. Essentially, the message was to bleed, and bleed, and bleed again, for a wide variety of illnesses and complaints, ranging from epilepsy and pneumonia, to "bastard pleurisy" and hydrocephalus.1 Venesection was also sometimes coordinated with astrological events, resulting in complex "bleeding charts" being formulated based on celestial cycles.2Instruments for venesection consisted of peculiarly shaped lancets called phlemes (Figure) which were wielded enthusiastically by doctors. For example, one patient in France was bled over 64 times in eight months,3 and sailors suffering from fever in the West Indies had up to 70 ounces of blood taken at the first sitting, with 250 ounces being drained off over three to four days. To add to patients' misery, bleeding was often accompanied by "purging and puking",2 with the use of medications such as epsom salts, ipecacuanha and blue vitriol to induce diarrhoea and vomiting. If blood could not be drained directly from severed veins, leeches in huge numbers were also applied, resulting in a lucrative trade in these small creatures. In one year in 19th-century France, over 40 million leeches were applied to increasingly pallid patients.4 So prevalent was the use of leeching in medicine that the art of healing was, on occasion, referred to as "leechcraft".5 Despite George IV being bled more than 100 times before his 30th birthday,2 royal casualties were not unknown. It is believed that both Emperor Leopold II of Austria and one Prince Schwartzenberg were hurried off to early graves by excessive venesecting.6 Although bleeding had been advocated by no less a figure than Hippocrates, it was left to barbers to perform the task in the Middle Ages, as it was deemed too menial for doctors. Subsequently, surgeons evolved to perform these duties. Rows of patients were often bled at the same time in special "bleeding houses".2 Early texts provide clear descriptions of how to perform venesections, including the use of "a proper bandage of silk, linen, or woollen cloth", and the provision of "wine or some other cordial" to revive those who may have fainted.7 In addition, regional venesections were also prescribed for particular conditions. Recommended areas included under the tongue, the eyes, the penis and the haemorrhoidal veins around the anus. In the event of poor blood flow, presumably because of high levels of circulating adrenaline, "immersing the parts in warm water was recommended".7 There is no doubt that doctors confidently and unquestioningly bled patients and themselves for many centuries. The fact that bleeding undoubtedly and obviously not only worsened some patients' conditions, but also actually caused illness, serves as a salutary reminder of the fallibility of our profession. Roger W Byard Forensic Pathologist Forensic Science Centre, Adelaide, SA References Laennec RTH. Disease of the chest. 4th ed. London: Longman, 1834: 222-226. Newman A. The illustrated history of medical curiosa. New York: McGraw-Hill, 1988: 43-48. Hastings P. Medicine — an international history. London: Ernest Benn, 1974: 56. Lyons AS, Petrucelli RJ. Medicine — an illustrated history. Melbourne: Macmillan Co, 1979: 513. Johnson's dictionary. 7th ed. London: Harrison & Co, 1786. Grossinger R. Planet medicine. Berkeley: North Atlantic Books,1985: 209-211. Encyclopaedia Britannica. 3rd Ed. Vol XVIII. Edinburgh: Bell and MacFarquar,1797: 116-119. Make a comment Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> A series of 18th- and 19th-century bleeding knives (phlemes), some of which were used in veterinary practice Back to text

Roger W Byard

Christmas offering Conference baggery MJA 2001; 175: 666 No, the title is not in error. I will not describe activities in the Iron Lady's Cabinet, nor what you imagine goes on in closed committees at English conferences. I refer to the bags provided to conference-goers, ostensibly to contain their notes and the papers provided by the conference, but useful for concealing all the free giveaways from the exhibits section. Some remnant of my Scottish background makes it difficult to throw away conference bags. My recent clean-up still left eight of them, too useful to throw away. Many of them have all sorts of useful features and pockets for modern essentials: laser pointers, computer disks, mobile phones — even pen and paper. Indeed, I and my family like them for everyday use. Conference planners buy them with part of the budget from our registration fees; this can waste resources. But a good bag that people keep and use will remind participants of a great conference for a long time. Envelopes or plastic folders are appropriate for one-day events, but not for a three-day event with multiple sessions and heavy abstract books. At one public health conference they gave out a calico bag, intended as a statement about resource use, but so weak that it tore during the first day. Sponsors splash their names and logos across the bag for maximum exposure, at least during the conference. But no one will take it home and become a walking advertisement. The title of the conference in large print also decreases subsequent use. Who wants to proclaim one's profession to passers by, or, worse, to inform everyone in the bus, train, street or the waiting room about attending a conference in some exotic location? They will not recognise that it was off-season, and the beaches were freezing, or the snow had melted. During the conference, when walking to and from the hotel, or at important sessions in the ethanol dispensary, such printing proclaims that one is a visitor, likely a good mark for pickpockets and muggers, or at least to restaurant and shop owners, who use more subtle ways of removing one's currency. Among the hundreds or thousands of identical bags floating around it is easy to pick up the wrong one. Organisers can be bedevilled by lost bags, while participants search desperately for their precious slides or disks. Better ways of identifying otherwise identical bags must be found. One conference organiser found a pallet of simple small backpacks through a disposal sale. They were identified with a large tag, with names printed large. The tag could be flipped inside the bag when leaving the building. The quality control on manufacture was faulty, and some of the zips failed quickly, but one or two of them survived vigorous use for some years. I currently carry a bag from a recent conference in Finland. It is sturdy, with useful pockets, and a discreet logo on the front that is suitably anonymous to outsiders. There is a drug advertisement under the flap, but the company probably gets some additional recognition from my seeing it over a long time. My portable computer fits in a bag from another conference, the title of which is printed in an unobtrusive colour only legible from close up. I doubt that the hotel cleaners who pick up most bags after conferences use more than a few. Perhaps conference organisers could choose bags that will be more extensively used, ensuring remembrance of good conferences, and reducing waste from the early disposal of otherwise functional bags. James A Dickinson Professor of Family Medicine Department of Family and Community Medicine Chinese University of Hong Kong, China Competing interests: I have no conflict of interest, except that I hope to get better and more useful bags from the next conference I attend. Regrettably no-one has provided any funds for this piece of research (but I would not be averse to donations from bag companies in the future). A = Broad shoulderstrap, padded with helium balloons to reduce weight B = Strain gauge overload alarm C = Electronic homing beacon for locating lost bag D = Programmable reminder system, synchronised to conference sessions E = Pockets for easy access to floppy, Zip, mini and compact disks F = Discreet logo G = Recycling unit with trapdoor dump to get rid of unnecessary gimmicks H = Sound- and radiowave-proof pocket for mobile phone I = Main pocket matched to the size of the conference documents J = GPS system to locate hidden seminar rooms K = Space blanket for keeping warm in frigid airconditioning L = Identification label M = Optional CPAP attachment to prevent snoring while sleeping in lectures GPS=global positioning system; CPAP=continuous positive airway pressure.

James A Dickinson

The Nation Celebrating the centenary of Federation Australian medicine in the last 50 years: from solid foundations to staggering diversity MJA 2001; 174: 3

Defining Moments In Medicine A golden age defined Fifty years of medical advances MJA 2001; 174: 8

Bronwyn Gaut

Defining Moments In Medicine General practice MJA 2000; 174: 9

Max Kamien

Defining Moments In Medicine Internal medicine MJA 2001; 174: 9-11

Colin I Johnston · Mark E Cooper · Andrew J Taylor · James A Shaw

Defining Moments in Medicine Pathology MJA 2001; 174: 11-12 College of Pathologists of Australia: The College of Pathologists of Australia was established in 1956, and from 1980 became the Royal College of Pathologists of Australasia. The College has established the internationally recognised journal Pathology, and from about 1983 the College has spread its influence to several countries, including Singapore, Malaysia, Hong Kong and Saudi Arabia, as well as Australia and New Zealand. Automated cell counters: These were initially used in haematology in the 1960s and subsequently applied more generally in flow cytometry. The principle of the Coulter counter, with blood cells counted as they pass in single file across a light or other energy source, has been applied in many aspects of clinical and research pathology. Automated clinical chemistry: Initially, in the early 1970s, multichannel analysers were used, then sequential analysis and dry chemistry techniques were introduced and, more recently, "near-patient" testing. Introduction of Medicare: Medicare's introduction in 1975 profoundly affected many aspects of clinical care, and has been partly responsible for a great increase in private pathology practices. Improved standards of forensic pathology and science: The debacle of the forensic investigation for the prosecution of the Azaria Chamberlain case in the 1980s showed up the appalling state of forensic pathology and forensic science in Australia, and was an impetus for the development of excellent forensic institutes and facilities in many Australian centres, with much-improved training programs and standards of practice. Frozen-section techniques and biopsies: Frozen-section techniques, percutaneous biopsies of kidney, liver and heart and, more recently, fine-needle aspiration and endoscopic biopsies have greatly improved knowledge of many disease processes, as well as provided accurate pathological diagnoses from very small samples. Medical laboratory accreditation: Nationwide medical laboratory accreditation in the early 1980s, together with quality control and quality assurance programs under the aegis of unique cooperative arrangements between the National Association of Testing Authorities and the Royal College of Pathologists of Australasia (NATA/RCPA) began in the late 1970s and continue to operate to a large extent as peer-review systems. Decline in hospital autopsies: The progressive decline in numbers of hospital autopsies during the latter part of the 20th century has resulted in the inevitable loss of clinicopathological correlations and valuable learning resources. Surveys of hospital deaths have shown large discrepancies between the clinical opinion of cause of death and comorbidities, and findings at autopsy. Advances in microscopy and staining: In both research and diagnostic pathology, the application of transmission and scanning electron microscopy and fluorescent and immunohistochemical techniques has contributed significantly to understanding the pathogenesis of many diseases, and to their accurate diagnosis. Advances in cytological techniques: Exfoliative cytology was initially used largely in gynaecology and pulmonary medicine, but subsequently in many other circumstances. More recently, cytology has been vastly expanded with the widespread use of fine-needle aspiration, and automated techniques for screening are coming into use, increasing overall diagnostic accuracy. Molecular pathology: Application of techniques of molecular biology and genetic analysis to diagnosis in pathology has had profound effects in all disciplines of pathology. Role of Helicobacter pylori: After the initial observations by pathologist Robin Warren and gastroenterologist Barry Marshall, in Perth in the early 1980s, the aetiological role of this organism in gastric and duodenal ulceration and cancer is now accepted by gastroenterologists and pathologists worldwide. Elucidation of aspects of viral infections: Elucidation of many aspects of viral infections, including the hepatitis viruses and HIV, is having profound effects on blood donations and blood transfusion technology, and patterns of behaviour in the community. Importance of apoptosis: The role of apoptosis (certain cells are programmed to die at a particular time) in embryological development has been known for 100 years or so. Its importance in normal adult physiology and in a large number of disease processes only became apparent after pioneering work undertaken by Brisbane pathologist John Kerr in the late 1960s. Corporatisation of private pathology practices: The increasing corporatisation of private pathology practices in Australia, with ownership going from practising pathologists to other individuals or companies, and public laboratories becoming business units, is cause for concern. More and more individual practices are controlled by fewer and fewer people. Peter B Herdson Forensic Pathologist, Canberra, ACT Richard A Scolyer Anatomical Pathologist Royal Prince Alfred Hospital, Sydney, NSW Alistair R McGregor Director, Microbiology and Infectious Diseases Royal Hobart Hospital, Hobart, TAS Above photograph courtesy Alfred Hospital Heritage Committee, Melbourne. Make a comment

Peter B Herdson · Richard A Scolyer · Alistair R McGregor

Defining Moments In Medicine Surgery MJA 2001; 174: 12-13

John P Maddern · Guy J Maddern

Defining Moments In Medicine Obstetrics and gynaecology MJA 2001; 174: 13-14 Family planning clinics: These clinics developed in the 1960s but were able to offer much more effective management once the oral contraceptive pill became readily available. The clinics improved access to contraceptive advice and therapeutic abortion, particularly among women of lower socioeconomic background. Cancer screening: Screening for cervical cancer has improved gradually over the past 50 years, initially with the use of routine Pap smears and colposcopy and, more recently, with human papillomavirus typing. Earlier detection of cancer of the uterine endometrium has been made possible by ultrasound scanning, endometrial sampling by intrauterine catheters and hysteroscopy with biopsy. Treatment of rhesus iso-immunisation: In 1961, New Zealander A W Liley first published on the management of pregnancy complicated by rhesus sensitisation. His pioneering work on analysis of the amniotic fluid was used to assess the need for exchange transfusion, leading eventually to the development of cordocentesis for accurate measurement of fetal haemoglobin. Sexual dysfunction clinics: The first Australian clinic for sexual dysfunction was founded by Elsie Koadlow at the Queen Victoria Memorial Hospital for Women, Melbourne, in the late 1960s. Fetal monitoring during labour: Methods to monitor the health of the fetus during labour were introduced in the mid-1960s. It became possible to monitor fetal heart rate continuously and to measure metabolic parameters in fetal scalp blood. The success of these techniques in reducing death and brain damage from hypoxia and circulatory failure was demonstrated by the world's first randomised controlled trial of new techniques for fetal monitoring at the Queen Victoria Memorial Hospital in 1969. Corticosteroid therapy for preterm delivery: In 1972, New Zealander G C Liggins found that exposing infants born between 24 and 34 weeks' gestation to corticosteroids before delivery halved the incidence of respiratory distress syndrome, protected against intraventricular haemorrhage and reduced mortality by 40%. It is now standard practice to give corticosteroids to women at 24-38 weeks' gestation at risk of preterm delivery. Royal Australian and New Zealand College of Obstetricians and Gynaecologists: Before 1978, Australians travelled to the United Kingdom to study and take the Royal College of Obstetricians and Gynaecologists' examinations. Formation of the Australian College in 1978 led to increased postgraduate education and better clinical standards, and encouraged research. In 1998, the Australian and New Zealand Colleges combined as the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. In-vitro fertilisation: The world's first in-vitro fertilisation (IVF) pregnancy was achieved in Melbourne in 1973. Although it was sustained for only a week, it heralded the world's first IVF baby in the United Kingdom in 1978. IVF became more practicable in 1980, when ovarian stimulation was first used to produce multiple eggs (and resulted in several pregnancies) at the Queen Victoria Medical Centre, Melbourne. With the world's first frozen-embryo baby and first donor-egg baby, produced by the Monash IVF team in 1983 and 1984, respectively, IVF became more acceptable and applicable to a wider variety of infertility problems. Ultrasound examination: Ultrasound has revolutionised obstetrics and gynaecology, with numerous diagnostic applications in pregnancy and labour, and in abnormalities of the ovaries, fallopian tubes and uterus. It has also made possible many operative procedures. Epidural anaesthesia: This has made a major contribution to obstetrics, both relieving pain in labour and allowing women to be conscious during caesarean section. It has added humanity to the too often accepted notion that labour should be synonymous with suffering. Prostaglandins: These drugs have altered management of second- and third-trimester pregnancies. Both gemeprost and dinoprostone vaginal gel can be used to induce labour. Misoprostol is an effective abortifacient, and is used increasingly in Australia as a cervical ripening agent before suction curettage in nulliparous women with a missed abortion. Hormone replacement therapy: Managing menopause with hormone replacement therapy (HRT) has become a specialty of its own. Although the risk of breast cancer is slightly increased, it is minuscule compared with the risks of developing the complications of postmenopausal osteoporosis. Endoscopic surgery: Operative laparoscopy has expanded to include techniques for nearly all procedures previously performed only by laparotomy. By the late 1990s, a small but increasing number of gynaecologists perform 90% or more of gynaecological surgery by laparoscopy. Endometriosis: An awareness of the burden of this disease, which affects 600 000 Australian women, developed only in the 1990s. Recent studies have shown that 90% of women with severe menstrual pain affecting work or school attendance have endometriosis. Surgical treatment has been improved by applying the principles of cancer surgery, while a polygenetic basis for the disease has been discovered. Subspecialty training: Over the past four years, obstetrics and gynaecology has been subdivided to produce subspecialists with particular expertise. Certification and accreditation is now available in Australasia in gynaecology, high-risk obstetrics, ultrasound, reproductive medicine and urogynaecology. Carl E Wood Emeritus Professor, Department of Obstetrics and Gynaecology Monash University, Melbourne, VIC Simon J Gordon Gynaecologist, Mercy Hospital for Women, Melbourne, VIC Make a comment

Carl E Wood · Simon J Gordon

Defining Moments In Medicine Radiology MJA 2001; 174: 14-15

David A Lisle

Defining Moments In Medicine Paediatrics MJA 2001; 174: 16-17 Australian Paediatric Association: Founded in 1950, the Association was of vital importance to the developing specialty of paediatrics in Australia. It became the Australian College of Paediatrics in 1978 and then joined with the Royal Australasian College of Physicians in 1998 to form the Division of Paediatrics and Child Health. Chemotherapy for childhood leukaemia: Melbourne paediatrician John Colebatch published the first Australian controlled trial in 1950, testing a chemotherapeutic drug in children with acute lymphatic leukaemia. This was followed by multicentre trials in Australia of treatment for leukaemia and other childhood malignancies. A majority of children with acute leukaemia can now be cured, and national and international collaborative randomised controlled trials have become the standard method for evaluating treatment. Management of premature infants: Recognition by Kate Campbell (Melbourne paediatrician) in 1951 that high concentrations of ambient oxygen caused retrolental fibroplasia in premature infants led to a major change in the management of premature infants and was an important milestone in the development of neonatology as a paediatric subspecialty. Introduction of triple antigen: Triple antigen was introduced to Australia in 1953. In 1957, the Australian Paediatric Association's recommendation to the National Health and Medical Research Council that all infants should be vaccinated routinely with triple antigen against diphtheria, pertussis and tetanus was accepted. Liberal hospital visiting times: Daily visiting by parents was introduced at the Royal Children's Hospital, Melbourne, in 1953, and two years later the Royal Alexandra Hospital for Children, Sydney, introduced extended visiting. This substantially reduced the emotional trauma of hospital admissions. Previously, visiting had been restricted in the erroneous belief that cross-infection would be increased, and the children would be upset and more difficult to care for. Vaccination for Aboriginal children: In 1954, to help reduce communicable diseases -- whooping cough, diphtheria and tetanus -- a routine vaccination program was commenced for Aboriginal children in the Northern Territory. Nasotracheal intubation: Melbourne anaesthetists Ian McDonald and John Stocks, in the British Journal of Anaesthesia in 1965, described prolonged nasotracheal intubation in infants and children, which was crucial in the development of intensive care for infants and children. It provided an alternative to tracheostomy for artificial ventilation, which had a very high complication rate. Australian Paediatric Journal: Established in 1965 by the Australian Paediatric Association, the Australian Paediatric Journal subsequently became the Journal of Paediatrics and Child Health. It publishes quality research in paediatrics from Australia and the Asia-Pacific region. Management of childhood asthma: From 1969 onwards, Howard Williams and Ken McNicol (of Melbourne's Royal Children's Hospital Research Foundation) published a series of articles clarifying the prevalence and natural history of asthma in children. These articles substantially changed the way childhood asthma was managed. They emphasised the importance of basing treatment on the pattern of symptoms, and the use of bronchodilators, rather than antibiotics, in the treatment of wheezy episodes. Preventing childhood injury: From 1969 regulations and programs were introduced in Australia to reduce morbidity and mortality of childhood injury (eg, safety standards for children's nightwear, other programs to reduce the risk of burns, compulsory child restraints in motor vehicles, and legislation to require that crash helmets be worn by bicyclists). Rotavirus in viral gastroenteritis: In 1973, Ruth Bishop, Ian Holmes, Geoff Davidson and colleagues (from the Royal Children's Hospital, Melbourne, and the Department of Microbiology, University of Melbourne) showed that rotavirus was the most important cause of viral gastroenteritis in infants and children. This was an important step in the understanding of this major worldwide cause of childhood morbidity and mortality. Vaccines are being developed in attempts to prevent this infection. Emergency transport services: The Neonatal Emergency Transport Service and the Paediatric Emergency Transport Service were established in Melbourne in 1976 and 1980, respectively. These two services have reduced morbidity and mortality from critical illness in neonates, infants and children presenting away from major tertiary centres. Fragile X syndrome: Recognition of fragile sites in chromosomes and identification in 1977 by Grant Sutherland (Adelaide Children's Hospital) of the fragile X syndrome, one of the more common causes of mental retardation, has led to an understanding of its familial nature and to in-vitro diagnosis. Adolescent Health Survey: Undertaken in Melbourne in 1992, this survey of 4000 adolescents provided essential information on risk factors for health problems and prevalence of such problems in adolescents. It was crucial in establishing adolescent health as an independent specialty with an academic base. Australian Childhood Immunisation Register: Established in 1995, the Register is an essential database of the vaccination status of Australian children and allows those whose vaccination is incomplete to be identified. There are now incentives for parents to to have their children fully vaccinated. Peter D Phelan Emeritus Professor of Paediatrics University of Melbourne, Melbourne, VIC Don M Roberton McGregor Reid Professor of Paediatrics University of Adelaide, Adelaide, SA Mike South Director, Department of General Medicine Royal Children's Hospital Melbourne, VIC and Associate Professor, Department of Paediatrics University of Melbourne, VIC Above photograph courtesy Royal Children's Hospital Archive, Victoria. Photographer: Laurie Richards. Make a comment

Peter D Phelan · Don M Roberton · Mike South

Defining Moments In Medicine Anaesthesia MJA 2001; 174: 17-18 New anaesthetic agents: Anaesthesia has been revolutionised over the past 50 years by the development of new anaesthetic agents. In 1957, the volatile agent halothane supplanted ether as the anaesthetic of choice. It is more pleasant for patients, potent and non-flammable. Later refinements were isoflurane and sevoflurane, the latter being particularly useful in children. Another key change was the introduction, in 1952, of the first short-acting, depolarising muscle relaxant, suxamethonium, while in 1967 pancuronium replaced d-tubocurarine as the main long-acting, non-depolarising muscle relaxant. The intravenous induction agent propofol (1986) was a major improvement on thiopentone, while the local anaesthetic bupivacaine (1963) provides longer duration of action for regional anaesthesia. Monitoring of anaesthetic deaths: Australia has led the world in the quality and safety of anaesthesia. In 1960, Ross Holland (Director of Anaesthesia at Lidcombe Hospital, Sydney) pioneered investigation of deaths associated with anaesthesia and education of anaesthetists to reduce anaesthesia-related mortality in New South Wales. Other States followed, and national data have been published triennially since 1985, documenting the safety of anaesthesia in Australia. Faculty of Anaesthetists: In 1952, postgraduate training in anaesthesia was formalised with the formation of the Faculty of Anaesthetists within the Royal Australasian College of Surgeons. In 1992, the Faculty became the Australian and New Zealand College of Anaesthetists. It has accredited training programs in Australia, New Zealand, Hong Kong, Malaysia and Singapore. Anaesthesia as an academic discipline: Anaesthesia advanced as an academic discipline in Australia with the appointment in 1962 of Douglas Joseph to the first chair in anaesthetics -- the Nuffield Chair at the University of Sydney. Subsequently, other chairs in anaesthesia were established in Brisbane, Melbourne, Sydney, Newcastle, Adelaide and Perth. Launch of Anaesthesia and Intensive Care: The journal Anaesthesia and Intensive Care was launched by the Australian Society of Anaesthetists in 1972. Specific training in intensive care: The world's first training and examination system in intensive care was established by the Faculty of Anaesthetists in 1976. After formation of the College of Anaesthetists, a Faculty of Intensive Care was inaugurated in 1993, with Geoff Clarke (Head of Intensive Care, Royal Perth Hospital) as the first Dean. Specific training in pain medicine: Training in pain medicine was begun by the College of Anaesthetists in 1996, and in 1998 a multidisciplinary Faculty of Pain Medicine was formed, with Michael Cousins (Head of Anaesthesia and Pain Management, Royal North Shore Hospital, Sydney) as the first Dean. Board members are drawn from the Australian and New Zealand College of Anaesthetists, the Royal Australasian College of Physicians and its Faculty of Rehabilitation Medicine, the Royal Australasian College of Surgeons and the Royal Australian and New Zealand College of Psychiatrists. Minimum standards for anaesthesia: Minimum standards for anaesthesia have been developed progressively and published over the past 50 years by the Faculty, and later College, of Anaesthetists. They have had a major impact on development of standards in hospitals throughout Australia, New Zealand and South-East Asia. Improved patient monitoring: Equipment that allows beat-by-beat monitoring of oxyhaemoglobin levels by pulse oximetry and breath-by-breath monitoring of end-tidal carbon dioxide levels by capnometry has significantly improved the safety of anaesthesia. Both became widely available in the 1980s and were required to meet Australian and other countries' standards. Laryngeal mask: Described by Archie Brain (Reading, UK) in 1983, this mask is an airway device that provides a hands-free method of maintaining the airway without intubation. It has become popular with many anaesthetists and is useful in situations when intubation is difficult. Medical retrieval of the critically ill: From the 1960s onwards, medical retrieval of the critically ill has provided intensive care and safe transport to major centres from anywhere in Australia. These multidisciplinary, multimodal services have extended the vision of John Flynn (founder of the Royal Flying Doctor Service) in an extraordinary way. J E (Fred) Gilligan (Director of Retrieval and Resuscitation, Royal Adelaide Hospital) is one of the longest-serving leaders in this field. Malignant hyperthermia: In 1960, the familial disease malignant hyperthermia, which is triggered by some anaesthetic agents in susceptible individuals, was first described by Michael Denborough and colleagues from Royal Melbourne Hospital. Recognition of the genetic nature of this disease has allowed members of affected families to be screened, while awareness of the early changes and appropriate management, including dantrolene and intensive care, has reduced mortality from around 80% to less than 10%. Continuing medical education: CME in anaesthetics has developed and expanded in Australia from its beginnings at section meetings of the Australasian Medical Congress (British Medical Association) in the 1950s. Indeed, in 1996, the Australian Society of Anaesthetists hosted the World Congress of Anaesthesiology in Sydney, with nearly 6000 delegates. Furthermore, Australian anaesthetists have conducted education and examinations in the South Pacific region, Papua New Guinea, Hong Kong, Malaysia and Singapore. Garry D Phillips Professor of Anaesthesia and Intensive Care Flinders Medical Centre, Adelaide, SA Above photograph of surgeons, 1959. (Courtesy of Wolfgang Sievers) Make a comment

Garry D Phillips

Defining Moments In Medicine Psychiatry MJA 2001; 174: 18-19 Lithium: While Melbourne psychiatrist John Cade both discovered the antimanic effects of lithium and published his findings in the Journal in the 1940s, its distinctive impact on bipolar disorder management only crystallised in Australia in the 1970s after extensive developmental work, and with a mid-90s article in Science estimating that, since 1970, lithium therapy had saved the US economy alone US$145 billion in health costs. Chlorpromazine: The introduction of this "major tranquilliser" in 1952, described by David Healy (University of Wales College of Medicine) as "the single most important breakthrough in psychiatric treatment", had a dramatic impact on the management of schizophrenia: for the first time some patients became non-psychotic, and the acute management of schizophrenia improved markedly. Improving the practice of ECT: Electroconvulsive therapy is still psychiatry's most powerful treatment for depression. Despite major advances -- the introduction of anaesthetics and muscle relaxants, stimulus dosing and electroencephalographic monitoring -- the antipathy of patients (and the community) to ECT has regrettably only slightly lessened. Lessons from military psychiatry and refugee groups: Principles developed between World War II and the Vietnam War (ie, making psychiatric care immediately available "on the spot", and communicating an expectation that recovery would occur) were intrinsically important and diffused into other practice domains, such as community psychiatry, and the management of post-traumatic stress disorder. Deinstitutionalisation: This misnomer was used to describe the moving of patients in the 1960s from maxi-institutional lives in large psychiatric hospitals to mini-institutional existences in boarding houses and nursing homes, often to be even more forgotten and neglected. Yet, we progressively recognised an old principle -- that while risking "dying with one's rights on", people value personal freedom above institutional existence. Forced community assimilation also modified images of the "insane" to softer, disability images. Mainstreaming: Moving the care of psychiatric patients from the Dickensian, isolated psychiatric institutions to general hospitals helped bring Australian clinical psychiatry into general medicine, reducing stigma and resulting in superior lines of responsibility. Malfeasance responses: Disturbing revelations of the Royal Commission into Deep Sleep Therapy at the Chelmsford Private Hospital, and the Queensland Commission of Inquiry into assault and maltreatment of patients in the psychiatric ward of the Townsville General Hospital, reports of sexual misconduct and other boundary violations surfaced in the past 20 years. Grave community concerns resulted in impressively non-defensive responses by the profession and the monitoring authorities to redress such issues, including increased legal involvement (and procedures) now intertwined with public mental health services. Formalised professional markers: The establishment in 1964 of a Royal College (the RANZCP) linking Australian and New Zealand psychiatrists, and, in 1967, of a professional journal (The Australian and New Zealand Journal of Psychiatry), together with the development of an innovative membership examination, were markers of a move from a small network of individual psychiatrists to a formalised grouping -- now one of the largest professional medical specialties in the region. Growth in Australian academic psychiatry: Once a "home alone" model (eg, David Maddison, Professor of Psychiatry, Sydney University, and Foundation Dean of the Newcastle University Medical School being one of a small set of identifiable local produce) or "run away from home" expatriate model (eg, local Adelaide lad, Aubrey Lewis, dominating British academic psychiatry), now "home grown" dominance is evident, with a disproportionately successful Australian impact on international research publications, but also a decrease in "critical attitude" by academics and an overvaluation of quantitative research. Clozapine: This "atypical" neuroleptic drug was produced in 1962, but only taken up in Australia in the past decade (because of its side effect of agranulocytosis). Despite its monitoring requirements and its expense, its wide prescribing by Australian public mental health services is noteworthy. Its use gradually causes a considerable number of patients with schizophrenia to "normalise", and its capacity to restore suggested cognitive limitations has changed our understanding of a disorder once called "dementia praecox". Growth of biological psychiatry and psychiatry as a neuroscience: This movement has delivered striking results in understanding the determinants of many major psychiatric disorders, in establishing a dominant and successful research paradigm, and in integrating psychiatry with medical research. Caveats emerge from overly zealous or inappropriate application of the model -- "the sin of biologism". At risk is rejection of psychiatry's distinctive contribution to the practice of medicine -- a pluralistic model, respecting and integrating (in formulation and management) the multiple paradigms of sentient human beings. Detumescence of psychotherapy: Psychotherapy has been shrunk less by failure to produce an evidence base, ad hominem attacks and growth of alternative contenders (eg, cognitive behavioural therapy) than by a loss of significance and relevance as biological psychiatry has "Pac-Manned" the old Zeitgeist. Psychotherapy requires revisionism, repositioning and more pragmatic advocacy. Introduction of "new" antidepressants and "atypical" antipsychotic drugs: The selective serotonin reuptake inhibitors (SSRIs) are not merely antidepressants, but non-addictive "anti-worry" agents, with the potential to modify "neurosis", a feat once thought impossible. The "atypical" antipsychotic drugs may only be slightly more effective for treating schizophrenia, but their more benign side-effect profile improves quality of life and medication compliance. Formulation of clinical depression as an economic problem: The number of people with depression is not growing substantially, despite historical formulations of depression as a response, a disorder, an illness and a disease. Its recent reformulation as a major economic cost due to its disabling effects, endorsed by the World Bank, Harvard University and the World Health Organization, provided the spin, attracting public, media, health department and political attention. Consumerism: At last year's RANZCP Conference, psychiatrists danced in a congo line to music played by a band of consumers. As the Convenor, Bob Barrett, observed: "It was a delicious sight indeed to see psychiatrists dancing, for the first time, to the tune of the patients." Consumers and their advocates have had a more difficult row to hoe in psychiatry than in most other medical specialties, with their contribution and impact on professional attitudes humbling. On doctors and nurses: Once non-psychiatrist doctors married their hospitals and, on the rebound, the ward sister, who was ever able to undertake ward rounds at home ("Are all the children in bed, sister?"). Once psychiatrists were strange schizoid creatures (to wit, "alienists"). Now doctors no longer marry nurses (most are professors now) and psychiatrists are rugby-following, tie-wearing, non-intellectual conservatives. As biological psychiatry has reached its zenith, psychiatry is no longer as attractive or distinctive to those seeking "different" medical careers. The "magic" in the therapeutic process has gone -- magic that could lead to foolishness and invite ridicule or, alternatively, which imbued psychiatrists with a luminous sense of understanding. Recruitment is down and there is a lack of plurality in the air. Has psychiatry been mainstreamed away from its ineffable status? Has it not become stale to medical student and graduates seeking a specialty? How will it reconstitute itself above and beyond its procrustean biological bed? The January 2051 issue of The Medical Journal of Australia will detail the rollback. Gordon B Parker Professor and Head School of Psychiatry University of New South Wales Prince of Wales Hospital, Sydney, NSW John H Ellard Psychiatrist Bead Lane Specialist Centre, Sydney, NSW Above photograph. Ambulatory psychiatric patients, who have been put to bed in broad day-light, Callan Park Mental Hospital, Sydney, circa 1960. From the Report of the Royal Commission into Callan Park Mental Hospital, 1961. Crown copyright. Make a comment

Gordon B Parker · John Ellard

Editorial "Should we treat leuchæmia in children?" Fifty years ago the first controlled clinical trial of cancer chemotherapy was published MJA 2000; 173: 568-569

Peter J Smith