foundation chair in hygiene. At the outbreak of Women and she took an active part in the agitation the American Civil War she organised the National against the contagious disease acts, a nasty piece of Sanitary Aid Institute and chaired a registration com- Victorian legislation which permitted the detention mittee for the training and deployment of nurses. and forcible examination of women suspected of having venereal disease. Although Elizabeth remained single throughout her BMJ: first published as 10.1136/bmj.303.6817.1583 on 21 December 1991. Downloaded from life, she adopted a 7 year old orphan.* When Elizabeth Elizabeth Blackwell lived on to see many other thought that her various American enterprises were women follow in her footsteps. By 1889 there were able to fend for themselves she settled in the south of 3000 registered women doctors in the United States, England in Hastings. In 1875 she became professor of and today thousands of women doctors graduate gynaecology at the School of Medicine for worldwide each year. Elizabeth continued writing throughout her life and visited America for the *Kitty Barry lived with and helped "Auntie" Blackwell through- in out her long life. She returned to America in 1920 and died in last time in 1906. She died in Hastings 1910 aged 1936. 89.

Death ofa heart surgeont reflections on press accounts ofthe murder ofVictor Chang

Deborah Lupton, Simon Chapman

On 4 July 1991 's most prominent heart Events are considered newsworthy if they concern , Dr Victor Chang, was murdered in a bungled elite persons or nations, are dramatic, can be person- extortion attempt by gunmen in a suburban street of alised, have negative consequences, and are part of an . The murder generated massive news coverage, existing newsworthy theme.' Chang's murder fulfilled far in excess of that accorded to any ordinary murder. all these characteristics. As a heart surgeon he was a For days almost all the Australian media ran lengthy member of an elite occupation that enjoys one of the lead stories on the killing, on Chang and his work, on highest social standings in Australian society. His those who mourned him, on speculation about his death was 'highly dramatic, involving elements of murderers, and on their eventual arrest. Aspects of tragedy (the sudden and violent death of a kind and Chang's work had long attracted wide publicity, giving brilliant man capable of saving other's lives), of a him great prominence in Australian public life. His mystery (who were his killers, what was their motive?), murder was thus not just the murder ofa man or ofany and suspense (when were the murderers going to doctor, but the murder ofa very public medical figure. be apprehended?). Because Chang had a wife and Victor Chang-portrayed as a Chief among the themes which dominated Chang's children, as well as many colleagues and patients who secular saint public profile were his work with transplantation and liked and respected him, his death could also be artificial hearts. The identity of some of Chang's portrayed in personal terms. His death had negative patients and their medical problems, recovery, and consequences because it robbed Australia of an experi- gratitude to him had been widely publicised. Some, enced, successful, and innovative heart surgeon who including politicians and media baron , could save lives; his work developing an artificial hearthttp://www.bmj.com/ already had public identities-their status as Chang's was cut short. Finally, the story could be slotted into patients simply added another layer to their public several wider newsworthy themes: the heroism ofheart personae. Such publicity positioned Chang as the surgery, the tragedy of violent crime directed against surgeon chosen by Australia's richest and most famous. innocent individuals, the sudden death of a loving Others, like teenage heart transplant recipient Fiona husband and father, and the success story of the rise to Coote, became national celebrities as a consequence of prominence, wealth, and social standing of an Asian being treated by Chang. Background articles that immigrant who arrived in Australia as a youth with a accompanied the news stories of his death and its poor command of English and achieved rags to riches on 26 September 2021 by guest. Protected copyright. sequelae concentrated much ofthis public profile. success in a strongly egalitarian society. All of these themes can bear more detailed analysis. We have chosen to explore the first, the heroic nature Chang's death as news of heart surgery, in greater detail, discussing the What was it about the combination of Victor Chang manner in which the popular press "made sense" of Centre for Applied Social the man, his background, his work, his patients, and Chang's murder and placed it on the cultural map of Research, School of the circumstances of his murder that the Australian meaning as an obvious news story. Little is random in Behavioural Sciences, media instantly identified as a major story? This paper the process whereby particular events are deemed by Macquarie University, examines in detail the press reportage of Chang's cultures to be newsworthy and to traverse North Ryde, New South journalistic Wales, Australia murder. The manifest content of the reportage was the pathway from arcane, behind the scenes scientific Deborah Lupton, MPH, "the murder of a heart surgeon," but, as we will or medical event to publicised media release and on to senior research officer show, the rhetorical devices employed to depict and selection, headlining, and publishing or broadcast by editorialise Chang's death were redolent with symbolic the media. A vast literature about media analysis Department ofCommunity imagery and subtextual meanings. Examination of contends that the way in which phenomena are both Medicine, University of these devices reveals much about wider ideologies selected and represented in the mass media facilitates Sydney, Westmead concerning the social importance of doctors (par- the reproduction ofcertain ideologies that serve various Hospital, Westmead, New ticularly ), medical technology (especially interest groups. We have adopted this approach to South Wales organs), the body as massive Simnon Chapman, PHD, senior transplantation and artificial understand why Chang's death received the lecturer machine, and the heart as an elite and highly symbolic media attention it did. organ. The huge media interest in Chang's m-urder Correspondence to: presents an opportunity to examine the processes by Dr Chapman. which such ideologies are reproduced in popular Doctors as heroes in the media culture and an opportunity to reflect on the interests In Australia doctors enjoy the highest social status, BMJ 1991;303:1583-6 which they both serve and, as a corollary, deny. although media reports of overservicing, doctors'

BMJ VOLUME 303 21-28 DECEMBER 1991 1583 strikes, and medical fraud have tarnished this image Such rhetoric is evidence of the exalted status of somewhat of late.2 The image of the family doctor as a heart surgery in modern Western society. Heart crusty yet benevolent middle aged man who is a pillar of surgery is commonly presented as heroic, dramatic, society predominates in the popular culture. The life saving, miraculous. It is probably the most revered casting of Dr Sharp senior in the high rating Australian form of medical endeavour, for its results seem so soap GP is clearly drawn from such an archetype. dramatic for those who are certain of death. It appears BMJ: first published as 10.1136/bmj.303.6817.1583 on 21 December 1991. Downloaded from Both the popular media and pharmaceutical adver- to offer them another "lease of life." tising have been instrumental in perpetuating this image of doctors for the population at large and reflecting it to doctors themselves.`8 Often in drug advertisements "physicians are depicted looming large How the St Vincent's team worked: in the background of a patient's life ... symbolically heartbeat that moved mountains: protecting or encompassing the patient." and by their insiders could feel the magnetism placement in photographs, "physicians' status and In the early days of the surgical gown he had worn to authority are affirmed. They are usually positioned heart transplant team there the theatre. All the surgeons higher in the photograph than others, high physical was always a kind ofelectricity were excited. There was a at the weekly meetings when- feeling of high drama which place symbolising high social place."I Many drug ever the surgeons had come was explained as Dr Chang advertisements are oriented to technology, with straight from an operation. It went through the events of physicians shown as "manipulators of technology came from Victor Chang. The the early morning hours, charge he felt after a trans- including the mid-operation behind the scenes.... The tendency is to show plant would excite the room crisis when Scott's heart brightly-coloured, high-tech imagery, such as of 30 or more people. Victor stopped beating. The surgical "I Chang endured 12 hour shifts team brought him back to life, computer simulations. with enthusiasm and tireless and eventually a complete Doctors in American television dramas are portrayed energy.... The morning of recovery. That was the as successful, benevolent, knowledgeable, and 10 year old Scott Campbell's mission at the core of Victor operation in September 1984, Chang's life. To use his skills authoritative, with almost mystical power to dominate DrChangcame to the meeting to restore as many people as and control the lives of others.3 They are commonly full of energy but looking possible to health. He said its depicted as miracle workers, able to solve all patients' tired and blood-stained. He job satisfaction was unbeat- problems and transform their lives,6 or as "Lone was still wearing the green able. Ranger" or "Superman" figures, able to restore order (Sydney Sunday Telegraph, 7 July 1991) and justice from chaos.9 Australian press reports of the death of Victor Chang presented images of doctors which conform to these stereotypes. In this editorial hyperbole such as "heartbeat that moved mountains," the couching of the heart surgery procedure in a dramatic, breathless style, the use of Chang as humble saviour such words as electricity, charge, energy, high drama, One of the dominant themes in accounts of the crisis, and mission give a sense of urgency and murder was the portrayal of Chang as a hero, saviour, excitement. saint, lifesaver, able to bring people back to life from Personalisation was another stylistic device whereby death. Despite his wealth and status Chang was press accounts reproduced the figure of Chang as portrayed as caring, unassuming, and hard working. saviour and hero. Reports likened his death to that of John F Kennedy (Sydney MorningHerald, 5 July 1991). Articles referred

constantly to his brilliance and great talent. Headlines http://www.bmj.com/ spoke of"A genius, a saint and a father" (Australian, 11 Patients stunned by brutal waste July 1991), "An energetic man of vision" (Melbourne Geoffrey Monk's heart saved Mr Monk's life.... Mr Age, 5 July 1991), "A humble man full of ideas" condition left him only two Monk could not believe weeks to live in 1984. But Dr yesterday that the man who (Australian, 5 July 1991), "A brilliant giver of life" Victor Chang gave him a new twice saved his life was dead. (Sydney Morning Herald, 5 July 1991), "A man in a heart and a new life. It was the "Australia has lost one of its million" (Sydney Daily Telegraph Mirror, 5 July 1991), second time Dr Chang had greatest," he said. "Dynamic and a multimillionaire-a born optimist (Sydney Morning Herald, 5 July 1991)

who was living a medical dream" (Sydney Sunday on 26 September 2021 by guest. Protected copyright. Telegraph, 7 July 1991). Chang's murderers were said to have "robbed others" of life and Australia of one of Another story was accompanied by a photograph of its finest researchers, and "the nation" was said to be Chang in the operating room wearing a surgeon's grieving about his untimely death; "Nation mourns gown, with a large theatre light like a halo above his Victor Chang" (Sydney Morning Herald, 5 July 1991). head. The following editorials are illustrative. The first uses the words rare talent, elite, ability to give new meaning, international, brink ofperfecting, and dream Patients mourn a friend and saviour -all of which connote importance and an almost messianic quality and support the image ofChang as no Dr Chang's most famous plants. Now 21, she has heart transplant patient, Ms become the most obvious ordinary man. Fiona Coote, was still trying symbol of Dr Chang's suc- to come to terms with his cess, going on to become death last night. "I can't grasp a model and television per- the world of a rare talent it. It's just so senseless. He sonality. "Victor was not only Death robs never hurt anyone...." my doctor but my friend, and The death of Dr Victor modern man.... From dawn Ms Coote was only 14 and I just can't believe that Chang has robbed a world to dark and beyond he toiled critically ill when she had anyone would want to harm far wider than Australia of not just with his patients the first of two heart trans- him," she said. a man of rare talent. He at St Vincent's Hospital but (Australian, 5 July 1991) was a member of an elite in his research and develop- company of international ment work. He was on the surgeons with the ability to brinik of perfecting an arti- extend and give new meaning ficial heart, a dream of many The assertion in these reports, reminiscent of Biblical to lives threatened and dis- brought close to reality by was that torted by cardiovascular the ceaseless, questing talent parables of the miracles performed by Christ, disease, the scourge of of Victor Chang. without Chang these people would have died long ago. (Sydney Daily Telegraph Mirror, 5 July 1991) He was their saviour, and it is a tragic irony that he himself is now dead. Importantly, those who did not

1584 BMJ VOLUME 303 21-28 DECEMBER 1991 survive a heart or lung transplant-Chang's "failures" rather than to alter social institutions or people's -received no mention in the press. behaviour. Within clinical medicine the specialties of brain and What sort of ideologies are reproduced or per- heart surgery rule supreme as the elite of medical petuated by these press accounts ofthe Chang murder? endeavours, a value that is reflected in Although overtly- referring to the death of a popular culture. surgeon, BMJ: first published as 10.1136/bmj.303.6817.1583 on 21 December 1991. Downloaded from A bright child's parents jest that he or she will grow up these press reports provide a vehicle for the public to be a heart or brain surgeon. The reasons for the demonstration of modern society's reverence towards elevated status of heart surgery can be traced to two medical technology and surgery. Chang's personal dominant ideologies. The first venerates high tech- qualities-his capacity for hard work, his charming nology; the second concerns the symbolic status of the nature and caring attitude to his patients-although heart as a body organ. laudatory, were not alone the stuff of saints. It was Why is biotechnology so revered? Part of its status Chang's work as a heart surgeon that elevated him may be due to the symbolic mastery over the forces of to such a position-his dramatic ability to bestow nature that technology seems to promise.2 Medical miraculous recoveries on desperately ill and often technology symbolises human mastery over mortality named people, to provide them with a tangible solution and is based upon centuries old notions ofthe body as a to a life threatening condition. Heart surgery provides machine with replaceable parts. "High technology the promise of the chance of cheating mortality, albeit comes the closest ofanything in our secularised society temporarily. to being consistently vested in the mantle of the sacred and imbued with its mystique."9 Heart surgery is especially conducive to this imagery; the heart is often Secular saint conceptualisedinmechanistic terms; it"pumps"blood; To place these contentions in context, it is instruc- it has "tubes" and "valves" that may become blocked, tive to consider what the press reaction to the murder and "chambers"; it "fails." When the body is con- of a leading preventive health practitioner might have ceptualised as a machine, the use of transplants is seen been. It is unlikely that the murder of a pioneer of car as a logical step: if a part is worn out then it might well safety engineering, highway design, or enviromental be replaced with a new one. sanitation, or of someone who influenced the shaping The heart is a particularly important organ in offood laws or tobacco control legislation would-even Western nythology, symbolising the seat of the if the individuals had the personal and biographical emotions, distinguishing humanity from the beasts. attributes of Chang-occasion the glowing tributes of Campaigns such as Heart Health Week exemplify the sainthood and miracle worker bestowed upon Chang, degree to which the heart is seen as an organ apart, not nor that such individuals' deaths would be portrayed in related to other systems of organs but an entity unto the press as national tragedies. itself. Heart disease differs symbolically from other The reason for this is simple. In the face of the diseases: unlike wasting diseases like cancer, it is often miracles wrought by heart surgeons, preventive health popularly viewed as a "positive" disease, the outcome is a poor cousin. Exhortions to the public to avoid heart of heroic achievement and able to be beaten by heroic disease by exercise, avoiding smoking, and make determination.9 10 The prominence given to the heart dietary changes are banal, dull, often depersonalised, attack of media mogul Kerry Packer epitomised the and frequently tinged with moralism and puritanism. popular concept ofthe successful and driven executive Success in prevention is defined in terms ofan absence, at risk from heart disease, despite the inverse class bias of something not happening. Prevention offers few ofheart disease in most Western societies. dramatic scenarios to the media: its huge successes (such as the dramatic reductions in road deaths, http://www.bmj.com/ immunisation at school entry, tobacco advertising Press fanfare bans, increased cervical smear rates) often do not reap The combination ofthese two ideologies has resulted changes in health status for decades. By contrast, in developments in heart surgery being portrayed in success in clinical medicine is resplendent with the press with fanfare, but its ultimate efficacy or cost dramatic elements. After treatment, patients with effectiveness has been questioned little."' 12 The biographies, families, and loved ones move from ill depiction of such innovations has taken on an arche- health to something better. Pain is relieved, bleeding typal format: stops, the sick rise from their beds, the lame walk, the on 26 September 2021 by guest. Protected copyright. blind see, frowns turn to smiles. Prevention can Journalists regularly clone the heart transplant story, wait; treatment cannot. Treatment always relates to producing perfect replicas ofprevious reports. They stress the identifiable individuals, preventive policies are desperation ofthose waiting for a heart, and the fear that time anonymous. will run out. The fatal alernative is made plain. The operation Chang was portrayed as a saint because he is the is depicted as offering the Chance of a new life or future, an nearest secular society has to such a thing. He saved a opportunity to vanquish death. Grief and joy are voiced, and the press conference following the operation is an aria of tiny number of lives in a highly dramatic fashion, hope.... Transplant reporting is also almost invariably ofthe compared with the less obvious results of preventive "milestones in medicine" kind. It mobilises the drama of health endeavours. The Australian National Heart flight.... Above all, medical skill is hymned.... [Heart Foundation estimates that between 1968 and 1988 the surgeons] are medical alchemists, offering the ultimate falling death rate from heart disease in Australia medical cure."' "saved" 115 144 lives.'4 Analysis ofthe dramatic decline in deaths from coronary heart disease in the United Similarly, illness- as portrayed in television dramas States between 1968 and 1976 attributes 54% of the tends to be acute, rather than chronic, requiring decline to lifestyle changes (principally reduction in immediate action and biomedical technology."3 The smoking and blood cholesterol levels) and only 3 5% to Australian press is no exception to this model. Victor coronary artery bypass surgery.'5 In such a context the Chang's murder provided a good source ofnewsworthy emphasis ofthe press on the use ofhigh technology and material, in which notions concerning the importance surgery to "cure" heart disease arguably negates or of heart surgery and transplant technology were severely detracts from the messages of public health. Because ofthe heart's symbolic trumpeted;unquestioningly. The very language used in Holding out heart surgery in such glowing terms as status, heart attacks ofmedia moguls such as KerryPacker describing heart transplants and artificial heart the solution to heart disease can only damage the epitomise the popular concept of technology in public discourse shows the preference of imperatives ofpreventive health. What need is there to the successful executive at risk our society to develop remedies based on technology give up smoking or take up exercise if one's heart can

BMJ VOLUME 303 21-28 DECEMBER 1991 '1585 simply be replaced by a better one? Why live a 5 Turow J. Playing doctor: television, stotytelling and medical power. New York: Oxford University Press, 1989. parsimonious and careful life if the miracle of medical 6 Gerbner G, Gross L, Morgan M, Signorrielli N. Health and medicine on technology provides an alternative? television. NEnglJMed 1981;305:901-4. 7 Krautzler NJ. Media images of physicians and nurses in the United States. Technology steps in after the damage has been done, Soc Sci Med 1986;22:933-52.

at a far greater cost to society but at much more 8 Karpf A. Doctoring ihe media: the reporting of health and medicine. London: BMJ: first published as 10.1136/bmj.303.6817.1583 on 21 December 1991. Downloaded from dramatic level. As long as these values are held in our Routledge, 1988. 9 Stein HF. American medicine as culture. Colorado: Westview, 1990. society, as long as popular culture continues both to 10 Helman C. Heart disease and the cultural construction of time: the type A reflect and to reproduce these values, public health behaviour pattern as a western culture-bound syndrome. Soc Sci Med 1987;25:%9-79. practitioners will be seen as spoilsports, not saints. 11 Pfund N, Hofstader L. Biomedical innovation and the press. Journal of Communication 1981;31: 138-54. 12 Hall JP, Heler RF, Dobson AJ, Lloyd DM, Sanson-Fisher RW, Leeder SR. 1 Galtang J, Rougue M. Structuring and selecting news. In: Cohen S, Young Y, A cost-effectiveness analysis of alternative strategies from the prevention of eds. The manufacture of news: social problems, deviance and mass media. heart disease. MedjAust 1988;148:273-7. London: Constable, 1973:62-72. 13 Turow J, Coe L. Curing television's ills: the portrayal ofhealth care.Joumalof 2 Bates E, Lapsley H. The health machine: the impact of medical technology. Communication i986;35:36-51. Ringwood- Penguin, 1985. 14 National Hpart Foundation. Heart facts report. Canberra: National Heart 3 McLaughlin J. The doctor shows.Journal ofCommunication 1975;25:182-4. Foundation, 1988:13. 4 Chapman S. Advertising and psychotropic drugs: the place of myth in 15 Goldman L, Cook EF. An analysis of the comparative effects of medical ideological reproduction. Soc Sci Med 1979;13A:751-64. - interventions and changes in lifestyle. Ann Intern Med 1984;101:825-36.

Changing the hideous face ofwar

B J S Grogono

Besides the thousands killed in war, millions are Auguste Valadier, a dental specialist to the officers of crippled or hideously deformed. During the first world the imperial staff, who repaired jaw defects by using war the British army developed improved medical tissue, such as bone, from other parts of the body. services to cope with the enormous number of casual- Gillies and Valadier operated together, and it was this ties from the incessant bombardments and furore of baptism into the realm of faciomaxillary injuries that trench warfare. Under the guidance of Sir Robert inspired Gillies. He was lent a book on these injuries Jones'2 a comprehensive management of injuries was written by a German surgeon, Lindeman; he visited established. After initial treatment in the field clearing Hippolyte Morestin, the most famous plastic surgeon station the wounded soldier was transferred to a base in Europe; and he persuaded the medical authorities of hospital for more definitive care and the extent of his the need for special centres for treating faciomaxillary injuries was assessed. He was then sent back to injuries. The authorities included Sir Alfred Keogh, "blighty," where he received skilled treatment, finally director general of the army medical services, and arriving at a rehabilitation hospital. The centre at Sir William Arbuthnot Lane, one of the most distin- Shepherd's Bush, London, managed severe skeletal guished surgeons in England. injuries, nerve lesions, and orthopaedic problems; Within a year the Cambridge Hospital at Aldershot hand injuries and amputation received special atten- was opened and Gillies was assigned special duties as tion. A young army doctor, Harold Delf Gillies, saw plastic surgeon. So that soldiers with facial injurieshttp://www.bmj.com/ that specialised management of facial and maxillary were sent to ' Is new unit Gillies bought £10 worth of injuries was needed. He was a New Zealander who had labels sayin, "Faciomaxillary injury-Cambridge specialised in ear, nose, and throat surgery and could Hospital, Aldershot" and sent them to the field see the urgent need to segregate the soldiers with these hospitals in France to be pinned to the casualty's chest. wounds from the rest of the casualties.3 In January 1916 the first naval casualties arrived, The young captain Gillies was not familiar with the followed shortly afterwards by 2000 injured soldiers classic work ofTagliocozzi,4 who had described the use from the battle of the Somme. Day after day, night

of pedicle grafts for the repair of amputated noses in after night they came with half their faces or jaws shot on 26 September 2021 by guest. Protected copyright. the sixteenth century, but he did encounter Charles away. Suffocation, sepsis, gangrene, and haemorrhage

Halifax, Nova Scotia, Canada B3H 1G3 B J S Grogono, FRCS, retired orthopaedic surgeon 4 Correspondence to: Mr B J S Grogono, 5854 Gorsebrook Ave, Halifax, Nova Scotia, Canada B3H 1G3. (Left)MajorHD Gillies as a medicalofficer, workingwith theRed Cross, 1915; (right)SirHarold Gillies teaching at Rooksdown House, 1944. BMJ 1991;303:1586-8 Photographer unknown;from R Pound, "Gillies, surgeon extraordinary."I

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