History and humanities

To the Editor: The entertaining history of Sydney Hospital by Kappagoda1 illustrates the risk of accepting local lore as fact. The assertions that Sydney Hospital “hosted the first operation [in Australia] under general anaesthetic” and that it was “a leg amputation under chloroform” are both incorrect. The first surgical operations under general anaesthesia in Australia took place in Launceston, Tasmania, on Monday 7 June 1847, using ether administered with apparatus that had been depicted in the Illustrated London News.2,3 Two patients were successfully anaesthetised by Dr William Russ Pugh — both walked home and were completely happy with the procedure. The operation referred to by Kappagoda was reported in the Sydney Morning Herald (SMH) on Monday 28 June 1847 as having occurred “a few days back”4 — at least 2 weeks after Pugh’s patients were anaesthetised. Further, ether, not chloroform, was used in Sydney. The SMH reporter had also seen ether used to anaesthetise patients on other occasions, but these patients were undergoing dental extraction. The decision to operate may have been precipitated by a news item in the SMH on Thursday 24 June 1847. The paper reported that “The medical men at Launceston have made several successful experiments in performing surgical operations on patients who have inhaled ether.”5 To local readers, it would have been obvious that this had occurred at least several days, and possibly several weeks, before the Sydney surgery, because of the delay in transmitting news from Launceston to Sydney. Perhaps this news spurred the Sydney surgeons to act.

John D Paull

To the Editor: The first recorded use of an anaesthetic in Australia was not at Sydney Hospital, as stated by Kappagoda,1 but was at Dr John Belisario’s rooms in Spring Street, Sydney. Belisario, with Dr Charles Nathan (honorary surgeon to Sydney Infirmary), administered ether to two patients having dental extractions on 6 June 1847, and possibly to other patients a day or two earlier.2,3 The first recorded use of an anaesthetic for surgery was in Launceston, Tasmania, by Dr William Russ Pugh on 7 June 1847, when he administered ether for removal of an epulis from a woman’s jaw, followed by excision of a cataract from a man. Pugh published these cases in the Australian Medical Journal — the first medical journal in Australia, of which the Medical Journal of Australia is the direct descendant,4 and which only existed for 15 months. The Editor, Dr Isaac Aaron, was one of the first surgeons at Sydney Infirmary. Ether was the sole anaesthetic available in Australia for 10 months before chloroform was introduced. The first recorded death under ether occurred in Sydney on 9 April 1848. Two days later, on Tuesday 11 April, Nathan gave evidence in the morning at the inquest of this death and, in the afternoon, gave the first chloroform anaesthetic in Australia at Sydney Infirmary, to a young girl. The first recorded death under chloroform anaesthesia in Australia occurred on 19 July 1848 at Windsor, New South Wales.2 Sydney Infirmary, later Hospital, was closely involved in the early days of anaesthesia in Australia, both on site and through its staff, but cannot claim priority.

Michael G Cooper

Viewing germs through biological and sociological lenses. In 1922, Simon Flexner, the director of the Rockefeller Institute in New York City, observed that “each generation receives its particular impression of epidemic diseases”. After the influenza pandemic of 1918, the postwar medical generation was trying to ...

Warwick H Anderson MD, PhD

Mackay and Burnet’s Autoimmune diseases, published in 1962, marked the beginning of autoimmunity as a clinical science and led to the future acceptance of the existence of autoimmunity. While there is still controversy regarding the mechanisms of autoimmunity, the authors’ insightful hypothesis based on clonal selection theory and the emergence of “forbidden clones”, due to somatic mutations, is still current, with recent evidence giving further credence to this hypothesis. We salute Mackay and Burnet on the 50th anniversary of this seminal publication. It is particularly pleasing that it has an iconic Australian origin.

Peter J Roberts-Thomson MD, DPhil(Oxon) · Michael W Jackson BSc, PhD · Thomas P Gordon FRACP, FRCPA, PhD

Objective: To determine whether emergency department (ED) patients’ self-rated levels of anxiety are affected by exposure to purpose-designed music or sound compositions with and without the audio frequencies of embedded binaural beat.Design, setting and participants: Randomised controlled trial in an ED between 1 February 2010 and 14 April 2010 among a convenience sample of adult patients who were rated as category 3 on the Australasian Triage Scale.Interventions: All interventions involved listening to soundtracks of 20 minutes’ duration that were purpose-designed by composers and sound-recording artists. Participants were allocated at random to one of five groups: headphones and iPod only, no soundtrack (control group); reconstructed ambient noise simulating an ED but free of clear verbalisations; electroacoustic musical composition; composed non-musical soundtracks derived from audio field recordings obtained from natural and constructed settings; sound composition of audio field recordings with embedded binaural beat. All soundtracks were presented on an iPod through headphones. Patients and researchers were blinded to allocation until interventions were administered. State–trait anxiety was self-assessed before the intervention and state anxiety was self-assessed again 20 minutes after the provision of the soundtrack.Main outcome measure: Spielberger State–Trait Anxiety Inventory.Results: Of 291 patients assessed for eligibility, 170 patients completed the pre-intervention anxiety self-assessment and 169 completed the post-intervention assessment. Significant decreases (all P < 0.001) in anxiety level were observed among patients exposed to the electroacoustic musical composition (pre-intervention mean, 39; post-intervention mean, 34), audio field recordings (42; 35) or audio field recordings with embedded bianaural beats (43; 37) when compared with those allocated to receive simulated ED ambient noise (40; 41) or headphones only (44; 44).Conclusion: In moderately anxious ED patients, state anxiety was reduced by 10%–15% following exposure to purpose-designed sound interventions.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN 12608000444381.

Tracey J Weiland BBSc(Hons), PhD/MPsych · George A Jelinek MB BS, MD, FACEM · Keely E Macarow BA, MA, PhD · Philip Samartzis GradDipArt · David M Brown DipArt, MA · Elizabeth M Grierson LicDip, MA, PhD · Craig Winter MB BS, MBA, FACEM

In February 2011, Cyclone Yasi was bearing down on the Queensland coast near Cairns. People living in coastal suburbs and towns from Cairns to Townsville were given orders to evacuate their homes, airlines put on extra flights to help people evacuate, and Queensland Health made the decision to evacuate Cairns hospitals for the first time in history. Cairns Base Hospital was established in 1884 on the waterfront overlooking the Coral Sea. The hospital’s location leaves it vulnerable to cyclones, tsunamis and storm surges. Based on the Bureau of Meteorology’s cyclone tracking model,1 Yasi’s landfall was predicted to coincide with high tide, which put hospital staff and patients at risk of inundation by a 5-metre storm surge. On Tuesday 1 February, more than 250 patients from Cairns Base Hospital and the nearby Cairns Private Hospital were airlifted to Brisbane hospitals in what is believed to be Queensland’s largest mass medical evacuation and the largest hospital evacuation ever undertaken in Australia. A timeline of events is summarised in the Box. Seven pregnant women, 16 babies, eight intensive care patients, 18 mental health patients and more than 60 dialysis patients were among those evacuated. General medical patients, the parents of evacuated children, medical escorts and carers were also airlifted to Brisbane. Many patients were transferred to regional hospitals or discharged home if considered safe to do so. Australian Defence Force personnel with 11 medivac-equipped C-130 Hercules aircraft, the Royal Flying Doctor Service, CareFlight, the Queensland Government Air Wing, and several commercial airlines (Qantas, Alliance Airlines and JetStar) were involved with the evacuation. A convoy of ambulances transported patients to Cairns Airport, from where they were flown to Brisbane. Another convoy of ambulances in Brisbane took arriving patients to a number of hospitals. By 3 am on Wednesday 2 February, the Cairns Base Hospital emergency department was eerily empty. The hospital was closed at 9 am that day. A temporary emergency medical facility, staffed by doctors and nurses, was set up at an indoor basketball stadium at the Fretwell Park Sporting Complex, about 10 km inland. By 4 am on Wednesday, Yasi intensified into a Category 5 cyclone, with a storm front 650 km wide, sustained wind speed of 205 km/h, and wind gusts of 285 km/h.1 Its forecast track had veered slightly southward away from Cairns. Yasi crossed the coast in the early hours of Thursday morning, and the northern Queensland towns of Innisfail, Tully, Mission Beach and Cardwell bore the brunt of one of the most powerful cyclones in Australia’s history. Four women gave birth during Cyclone Yasi. One baby was born at Fretwell Park under a soccer net covered with a bed sheet for privacy, and another at an emergency shelter. The other two babies were born at Innisfail Hospital. Cairns Base Hospital reopened at 12 pm on Thursday 3 February with limited services until staffing levels returned to normal. Some staff were unaware the hospital had reopened and others were unable to reach the hospital because of flooded and blocked roads. The Fretwell Park emergency medical facility closed at 4 pm the same day. Parts of Cairns were without power for several days after the cyclone, and roads leading south were impassable due to floodwaters. Trucks carrying essential food and supplies were unable to reach Cairns to restock supermarket shelves that had been stripped bare before the cyclone. Doctors and nurses who organised the evacuation of patients did an amazing job under extreme pressure, as did those who staffed the emergency medical facility while the cyclone raged around them. No patients died as a result of the evacuation. Eventually all evacuated patients were returned to Cairns, although this took several weeks and was stressful for patients and their families. The evacuation posed enormous logistical challenges in terms of medical records, medications and equipment required. Continuity of care for acutely unwell patients, including those receiving dialysis or in coronary care, intensive care and mental health units, was extremely complex, and it is a tribute to the dedication of the staff at the respective hospitals that there were no major adverse outcomes. Pre-emptive evacuations of hospitals are rare events, occurring just three times in the United States since 2005.2-4 Detailed analyses of the evacuation process are underway and will improve our ability to respond to future disasters. Timeline of events in evacuation of Cairns hospitals due to Cyclone Yasi, 2011 Date and time Event 29 January Tropical low identified north-west of Fiji, tracking westward 30 January 10 pm Low intensified into a cyclone, named Yasi, located north of Vanuatu 31 January 10 am Yasi intensified into a Category 2 cyclone 4 pm Yasi upgraded to a Category 3 cyclone, still maintaining a westward track 1 February Queensland Chief Health Officer makes decision to evacuate Cairns Base Hospital and Cairns Private Hospital 7 pm Yasi upgraded to a Category 4 cyclone, moving west-south-west and accelerating towards tropical Queensland coast 10 pm Patients airlifted from Cairns hospitals to Brisbane 2 February 3 am First patients arrive in Brisbane 4 am Yasi upgraded to a Category 5 cyclone, maintaining a west-south-west movement 9 am Cairns Base Hospital closes and temporary emergency medical facility opens at Fretwell Park Sporting Complex 10 am Airport, university, schools and businesses in Cairns closed 12 pm Last Cairns patients (four special-care babies) arrive in Brisbane 3 February 12–1 am Cyclone Yasi crosses the coast near Mission Beach 12 pm Cairns Base Hospital reopens 4 pm Fretwell Park emergency medical facility closes 16 February 40 Cairns patients still in Brisbane hospitals 19 February 29 Cairns patients still in Brisbane hospitals Cyclone Yasi approaching the Queensland coast, 1 February 2011, 5.30 pm (satellite image originally processed by the Bureau of Meteorology from the Geostationary Meteorological Satellite MTSAT-2 operated by the Japan Meteorological Agency).

Cindy E Woods BEd(Hons) · Donna Goodman BPsych, PhD · Jane Mills MN, MEd, PhD · Kim Usher MNSt, PhD, FRCNA · William J H McBride FRACP, FRCPA, PhD

During a time of war, the federal government passed the National Fitness Act 1941 to improve the fitness of the youth of Australia and better prepare them for roles in the armed services and industry. Implementation of the National Fitness Act made federal funds available at a local level through state-based national fitness councils, which coordinated promotional campaigns, programs, education and infrastructure for physical fitness, with volunteers undertaking most of the work. Specifically focused on children and youth, national fitness councils supported the provision of children’s playgrounds, youth clubs and school camping programs, as well as the development of physical education in schools and its teaching and research in universities. By the time the Act was repealed in 1994, fitness had become associated with leisure and recreation rather than being seen as equipping people for everyday life and work. The emergence of the Australian National Preventive Health Agency Act 2010 offers the opportunity to reflect on synergies with its historic precedent.

Julie A Collins BArch, PhD · Peter Lekkas BPty, MPty

Many years ago, I rescued from destruction a unique 120-year-old leprosy register of the colony of New South Wales (Box 1). This register commenced in 1891 and continued after federation under NSW legislation.1,2 With 101 double pages, patient details were entered into 12 columns, in clearly legible copperplate handwriting (Box 2). As leprosy notification was compulsory, entries were a provisional diagnosis. Patients were subsequently examined by specialists, sometimes chaperoned by police. The diagnosis was entered into the register. If the patient had leprosy, warrants were issued for their detention at the Coast Hospital lazaret at Little Bay in Sydney. For many, this was a sentence of life imprisonment as there was no effective treatment. Some absconded only to be returned by the constabulary. Patients were treated compassionately, being allowed to keep pets, grow vegetables, and to fish. Chinese patients were even given a liberal allowance of opium.3 In the first four decades, to 1931, 290 patients were entered in the register; 224 of these (77.2%) had leprosy (other diagnoses included beri-beri, “cretinism”, eczema, gangrene, hemiplegia, psoriasis and, frequently, syphilis). Of those with leprosy, 203 were men and 21 were women, one of whom was a nun. “Nationality”, where recorded, showed the highest prevalences of leprosy among Australian or European patients (79 [35%]), Chinese patients (66 [30%]) and Pacific Islanders (22 [10%]). Only three (1%) were Aboriginal, corroborating the fact that leprosy was not endemic before European settlement. Other patients were from Ceylon, Egypt, India, Syria, the United States and Zanzibar. In the fifth decade (1934), the hospital was renamed the Prince Henry Hospital of Sydney. Subsequently, with the advent of sulfones, patients could be rendered non-infectious within 12 months and be discharged on treatment (with regular reviews) rather than remain incarcerated. Many were readmitted, probably because their compliance with treatment lapsed. The last entry in the register was made in 1950, 59 years after its commencement. There was no confidentiality coding as there is now with HIV-AIDS registers. Nowadays, leprosy is rare in Australia and immigrants are screened;4 globally, there is a decreasing trend in new cases, with the World Health Organization reporting about half a million in 2003 falling to about a quarter of a million in 2009.5

Peter Christopher

To the Editor: A recent American study found that in 2009, girls aged 14–17 years sent an average of 112 text messages per day.1 Australian teenagers are no different. During a ward round earlier this year, I saw three teenage girls in a row in various stages of recovery from acute asthma. Despite the best efforts of the team, none of the teenagers spoke; the management of their conditions was discussed with their parents instead. However, the teenagers were clearly still awake, often giggling and actively texting, with their ubiquitous mobile phones tightly gripped in their hands. This phenomenon of the non-talking teenage girl who is actively texting during the bedside consultation has continued throughout 2011. A new way to assess the neurological examination of teenage girls that takes into account their level of interaction with their mobile phone is required. Based loosely on the standard neurological examination and Glasgow Coma Scale,2 I have developed the Telco Coma Scale to assist doctors and nurses in the neurological assessment of teenage girls addicted to the use of their mobile phone. Normal orientation in time, place and person in the new scale means that the teenager is able to send text messages, respond to Facebook alerts, and demonstrate a variety of facial expressions in response to the messages received. Despite an absence of verbal response to any surrounding adult and an intense flexion reflex that makes it impossible to remove the mobile phone from the hand, the treating health care professional can be reassured that this is the equivalent of a Glasgow Coma Scale score of 15 and that the teenager is fully conscious. Deep tendon reflexes are measured by the speed at which that the teenager is able to type text messages. Sensory and pain responses are accurately assessed by measuring the response time to Facebook alerts and observing the teenager’s facial expressions. The measurement of power requires the resident to attempt to remove the phone from the teenager’s hand. A normal flexion and power response is demonstrated by the teenager being able to successfully pull a resident of greater than their own body weight off balance rather than give up the phone. In my experience, the mobile phone has never once been able to be removed from the grasp of a normal teenage girl.

Peter D Jones

It has been the ambition of physicians since the origin of time to diagnose illness and internal pathology by some external means. The ancients used observation, palpation, succussion, the pulse, mensuration, uroscopy and later percussion but the first instrument to examine the inside the body in a non-invasive way was the stethoscope, which was devised by René Théophile Hyacinthe Laennec (1781–1826). The history of listening to breath sounds dates back to antiquity, being mentioned in the Ebers Papyrus (c.1500 BC), the Hindu Vedas (c.1400–1200 BC) and the Hippocratic writings (c.400 BC),1 but a proper examination of the chest started with Josef Leopold Auenbrugger’s (1722–1809) introduction of percussion, which he learnt from his father, who used to tap kegs to determine the fluid level.2 Jean-Nicolas Corvisart (1755–1821), physician to Napoleon I, translated Auenbrugger’s book3 into French in 1808, thus popularising percussion, and taught direct auscultation by pressing the ear to the chest. Corvisart4 taught Laennec these techniques, but London physician Augustus Bozzi Granville5 stated that Laennec was dissatisfied with the results. Granville relates that Laennec became frustrated with the use of percussion and direct auscultation to examine a patient. Laennec asked “Why should we not avail ourselves of the help which acoustics yield to us?”, took a notebook from a student, rolled it lengthwise and listened to the patient’s chest.2 However, Laennec’s account of the discovery differs.6 In 1816, when he was consulting an obese female patient with heart disease, he found that “percussion and the application of the ear were of little avail on account of the great degree of fatness”.2 He states that he rolled three quires of paper into a cylinder and applied one end onto the region of the heart and the other to his ear, and was pleasantly surprised to hear the heartbeat more clearly than on direct auscultation. Laennec named his instrument “stethoscope”, derived from the Greek words stethos (chest) and skope (examination). Thus the original stethoscope was made of paper, and Granville took one home to England when he returned in November 1817. Laennec was a good wood-turner and made his own stethoscopes out of wood (of various kinds) and sold one with each copy of his book. He also provided a do-it-yourself description of how to make one. These stethoscopes were about 30 cm long and 40 mm in diameter, with a 6 mm central bore. Laennec was fortunate to be working at a time when hospitals were becoming cleaner and more accepted, and he was consequently able to examine a large variety of patients and correlate physical findings with morbid pathology. He described bronchitis, bronchiectasis, pleurisy, lobar pneumonia, emphysema, pneumothorax, pulmonary oedema and gangrene, and his terms, such as rales, bronchophony, bruit, fremitus, cracked-pot sound, cavernous breathing and pectoriloquy, are still in use today.2 He is also known for his work on alcoholic cirrhosis: the term “Laennec’s cirrhosis” was popularised in the United States and Canada by William Osler, but ignored in France.7 The monaural stethoscope was carried, by a clip, in the crown of a top hat, and was given by teachers as a prize to top students and as a gift by wives to husbands. In 1848, Oliver Wendell Holmes wrote his “Stethoscope song” as a satirical tribute.8 The binaural stethoscope became popular in the United States earlier than in Europe, thanks to a good practical version designed by G P Cammann of New York in 1852 and William Osler’s preference for the design.1 Farquhar McCrae is believed to have brought the stethoscope to Australia in 1839.9 What of the glass stethoscope? Laennec made stethoscopes out of wood, glass, metals and “goldbeaters skin” (calf intestine), but he thought that paper, lighter wood or Indian cane were superior to glass or metal10 (he also stressed that metal and glass stethoscopes felt cold when applied to the chest11). In 1856, Austin Flint, “the American Laennec”, disagreed, believing that wood did not conduct sound as well as metal or glass.11 However, this is a strange statement, as glass itself is a poor conductor of sound and glass stethoscopes conduct sound by air alone. Fortunately, Flint changed his opinion in 1866.2 In 1864, Routh wrote that the glass stethoscope “has been used for a long time; and glass has a signal advantage. It is a beautiful conductor of sound, and rather, I think, raises the pitch”.12 He goes on to enumerate its other advantages — it is easy to clean, makes no noise when it is rubbed against clothes, and preserves women’s modesty. Routh preferred a curved type. It may also be that obstetric glass stethoscopes were more widely used because their shorter stem conducted sound better than those made from other materials. There is a short-stemmed glass stethoscope in the museum of the Royal College of Physicians in London that may have seen use in obstetrics. Few glass stethoscopes have stood the test of time, although it is difficult to say whether this is due to their limited production or their fragility. I have been able to trace only three: the short-stemmed obstetric example mentioned above, and two others in my collection. One, probably made in the early part of the nineteenth century, is ornate and finely sculpted, probably of French origin and about 40 cm long, with a central bore of 17 mm (Box 1). The other is of sturdier quality, heavier and of plain appearance, also about 40 cm long, with a central bore of 40 mm (Box 2). They were sometimes described as epidemic stethoscopes due to the distance they interposed between the doctor and an infected patient, or as pauper’s stethoscopes, because they were used in public clinics where the patients were poor and often filthy. Sound conduction in these glass stethoscopes does not compare with modern stethoscopes, but it was better to use such a stethoscope than to put an ear directly, in an indiscreet way, to the chest of a naked and dirty patient.

Milton G Roxanas MB BS, FRANZCP

First published in 1935, the original Penguin books are instantly recognisable, with three horizontal bands on the cover, and a colour scheme according to genre. They originally sold for sixpence. First editions remain highly collectible. Here, I describe Penguinius collectionavidus infection, following a firsthand encounter with this fiction affliction. Clinical features: The host has a penchant for collecting first edition Penguin books, especially from the period 1935–1950. A proclivity for dust jackets and a bias towards creaseless and unchipped volumes are the norm. Patients may often be seen browsing in second-hand bookstores and scouring eBay and AbeBooks for obscure titles. Joyful exclamations and/or dancing a jig characteristically follow serendipitous discoveries. Patients will often experience palpitations on locating an antiquarian bookstore — this is an important differential diagnosis for consideration by emergency physicians. Insomnia and disturbed sleep are not unusual, with many online auctions based on Greenwich Mean Time. The staking out of letterboxes and trailing of postmen may sometimes be confused with more illicit activities. A hallmark of P. collectionavidus infection is chromophilia — with a predilection for green (crime), orange (fiction), cerise (travel and adventure) and dark blue (biography). Patients with severe infection may also have an affinity for yellow (miscellaneous), purple (essays and belles-lettres), red (plays) and even grey (world affairs). Disposition toward animals is varied. A partiality for species of avian origin is pathognomonic, especially pelicans, puffins, peregrines and peacocks. This is in stark contrast to a general aversion to dog (ears) and a total abhorrence for foxing. Transmission: The author’s case was acquired in Singapore in July 2011 at an exhibition entitled “An Ode to Penguin”, apparently organised by a fellow sufferer, without a warning to visitors that the disease is highly contagious. Complications: Multiple trauma (faulty stepladders, collapse of shelving), concussion (falling folios), rhinitis (dusty volumes) and, rarely, mycetoma (musty monographs). The discovery in tomes of writing in margins, coffee stains or graffiti may result in trichotillomania. Prognosis: With thousands of titles in print, the course of illness may be protracted. Rapid serial acquisition may result in tachyphylaxis. With some editions fetching three figures, walleticus bankruptosis may feature. The author is yet to remortgage his house. Size of bookcases may not contain propagation of the illness, with books known to reside in drawers, wardrobes and under the bed. Treatment: Suggestions welcome. Competing interests: Other collectors, particularly book scouts, whose deportment at book fairs has been observed to be questionable. Actions such as book snatching and crawling under tables may indicate conversion to bibliomania. Patients are warned that the final minute of eBay auctions can be a veritable bloodbath.

Darren J Kester MB BS, FRACGP

Temporal lobe stimulation, endorphins, hypoxia, or something else? I discounted near-death experiences until 20 years ago when I cared for a 7-year-old boy with asthma. He was receiving maximal doses of steroids and salbutamol and we were poised to intubate, but his oxygen and carbon dioxide levels were reasonable and he was not acidotic. His blood pressure and electrolyte and blood sugar levels were normal and he was otherwise healthy, and not taking any other medications. His condition teetered, then improved over a couple of hours during which a female nurse and I were the only people around. Two days later he was better and, when talking to him, I suggested he must have been very frightened when he had been so sick. However, he denied it, and with great conviction. I looked him in the eye and asked “really?” He returned the look and repeated his answer. Curious, I asked “why not?” He replied, “because there was a man there”. I can still recall the flush of warmth I had begun to feel when I declared, “Of course there was a man there. It was me”, and then the let-down when he coolly replied, “No, it wasn’t”. Skin beginning to creep, I asked “who was it?” He did not know. “What was he was like? Was he frightening?” “No”, he replied, “he was a friendly man”. “What did he look like?” There had been some “shininess” about him. “What did he want?” “He wanted me to go with him.” “Where to?” He didn’t know. “Were you frightened to go?” “No.” “Why didn’t you go?” “I did not want to leave Mummy and Daddy.” Next day, I saw the boy before he went home with his parents, who had heard the story. Being of the Greek Orthodox faith, they were delighted that their son had been conversing with St George and considered it a miracle. But was it? Since the publication of a book on near-death experience by psychiatrist Raymond Moody in 1975,1 there have been sparse, rationalist explanations in mainstream medical literature about these experiences.2 These explanations have been opposed by profuse affirmation of the transcendental in alternative media, but both sides seem to agree the phenomenon exists. This was my first case, and I acknowledge it may not fill the diagnostic near-death experience scale of Greyson, which includes cognitive changes of accelerated thought processes and reviews of the past, affective experiences of joy, “autoscopy” or viewing oneself from without, and the transcendental experience of recognising a spiritual being.3 Greyson’s scale, however, was constructed on the memories of adults, and cases of near-death experiences among children in medical literature are rare. However, one review of 11 paediatric patients reported “an absence of life review, time alteration, worldly detachment or transcendent feelings”.4 The handbook of near-death experiences claims that “several hundred” have been reported in children but laments imprecision.5 What might cause such a defined phenomenon? Some rationalists point to stimulation of the temporal lobe, others to the hallucinatory effects of various chemicals, including endorphins. Others blame hypoxia, and some, getting closer to home for my young patient, blame hypercapnia, but without giving the level of carbon dioxide necessary to produce the near-death experience. There is a hypothesis that noradrenaline may ultimately evoke positive hallucinatory experiences, and my patient was heavily dosed with sympathomimetic drugs. I favoured the idea of some kind of endorphin effect in my young patient until I had my own kind of experience while recovering from intestinal thromboses from which I had been given a 50% chance of survival. I had turned the corner and was happy to be alive. I was clear-headed, not stressed, no longer under the influence of morphine and was beginning to walk. I had not been thinking of my mother during that period. She had died 3 years before after a most unhappy life: bitter over abandonment as a baby, my father’s death in World War II, a failed second and tumultuous third marriage, and increasing physical debility. During the closest thing to a near-death experience I have personally experienced, I entered a room where my mother was seated on the end of a sofa in front of a window through which streamed the only light. She was beautiful, youthful, radiant and happy. She was singing, and I remembered how she sang when I was very small. Despite a combative attitude to Christianity, she was singing a hymn! I was astonished, and sat down on the other end of the sofa in time to hear her stumble on the second verse. “I know that hymn”, I said, and reached for a hymnal among a pile of books on the table. But she reached across me and poked me, hard, in the right shoulder. She declared with a smile, “but I am not here”. I was not unaccustomed to my mother not making sense, and reached again for the hymnal. She poked me again: “But I am not here”, she said again, this time with an edge of amusement in her voice. I stared, trying to understand, and as I stared, she faded from view. I woke searching for the poker. The room was empty. I don’t understand the physiology of my two experiences, but I do recognise their effect. They both point to another dimension.

John S Whitehall MB BS, FRACP

Professor Sir Graham Collingwood Liggins (24 June 1926 – 24 August 2010)Sir Graham Liggins, who died last year aged 84, made arguably the greatest contribution of any Australian or New Zealand practitioner to modern obstetric practice. Educated at the University of Otago, his work in the 1960s on causes of prematurity led to the publication of a landmark randomised controlled trial. This 1972 report demonstrated a two-thirds reduction in the incidence of respiratory distress syndrome in preterm neonates who had received antenatal corticosteroids. Although not immediately universally accepted, subsequent work substantiated the benefit of this simple, ground-breaking treatment. The administration of antenatal glucocorticoids, now standard obstetric practice, is widely acknowledged as the single most effective therapy in minimising mortality from prematurity. Image courtesy: Bruce Jarvis, Auckland, New Zealand. Professor Ian Frazer (6 January 1953 –)Named Australian of the Year in 2006, Professor Ian Frazer’s development of a vaccine against the human papillomavirus (HPV) is arguably the most significant advancement in the prevention of gynaecological cancer in modern times. After completing medical studies in his native Scotland, he emigrated to Melbourne. Initial research into HIV-related immunodeficiency led to work on HPV and subsequently the creation of virus-like particles, from which the HPV vaccine would eventually develop. The recipient of numerous scientific and medical accolades, including the 2009 Australian Medical Association Gold Medal, he is currently Director of the Diamantina Institute at the University of Queensland. Sir Albert William Liley (12 March 1929 – 15 June 1983) Born and educated in Auckland, the “Father of Fetology” was a pioneer in maternal and fetal physiology. Practising at a time when Rhesus isoimmunisation was a major disease, he developed a graph that enabled interpretation of amniotic bilirubin levels into prognostic “Liley’s zones”, allowing more accurate prediction of stillbirth risk. Over 4 years, Rhesus-associated perinatal mortality in Auckland fell from 22% to less than 9%. Liley is also credited with the first successful intrauterine fetal transfusion, in 1963. This case laid the foundation for the evolution of fetal therapy and the acceptance of the fetus as a person in his or her own right in the decades that followed. Ian Alexander McDonald (1 April 1922 – 4 September 1990)Ian McDonald was born in Perth, Western Australia, but throughout his career practised mostly at the Royal Melbourne Hospital. His most significant contribution to modern obstetric care is the cervical cerclage (suture) that bears his name. The concept of inserting a stitch to close an incompetent cervix was first introduced by Vithal Shirodkar in 1955. In 1957, McDonald published a technically easier approach: a simple purse-string suture involving circumferential bites around the cervix at the level of the internal os, without the need for bladder dissection. The McDonald cerclage now forms part of the standard surgical armamentarium of the contemporary obstetrician. Image courtesy: Archives of the Royal Melbourne Hospital. George Simpson (14 May 1899 – 24 November 1960)Born in Clifton, Victoria, the young George Simpson was introduced to a number of ministers from the Presbyterian Church, including Reverend John Flynn. This was the beginning of a collaboration from which the Aerial Medical Service (later known as the Royal Flying Doctor Service of Australia) would eventually emerge. Simpson graduated from the University of Melbourne and, in 1927, undertook a 3-month survey to assess the medical needs of the Australian outback. In that year, he undertook the first unofficial flight of the Service, evacuating a miner with a spinal fracture from Mount Isa. Later, he established Melbourne’s first family planning clinic. Appointed an Officer of the Order of the British Empire in 1957, he died 3 years later aged 61. Image courtesy: National Archives of Australia

Jennifer N Lees MB BS · Colin A Walsh MB BCh, BAO, MRCOG

What can we do to avoid discrimination against the obese? A few years ago I had the pleasure of tutoring groups of medical students in their communication course. One topic on the syllabus was discrimination — an opportunity for the students to reflect on their own potential biases. During these sessions I discovered that most students could overcome racism, homophobia and religious prejudice quite readily, but had considerable difficulty in being non-judgemental about Australia’s most prevalent health condition: obesity. In an effort to help my students, I would recount the following anecdote. In the 1980s, I worked in a small endoscopy facility that employed some nurses who were significantly obese. One of these nurses, whom I shall call Janet, was not normally especially friendly to patients. One day I was struck by a particular encounter. A patient was wheeled in, on an extra wide trolley — a patient with morbid obesity. Janet started to stroke the patient’s forehead and call her “dear” and “darling” in the gentlest tone of voice. I had never seen Janet so compassionate before. This made me realise that Janet herself must have experienced negative attitudes from health professionals. My students have now graduated and will be fine non-judgemental doctors, I hope. But discrimination against obese people in health care settings is still common. Take this example from a blog written by “Midlife Midwife” in the United States: I have to admit. I have a hard time emotionally with severely overweight people ... I have to really work at not being judgmental of them. I get a sinking feeling in my stomach and frustration bubbles up into my chest when I see a patient’s weight is over 250 pounds. I have to really work to put on my smile and be as kind as possible.1 Midlife Midwife goes on to discuss the technical difficulties of doing a Pap smear, including lack of appropriate specula, in obese women. The negative attitudes held by Midlife Midwife have been shown to be held by a large percentage of doctors, students, nurses and others.2 Overweight people suffer inferior care, negativity and even ridicule, and they become reluctant to access health care. They are then at risk of further deterioration in health. Critical attitudes and stigmatisation of obesity do not make weight reduction more likely — in fact the reverse is true. Discrimination has been shown to lead to worsening of unhealthy eating patterns. Conversely, it has been shown that empathy enhances weight reduction. Overweight people are now claiming the moral high ground. There is a fat acceptance movement, which has spawned various societies, such as the International Size Acceptance Association. However, critics of the fat acceptance movement aver that societal acceptance of obesity will reduce the aspirations of the community to lose weight. If I were tutoring medical students today, they might ask: what do we do? Do we treat obesity as a disease or simply a physical attribute? If we overcome our prejudices and show empathy, are we normalising obesity? To help in my answer, I might reflect further on my own practice. Over the years I have seen many patients with non-alcoholic fatty liver disease, and so counselling on weight reduction has become part of my bread and butter (thin scrape only!). I think I have been able to empathise with the patient without normalising obesity — obesity is a chronic medical condition. Fat acts as a huge metabolic organ, producing cytokines that cause symptomatic bad health. I have learned that if you add a few E-verbs to a good spoonful of Empathy you will help your patient achieve weight loss. The mix should include some Empathising, some Evoking of the patient’s reasons to change, a good helping of Enabling (with simple strategies such as a daily walk), some Educating and some Empowering the patient to take control, all while Enjoying the collaboration. If you work with your patient as a team — acting as an ally and an Equal (the final E-word) — you will have a great recipe for success. Midlife Midwife may have learned a thing or two from one of the responses to his or her blog: Maybe speculums should be made to fit the people who need them. And maybe fat people are human enough to KNOW that you don’t like them and that you automatically think less of them, and that’s why many would rather go for years without medical care than subject themselves to a snotty, superior attitude and knowing that they’ll be snickered at behind their backs. Oh, and my husband has no trouble finding where to put the “speculum” in, and I’m 350 lbs. And I regularly walk 5 miles for the hell of it. Put that in your pipe and smoke it.1 Yes, a daily walk is good for everyone — but the most important walk for doctors is the walk in our patients’ shoes.

Katrina J R Watson MB BS, FRACP, MPH

Hardworking rural doctors make an unrecognised but large difference During my career as a city-based gastroenterologist, I was fortunate to make many trips to Victorian country towns to give educational talks. I often met inspiring people, and one of these was a senior country surgeon on the verge of retirement. This is his story. The older surgeon and I had been chatting with a younger surgeon, new to the town. The new surgeon had proudly told us about the lovely home he had just purchased, some 2 kilometres from the local hospital. The older surgeon sighed and confided to me that he would never have been able to live so far from the hospital, but had always lived within 500 metres because he often had to get to the hospital quickly. He had taken almost no holidays in 35 years of practice because there was rarely anyone to cover his absence. The surgeon gave me an example of his lifestyle over that time. One Easter Thursday he was having his first mouthful of dinner, thinking it was quiet and that he might even get a rest over the Easter break. The phone rang — a multiple-car crash had occurred on the Princes Highway, with a couple of fatalities and several casualties — and that was his Easter gone. He tried to send the patients with head injuries to Melbourne. He rang four hospitals and gave the same details to four admitting officers, to be told four times that there were no beds for them. So he managed the head injuries as best he could, together with all the other injuries, and spent most of his Easter in theatre. The city folk all survived, and were eventually transferred to city hospitals. There were no thanks and no chocolates. In fact, he said he could not remember ever receiving a thankyou letter from any city-based patient. A couple of years later, a trauma helicopter service was introduced and he was informed most decidedly, in a castigatory tone, that he must never manage any neurosurgical patient again. There was no thankyou for past services. I knew this surgeon had an outstanding local reputation for dedicated, expert and compassionate care, but such a reputation would not have carried much weight with city doctors. He had known the limits of his expertise, and had asked for help when appropriate, but often had not received it. His story moved me profoundly. It reminded me of an event from my distant past, when I was a first-year intern in another Victorian country town, on rotation from a city hospital. There were two of us interns, and we thought we were pretty smart. We also thought all the local general practitioners were basically hopeless — they could not read echocardiograms, knew nothing about electrolytes and prescribed old-fashioned drugs. One Sunday morning I was in the shower about to wash my hair, having been in the wards most of the weekend, and my beeper went off. I grudgingly got out of my shower. “It’s the children’s ward; Jason doesn’t look too well; he’s had diarrhoea all weekend.” I wanted to wash my hair and knew I would not get a chance for the rest of the day, so said I’d be there shortly, and continued washing my hair. My beeper went off again: “Jason doesn’t look too well at all,” and I thought “What a nuisance, I’m not even dressed.” Jason was a thin, pale child aged about 5 years who seemed to have been in hospital for weeks, appeared to have no proper family, was always sniffly and was frequently being treated for head lice or scabies; he was none too adorable. Then a third page sounded: “You’d better come right away, Jason has collapsed.” I hurried to the hospital and ran to discover a cold, clammy, blue Jason with a thready pulse and no detectable blood pressure. I panicked: I tried butterfly needles in his hand and in his foot, but it seemed there were no accessible veins. “Should we call Dr Jones?” asked the nurses. “Yes!” I squeaked in desperation. Fortunately, Dr Jones (one of the “hopeless” local GPs) was close by. He did a cut-down in Jason’s cubital fossa, found a vein and ran some fluid in. Jason started to pick up with a bit of saline: his blood pressure became recordable, he opened his eyes, and suddenly seemed quite adorable after all. He lived. I learned many lessons from that episode: that I should always trust the nurses and respond quickly to their call for help; that I, in turn, must ask for help quickly when I need it; that looking after someone engenders love; and that country doctors actually do know quite a lot. So, what of the senior country surgeon? I hope he is happy and relaxed in retirement. Many people owe their lives to him — not only country people, but city people who have been scraped off the roads into his care. I sent a summary of his life to the staff of Australian story (ABC Television), suggesting that he would be a great subject for the program. They never wrote back. Maybe they didn’t think it was much of a story after all.

Katrina J R Watson MB BS, FRACP, MPH

Readers who may contemplate referring patients to practitioners of complementary medicine may be interested in the fate of Dr Frederick Axham. He was an English anaesthetist, who was struck off the medical register for medical malpractice in 1911 at the urging of the General Medical Council, having been found guilty of “covering” (ie, professionally assisting a person not on the medical register). Axham had — despite dire warnings — anaesthetised eight patients of Herbert Barker, a renowned bone setter (now a lost art), who had successfully set and stabilised the complex fractures of seven of these eight patients whose fractures had been found to be inoperable by a number of eminent surgeons. Axham, who died in 1926 aged 86 years, still deregistered, was posthumously rehabilitated when the medical faculty of the University of Edinburgh made him a Licentiate of the Royal College of Physicians some weeks after his death.1 The whole affair caused a huge outcry throughout England, leading to a petition to Lambeth Palace, the residence of the Most Reverend Lord Randall Davidson, Archbishop of Canterbury, to make Barker a Doctor of Medicine, in reliance on the Ecclesiastical Licences Act 1533 (25 Henry VIII, c 21). The petition included not only leading members of the aristocracy, but, more importantly, Sir Henry Morris Bt, former President of the Royal College of Surgeons, Sir Alfred Downing Fripp, “Surgeon in Ordinary” to King George V, Sir William Arbuthnot Lane Bt, consulting surgeon to Guy’s Hospital, and physician Sir Bruce Bruce-Porter, all testifying to Barker’s coampetence. It also led George Bernard Shaw to write: Until the General Medical Council, which at present exhibits every constitutional vice that a trade union or professional association can have, is completely reformed by its legal constitution, we shall continue to hasten more and more precipitously to the not far distant day when the vogue of the unregistered practitioners, already very great (Mr. Barker is only a specially famous example of a large and growing body), will become so irresistible that the registered will be shunned by the public and driven to earning a scanty wage by signing death certificates for their unregistered employers.2 Alas, the Archbishop declined to award the degree. A press cuttings file at Lambeth Palace (Davidson’s Papers Vol 404, page 110) shows that he stated on 21 June 1920: The legislation which limits registration to men qualified by the ordinary professional training expressly, and I think rightly, provides that the status acquired by registration is not given by the Degree which the petitioners invite me to confer on Mr Barker.2 In frustration, King George V did the only thing he could do, which was to make Herbert Barker a knight of the realm. Sir Herbert continued bone setting till he died in 1946. Medicine. An Illustrated History

Paul Gerber LLB, DJur

Ken Paver was an outstanding dermatologist with broad vision and a remarkable ability to get things done. To paraphrase one of his maxims, Ken had great ability to which he applied a lot of effort. He was born in Kensington, Sydney, on 24 May 1920 and grew up in Mosman. After gaining his Intermediate Certificate in 1933, he left school to work at an insurance firm to help his family, because his father suffered from debilitating rheumatoid arthritis. During World War II, Ken served as a Private and then Captain in the Coastal Artillery. After the war, Ken studied medicine at the University of Sydney, where he met Elaine Kerr. They married in 1948 and graduated together in 1952. In 1953, after a year of residency at Royal North Shore Hospital, Ken joined a general practice at Merrylands. While working as a general practitioner, he obtained membership of the Royal Australasian College of Physicians (RACP). He received his Diploma of Dermatological Medicine in 1964 and was subsequently awarded the medal of the New South Wales branch of the British Association of Dermatologists. He gained Fellowships of the Australasian College of Dermatologists in 1966 and the RACP in 1971. Ken established a successful private practice in dermatology at Blacktown and was appointed Honorary Dermatologist at St Vincent’s Hospital, Sydney, where he was Chairman of the Department of Dermatology from 1966 to 1975. In 1978, Ken’s drive and momentum led to the establishment of the Skin and Cancer Foundation Australia, of which he was the first Chairman. He was appointed a Member of the Order of Australia in 1988. In 1989, Ken retired to the NSW Central Coast. He became a keen woodworker, an Associate of the Securities Institute of Australia and, in 2005, a Fellow of the Financial Services Institute of Australasia. He also acquired a Bachelor of Arts in sociology and worked on writing the history of the Skin and Cancer Foundation Australia. Ken died on 18 March 2011, and is survived by Elaine and children Graham, Rob, Phil and Cathy.

William Regan

A city specialist consulting in the country ponders the tyrannies of life, including health care, in the bush One of the many privileges I had while in clinical practice as a gastroenterologist was to work in the country. I consulted and did procedures in the beautiful regional city of Bairnsdale — in East Gippsland, about 3 hours’ drive from Melbourne — for 2 days in 1 week every month, for several years. The secretaries in my rooms in Melbourne used to dread my “Bairnsdale weeks”, because I would leave the office with a large suitcase half-full of files, and return with the same suitcase completely full of files, plus multiple dictation tapes. They also dreaded the letters, which were very long because they usually contained detailed information about the patients for the referring general practitioners, so that much of the management of the patients could be done without the need to see me again, given that I was not in Bairnsdale full-time. Bairnsdale is a lucky town when it comes to medicine. It has an outstanding collection of GPs, many of whom have worked in developing countries, so they have excellent skills in anaesthetics and obstetrics which they are keen to maintain. They are empathic, compassionate and strong advocates for their patients. Bairnsdale has a few specialists of its own, and used to have an unusually strong program of visiting specialists. But the Bairnsdale visiting specialist program has been cut back severely. People can get to the city, can’t they? Just give them a subsidised train fare. Apparently it is better to make 60 patients travel a 600 km round trip, rather than just one doctor. On my drives back to Melbourne I would have the feeling that I had done more good in 2 days’ regional practice than in a month of city practice. It felt similar to my thoughts on returning from a trip to the developing countries in which I had worked — Samoa and Zimbabwe, for example. The people of Bairnsdale, I gradually came to realise, faced multiple tyrannies, starting with the tyranny of distance. I remember once apologising to a patient for running late. “I’ve had a 3-hour drive this morning, from Melbourne”, I said. “Well so have I”, the patient shot back, “from Mallacoota” (240 km from Bairnsdale). Another patient commented to me somewhat bitterly that city folk were always reluctant to come to the country, but country people have no choice but to make trips to the city: “It’s a lot longer from Melbourne to Bairnsdale than Bairnsdale to Melbourne”. But it was not only the tyranny of distance: it was the tyranny of poverty. I could see its mark in many of the patients I saw. There were demographic patterns — the young drug users, now clean because they had moved away from “the valley” (the industrial Latrobe Valley, an hour’s drive to the west of Bairnsdale). There were the thin, careworn young mothers of four children by four different fathers, one child with autism, one or two with ADHD, and one with epilepsy. A history of childhood and domestic abuse seemed to be the rule rather than the exception. There were the toddlers destroying the consulting room — in the city, toddlers did not often come with their mothers; perhaps there was more support at home. And there were the young men with alcohol dependence, perhaps chronic pain syndrome, living in trailers in forestry towns, who could never come to Bairnsdale for review because of the cost of petrol. The tyranny of isolation meant that middle-aged farmers with body mass indices over 30, waist measurements over a metre, and abnormal liver function couldn’t walk for exercise because they didn’t have the time or company. Single mothers with chronic hepatitis C could not join an interferon program because there was no one to support them or help with the children. And then there was the tyranny of nature: in January 2003, many men and women, including all the orderlies in the hospital, had gone to fight bushfires, and the town’s economy was suffering. In February, Bairnsdale itself was threatened, the sky dark and the sun red. In March, a farmer with tears in his eyes told me about his cattle burning, and then — laughing sarcastically about government bushfire “relief” — that the authorities decided the new funded fences (replacing the burnt ones) had to be dingo-proof, with wires down to 10 cm from the ground. His farm had steep ups and downs, and this new fencing was “bloody impossible to build”, “bloody expensive” and “bloody stupid”. In April, his new fences all washed away into the Gippsland Lakes during floods. In my work in Bairnsdale, I know I changed peoples’ lives — people with gastro-oesophageal reflux disorder, hepatitis C and colitis. If I had not gone there, those people would still be suffering; they just could not, or would not, have come to the city. Subsidised train fares for them to come and see me in Melbourne would not have fixed their problems. However, many other specialties easily available in Melbourne are just not available in East Gippsland, even though we, in both the city and the country, all pay (and are effectively paid by) the same taxes. Overservicing in the city and no servicing in the country? Yes, it’s a long way from the city to the country, and distance is not the only tyranny.

Katrina J R Watson MB BS, FRACP, MPH

The death of John Buckingham on 29 March 2011, after a courageous battle with pancreatic cancer, robbed the Canberra medical community of its leading breast cancer surgeon, whose knowledge and skill was paired with devotion and kindness to his patients. John was born in Sydney on 19 July 1947. He attended St Ignatius College and graduated in medicine from the University of Sydney in 1971. He completed his advanced surgical training in the United States at Mayo Clinic in Rochester, Minnesota. In 1978, John returned to Australia and attained Fellowship of the Royal Australasian College of Surgeons in 1979. In that year, he commenced as a consultant general surgeon at the newly opened Calvary Hospital in Canberra, where he concentrated his practice for his entire career. In addition to his clinical commitments, he filled roles in the hospital as Head of the Division of Surgery and Chairman of the Medical Staff Council. His inclusive style and collegiate approach allowed all views to be heard and acknowledged. His wise counsel was valued by the Sisters of the Little Company of Mary, board members and clinicians. Throughout his career, John was involved in the broad expanse of general surgical conditions. He was a cautious, methodical and technically proficient operator, who was diligent and attentive in the postoperative care phase. Over time, he came to concentrate exclusively on breast cancer surgery. He developed a comprehensive model of care, involving colleagues from nursing, radiology and oncology, and suffusing it with his virtues of care and compassion. The development of a graduate medical program at the Australian National University Medical School in Canberra allowed John to expand his interest in teaching to both students and registrars. His excellence in this role was recognised with his appointment as Clinical Associate Professor when he retired in 2011. His contribution to the wider ACT community was recognised when he was named ACT Senior Australian of the Year in 2010. John was a remarkable man, who, despite his many achievements, was humble and self-effacing. He was interested in the lives of his coworkers and was unfailingly courteous to everyone he encountered. He was a man of deep religious conviction, and his Catholic faith sustained him in his final illness. Indeed, he lived all his life demonstrating the faith principles he so strongly embraced. John is survived by his wife Sue and children James, Peter, Kate and Michael.

Michael J Gillespie · Stephen A Deane

Illness in colonial Australia. FB Smith. Melbourne: Australian Scholarly Publishing Pty Ltd, 2011 (371 pp, $49.95). ISBN 9781921509193. Emeritus Professor Francis Barrymore “Barry” Smith, at the Australian National University, Canberra, is one of Australia’s most influential historians. His latest work is both a scholarly review, packed with an immense amount of well supported data, and a collection of largely ill founded opinions from the health professionals of the time, on the origin, causes and management of illness and disease. Smith also considers the influence of public policy and the conflicts between business and health management as, for example, in the avoidance of quarantine. It is clear that the doctors were concerned about the financial impact of quacks and paramedical providers, especially midwives, undercutting their fees. Nothing new! The devastation of Aboriginal communities by illness is described in detail. Smith notes the geographical variation in death rates and the greater ease with which squatters acquired land in some areas as a result. It is clear that these were dangerous times for all. Deaths in the white population were also at phenomenal rates in today’s terms. Parents often put children in contact with sick children to “get it over with”, accepting high rates of death. Unfortunately, the book suffers from poor editing. There are many irritating, long and contorted sentences. In an interesting chapter on tuberculosis, the same quote appears twice within the space of five pages. Chapter Six, “Children”, is not particularly about children, but more to do with the epidemiology of small pox and its management. However, there is an excellent bibliography and a reasonable index. One reads history for information, for entertainment, for general interest and especially to learn where we are coming from and, perhaps, where we are going. It is unclear who the target audience is for this book. Smith does not tie the book together with any conclusions but leaves us to draw our own. Despite its literary failings, this book provides a fascinating insight into illness, and life, in colonial times. We have more evidence today but the nature of man has not changed.

Elliot Rubinstein

"Training and working abroad is rewarding professionally and personally for medical students and junior doctors ... A guide to working abroad ... provides everything that travelling students or junior doctors need to make their placement a success. It will be absolutely essential reading for any medical student or junior doctor planning to work abroad. Senior doctors will also find the contents of the guide invaluable." Dr Andrew Pesce and Dr Michael Bonning "... thoroughly researched, tightly written and really useful guide which is, in fact, destined to become a classic." Sir Gustav Nossal eSupplement available as an eBook - . For downloadable PDF, click here.

Jake Parker · Rob Mitchell · Sarah Mansfield · Jenny Jamieson · David Humphreys · Fred Hersch · Hamish Graham · Kate Brennan

This article examines military medicine and its links to civilian general practice education and training, drawing attention to the variations and difficulties in, and successful approaches for, training Australian Defence Force (ADF) Medical Officers. Military medicine has been an area of change over the 10 years of the Australian General Practice Training (AGPT) program. Crisis situations like those in Timor Leste and Afghanistan have focused attention and recognition on the importance of primary health care in the work of the ADF. To train doctors in military medicine, there are several different models at different locations around Australia, as well as large variations in military course and experience recognition and approvals between AGPT regional training providers. At times, the lack of standardisation in training delays the progress of ADF registrars moving through the AGPT program and becoming independently deployable Medical Officers.

Scott J Kitchener MD, FAFPHM, FRACMA · Elizabeth Rushbrook MB BS, MHA, FRACMA · Leonard Brennan MHA, FRACMA, FACRRM · Stephen Davis MB BS, MHA

War wounds: medicine and the trauma of conflict. Ashley Ekins and Elizabeth Stewart, editors. Wollombi: Exisle Publishing, 2011 (240 pp, $49.99). ISBN 9781921497872. ORIGINALLY presented at an international conference by the Australian War Memorial (AWM) and the Department of Veterans’ Affairs in September 2009, this book is edited by two military historians at the AWM. It is well illustrated and contains 14 chapters covering both World Wars and the Korea and Vietnam conflicts, written predominantly by Australian historians and military medical and nursing personnel. There are four chapters on World War I. American historian Jay Winter expounds on shell shock syndrome. Ashley Ekins, head of the Military History Section at the AWM, discusses self-inflicted wounds. Kerry Neale, from the Australian Defence Force Academy (ADFA), provides an excellent narrative on the facially disfigured soldier. Melbourne historian Marina Larsson takes a sensitive look at the psychiatrically impaired veteran. There are similar contributions on World War II. Paul Weindling, a professor in the history of medicine at Oxford Brookes University in the United Kingdom, describes the “medical” experiments at Ravensbrück concentration camp. Debbie Lackerstein, a lecturer in history at ADFA, writes of the overwhelmed Allied forces’ medical response to survivors of concentration camps. Professor Simon Gandevia, deputy director of the Prince of Wales Medical Research Institute in Sydney, gives an account of his father’s service in Korea and his contribution to medical history. The essays on the Vietnam War cover a regimental medical officer’s experience in managing sexually transmitted infections, the work of the Australian civilian surgical teams, and Agent Orange. The book concludes with three personal accounts: Tony White on the nightmare of treating injured soldiers in a minefield; nurse Sharon Cooper on medical recovery after a helicopter crash in Timor-Leste; and Graham Edwards on how, after sustaining double lower limb amputations, he overcame severe disability to enter federal Parliament. I recommend this book to those working in military medicine, to military medical historians, to present and past serving members and their families, and to the enquiring general reader.

Bruce H Short