Volume 41 No. 1 June 2015

The Adler Museum of Medicine was founded in 1962and was situated in the grounds of the South AfricanInstitute for Medical Research, Johannesburg. It isnow housed at the University of the Witwatersrand’sMedical School Campus in Parktown, Johannesburg.

In June 1974 the Museum’s co-founders, Drs Cyriland Esther Adler, presented the Museum to theUniversity of the Witwatersrand which named it theAdler Museum as a token of the esteem in which thefounders were held by the University. In addition, theUniversity bestowed the degree of Doctor of Laws(honoris causa) upon Dr Adler and the degree ofDoctor of Philosophy (honoris causa) upon MrsEsther Adler. Until Esther Adler’s death in 1982 shewas the Museum’s Honorary Curator while CyrilAdler acted as Honorary Director of the Museum.From 1982 Dr Cyril Adler was appointed by theUniversity as Director/Curator of the Adler Museum,a post he held until his death in 1988.

1975 saw the inception of the Adler MuseumBulletin, the brainchild of Mrs Rose Meltzer. MrsMeltzer produced the first edition single-handedlyand she continued to edit it until her retirement in1991 and was editorial consultant until her death in1992.

The Museum contains interesting and invaluablecollections depicting the history of medicine,dentistry, optometry and pharmacy through theages. Items of medical historical interest on displayinclude microscopes and other scientific instruments,early bleeding and cupping equipment with anexquisitely crafted incision knife, ceramic pharmacyjars dating back to the 17th century, a collection ofbone china and ceramic feeding cups, some datingfrom the 18th and 19th centuries, an early 19th centurywooden handled amputation set in a wooden case,diagnostic and surgical instruments, treatmentapparatus such as one advertised as ‘Patent magneticelectrical machine for nervous diseases’ used byQueen Victoria to ease her rheumatism (19th century)and the first electrocardiograph machine (1917) used

in the Johannesburg General Hospital, the originalartificial kidney machine used in South Africa, earlyanaesthetic apparatus, ear trumpets and brass earsyringes (early 20th century), hospital and nursingequipment and medical ephemera.

There are reconstructions of an African herb shop, apatient consulting a sangoma (traditional healer),and a 20th century Johannesburg pharmacy, adoctor’s consulting room, a dental surgery, anoperating theatre and an optometry display of thesame period. A history of scientific medicine isaugmented with displays of several alternativemodalities. Other attractions range from areconstruction of a patient being treated by thefamous Persian physician Avicenna to an exhibitionof early electro-medical equipment, and a collectionof rare iron lungs.

A showcase containing new acquisitions to thecollection is constantly changed as donations arereceived. The objects displayed provide an insightinto the range and diversity of the collection.

In the foyer outside the Museum are panels relatingto the history of the Cradle of Humankind(Sterkfontein and environs) and a display of replicasfrom the site give visitors a fascinating glimpse intothis world heritage site.

The Museum has a rare book collection and asignificant history of health sciences reference library.An archive arranged by subject matter is housed inthe library. Biographical information relating tothousands of medical and allied health professionalsis available for research purposes which includesphotographs, notebooks, academic certificates,records, personal papers and memorabilia ofprominent health professionals and academics.

The Museum arranges public lectures, tours,temporary exhibitions and provides excellentfacilities for health sciences historical teaching andresearch.

Adler Museum of MedicineFaculty of Health Sciences, University of the Witwatersrand, Johannesburg

Opinions expressed in this publication are those of the authors concerned and do not necessarily reflect the views of the Editors, the Editorial Board or the Board of Control of the Adler Museum of Medicine.

Application forms for membership of the Adler Museum of Medicine can be obtained from the Curator, Adler Museum of Medicine, 7 York Road, Parktown, 2193. Telephone and fax: (+11) 717 2081.

Visit the Museum on the Internet: www.http://health.wits.ac.za/adlermuseum

Contributions © the authors. All rights reserved. The contents of this publication may not be reproduced in any form in part or in full without the consent of the Editors or the prior permission of the author(s) concerned.

ISSN 0379-6531

BOARD OF CONTROL

The Board of the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, has

appointed the following members to serve on the Board of Control:

Faculty of Health Sciences ________________________ Adjunct Professor Lionel Green-Thompson

Department of Anatomical Sciences _______________ Mr Brendon Billings

Health Graduates’ Association ____________________ Dr Paul Davis

Arts, Heritage and Culture, Ekurhuleni Municipality _ Ms Alba Letts

Health Services, City of Johannesburg _____________ Dr Refik Bismilla

Medical Students’ Council ________________________ Mr Thabo Leonard Muhango

Other members __________________________________ Dr Catherine Burns

Associate Professor Sekibakiba Peter Lekgoathi

Dr Ann Wanless

STAFF MEMBERS

Curator _________________________________________ Mr Luvuyo Dondolo

Professional Officer _______________________________ Ms Cheryl-Anne Zillmann

Professional Officer (Collections) __________________ Mr David Sekgwele

Museum Attendant ______________________________ Mr Gilbert Singo

ADLER MUSEUM BULLETIN

7 York Road, Parktown, 2193

Editors

Professor JI Phillips BSc (Hons), PhD (Leeds)

Rochelle Keene BA (Hons)(Witwatersrand)

Email

Adler.museum@wits.ac.za

Adler Museum of MedicineFaculty of Health Sciences

Editorial ____________________________________________________________________________ 1Professor Jim Phillips

The illness of Crown Prince Frederick III _______________________________________________ 3Dr Peter Warren

My contribution to the development of paediatric cardiology and echocardiography _____ 11Professor Norman Henry Silverman

Reflections on a career in academic paediatrics ________________________________________ 21Professsor Denis Daneman

From the Curator’s Desk: Change and continuity ______________________________________ 28Luvuyo Dondolo

Book review: Seen with other eyes by Erika Sutter ______________________________________ 35Reviewed by Dr Nicky Welsh

Letter to the Editors: Dr Ronald Ingle _________________________________________________ 37

Guidelines for authors _______________________________________________________________ 38

Contents

Forty years on …

Professor Jim Phillips

Editorial

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From 1974 to 1998, the large and interestingcollection of medical artefacts assembled byCyril and Esther Adler was displayed in theDirector’s House on the premises of the SouthAfrican Institute for Medical Research inBraamfontein. The Adler Museum ofMedicine was officially handed over to Witsin 1974 when both Adlers received honorarydegrees from Wits in recognition of the gift ofthis important historical collection. Thename of the museum was changed to theAdler Museum of the History of Medicine inhonour of the Adlers.

In 1975 Mrs Rose Meltzer produced andedited the first Adler Museum Bulletin, thepurpose of which was to showcase themuseum and to raise the academic andpublic profile of the study of the history ofmedicine.

Mrs Meltzer continued as the editor of theBulletin until 1992 and was assisted by MrsAdele Kahn who was co-editor from 1978 to1986; and Mrs Pearl Benatera who washonorary assistant editor from 1987 to 1989. In1992 Professor Donald George Moyes becamethe editor until 1995, succeeded by ProfessorAsher Dubb in 1996 until 2004. From 2005 to2014 Professor JCA (Tony) Davies became theco-editor. The Curator of the Museum, MsRochelle Keene, served as co-editor of theBulletin from 2004 to 2014.

Professor Davies’ first editorial in 2005 markedthe 30 year anniversary of the Bulletin. Fromthe time he became co-editor, until hisretirement in February 2015, he wrote 18editorials, 5 articles and 3 book reviews.

In 1998, the Adler Museum in Braamfonteinclosed and reopened in 2002 in the foyer ofthe Medical School of the University of theWitwatersrand Parkton Campus. During thistime the production of the Adler MuseumBulletin continued uninterrupted and thisissue marks its 40th anniversary.

After ten years of editing the Bulletin, it isappropriate to take a very brief look atProfessor Davies’ career. Although he was bornin 1931 in Scotland, he was brought up andeducated in Johannesburg. He left St John’sCollege to train as a medical doctor in London,obtaining his MB BS at Guy’s Hospital. Hespent another two years at Preston HallHospital working with chest surgeons andlearning a lot about tuberculosis. In 1959 hejoined the Central African Federal MedicalService in what was then Rhodesia and wasassigned to a hospital in Mpilo, Bulawayo.Later, at an outstation at Shangani, he sawmany patients with tuberculosis. He acceptedan offer to become the first tuberculosis officerin the country. His tuberculosis eradicationcampaign was a great success with a networkof 67 clinics throughout the Midlandsprovince. Professor Davies returned to Londonon a WHO Fellowship to do a Diploma inPublic Health at the London School of Hygieneand Tropical Medicine. He returned toSalisbury (now Harare) to work in the CityHealth Department. Eight years later hemoved to Wits with a joint post as Director forthe National Centre for Occupational Health.In 1996 Professor Davies retired but continuedto work at the NCOH, which became theNIOH, for 19 years. His work at the NIOH waspro deo. His ‘grace and favour’ office at the

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NIOH allowed him to continue his work ondiseases associated with the mining industry.He was a worker advocate throughout hiscareer and beyond and had a particularinterest in the health of workers and chestdisease. His work brought him into conflictwith big business and he has been involved inseveral legal cases. In addition to medico-legalwork for the police in Zimbabwe, he gaveevidence in cases against a fertilizer factory, abone meal factory, a mercury plant andasbestos mining companies. The result of theseasbestos mining cases was the establishmentof trust funds worth millions of rands to assistasbestos workers and their dependants.Professor Davies states with confidence thatindustry will continue to lose court cases solong as they have money and lawyers but nomeasurements.

After a long and significant career inmedicine, Professor Davies, together with hiswife Deirdre, has finally retired to Kenton-on-Sea on the Eastern Cape coast. We wish themhappiness in their well-earned retirement.

As far as we are aware, the Adler MuseumBulletin is the only journal devoted to thestudy of medical history on the Africancontinent. Through the museum’s web siterequests for articles are received fromscholars of medical history from around theworld. The Bulletin was recently listed on theResearchGate portal and has already had405 profile views and 53 publicationdownloads. Interestingly, seven of thesedownloads were the last week of May 2015.

In addition to being a scholarly resource, theBulletin has become an important vehiclethrough which Wits Alumni are given space topublish their autobiographies. It was in fact inthe June 2005 Bulletin (31[1] June 2005) thatthe editorial stated: ‘One of the functions ofthis Bulletin as we see it is to record theimmense contribution that the Faculty ofHealth Sciences and this Medical School has

made, through its graduates and alumni,locally and internationally.’ In an editorial inDecember of the same year (31[2]: December2005) Professor Davies wrote: ‘Many SouthAfricans [have] made contributions of globalsignificance and only they can tell us howthese came about – how much was chance,how much a long hard slog or how much wasdue to the welding together of a productiveteam with common interests. It is our intentionto seek out and publish these stories in orderto ensure that as much of this history isrecorded and preserved.’ The editorial went onto list many of the contributions received andsolicited and ended: ‘[We] would welcome[readers’] suggestions for future articles, orbetter still, a contribution written frankly andwithout (false) modesty.’

In this issue two distinguished Wits graduatesgive accounts of their careers and theircontributions to the discipline of paediatricmedicine. Norman Silverman and DenisDaneman have made significantcontributions to the study and practise ofpaediatric echocardiography and diabetesrespectively. Both had careers in paediatricdisease and both were descendants ofimmigrants. Currently there is much debatearound the subject of immigration into SouthAfrica the two biographies are testimony tothe positive aspects of immigration. Theyboth attest to the excellent training theyreceived at Wits Medical School and bothhave recalled many of their teachers withgreat respect and admiration.

Scholars of the history of medicine will notneed reminding of how illness can changethe course of history. The fascinating story ofFredrick III, Crown Prince of the GermanEmpire, is told with insight by another oldWitsie, Peter Warren, an ear, nose and throatsurgeon in Durban. Had Frederick notsuccumbed to cancer of the larynx, thecourse of history may have beenfundamentally changed.

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The story of Morell Mackenzie and his famouspatient, the most celebrated case of laryngealcarcinoma in the history of otorhinolaryngology,is of great interest from both a historical and amedical perspective. The lessons derived byreviewing the events are still applicable today.

In the history of mankind, there are manyexamples of a single event which changed thecourse of history. This illness was one such event:it was a real life drama in which the variouscharacters created huge controversy which sentshock waves through Europe in the late 1880s andwhich to this day is still being felt. Medicalpractitioners find the saga interesting in the lightof medical practice today: doctors under stress(typically the result of factors such asinterpersonal conflict with colleagues, adverseoutcomes in management of a special patient,public exposure in a negative light), the mediawhich is increasingly hostile to doctors andexternal interference from politicians and othercontrolling groups. Little has changed in ahundred years.

THE PHYSICIAN

Morell Mackenzie underwent medical training inthe middle of what is generally recognised as thegolden age of medicine. That was a time lasting alittle over a decade in the mid-19th century whenthe face of medicine was transformed by severalimportant developments.

Claude Bernard advanced the science ofphysiology. Louis Pasteur and his germ theory ofdisease was probably the century’s greatest gift tomedicine. Rudolf Virchow founded the speciality ofhistopathology and Joseph Lister developed theconcept of antiseptic surgery. Florence Nightingalewas responsible for professionalising nursing.America’s contribution was the introduction ofgeneral anaesthesia which changed the practice ofsurgery. William Green Morton gave the first etheranaesthetic at the Massachusetts General Hospital,16 October 1846.

Another big change in the medical profession atthat time, and one which rescued medicine fromthe hands of charlatans in England, was thepassing of the General Medical Act of 1858. Thisregulated entry into the profession by requiringcompulsory registration of practitioners who hadundergone recognised training and passed aqualifying examination. Morell Mackenzie, havingjust qualified, was one of the first registrations.

This age also saw the birth of the speciality oflaryngology, brought about by the developmentof the laryngoscope as it was known then. Thelaryngeal mirror, as we know it now, was actuallydiscovered by Manuel Garcia, a singing teacher.He had the bright idea of viewing his own vocalchords by means of a dental mirror and describedthe technique of autolaryngoscopy. This wasdescribed in a paper he read to the Royal Society

The Illness of Crown Prince Frederick III

Dr Peter Warren, MBBCh (Witwatersrand), MFGP (SA), MMed (Witwatersrand), FCS (SA)

Ear, nose and throat surgeon, Durban

Sir Morell Mackenzie

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of Medicine in 1855, a technique taken up withenthusiasm by some physicians. They furtherdeveloped the technique to use on their ownpatients, the principle pioneer in this respectbeing Professor Johan Czermak of Budapest.

Morell Mackenzie was the eldest son of a Sussexgeneral practitioner. When his father died afteran accident while doing a house call, he had toleave school at age sixteen, but being extremelybright he completed his studies at night school.He then had the good fortune of having adoting and wealthy aunt who sponsored him tostudy medicine. She also provided funding forhim to undertake two years of postgraduatestudies on the Continent. While in Budapest in1861, he learned the technique of laryngoscopy,acquired the instrumentation and then tookback to London his newly acquired skills. Hebecame one of the first British laryngologists,and went on to become one of the mostdistinguished laryngologists of his generation.He is generally known as the father of Britishlaryngology.

Apart from winning awards and collectingdegrees and qualifications at regular intervals,Mackenzie wrote extensively on his subject. Hissecond book, published in 1871 detailing hisexperience with one hundred cases of laryngeallesions, established him as a foremost authorityon laryngeal neoplasia. His major work, a two-volume text published in 1880, “Manual ofDiseases of the Nose and Throat”, became thedefinitive British work in the speciality until themid-20th century.2 He founded the first hospitalin the world devoted to diseases of the throat atGolden Square in London. This hospital rapidlybecame the centre for diseases of the larynx inEurope. A teaching mecca, it was a model formany such hospitals which later started inEurope and the USA. When Felix Semon (laterto take up the mantle of premier Britishlaryngologist after Mackenzie) visited GoldenSquare as a young graduate, he was amazed atthe wealth of clinical material which farexceeded that of all the departments of Viennaand Berlin put together.3 Mackenziedocumented over a thousand cases of laryngealsyphilis in his first 10 000 patients.

Mackenzie designed a number of instrumentsfor use in the larynx under indirect vision andwas described as a practitioner of breath-takingtechnical ability. He could invariably remove alaryngeal polyp at first attempt: a remarkable

achievement considering cocaine was onlyintroduced as a topical anaesthetic agent in1880.

At the height of his career he had a very largeand thriving private practice in Harley Street,larger than any other specialist in London at thetime. He regularly saw up to sixty patients a day,charging £2 for a new patient and £1 for a repeatvisit. This enabled him to earn up to £15 000 peryear at a time when each pound would buy anequivalent of about £50 today. Income tax in1880 was thruppence per pound.

Mackenzie had been in practice some twenty sixyears and was at the pinnacle of his career when DrJohn Reid, Physician to Queen Victoria, called onhim and requested him to leave immediately forBerlin for an urgent consultation with the Queen’sson-in-law, Frederick William III, Crown Prince ofGermany and Emperor in Waiting, who was hoarse.

THE PATIENT

The dominant political figure in Germany at thetime was Otto von Bismarck. Following theunification of the German States, the GermanEmpire came into being in January 1871 withBismarck as Chancellor and the ageing Wilhelm(William I) as Kaiser or Emperor. Both men weredeeply conservative and ensured an authoritarianmilitaristic German state with all the Prussianvalues of discipline, order and obedience. Bismarck,the “Iron Chancellor”, was very much in control ofGermany’s foreign policy and relations. He stroveto maintain a delicate balance of power in Europeso as to keep Germany strong. Essentially he tried tokeep France isolated by forming alliances withRussia, Austria and Italy, and generallyencouraged Britain to continue pursuing her policyof “splendid isolation”.10

Mackenzie’s laryngeal instruments

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Frederick, William I’s son, was a completelydifferent kettle of fish. A gentle and goodhumoured man, he had a military backgroundand was a very popular figure in Germanyhaving distinguished himself in the unificationwars. However, after spending some time in exilein England, his political character was bothliberal and democratic. He was a great admirer ofGladstone and the Liberal Party.

In 1858 he married Queen Victoria’s eldest andfavourite daughter, Victoria (Vicky). She was saidto exceed him in both intelligence and vigour andwas politically very aware. She certainly had agreat influence on him in all his political andother attitudes. He was due to take over asEmperor from the ageing William and it wasexpected that he would substantially reverse theautocratic Bismarckian system in Germany andcertainly have more amicable relationships withGermany’s neighbours. Importantly, there wasundoubtedly going to be a close union withBritain under his rule.

The only perceptible cloud on this idyllic horizonwas his son William II, known as Willy. Willy forvarious family and personal reasons, developedinto the epitome of the Prussian autocrat so

despised by his parents. Born with a deformed leftarm, which prevented him from having a normalchildhood, his was a lonely and indulged earlylife controlled by authoritarian tutors andgovernors. His relationship with his Englishmother and numerous cousins who teased himunmercifully, was poor. This all clouded his futurepolitical conduct. He grew up into the arrogant,selfish, strutting and self-glorifying young manseen in the portrait done soon after the death ofhis father.

THE ILLNESS

Frederick became hoarse in January 1887. Hispersonal physician, Dr Wegner announced that“the Crown Prince had taken cold and would soonbe restored to health”. There was, however, littleimprovement and in March he called in ProfessorCarl Gerhardt, Professor of Clinical Medicine atBerlin University. He was a general physician withsome skill in indirect laryngoscopy.

Gerhardt managed to see the vocal cords and noteda smooth growth on the left cord. He tried toremove this with some of the primitive instrumentsavailable in Berlin but was unsuccessful. He then

Frederick III (1831-1888)

Carl Gerhardt (1833-1902)

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delivered daily galvanocautery over a fortnight,again using the laryngeal mirror, but improvementin the Crown Prince’s voice was very limited. Thephysicians then prescribed a short period of restand Prince Frederick and Princess Vicky travelled toEmms on the North German coast. From thereVicky wrote to Queen Victoria: “Part of a littlegranula which Prof. Gerhardt could not take offwith the hot wire because the throat was too muchirritated, is still on the surface of one of thestimmbander and will have to be removed whenwe go home. Then I think the hoarseness will quitedisappear”.7

Sadly when the couple returned to Berlin the CrownPrince’s voice was barely more than a whisper. Thedoctors felt that further help should be sought andDr Ernst von Bergmann was called in on Monday16th May. He was a suave and charismatic man, theleading German surgeon of his generation butuntrained in laryngoscopy. On the basis ofGerhardt’s findings, he announced that the growthwas almost certainly cancerous and should beremoved forthwith by a thyrotomy approach.Operating tables and nurses were hired and surgeryarranged for the Saturday at the Palace. Thyrotomy(or laryngofissure) was infrequently practised atthat time for removal of lesions of the larynx.

Von Bergmann claimed that he had himselfundertaken several such operations with successin every case. The other operation performed onthe larynx in the 1880s was of course totallaryngectomy, mostly done for syphilis ortuberculosis, but also for malignant disease.Theodor Bilroth (1829-94), the famous Chief ofSurgery in Vienna, had performed the firstlaryngectomy fourteen years earlier, but it hadfew supporters as the peri-operative mortality ratewas extremely high.

When the suggestion of surgery became known toPrincess Vicky, she was alarmed and demurred. Shewrote to her mother: “The idea of a knife touchinghis dear throat is terrible to me. Of course Fritz is asyet not to know a word about this.” 7 Bismarcksupported her and later wrote in his memoirs: “Thedoctors are determined to make the Crown Princeunconscious and to carry out the removal of thelarynx without having informed him of theirintentions. I raised objections and required that theyshould not proceed without his consent.”9 TheKaiser agreed and on his instructions the proposedoperation was forbidden. Three further opinionswere sought: Fredericks’s personal surgeon, thephysician-in-chief to the German army and a Berlinlaryngologist, Professor Tobold. On Wednesday 18th

May the six German doctors delivered theirconsensus opinion: the growth was malignant andsurgery as recommended should be performed.

The Crown Princess, the Emperor and Bismarckdemanded another consultation. Gerhardt andvon Bergmann thought this was a mere formalityand agreed. The choice fell naturally on “thegreatest living authority on diseases of the throatat that time”, Morell Mackenzie.10 PrincessVictoria was greatly relieved as she consideredEnglish physicians superior to Germanphysicians. This was the result of many factors,including Willy’s birth injury. The Germannewspapers noted with disdain the calling of anEnglish physician to examine the Crown Prince.

Mackenzie arrived on the Friday and having beenfully briefed by the six German doctors, examinedthe throat of Prince Frederick. Whilst he had hissuspicions about the nature of the laryngealgrowth, he declared that in his opinion nooperation, least of all an operation with a highmortality and an uncertain outcome, should beperformed until there was microscopic proof thatthe growth was indeed cancerous. He proposedperforming a biopsy and sending the specimen toVirchow who was at the time resident in Berlin.Ernst von Bergmann (1836-1907)

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The operation was put on hold and on 22nd May inthe presence of all the doctors concerned,Mackenzie cocainised the throat and succeeded ingetting a specimen at his second attempt. Virchowreported that no malignant tissue was found butrequested a larger specimen.

Mackenzie had undertaken the biopsy with borrowedand inferior instruments so he proposed allowing thelarynx to settle while he travelled back to London forhis own instruments before repeating the biopsy. Bynow there were signs of dissension amongst thedoctors with the German doctors getting decidedlydisgruntled about the delay in treatment. A repeatand substantial biopsy was done on 7th June.Virchow’s extensive report was essentially negative,but he did not entirely rule out malignancy. PrincessVictoria and the politicians sided with the morefavourable opinion of Mackenzie, and the operationwas abandoned, much to the chagrin of Gerhardtand von Bergmann. There was now open warfarebetween Mackenzie and the German doctors andGerhardt warned about the consequences of anyfurther delay. Frederick did not seem to have any sayin the decision making and it seems he was kept inignorance as to the true state of affairs by his wifeand his doctors, although just about everyone elseknew what was going on.

As Frederick and Vicky were due to leave soon forQueen Victoria’s golden jubilee celebration of heraccession to the throne, it was decided by all doctorsconcerned that Mackenzie would thereafter be thephysician in charge and monitor the royal throatclosely.

The 50th anniversary celebrations in London werelavish and Fritz and Vicky were very much inevidence as a dashing couple. By now the popularpress in both Britain and Germany were writingdaily about the royal couple and the illness. Publichysteria was whipped up and there was aperception in the British media that the Germandoctors had been unable to adequately manage theillness of the beloved Crown Prince and that he wasonly saved from certain death by the interventionof the distinguished Dr Mackenzie.

On 28th June, in his own offices, Mackenzieremoved what appeared to be all of the remainingtumour and applied galvanocautery. Again thespecimen was sent to Virchow and no malignancywas found.

The royal couple stayed in England for the nextthree months and Mackenzie kept Frederick’s larynx

under close surveillance. His cords appeared normal,his voice returned to normal and during this timeFrederick and Mackenzie became close friends. InSeptember, Queen Victoria knighted Mackenzie forservices to medicine and also for saving the life ofher son-in-law. Mackenzie was now a public andnational figure. Greatly in demand, people wereknown to stand on their chairs in restaurants to geta glimpse of him eating his lunch. In medical circleshowever, Frederick’s management was morecontroversial. Biopsy and histological diagnosis wasnot yet generally accepted and in medical journalsthere was disagreement with his management. EvenMackenzie himself was not optimistic. He wrote to afriend: “I shall not feel safe from anxiety until sixmonths have elapsed since the application ofelectocautery.”1

By October the elderly Kaiser was on his deathbedand Frederick was sent to San Remo on the Italiancoast to recover from a mild cold before returningto Germany and preparing for his accession.While there, his health and airway began todeteriorate and Mackenzie was sent for.

Sketch made by Mackenzie on 5 November 1887,showing a large new growth below the left vocal cord

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Mackenzie examined Frederick on 5th

November and, seeing a sinister subglotticswelling, he realised to his horror that theGerman doctors had been right after all. TheCrown Prince asked: “Is it cancer?” Mackenziereplied: “I am sorry to say sir, it looks verymuch like it, but it is impossible to be certain.”The Prince received this with calmness. After amoment’s silence, he grasped Sir Morell’s handand said: “I have lately been fearing somethingof this sort. I thank you Sir Morell for being sofrank with me.”12 Mackenzie immediatelyrequested more consultations: two eminent andunbiased laryngologists, one from Vienna andthe other from Berlin were chosen and theyconcurred with the diagnosis. Eleven monthsafter his symptoms had begun, the patient wasgiven a say in his management for the firsttime. Frederick was offered the choice of eithertotal laryngectomy or of no treatment, buthaving a tracheostomy if it became necessary.After a time of reflection he chose the latter.Telegrams were sent to the Kaiser and to DrReid for Queen Victoria. The press were alsonotified.

This catapulted the Crown Prince’s illness intothe International press and they descended onSan Remo. Mackenzie would often have a posseof thirty reporters following him around. Liketoday, the press had no regard for personalitiesor the feelings of the people concerned andclaimed that the Royal family were newsworthyitems and that their most intimate affairs wereof public interest.

On 13th November the 91 year old Kaiser,learning of his son’s decision, sent for eight ofthe German doctors who had been looking afterFrederick. He asked them two questions: Shouldthe radical operation be advised in spite ofFrederick’s refusal; and why, when theoperation was abandoned in May, was itsuggested again at such a late stage in theillness? To the first question they answered thatas the operation was so dangerous the patientmust decide and to the second they replied that:“the responsibility for its non-performanceuntil too late had been incurred by thatphysician who had overlooked, nay evendenied, the increase of the growth”, namelyMorell Mackenzie.7 The German press wasfurious. The prince of Germany would diebecause of the mistake of an English doctorwhile the opinion of the German doctors, whohad been correct, was set aside.

Mackenzie remained aloof and countered thecriticism by stating that he had relied on thefindings of the world’s leading pathologist,Virchow, who had found no indication ofmalignancy and predicted a favourable outcome.Virchow of course denied this and stated thatMackenzie had not biopsied the real tumourbelow the cords but rather another benign lesionon the cords. By January Frederick was mostunwell, losing weight and coughing up sloughsof tissue. He spent his days in his dressing room,sucking on ice and wearing ice bags around hisneck day and night. Publically the Royal coupleput on a brave face but privately they were ingreat anguish. To Queen Victoria Frederick wrote:“To think that I should have such a horrid,disgusting illness. I had so hoped to be of use tomy country. Why is heaven so cruel to me? Whathave I done to be thus stricken down andcondemned?”8 Vicky’s pessimism showed whenwriting to a friend: “Who can tell us how muchtime he will still be granted?”7 The press set up amacabre vigil and the world watched withinterest as events unfolded in Germany. Wouldthe elderly emperor, obviously now in decline, diebefore his son suffocated?

On 9th January 1888 Frederick’s airway becameobstructed and the long deferred tracheostomywas performed by a Dr von Bramann,von Bergmann’s assistant in San Remo. Anillustration from a magazine of the periodgraphically depicted the tracheostomy inprogress.

The elderly Kaiser finally died on 9th March andFrederick travelled to Berlin to begin his shortImperial reign. By then he was too sick to attendhis father’s funeral and handed most of his dutiesover to Bismarck. By April the tracheostomy sitewas indurated and surrounded by fungatingtumour.

On 12th April, Frederick was deeply cyanosed andhad stridor which could be heard in the nextroom. Professor von Bergmann changed thetracheostomy tube in the presence of Mackenzie.Frederick had a violent attack of coughing andbled profusely for some time from thetracheostomy. Mackenzie accused von Bergmannof ill-treating the emperor and making a falsepassage in the neck. He did not hesitate to saythat Fritz had received his deathblow at thehands of von Bergmann. This was the partingways for Mackenzie and von Bergmann and on30th April von Bergmann retired from the case.

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Early in June Frederick moved to the Neue Palaiswhere he had been born. By 13th June Frederick’scondition was deteriorating rapidly. He was beingfed by tube and the fungating tumour wascausing an awful smell. Vicky wrote; “My poordarling is so changed! He is a perfect skeletonnow and his fine thick hair is quite thin. His poorthroat is such a painful and shocking sight that Ican often hardly bear to look at it … it is verydifficult to keep the air in the room pure.”7 Twodays later at 11:00 on 15th June 1888, EmperorFrederick died. He was 56 at the time of his deathhaving reigned for only 98 days.

THE AFTERMATH

One would have thought that this would havebeen the end of the sad saga: far from it. Willy,the new Kaiser, impetuous and now openlyhostile to Britain, ordered a post mortem on hisfather. Vicky, very against this, appealed toBismarck not to allow the post mortem. Herefused to see her, stating Prussian law required acause of death. She countered by refusing toattend the lavish state funeral of her husband.Relations between the two Governments werenow at an all-time low.

Emperor Frederick’s post mortem was carried outby Virchow who was eager to clear his name. Heconcluded that Frederick had died from a hugecarcinoma of the larynx and pneumonia. It wasthe last work Virchow performed. Thereafter heretired from medical practice. He was a goodfriend of Frederick’s and, although he neverstated it, it was felt that he blamed himself forFrederick’s death.

The quarrel which raged between Mackenzie andthe German doctors did not end with Frederick’sdeath. A month later the German press officereleased a pamphlet entitled: “Die KrankheidtKaiser Frederick des Dritten.” (The fatal illness ofKaiser Frederick the Third) Purportedly todocument the medical facts of the case, largelywritten by von Bergmann and Gerhardt, it was ascathing criticism of Mackenzie and hismanagement of the case. It included allegationsthat he had taken a biopsy from the wrong cord,that he had not sterilised his instrumentsproperly, that he failed to tell the Prince theseriousness of his disease, had obstructed theaccess of the German doctors to their patient andfinally had spirited him off to England withouttheir consent.

Mackenzie was incensed. Queen Victoria and theBritish Prime Minister demanded that he issue aformal riposte. Mackenzie duly published abooklet, “The Fatal Illness of Frederick theNoble.” Illustrated in his own hand with 21watercolours of the Imperial larynx at variousstages in the evolution of the disease, not onlydid he refute the allegations made about hisinvolvement, he introduced some of his ownallegations of mismanagement by the Germanphysicians. Describing Gerhardt as incompetent,indiscreet and obstructive, he stated thatGerhardt’s excessive electocautery wasresponsible for turning a benign lesion intocancer. He produced extensive figures on themortality rate of both laryngectomy andlaryngofissure at that time and despite vonBergmann’s claims to the contrary, hedemonstrated that operations had an extremelypoor success rate, up to 50% immediate mortalityand only 6-10% one year survival. He felt theoperation would have undoubtedly been fatal.He further alleged that the tracheostomy hadbeen poorly performed and off the mid-line.

He graphically described how von Bergmann hadcreated a false passage when changing thetracheostomy tube with some difficulty and in sodoing, had created an abscess and so hastenedthe Emperor’s death. He concluded by saying thatthe German doctors shared responsibility for thetreatment and wrote that if the case had turnedout well these gentlemen would no doubt havebeen ready enough to claim their share in thetriumph.

The book was very successful and ran into severaleditions, not only in English but in German andFrench as well. The book, however, essentiallymarked the end of Mackenzie’s career. He wascastigated by the Royal College of Surgeons forbreach of confidentiality and unethical conduct.He was condemned by the BMA and summonedto a disciplinary hearing of the Royal College ofPhysicians. Knowing his likely fate, he resigned.His practice in any event had more or less folded.In his thirteen month absence from England, hisassistant Dr Macdonald had run his practice andnow retained most of it. Mackenzie wasdepressed, fretful, and inattentive. He had noenergy or enthusiasm to resume his practiceanyway. He successfully sued the London Timesfor slander but the award of £1,500 did not makehim feel any better, nor did the payment of£12 000 for his care of Frederick help his anguish.His previous mild asthma got much worse and in

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1892 he died a broken man at the age of 54, lessthan four years after the death of his famouspatient.

CONCLUSION

Much has been written about the politicalconsequences of this event. Historians havespeculated about what would have happened hadFrederick survived. The fact of the matter is thatWilly as Kaiser was immature, impetuous andimmediately sought to assert Germany’s mightand, in so doing, unsettled an already delicatebalance of power in Europe. He fired Bismarck,offended France, allowed the treaty with Russia tolapse and at every turn baited and challengedBritain, especially in terms of naval power. Andso Europe moved towards World War I.

The medical consequences are of more interest tous: we only have space to mention some of them.The cause of biopsy and histopathologicaldiagnosis was lost for the next few decades. Therehas in recent years been much debate as to theexact nature of the Prince’s pathology. Was itsimply a missed diagnosis? Pathologists will attestto the difficulty of diagnosis sometimes inlaryngeal biopsy. Mackenzie was an expert in thefield, unlikely to miss an obvious clinicaldiagnosis which was made by German doctors:why did he pursue his course of action? Was thedisease in fact a syphilitic gumma with secondaryinfection, and with carcinoma a second or laterpathology? There is much to support this latterhypothesis, including Mackenzie’s privatecorrespondence with a friend.1

What happened to Mackenzie was unfortunate:he had become a close personal friend andadvisor to the Royal couple. It would seem thathe had Frederick’s best interest at heart asopposed to most of the other players in the sagaincluding the German doctors, politicians andthe press, who had their own personal agendas.Yet it was Mackenzie who bore the consequencesof the unfortunate outcome. It is interesting tocompare the circumstances surrounding thisillness and the management of the throat cancerof Ulysses Grant, the only US President to die ofcancer, which occurred at about the same time(1884-1885).14

After the War many in the medical establishmentagreed that Mackenzie had been treated shabbilyand in 1921 there was a graveside memorial

service attended by many medical luminaries,where a marble monument bearing Longfellow’swords was erected:

“Lives of great men all remind us that we canmake our lives sublime, and departing leavebehind us footprints in the sands of time”

However, if one opens any reference book, underMackenzie’s name one reads that he isremembered not for his pioneering work andmedical prowess, but in connection with thecontroversial management of Frederick’s finalillness.

“Men’s evil manners live in brass: their virtueswe write in water.”15

BIBLIOGRAPY

1. Stevenson R. 1946. Morell Mackenzie. William

Heinemann, London.

2. Stevenson R and Guthrie D. 1949. A History of

Otolaryngology. E & S Livingstone, Ltd. Edinburgh.

3. Brain D. 1987. Famous ENT Surgeons of the past. JLO,

101: 875-881.

4. Kerr AG. 1987. Controversies in Otology (The first Morell

Mackenzie lecture.) JLO, 101:983-995.

5. Chalat NI. 1984. Sir Morell Mackenzie Revisited.

Laryngoscope, 94:1037-1310.

6. Minningerode B. 1986. The Disease of Emperor Frederick

III. Laryngoscope, 96:200-3.

7. Ponsonby Sir F. 1929. Letters of the Empress Frederick.

Macmillan, London.

8. Fulford R. (Ed.) 1971. Your Dear Letter: Private

correspondence of Queen Victoria and the Crown

Princess of Prussia. Scribner’s, New York.

9. Von Bismark O. 1898. Bismark, the Man and the

Statesman: Reflections and Reminiscences. Smith, Elder,

London.

10. Massie RK. 1992. Dreadnought. Jonathan Cape,

London.

11. Grace PA. 1992. Doctors differ over the German crown

prince. BMJ, Vol 305: 1536-1538. Dec.

12. Mackenzie M. 1888. The fatal illness of Frederick the

Noble. Sampson Low, Marston, Searle and Rivington,

London.

13. McInnes WD, Egan W, Aust JB. 1976. The management

of Carcinoma of the Larynx in a Prominent Patient, or

did Morell Mackenzie really cause World War I?

American Journal of Surgery, Vol 132: 515-522.

14. Steckler RM, Snedd DP. 1976. General Grant: His

physicians and his cancer. American Journal of Surgery,

Vol 132: 508-514. Oct.

15. Shakespeare W. Henry VIII: IV:2.

11

EARLY LIFE

I was born in Johannesburg, South Africa in 1942during some of the darkest moments of WorldWar II. My parents were both from poor,uneducated, immigrant Jewish families who,although their formal education ended in the 6th

grade, continued their education throughout theirlives. Realising the importance of education, theygave me opportunities they were denied, makingsure I learned music, graphic arts and singing. Myschool education took place at Orange GrovePrimary School, and at Highlands North Highwhere I played soccer and rugby. I was also in theschool chess team. In 1961, after matriculating,I began my study of medicine at Wits MedicalSchool - partly motivated by the fact that, threeyears after my birth, my sister had been born withDown’s syndrome.

EARLY FORMATIVE TRAINING

I graduated in 1966 and interned in surgery for sixmonths with Professor Daniel (Sonny) du Plessis,and then with Dr Moses Suzman in medicine.This lasted for only six weeks because I wastransferred to work in cardiology with DrJohn Barlow for the remainder of the six monthterm. One of the senior cardiology internsworking for Dr Barlow had left for privatepractice. The medical interns devised a lottery forthe vacant position in which I drew the shorteststraw. This was when my interest in cardiologybegan. At that time I married Heather Rosenberg,a partnership that has lasted for more than forty-seven years.

During the year in which I served in the SouthAfrican Defence Force, I spent time in the paediatricarea, where I became intimidated by my weaknessin examining small children. Therefore, onweekends when I was not on duty at the militaryhospital, I attended paediatric rounds at theTransvaal Memorial Hospital for Children (TMHC)with Dr Avroy Fanaroff. He encouraged me toapply there for a senior internship. At the end of1968, after completing my military service, I wasaccepted into Professor ‘Boet’ Heese’s programmeat TMHC where I worked under the closesupervision of Dr Solomon E Levin, my mentorand role model, and also Dr Jack Wolfsdorf. Thesetwo physicians stimulated my interest incardiology and research.

I completed my registrarship in 1972, havingworked at TMHC and Baragwanath Hospital.I also passed the examination – FCP inPaediatrics. Dr Wolfsdorf, Dr Levin and I discussedwhere I should go for further training. The choicewas between paediatric cardiology andneonatology. I decided pursue cardiology asI liked the intensity of the catheterizationlaboratory and was intrigued by the prospect ofthe complexity of cardiology in the young.

My contribution to the development of paediatric cardiology and echocardiography

Norman Henry Silverman, MBBCh, DSc (Med) (Witwatersrand), FACC, FASE, FAHA. FCP (Paed) SA

Professor of Pediatrics (Emeritus), Division of Pediatric Cardiology, Stanford University and University of California, San Francisco; Honorary Professor of Pediatrics, University of Cape Town

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I was fascinated by the science of phonocardiography– the graphic representation of cardiac sounds andmurmurs in relationship to other physical eventswithin the cardiac cycle. Dr Levin was my instructorin that discipline, as well as in the elements ofpaediatric cardiac catheterization.

MOVE TO THE USA

Wanting to further my specialisation, I was acceptedinto the programmes of two former ‘Wits doctors’:Dr Samuel Kaplan of Cincinnati and Dr Abraham(Abe) Rudolph of the University of California. DrLevin advised me to study under Dr Rudolph, and sobegan my long journey to the West Coast of theUnited States. The Vietnam War was winding downand the only positions open to me necessitated mytaking out United States citizenship for the purposes offunding, as the National Institute of MedicineFellowships were only offered to United States citizens.

After much negotiation, Dr Rudolph offered me apost. This was as a National Institute of HealthFellow in the Cardiovascular Research Institute(CVRI), based in San Francisco. I arrived in the USAin the early part of June 1972 to begin my fellowship.

The education programme under ProfessorJulius Comroe was amazing as he had a broadvision of what it takes to train a successful scientist.Fellows had come from Africa, Asia, Australia,Europe and different parts of America. All wereeither physicians or scientists interested in thecardiovascular system but with different levels oftraining and expertise. A three-month course inmathematics, calculus, statistics, electronics,computer programming, medical literature,criticism, the art of scientific presentation, as well asnumerous symposia and lectures of public interestwere prescribed. Social events for families andopportunities to meet all the course instructors andprofessors added to our experience. Many of thefriendships we made have lasted all our lives.

I began work under Dr Abe Rudolph and his ex-WitsMedical School colleagues, Drs Julien Hoffman andMichael Heymann who introduced me to the animallaboratory and the cardiac unit in the Moffit Hospitalwithin the University of California, San Francisco.I had to assimilate a monumental amount of newinformation. This required a great deal of time anddevotion to understand the elements of cardiacphysiology, to work with instruments, to understandthe effects of radiation, animal preparation andinstrumentation.

Compared to many of the American trainees,I initially felt quite inadequate. With time, I started tofeel that I had begun to understand paediatriccardiology and the direction towards which myanimal experiments were heading. To be associatedwith great minds in the field that interested me wasa great privilege. I learnt from the many eminentscientists and physicians at the CVRI. Drs Rudolphand Heymann supervised my foetal animal work.I learned a great deal of cardiovascular physiologyfrom them that formed the basis of myunderstanding of paediatric cardiology. Dr Rudolphwas my role model, my surrogate father and mentorand became one of my dearest friends. Even today, atthe age of 90, he has a sharp and incisive mind andknows more about foetal cardiovascular physiologythan anyone alive.

THE START OF ECHOCARDIOGRAPHY

The university and the CVRI provided an importantopportunity for collaboration across manydisciplines, and I had the opportunity to meetand work with a co-fellow in adult cardiology, DrNelson Schiller. He was in contact with a member ofthe radiology department, Dr Granville Coggs, aformer Tuskegee Airman, radiologist and seniorOlympian. Dr Coggs had acquired a newultrasonographic machine from the PickerCompany. It was a simple, modified electronicoscilloscope with a black and white Polaroid® cameramounted on its front end. The camera swept from thebottom to the top of the screen, having enoughpersistence that, when activated, produced a time-lapse photograph of cardiac motion with respect totime. An electrocardiogram facilitated viewing therelationship of the ultrasonic events from systole todiastole. Nowadays, this is called anechocardiogram.

One could understand why radiologists used to realimages obtained by X-ray, thought this system didnot have much of a future. Cardiologists on the otherhand, especially ones who had been trained inphonocardiography (as I was by Dr Solomon Levin),were quite facile with this form of technology. For thefirst time we could see graphs of heart valves movingduring the cardiac cycle. We could identify signalscoming from the muscular walls of the heart anddetermine how the ventricles were performing. Thetechnique was in its infancy and I started taking theinstrument to the nursery in order to gain someexperience with it. Dr Nelson Schiller and I sharedthe instrument equally – or nearly so. I was workingduring the day in the animal or cardiac

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catheterization laboratory so we made a pact that hecould use the instrument from 09:00 to 17:00, whileI got the instrument at 17:00, and could work in thenursery through the night until 09:00 withoutbothering the day staff. Our pact worked perfectly!

During my nightly examinations I noticed thatpremature infants with large patent arterial ductshad large left atria. We began to measure the size ofthe left atrium and, having no normal values at thattime, we made a ratio of the size of the left atriumagainst the size of the adjacent aortic valve (Figures2 and 3). Normally the ratio was less than 1, butwhen it exceeded 1.3:1 the babies were found torequire surgical ligation of their patent arterial ducts.After surgery this ratio returned to normal, reflectingdiminishing distention of the left atrium due todecreased left-to-right ductus shunting. This was thefirst time the observation had been made and Ipresented our group’s experience at a nationalmeeting in Washington DC. The work was wellreceived and formed one of the basic measurementsindicating a large ductus shunt in premature infants.

ESTABLISHMENT OFECHOCARDIOGRAPHICLABORATORY AT UCSF

After my fellowship I accepted a position asAssistant Professor of Pediatrics at StanfordUniversity, where I worked for one year. I continuedmy own animal research at Stanford but usedmany of Dr Rudolph’s facilities to analyze myresearch. He was most generous, allowing me theuse of his facilities and finances to complete mywork. I was attracted back to UCSF the followingyear (1975) by Dr Rudolph when a notedcongenital heart surgeon, Dr Paul Ebert, accepted aposition at UCSF. Dr Rudolph needed someone torun the newly established echocardiographiclaboratory to support his work. I published a paperon normal ultrasound values which were needed inthe paediatric area.

My colleague, Nelson Schiller, and I tested a newtwo-dimensional echo machine made by a localcompany, Varian Physics of Palo Alto, California.Being a local company, they gave a trialinstrument both to UCSF and to Stanford.

The machine was initially unusable for babies asthe heart scale on its television screen was 21 cm,while the heart of a neonate is less than 5 cm, anda premature infant less than 3 cm in depth. Thesesmall hearts were obscured by the initial noise

coming from the transducer. The companywanted feedback on the instrument and, after Itold them about its unsuitability for small infantsand children, it was redesigned withmagnification so that even neonates could beexamined. With the new technology we were nowable to evaluate many more infants.

Dr Schiller and I pondered ways of imaging theheart with the probe that were different from theconventionally accepted precordial examinationwindows. We looked at imaging from the cardiacapex. This angle produced an image of all thefour chambers of the heart – the apical four-chamber view. This is like a St Valentine’s heart

Figure 2: Original echocardiogram recorded in 1973. Thisis an M-Mode Motion recording with respect to time. Justlike the electrocardiogram (ECG) noted in the Figures. TheLeft atrium (LA) and Aorta AO are shown. Although thescales for recording the Before Left and After DuctusLigation are slightly different, one can recognise how theleft atrial size has returned to normal.

Figure 3: Graph of the changes in size in millimetres ofthe left atrial to aortic root ratio from our study andshows the dramatic decline in the size of the left atriumas the left-to-right shunt at the ductus was interruptedafter ligation.

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but inverted, so that the atria lie in the round partof the heart and the apex of the image containsthe ventricles - a view applicable both to adultsand to children (Figure 4).

We began collecting all of these data, and I wasable to work out how to evaluate congenital heartdisease using the four-chamber view. I could defineholes in the septa of the heart, the relative size ofthe chambers, the thickness of the walls, andwhether there was under or over-development ofany of the chambers. In 1977, I submitted anabstract to the American College of Cardiologymeeting in Las Vegas. Our studies had beenrecorded on broadcast-quality videotape that hadto be converted to 16 mm film for the meeting.Varian sponsored the expensive conversion.

On the opening Sunday of the conference,because the adult section had not yet begun, all ofthe attendees came to the paediatric meetingwhere I was the third presenter. Everything wentoff without a hitch. At the end of any presentationthere is usually applause, either polite orenthusiastic, but at the end of my presentationthere was stunned silence. The audienceappreciated the momentous nature of ourdiscovery; one that has been adopted by themedical community at large and is now used

thousands of times a day by cardiologists andimagers around the world. That evening I becamea Fellow of the American College of Cardiology.

TWO-DIMENSIONALECHOCARDIOGRAPHY

Over the next few years the echo laboratory thrived.Dr Rebecca Snider was one of our first fellows. Shebecome fascinated by echocardiography and joinedme in writing the first book on paediatric two-dimensional echocardiography. Everything we sawwas new. We collected many series and published ona variety of structural congenital heart diseases aswell as examining physiologic variables such as two-dimensional measurement of ejection fraction, acommonly-used index of cardiac function. Theinformation I gathered from these studies led to thepublication of this book (See book 1).

I discovered another view for examining the heartthrough the space above the clavicles in the neckcalled the suprasternal space. This is useful forexamining the aortic arch, branch pulmonaryarteries and the great systemic veins of the upperbody. With this view we were able to recognisecommon diseases like coarctation of the aorta(Figure 5).

Figure 4: This figure has a two-dimensional image with adiagramme of the heart superimposed upon it and showsthe four chamber image of the heart applied from theapical application of the transducer to the chest wall.

Figure 5: Application of the transducer to thesuprasternal notch and the diagramme of what can beseen with coronal (left) and sagittal (right) orientation ofthe transducer.The lower frames are the corresponding echocardiogramsin those planes. These images are from 1981.

Figure 6: Human foetus of 20 week gestation. The scan in thetop frame passes through the four chambers of the foetalheart and shows the left atrium (LA) left ventricle (LV) rightatrium (RA) and right ventricle (RV). In the bottom frame,the scan passes slightly more cranially and brings the aorta(AO) into view as it arises from the left ventricle.

15

DOPPLER ULTRASOUND TECHNIQUE

In the early 1980s, the Doppler ultrasoundtechnique which bounced ultrasound waves offthe red blood cells became available. We wereable to measure blood flow directly in the vessels,and to estimate pressure drop across stenotic andregurgitant heart valves. We began to evaluatethis new technique with our fellows and topublish our findings in recognised journals.

THE USE OF CONTRASTECHOCARDIOGRAPHY

I also began to use contrast echocardiography,first described by Dr Raymond Gramiac, to followthe passage of blood through the heart incongenital heart disease. Using tiny quantities ofaerated saline injected into the veins of ourpatients with congenital heart disease, we wereable to provide remarkable images of abnormalpatterns of blood flow, particularly where thisoccurred inappropriately through abnormalcommunications and defects in the heart.

EXPERIENCE WITH FOETAL HEARTECHOCARDIOGRAPHY

Working with some of my obstetrical colleaguesI had begun imaging the foetal heart using two-dimensional ultrasound. At the outset, with thistechnique I obtained images of foetal cardiacabnormalities from the 20th week onward (Figure6). Later this technique was applied to youngerfoetuses from the 12th week of gestation onward.

WORK WITH PROFESSOR ROBERTANDERSON IN LONDON

I had always been intrigued by pathologicaldescriptions of heart defects. Indeed, I found itvery difficult to relate to images in the literatureand was much more familiar with theangiographic appearances of these lesions. Withthe development of ultrasound techniquesproving to be ever more valuable, a detailedunderstanding of the morphological aspects ofmorbid anatomy seemed to me essential. Mycolleague, Dr Michael Heymann, gave me a bookdetailing the proceedings of a symposium inNewcastle-upon-Tyne, England. After readingabout congenital structural heart abnormalitiesI felt that a new world had sprung into my view.

As another physician, John Keats, had remarkedabout looking into Chapman’s Homer:

“Then felt I like some watcher of the skiesWhen a new planet swims into his ken.”

Professor Robert Anderson of the BromptonHospital, London and his book on patients withonly one ventricular chamber was the new planetin my world. I resolved to go and work with him.When I had my first sabbatical in 1982, I went toLondon for six months with my family. I workedevery day in Professor Anderson’s laboratory,examining almost every one of 1500 specimensand familiarizing myself with the fine details ofabnormal heart structure that proved so vital forsomeone working with imaging the pathology ofcardiac diseases. I wrote an important paper withProfessor Anderson on the comparative anatomy

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of the cuts produced by ultrasound in the normalheart, as well as papers on other structuralabnormalities with Dr Leon Gerlis, who workedwith Professor Anderson and the clinical group atthe Brompton Hospital.

RETURN TO USA

I returned to San Francisco to find that Dr Sniderwas soon to leave for the chief’s position at theUniversity of Michigan. I was then alone, incharge of an ever-growing echocardiographiclaboratory. However, because of the abundance ofnew and vital knowledge, cardiovascular traineesflocked to the laboratory wanting to participatein the new discoveries.

In order to keep them motivated, and becausethere was great competition for their attentionwithin the CVRI, I instituted a wine and cheeseappreciation course, in addition to our weeklyfellows’ conference. These meetings provedenormously popular with the fellows who came,perhaps, for the food and wine but becameinfected with enthusiasm for the investigationalaspects of my work. The fellows were usuallyproductive, and many made great strides andpresentations. It is said that one can see far whenone stands on the shoulders of giants. I believethat I was able to see far for this reason, and alsobecause I was able to stand on the shoulders ofmy fellows who produced insightful publications.

I need to single out many post-doctoral fellows whoproduced outstanding and wonderful publications,including Dr Klaus Schmidt from Heidelberg,Germany, Dr Rebecca Snider from South Carolina, DrWayne Tworetzky from Cape Town, Dr Doff McElhineyfrom San Francisco, Dr Mark Friedberg from Israel, DrDavid Roberson from Chicago, Dr George van Harefrom St Louis, Dr Thomas Kohl from Giessen,Germany, Dr Colin Phoon from New York and DrRajesh Punn from San Diego. They helped open upnew areas of ultrasound with their research andhard work.

In 1985, Dr Klaus Schmidt from Heidelbergarrived and immediately plunged himself intoworking with ultrasound, and in the animallaboratory, accumulating as much experience ashe could. I had received a grant from theAmerican Heart Association for evaluating thefoetal circulation, and we studied instrumentedanimals, courtesy of the ever-supportive DrRudolph.

We used Doppler colour flow and two-dimensional ultrasound to define several aspectsof the circulation, which spawned a great numberof papers that provided understanding of severalmechanisms of flow physiology at the sites wheremixing of blood streams in the foetal circulationoccurs (Figure 7). We also measured foetal cardiacfunction. The measurements showed a closecorrelation with the physiological variablesmeasured in chronically instrumented foetallambs that were part of Dr Rudolph’s ongoingresearch (See Adler Museum Bulletin: 33[1] June2007). Thus we took what we had learned in thefoetal animal laboratory and applied thesetechniques to the human foetus.

DEVELOPMENT OF NEWTECHNOLOGY AND APPLICATION OFTRANS-OESOPHAGEALECHOCARDIOGRAPHY TO CHILDREN

In 1986 Hewlett Packard provided us with a newultrasound instrument in which Doppler colourflow had been integrated. This system, developedfirst in Seattle, Washington, and then in Japan bythe Aloka® Company, provided a two-dimensional image of flow superimposed on theimage of the heart. For the first time we could see

Figure 7: Foetal blood flow in a foetal sheep demonstratesDoppler colour flow in the inferior vena cava (IVC). Thedegree of brightness varies are coded to show velocities ofblood flow that are different. This image shows theseparation from the high-velocity ductus venosus bloodstream (light signal), which is well saturated with oxygenand the rest of the lower body flow (dark signal) from theinferior vena cava (IVC), which has desaturated blood. Theductus venosus blood goes directly into the left atrium (LA),bringing oxygen-rich blood to the brain and heart.

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blood flow in vessels, see through holes in theheart, and image cardiac leaks and blockages.The technique was more sensitive in recognisingthe site and amount of flow, both normal andabnormal. In addition, we were able to acquireimages of pulmonary veins that drainedabnormally, abnormal coronary arterial flow,and the presence of coronary arterial fistulae. Wealso used the technique to evaluate disease in thefoetus.

A colleague since 1982, Dr Nelson Schiller hadbegun working with an ultrasound probeembedded in a gastroscope that could be passeddown the oesophagus of adults to image theheart from its posterior aspect (trans-oesophagealechocardiography [TEE]). Adults have thick chestwalls that often preclude imaging, and theoesophageal route both overcame thatimpediment and created some clear images. Inthe late 1980s, driven by Japanese electronicscompanies, the technique of Doppler colour flowwas added to miniaturized transducers that couldnow be safely passed via the oesophageal routein neonates. We first explored the use of thistechnology and found it to be of enormousbenefit in the management of patients duringoperation. Because we could look at the results ofthe surgery immediately after the heart began tobeat, but before the patient was separated fromthe heart-lung machine, we could evaluatewhether the operation was adequate, whetherthe repair was satisfactory, and whether therewere additional operative procedures that wouldbenefit the patient. The TEE technique led tobetter surgical results, making a barrage ofpost-operative tests unnecessary. I worked onthis aspect of care with my cardiac post-doctoralfellow, Dr David Roberson of Chicago, andthe anaesthesiology team headed by DrMichael Cahalan of Salt Lake City. I also workedwith Dr Isobel Russell and Dr Lydia Cassorla andpublished several papers on the value of thetechnique.

TEE soon became the standard of care forpatients undergoing cardiopulmonary bypassand the technique itself is considered to be one ofthe most outstanding discoveries since theinstitution of cardiac catheterization.

At that time our laboratory was recognised as anoutstanding institution and many publicationsfollowed. During the next few years I was joinedby Dr Michael Brook and Dr Theresa Tacy. DrBrook succeeded me as the director of the echo

laboratory at UCSF when I stepped down fromthat position in 2002. Dr Tacy succeeded me asdirector of echocardiography in 2008 from myposition at Stanford.

I first collaborated with Dr Charles Higgins,a radiological colleague in magneticresonance imaging (MRI), to write a bookconcerning the relative value of MRI andechocardiography, being joined in thisendeavour by our two fellows, Dr Klaus Schmidtand Dr Barbara Kersting-Summerhoff.

I had begun writing a second book onechocardiography because our experience hadgrown so substantially since our first volume, withassiduously collected material. Williams andWilkins published this book in 1990 (See book 2).My second book on echocardiography appearedin1993 and was over 600 pages long. It containedinstruction on basic anatomy and physiology, onechocardiographic techniques and on all thecongenital and acquired diseases with which Ihad experience. There was also an extensivechapter on foetal cardiology. My associatesDavid Roberson and Isobel Russell joined me inwriting the chapter on TEE. I was honored to havemy mentor, Dr Abraham Rudolph, write thepreface (See book 3).

BEYOND 2000

In 2003 I was asked to write a book on foetalcardiology with Drs Simcha Yagel of Israel andDr Ulrich Gembruch of Bonn, Germany (Seebook 4). This volume proved so popular that asecond edition was published in 2008 with manyadditions, including the use of three-dimensional technology of the foetal heart (Seebook 5). I invited several authors to write newchapters on foetal cardiac physiology andincidence. That same year I authored a book infoetal echocardiographic anatomy with DrsEnrico Chiappa of Turin, Italy (also a formerfellow), along with Drs Andrew Cook of London,and Giani Botta, a pathologist from Turin (Seebook 6).

Over the years I have gravitated to teaching andmentorship, augmenting my teaching sessionsto include echocardiography in all of itsdimensions to fellows of various disciplines whoare interested in paediatric cardiology. Fellowsincluded surgeons, anaesthesiologists,radiologists, neonatologists and perinatologists.

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My wine-tasting sessions have become animportant part of my teaching and manyattending cardiologists came in to sample thebeverage but stayed for the education.

My other major teaching adventure, stillongoing, in addition to my regular day-to-dayactivities, is the weekly session of morbidanatomy of congenital heart disease. I do thisin the morgue at UCSF where the curator, DrPhillip Ursell, lays out the particular diseases tobe studied from his collection of over 1800 heartspecimens. I started this practice in 1982 whichcontinues until today. Even after I left UCSF forStanford I continued the sessions, teaching theStanford interns and post-doctoral fellows withthe UCSF fellows.

During the one hour drive to UCSF I reviewedthe embryology, anatomic classification andcardiac catheterization of the lesions to be seen.The actual session consists of an hour ofexamining heart specimens with the particularselected disease. In the last few minutes I recordthe pathology with a video camera to display tofuture generations of students, because thenumber of cardiac specimens remaining inteaching libraries around the world is declining.On the drive back to Stanford the group has anhour’s symposium on medical and surgicaltreatment of the conditions and the philosophyof the therapeutic manoeuvres associated withthe specific lesion they have seen. All-told thesession lasts for three hours, and is a highlightfor all the fellows.

In the late 1990s Stanford University and theUCSF discussed the possibility of a merger.Paediatrics and cardiology were targeted foramalgamation. I was appointed echo-director ofboth institutions and began visiting Stanfordwhere I got to know the team one day a week.The merger ultimately failed, but I retained myassociation with both institutions. I lived nearthe Stanford campus and, after the 1989earthquake brought down part of the freewaysystem, the commute to UCSF become tiresome.Dr Daniel Bernstein, one of my former traineesand then director of paediatric cardiology atStanford, and I began to discuss the possibilityof my returning to Stanford. In August 2002,I re-joined the faculty.

I brought my previous teaching methods andsymposia to Stanford, and improved thestandards of the ultrasound technologists with

extensive tuition. Dr David Rosenthal and Idigitized the reporting system, making thereports immediately accessible to allphysicians.

Dr Frank Hanley, chief surgeon at Packard anda noted leader in paediatric cardiac surgeryhad left UCSF for Stanford six months beforeand we were happy to renew our association.We were able to increase the faculty, attracthigh-quality fellows to the programme andproduce numerous research papers. I wasfortunate to continue to mentor excellentfellows who entered research and teachingpositions at other universities and also enteredprivate paediatric cardiology practice.

During my career I have been honoured withmany named lectureships and awards. In 2000I received the founders’ award by the AmericanSociety of Echocardiography where I hadserved on the board since its inception. In 2008I was again honoured by the society with itsteaching award. In 2005, during my tenure asprofessor of paediatrics and director of the echolaboratory at Stanford, I was awarded theRoma and Marvin Auerback Scholarship inPediatric Cardiology, a post I held until Iretired in 2012. The award was established toteach and mentor Stanford post-doctoralfellows, as teaching is so vital but so poorlyreimbursed. The scholarship, created by hiswife, Roma, honoured the memory of DrMarvin Auerback, who had been a paediatriccardiologist in the San Francisco area, mylong-time friend and colleague. This award hasnow passed from me to Dr Stanton Perry andwill remain in the Stanford General Fund inperpetuity. Stanford honoured me after myretirement by appointing me EmeritusProfessor as well as appointing me to thehonorary clinical faculty.

In the course of my extensive travels andvisiting professorships through America andaround the world, I have enjoyed instructingmany in paediatric cardiology andechocardiography. My last reward, of which Iam extremely proud, was a long-term honoraryprofessorship at the University of Cape Town.What makes me most proud and provides mewith the greatest delight is to see so many of theover 180 post-doctoral fellows succeed andexceed me in their ability, knowledge andsuccess. That remains my greatest honour andlegacy.

19

SEMINAL REFERENCES

1. Silverman NH, Lewis AB, Heymann MA, Rudolph AM.

Echocardiographic assessment of ductus arteriosus shunt

in premature infants. Circulation 1974; 50:821–5.

2. Roge CL, Silverman NH, Hart PA, Ray RM. Cardiac

structure growth pattern determined by

echocardiography. Circulation 1978; 57:285–90.

3. Silverman NH, Schiller NB. Apex echocardiography: A

two-dimensional technique for evaluating congenital

heart disease. Circulation 1978; 57:503.

4. Ports TA, Silverman NH, Schiller NB. Two-dimensional

echocardiographic assessment of Ebstein’s anomaly.

Circulation 1978; 58:336.

5. Schiller NB, Acquatella H, Ports TA, Drew D, Goerke J,

Ringerts H, Silverman NH. Left ventricular volume from

paired biplane two-dimensional echocardiographs.

Circulation 1979; 60:547.

6. Silverman NH, Ports TA, Snider AR, Schiller NB, Carlsson

E, Heilbron DC. Determination of left ventricular volume

in children: echocardiographic and angiographic

comparisons. Circulation 1980; 62:548.

7. Heymann MA, Rudolph AM, Silverman NH. Closure of the

ductus arteriosus in premature infants by inhibition of

prostaglandin synthesis. N Engl J Med 1976; 295:530–3.

8. Snider AR, Silverman NH. Suprasternal notch

echocardiography: a two-dimensional technique for

evaluating congenital heart disease. Circulation 1981;

63:165–73.

9. Silverman NH, Hunter S, Anderson RH, Ho SY,

Sutherland GR, Davies MJ. Anatomical basis of cross

sectional echocardiography. Br Heart J 1983; 50:421–31.

10. Silverman NH, Enderlein MA, Golbus MS. Ultrasonic

recognition of aortic valve atresia in utero. Am J Cardiol

1984; 53:391–2.

11. Schmidt KG, Cooper MJ, Silverman NH, Stanger P.

Pulmonary artery origin of the left coronary artery:

diagnosis by two-dimensional echocardiography, pulsed

Doppler ultrasound and color flow mapping. J Am Coll

Cardiol 1988; 11:396–402.

12. Schmidt KG, Silverman NH, Harrison MR, Callen PW.

High-output cardiac failure in fetuses with large

sacrococcygealteratoma: diagnosis by echocardiography

and Doppler ultrasound. J Pediatr 1989; 114:1023–8.

13. Roberson DA, Silverman NH. Ebstein’s anomaly:

echocardiographic and clinical features in the fetus and

neonate. J Am Coll Cardiol 1989; 14:1300–7.

14. Muhiudeen IA, Robereon DA, Silverman NH, Haas G,

Turley K, Cahalan MK. Intraoperative echocardiography

in infants and children with congenital cardiac shunt

lesions: transesophageal versus epicardial

echocardiography. J Am Coll Cardiol 1990; 16:1687–95.

15. Schmidt KG, Silverman NH, Van Hare GF, Hawkins JA, Cloez

J-L, Rudolph AM. Two- dimensional echocardiographic

determination of ventricular volumes in the fetal heart:

validation studies in fetal lambs. Circulation 1990; 81:325–33.

16. Velvis H, Schmidt KG, Silverman NH, Turley K. Diagnosis

of coronary artery fistula by two-dimensional

echocardiography, pulsed Doppler ultrasound and color

flow imaging. J Am Coll Cardiol 1989; 14:968–976.

17. Ciricillo SF, Schmidt KG, Silverman NH, Hieshima GB,

Higashida RT, Halbach VV, Edwards MSB. Serial

ultrasonographic evaluation of neonatal vein of Galen

malformations to assess the efficacy of interventional

neuroradiological procedures. Neurosurgery 1990; 27:544–8.

18. Schmidt KG, Di Tommaso M, Silverman NH, Rudolph

AM. Evaluation of changes in umbilical blood flow in

the fetal lamb by Doppler waveform analysis. Am J

Obstet Gynecol 1991; 164:1118–26.

19. Schmidt KG, Silverman NH, Rudolph AM. Assessment of

flow events at the ductus venosus –inferior vena cava

junction and at the foramen ovale in fetal sheep by use

of multimodal ultrasound. Circulation 1996; 93:826–33.

20. Kohl T, Szabo Z, Suda K, Petrossian E, Ko E, Kececioglu

D, Moore P, Silverman NH, Harrison MR, Chou TM,

Hanley FL. Fetoscopic and open transumbilical fetal

cardiac catheterization in sheep. Potential approaches

for human fetal cardiac intervention. Circulation 1997;

95:1048–53.

21. Schmidt KG, Silverman NH, Rudolph AM. Phasic flow

events at the aortic isthmus – ductus arteriosus junction

and branch pulmonary artery evaluated by multimodal

ultrasound in fetal lambs. Am J Obstet Gynecol 1998;

179:1338–47.

22. Schmidt KG, Ulmer HE, Silverman NH, Kleinman CS,

Copel JA. Perinatal outcome of fetal complete

atrioventricular block: a multicenter experience. J Am

Coll Cardiol 1991; 17:1360–6.

23. Silverman NH, Gerlis LM, Ho SY, Anderson RH. Fibrous

obstruction within the left ventricular outflow tract

associated with ventricular septal defect: a pathologic

study. J Am Coll Cardiol 1995; 25:475–81.

24. Bernstein HS, Moore P, Stanger P, Silverman NH. The

levoatriocardinal vein: morphology and

echocardiographic identification of the pulmonary-

systemic connection. J Am Coll Cardiol 1995; 26:995–1001.

25. Schmidt KG, Silverman NH, Hoffman JIE. Determination

of ventricular volumes in human fetal hearts by two-

dimensional echocardiography. Am J Cardiol 1995;

76:1313–16.

26. Bernstein HS, Brook MM, Silverman NH, Bristow J.

Development of pulmonary arteriovenous fistulae in

children after cavopulmonary shunt. Circulation 1995;

92:309-314.

27. Tworetzky W, McElhinney D, Brook MM, Reddy VM,

Hanley FL, Silverman NH. Echocardiographic diagnosis

alone for the complete repair of major congenital heart

defects. J Am Coll Cardiol 1999; 33:228–33.

28. Tworetzky W, McElhinney DB, Reddy VM, Hanley FL,

Brook MB, Silverman NH. Improved surgical outcome

after fetal diagnosis of hypoplastic left heart syndrome.

Circulation 2001; 103:1269–73.

20

29. Firpo C, Hoffman J, Silverman NH. Measurements of the

fetal heart dimensions from 12 weeks to term. Am J

Cardiol 2001; 87:594–600.

30. Friedberg MK, Ursell PC, Silverman NH. Isomerism of the

left atrial appendage associated with ventricular

noncompaction. Am J Cardiol 2005; 96:985–90.

31. Friedberg MK, Silverman NH. The systolic to diastolic

duration ratio in children with heart failure secondary

to restrictive cardiomyopathy. J Am Soc Echocardiogr

2006; 19:1326–3.

32. Vlahos AP, Feinstein JA, Schiller NB, Silverman NH.

Extension of Doppler-derived echocardiographic

measures of pulmonary vascular resistance to patients

with moderate or severe pulmonary vascular disease. J

Am Soc Echocardiogr 2008 June 21; (6):711–24.

33. Sarnari R, Yousef Kamal R, Friedberg MK, Silverman NH.

Doppler assessment of the ratio of the systolic to diastolic

duration in normal children: relation to heart rate, age

and body surface area. J Am Soc Echocardiogr 2009; 22:

928–32.

34. Friedberg MK, Silverman NH, Moon-Grady AJ, Tong E,

Nourse J, Sorenson B, Lee J, Hornberger LK. Prenatal

detection of congenital heart disease. J Pediatr 2009;

155(1): 26–31.

35. Punn Rajesh, Silverman NH. Cardiac segmental analysis

in left ventricular noncompaction: experience in a

pediatric population. J Am Soc Echocardiogr 2010; 23

(1): 46-53.

36. Punn R, Silverman NH. Fetal predictors of urgent balloon

atrial septostomy in neonates with complete

transposition. J Am Soc Echocardiogr 2011; 24: 425-30.

37. Arunamata A, Punn R, Cuneo B, Bharati S, Silverman

NH. Echocardiographic diagnosis and prognosis of fetal

left ventricular noncompaction. J Am Soc Echocardiogr

2011, J Am Soc Echocardogr. 2012 Jan:25 (1): 112-20.

Epub 2011 Oct 19.

38. Ganesan S, Brook M, Silverman N, Moon-Grady AJ.

Prenatal findings in total anomalous 1 pulmonary

venous return – a diagnostic road map starts with

obstetric screening views. J Ultrasound Med. 2014;

33(7):1193-207.

BOOKS PUBLISHED

1. Silverman NH, Snider AR. Two-Dimensional

Echocardiography in Congenital Heart Disease.

Norwalk, CT: Appleton-Century-Crofts; 1982.

2. Higgins CB, Silverman NH, Schmidt KG, Kersting-

Sommerhoff BA, eds. Tomographic Imaging of

Congenital Heart Disease: Echocardiography and

Magnetic Resonance Imaging. New York, NY: Raven

Press; 1990.

3. Silverman NH. Pediatric Echocardiography. Baltimore,

MD: Williams and Wilkins; 1993.

4. Yagel S, Silverman NH, Gembruch U, Cohen SM, eds.

Fetal Cardiology: Embryology, Genetics, Physiology,

Echocardiographic Evaluation, Diagnosis and Perinatal

Management of Cardiac Diseases. London, Springer;

2003.

5. Yagel S, Silverman NH, Gembruch U, Cohen SM, eds.

Fetal Cardiology: Embryology, Genetics, Physiology,

Echocardiographic Evaluation, Diagnosis and Perinatal

Management of Cardiac Diseases. New York, Informa.;

2nd Edition; 2008.

6. Chiappa, EM, Cook, AC, Botta, G, Silverman, NH.

Echocardiographic Anatomy in the Fetus. London,

Springer; 2008.

21

My career direction was set in motion by threeunrelated events. First, my father’s long-standingand unrequited desire to have been a paediatrician:financial circumstances demanded that he workwhile pursuing his post-high school education. Lawwas a more appropriate route to take, so he becamea lawyer with the heart and soul of a paediatrician.My decision to pursue a career in paediatrics wasthus ‘bred in the bone,’ or at least the psyche.

Second, I am the grandson of Lithuanian- andLatvian-born Jewish immigrants to South Africawho fled the pogroms of Eastern Europe of the late1800s and very early 1900s. My maternalgrandparents, from a shtetl called Plungyan (nowPlunge), went to Heilbron in the then Orange FreeState, where many of their family members hadsettled; my paternal grandparents (from Riga) toCeres in the then Cape of Good Hope. My maternalgrandfather, himself without much formalschooling, set the tone for future generations: hebelieved passionately that education was the mostimportant ticket out of the ghetto, producing twodoctors (Blumy Segal 1933 and Max Segal 1938), alawyer (my mother) and a pharmacist (my aunt)along the way, all at Wits. His demand for a goodeducation for his children was facilitated by thelocal high school principal, Mr Lamprecht(Lampie), who became something of a legendamong the immigrants of the area. His influenceon our family was so strong that I distinctlyremember his attendance at my grandparents’ 50th

wedding anniversary in Johannesburg in the late1950s: his arrival was almost messianic. Quitefrankly, I grew up with the impression that almosteveryone we knew came from Plungyan,immigrated to Heilbron and had experienced theaura of Lampie. There was clearly imprinting ofthis commitment to education in certain membersof our family: my brother, Alan graduated fromWits Medical School in 1971 and I graduated in1973, both having completed a BSc (Med) along theway.

Third, a chance conversation in the corridors ofBaragwanath Hospital in 1972 opened upinteresting possibilities. David (Dave) Coombs, thena surgical registrar at Baragwanath Hospital (andin 1974 my senior registrar in Professor ‘Sonny’ duPlessis’ ward at the Johannesburg General Hospital)asked me what I was doing for my fifth yearelective. When I said paediatrics, he asked: “At theHospital for Sick Children in London or Toronto?”Great Ormond Street in London was known to mebut what about the one in Toronto? It is, he said,the biggest and best children’s hospital in theworld! What a great idea: my brother was an internin the USA, Pierre Trudeau was the Prime Ministerof Canada and a proponent of liberal politics,Canada was intriguing and I was adventurous.Plus I needed a break from the ever-increasingstrictures of apartheid South Africa. Little did Iknow where such an experience would lead.

THE ‘LUCKY’ ELECTIVE

I spent the last 10 weeks of 1972 in Toronto atSickKids as it is colloquially known, learningpaediatrics, making new friends, exploring a newenvironment, simply reveling in the freedomsafforded: free to interact with colleagues fromaround the world, free to walk the city streetsunafraid at any time of the day or night, free tocare for patients independent of race, or otherdesignation. A few Witsies in Toronto at the timecontributed to the richness of this experience:Moshe Ipp was a junior resident, Mark Greenberg

Reflections on a career in academic paediatrics

Denis Daneman, BSc (Med) 1969, MBBCh 1973, DSc (Med) 2013(Witwatersrand), FRCPC

Professor and Chair, Department of Paediatrics, University of TorontoPaediatrician-in-Chief, The Hospital for Sick Children, RS McLaughlin Foundation Chair in Paediatrics

Receiving a DSc (Med) in December 2013

22

an oncology fellow, and Antony (Tony) Olinsky, aresearch fellow in neonatology. On one of mythree rotations during the elective, paediatricendocrinology, I found a phenomenal role model,mentor and supporter in Robert (Bob) Ehrlich.

By the end of the elective, I knew I wanted toreturn to SickKids and the University of Toronto(UofT) to train as a paediatrician, and specificallyas a paediatric endocrinologist, and knew Torontowould be a great place to live. Fortunately, myacademic record met the bar for acceptance as ajunior resident following 18 months of internshipat the Johannesburg General and TransvaalMemorial Children’s Hospitals. So in late June1975, accompanied by my pregnant wife,Meredyth, and 11 month-old son, Nick, we leftJohannesburg for Toronto.

The residency in paediatrics was pretty arduous:in-house on call one night in three, every thirdweekend from Saturday morning to Mondayevening, caring for very sick children. The paywas meager ($11,500 pa to start). But the housestaff, from every corner of the globe, was up to thetask. More than 35 years later I still maintaincontact with a number of my fellow residents andcount some among my closest friends. SickKidswas everything Dave Coombs predicted it wouldbe: very big and very good.

In 1977 I started as a fellow in paediatricendocrinology. I had no doubt that this was thesubspecialty in which I belonged. Professor HarrySeftel at Wits had ignited an intense interest indiabetes, John Hansen and Peter Thompsonamong others encouraged the focus in paediatrics,and Bob Ehrlich in Toronto mentored andencouraged me in this direction. So much so thathe recommended that I go to the University ofPittsburgh and the Children’s Hospital ofPittsburgh to complete my training with AllanDrash, the North American leader in the field.That is exactly what I did and am eternallygrateful to both Bob and Allan for theirunwavering support, mentorship, collaborationand friendship. Pittsburgh was a good choice froma family point of view, since my wife was able tocomplete her doctorate in cognitive psychology atCarnegie Mellon University, one of the leadinginstitutions in the world in this field.

At the end of three years of training in Pittsburghand with rich clinical research experience undermy belt, Meredyth and I were faced with a choiceamong a number of positions in the USA and

Canada. We opted to return to Toronto, me to theUofT and SickKids, Meredyth to the nearbyUniversity of Waterloo, then UofT. I came back in1981 and have remained in the same placethroughout my academic career. Although in theUSA movement of faculty between institutions iscommonplace, such is not the case in Canada.

FINALLY, A FACULTY MEMBER

Reflecting back, there are some specific reasons whyI was ready to start as a staff endocrinologist atSickKids, and as an Assistant Professor at the UofT.First, I had done the time: seven-and-a-half yearsof postgraduate training was significantly morethan most North American graduates were doing,but not at all atypical for international medicalgraduates who were seeking academic careers inNorth America. Second, I had trained in threeoutstanding places: a solid foundation in clinicalmedicine at Wits, general paediatrics at SickKidsand UofT, and paediatric endocrinology here andin Pittsburgh. A medical degree from Wits wasexceedingly highly respected throughout NorthAmerica. Third, quite frankly, there were only asmall handful of academically trainedsubspecialists seeking careers, and jobs wereincreasingly available for those best trained.Fourth, I had done clinical research in Pittsburghthat was highly relevant to the field of childhooddiabetes: validation and analysis of the HbA1c andC-peptide assays; analysis of early self-bloodglucose monitoring in paediatrics, and an earlyforay into behavioural interventions. This led tooral presentations at national and internationalmeetings, about 12 papers published duringtraining, and the support of my mentors when itcame time to apply for positions. The careful choiceof mentors and their ongoing support are twoessentials when embarking on an academic career.To understand the mentor-mentee relationship, Iwould refer everyone to Frank Oski’s brilliantpresidential address to the Society for PediatricResearch in 1978.1

The decision to return to Toronto on completing myfellowship was one I will not ever regret. SickKidsand UofT have been my academic homes for nearly35 years and have offered me opportunities forpersonal and professional advancement that I hadnot even dreamed of as a 17 year-old entering WitsMedical School in 1967.

The milestones of my career are quite typical ofmost of those entering academic medicine.

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A colleague and I wrote about these a few yearsago,2 starting with the ‘nervous novice’ phase inwhich I felt that it was only a matter of timebefore my colleagues would discover just howlittle I knew (the classic ‘imposter syndrome’).I progressed quite quickly to the ‘gung ho’ phase,was promoted to Associate Professor, joinedinnumerable local, national and internationalcommittees, collaborated widely and settled in forthe long haul. After about 12 years on faculty,I was promoted to full professor at the UofT, andappointed Head of the Division of Endocrinologyat SickKids. This opened even more doors,including leadership positions in the CanadianDiabetes Association, the International Society forPediatric and Adolescent Diabetes, and firstPresident of the Canadian Paediatric EndocrineGroup. Time to move from the ‘gung ho’ to ‘self-respect’ phase.

The trajectory of my career seemed to havereached a peak in about 2006: full professor,division head, over 200 peer-reviewedpublications, invitations around the world. Whatnext? Well, the Chair of Paediatrics at UofT andPaediatrician-in-Chief at SickKids (a combinedposition) reached the end of his 10 year tenure,the limit allowed for these positions. I had longwondered whether this would be a natural nextstep for me, but had turned down offers to applyfor similar positions that would have required afamily move from Toronto. I submitted mycurriculum vitae and, after a wide search, wasoffered the position.

On reflection, I think three factors played majorroles in being considered a credible candidate forsuch a prestigious position. First, and without doubtthe core to establishment of an academic career,was clinical credibility. This requires tremendouslyhard work, keeping up with the literature,establishing relationships with colleagues, and,more especially the children and their families forwhom I provided care. This remains a remarkablyrewarding part of my academic life. I amenormously grateful to the children and familieswho let me into their lives. They have taught meendless lessons in health care, communication,professionalism, compassion and humanity. Thepursuit of clinical excellence ought to be inherentin the careers of all academic physicians.

Second, was the combination of education andmentorship: ensuring the next generation ofphysicians, paediatricians and paediatricsubspecialists were superbly well trained. In

academic medicine, one is always surrounded bylearners AND one is always a learner. What a joy tobe surrounded by smart men and women at allstages of their careers, and in all health careprofessions.

Third, and an imperative at academic institutions,is studying aspects of the etiology, course andcomplications of the diseases one treats, at a basicor clinical science level. For me, this was a given,i.e. attempting to provide increasingly betterevidence-informed care for, in my case, childrenwith type 1 diabetes. Again this led to remarkablymeaningful and productive collaborations, andopened avenues of investigation not obvious at firstglance. And again one is surrounded byexceedingly talented and innovative people.

Once credibility has been established, endlessopportunities present themselves: opportunities tocollaborate in international studies, do teaching invarious places, join national and internationalsocieties, participate in guideline development, andmuch more. The attainment of academic credibility(inevitably the harvest of hard work) has anotherbenefit: acceptance into the world of scholars inone’s field, in my case paediatric diabetes. This ledto collaborations and friendships with colleaguesaround the world, and the opportunity to give backin some ways or contribute to a wider mandate:social responsibility.

Along the way, my colleagues nominated me for anumber of leadership positions, as well asprestigious awards, locally within our departmentat UofT, nationally and internationally. Most aresignificant to me because they encompass all threeaspects of academic life: clinical excellence,teaching and research. Three have a specialmeaning: the lifetime achievement awards of theInternational Society for Pediatric and AdolescentDiabetes (2010) and the Canadian DiabetesAssociation (2013). Also, on 10 December 2013 Ireceived a DSc (Med) from Wits for my thesis:Understanding the early course and complicationsof type 1 diabetes in children and adolescents.

PERSPECTIVE

On 1 July 2015 I will enter the final year of my tenyear appointment as Department Chair. How haveI done? Well, that is for others to decide and time todetermine. During these years, we have hired morethan 85 new faculty members from Canada andabroad, measurably improved the safety and quality

24

Delegates to the 1970 AMSSA meeting in Durban. I am seated 7th from the left, second row from the front

of patient care, trained hundreds of paediatriciansand paediatric subspecialists from around the world,and remained in the top three departments ofpaediatrics in North America with respect toresearch productivity. Interestingly, of my threeAssociate Chairs, one, Rayfel Schneider is a Witsgraduate, and one, Jeremy Friedman, is from UCT:they were the most qualified for these positions.

I would like to reflect on two aspects: whatexperiences I had had that prepared me to be acandidate for such a prestigious position, and whatlessons I have learned and continue to learn as amedical leader.

GETTING THERE

Were there any early experiences in leadership thathad an impact? The high school I attended, KingEdward Vll or KES, placed sports prowess aboveacademic achievement in nurturing studentleaders. And what about the weekly militaryexercise called Cadets? (That this continues inmany schools beyond the end of the apartheid-erais beyond my comprehension.)

While I do not much regard myself as an OldEdwardian, having been to KES, I am foreverwillingly and proudly branded a Witsie: I spenteight-and-a-half glorious years in and aroundWits (six as a medical student, one as a sciencestudent, graduating with a BSc (Med) in 1969,MBBCh (cum laude) in 1973, and 18 months asan intern and senior house officer in the Witsteaching hospitals). Wits welcomed me, and Iwelcomed the opportunities it provided. Little didI understand at the time that certain experiencesat Wits Medical School would serve as thefoundation stones for leadership development.Two of these experiences warrant mention.

In 1969 as a BSc (Med) student I became involvedwith the Association of Medical Students of SouthAfrica (AMSSA), serving on its leadership group fortwo of the next three years. AMSSA was the lastmultiracial students’ organisation, and broughttogether students from Wits, UCT and University ofNatal. The meetings were a hotbed of politicaldebate: a real eye-opener for a naïve 19 year old.Meeting and socialising with students from acrossthe country, with diverse backgrounds, providedimpetus to work for change.

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Second, was the development with twocolleagues, Julian Judelman and Adrian Grek,of an activist newsletter in medical education,New Perspective. In it we challengedconventional wisdoms regarding medicaleducation and brought new ideas to old issues.Some of the issues we raised brought us intodirect conflict with the powers that be.Nonetheless, it proved to be quite an effectivevehicle for change. Unfortunately, NewPerspective lasted only a couple of years after wegraduated and is now just a tiny footnote inWits Medical School’s history.

I am not sure that I can pinpoint specific eventsduring my specialty training that steered me orothers into leadership directions. It was clear,however, that in order to succeed, one had tobuild both credibility and accomplishment.After all, there can be no doubt that the “bestpredictor of future behaviour is past behaviour.”So in order for one’s mentors and peers to takeone seriously in the long run, currentperformance was an essential.

In my estimation, successful academic careersare built on a foundation of content knowledgeplus methodological skills, whether in clinicalor basic science research. The firmer thefoundation, the more that sustainability is builtfirmly into the mix. One additional ingredient isresilience, something that is not easily taught,and, rather, may be an innate characteristic.

As a junior faculty member, the organisationwhich gave me a start in leadership was theCanadian Diabetes Association, starting ontheir Education Committee, and about a decadelater becoming Chair of the Clinical andScientific Section. This led to leadership in thefirst Canadian Diabetes Clinical PracticeGuidelines3 as well as the first evidence-basedguidelines.4 Furthermore, in the early 1990s,I was the driving force behind the developmentof the Network of Ontario Paediatric DiabetesPrograms, which ensured and continues toensure excellent care for all of the children inOntario with diabetes.

The second organisation, the CanadianPaediatric Endocrinology Group (CPEG) wasformed as a result of a number of us advocatingfor the joining together of those paediatricendocrinologists in Canada predominantlyinvolved in growth hormone therapy and thoseinvolved in diabetes. I was first President of the

fledgling CPEG, an organisation whichcontinues to grow and flourish.

The other organisations that warrant mentionare the Hvidore International Study Group forChildhood Diabetes (Hvidore Group) and thethe International Society for Pediatric andAdolescent Diabetes (ISPAD), since both openeddoors for international collaborations that haveproved exceedingly meaningful. The HvidoreGroup was formed in the mid-1990s andconsisted of just over 20 individuals fromprominent paediatric diabetes centres aroundthe world, who gathered once or twice a year todevelop protocols to benchmark childhooddiabetes care in their centres. This group soonbecame an intensely close-knit team, which hashad a major impact on diabetes care worldwideas did many of its individual members. Thefriendships developed across many countryboundaries have been an exciting off-shoot ofthis enterprise.

Joining ISPAD, becoming an Executive member,then President for two years at the time of itsmajor transformation into a seriousinternational organisation, has also been acareer highlight and training ground forleadership development. It is one thing to visitmany places around the globe for medicalconferences, another altogether to be introducedto these places by locals with whom one hasdeveloped a conjoined sense of purpose.

Probably the most fertile ground for leadershipdevelopment has been my home academicenvironment, SickKids and UofT. BecomingHead of the Division of Endocrinology, meantjoining the team of Division Heads in ourdepartment and working closely with twohighly accomplished department chairs, Robert(Bob) Haslam and Hugh O’Brodovich. Then,joining numerous committees opened excitingnew experiences, none more so than the Facultyof Medicine’s Decanal Promotions’ Committee(I was a member for 7 years, the last three asChair of the committee) which adjudicates allfaculty promotions. During this time I got to seethe accomplishments of hundreds of my facultycolleagues, as well as to interact with all thedepartment chairs. What is self-evident is thataccomplishment as well as leadership comes inmany different shapes and sizes. Mostparticularly I was able to see which stylesworked and which did not, and of those thatworked which fitted my personal philosophies.

26

Thus, when the positions of Chair at UofT andChief at SickKids were posted, I felt ready to bea candidate.

Another exceedingly important lesson learnedalong the way was that as a leader I did nothave to provide care to each and every singlepatient, but rather to ensure that outstandingsystems and people were in place to do this. Nordid one have to do every teaching session,mentor every trainee, and so forth.

BEING THERE

When I accepted the job as Chair/Chief, I askedmy two ‘bosses,’ the Dean of the Faculty ofMedicine and the Hospital CEO, whether Ishould enroll in a leadership course. Both saidno, rather read widely, watch others, and askquestions. I questioned my colleagues in thePaediatric Chairs of Canada (PCC) group aboutinnumerable issues, and found that these issueswere pretty well universal.

Along the way there have been opportunities forattending short courses in leadership, boththrough our departmental leadership program,or at annual meetings of PCC, where one day isset aside for a facilitated leadership seminar. Ido not respond to those presenters who appearto have all the answers, much more so to thosewho understand the nature of the questions athand.

As I see it, I play three roles: developing studentand faculty, ensuring excellence in all threepillars of academia, i.e. clinical care, educationand research, and responsibility for thefinancial health of our department. Inapproaching all leadership positions that I havehad, I have tried to live by a number of simpleand self-imposed rules: first and foremost is tohave a set of basic principles which are notnegotiable, or varied according to individualcontext. These include fairness, transparency,forthrightness, and avoidance of favouritism.Second, is to set very high standards: a recentpotential recruit withdrew his applicationbecause he said he was overawed by ouracademic expectations. My response was one ofsignificant satisfaction that at least ourexpectations for academic accomplishmentwere known to be of the highest order. Third, is,wherever possible, to recruit people who are‘smarter than oneself,’ and not be threatened by

their achievements. Finally, as Chief/Chair itshould always be about ‘us,’ never about ‘me!’

Early on in my tenure, I heard the then head ofDisney, Michael Eisner, talk about leadership.He said two things that rang very true: sweat thesmall stuff and have at least one very closeconfidante by whom you can run all new ideaswhich means that all ideas are thoroughlyevaluated before being put into action.

I once heard a talk by Henry Mintzberg, thebrilliant McGill Professor, who is the ‘anti-management’ guru. He talked about the risks oftreating public institutions such as hospitalsand universities like big corporations. I heartilyagree with his differentiation of leadership andmanagement, and his disdain for applying theoften pop-psychology of corporations to ourpublic institutions.

Nelson Mandela, in The Long Walk to Freedom,talks of two methods of leadership: the majorityof the time being the shepherd helping keep theflock moving forward to meet the ambitiousvision and mission we have developed; thesecond, only used when one is certain of thedirection needed and the way to get there, is bypulling the flock forward with you, being waryof getting too far ahead and losing them. Therewere other principles by which Mandela led,including keeping the enemy close, knowinghis/her favorite sport, and not being scared toshow fear.

What happens to the major academic elementsof one’s own career, particularly research, whenone becomes a Department Chair/Chief?Despite significant attempts, often life is just toobusy to manage everything.5 Rather than beingthe shining light in research oneself, the role ofthe Chair is to train the light on younger facultymembers by supporting their careers.

Finally, being Department Chair/Chief hasallowed me to help focus our department’sattention on ‘social paediatrics,’ that is, ensuringthe best outcomes for the disadvantagedchildren in our societies and their families. Thishas occurred through the organisation ofmedical student and resident electives, summerstudentships, global child health research andclinical activities, and by mobilising the PCCbehind this endeavour.6,7 In the process, I havelearned a great deal about how child health andwell-being struggles to find its place in the

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forefront of medical and social agendas. It needsa holistic approach to improving maternalhealth, early childhood experiences and societalchallenges to ensure that the full potential of ournext generations is realized.

ACKNOWLEDGMENTS

What would I do if I had to start all over again?The answer is simple: with some minorvariations, essentially the same. This continuesto be an astonishingly rewarding career. Whydo I use the word astonishing: well, I worriedthat taking on such a leadership position wouldbe isolating and insular, shutting me off fromthe three sustaining pillars of clinical care,education and research. Nothing could befurther from the truth: although more restricted,I still manage to incorporate some of each pillarinto a busy schedule of hospital and universityaffairs. The two aspects of my position that aremost rewarding are: the nurturing of youngfaculty, and the development of ever improvingsystems for delivery of those three pillars. Butone does not do these things alone: academicmedicine is indeed an intensely team sport,members of the team include one’s ‘bosses,’ theUofT Dean and hospital CEO, and theiradministrative groups, one’s own departmentalleadership team, and all its members. Withinthat team there is a strong sense of cooperation.

My family is a tremendous source of support:my wife, Meredyth, has pursued a highlysuccessful career as an academic cognitivepsychologist; and our two sons have been bittenby the academic bug: Nick is an AssistantProfessor in Internal Medicine and an InfectiousDisease clinical epidemiologist at UofT andSunnybrook Health Science Centre, and Rich,an Assistant Professor of Pharmacology andNeuroscience at University of California, SanDiego. The baton has been passed.

When I received my DSc (Med) from Wits inDecember 2013, on the very same day as thememorial to Nelson Mandela, the then ActingDean of the Faculty of Medicine, Sharon Fonn,in a beautifully written citation, said simply“… and his origins are here at Wits!” (Photo2). That phrase describes me perfectly: I oweWits a life-long debt of gratitude for aneducational opportunity that has served mefor my entire career. Wits helped shape melong after I had completed my formaleducation: Once a Witsie …

REFERENCES

1. Oski FA. 1978 Presidential Address of the Society for

Pediatric Research April 27. Pediatr Res. 1978;

12:1145-8.

2. Daneman D, Kellner J. 2012. Navigating the various

stages of an academic career in Pediatrics. Paediatrics

and Child Health; 17:301-303.

3. Expert Committee of the Canadian Diabetes Advisory

Board. Clinical Practice Guidelines for Treatment of

Diabetes Mellitus. 1992. (MH Tan, Chair, D Daneman,

Co-Chair). CMAJ 147: 697-712.

4. Meltzer S, Leiter L, Daneman D, Gerstein H, Lau D,

Ludwig S, Yale J-F, Zinman B, Lillie D. 1998 Clinical

Practice Guidelines for the Management of Diabetes in

Canada. CMAJ 159 (8 Suppl).

5. McCarter R, Batshaw ML. 2006. Is there life as an

investigator after becoming a pediatric department

chair? J Pediatr. Apr;148(4):425-6.

6. Ford-Jones L, Levin L, Schneider R, Daneman D. 2012.

Social Pediatrics Working Group. A new social

pediatrics elective--a tool for moving to life course

developmental health. J Pediatr. Mar;160(3):357-358.

7. Daneman D, Kellner J, Bernstein M, Dow K, Dugas

MA, Duffy C, Eddy A, Filler G, Frappier JY, Gilmour S,

Givelichian L, Huang L, Rockman-Greenberg C,

Shevell M, Vardy C, Walti H, Orrbine E, Williams M.

2013. Social paediatrics: From 'lip service' to the health

and well-being of Canada's children and youth.

Paediatr Child Health. Aug;18(7):351-2.

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The Adler Museum of Medicine has a wellestablished reputation within the Wits Faculty ofHealth Sciences and the broader Universitycommunity. It has branded and strategicallypositioned itself within the Faculty, particularly withregard to pedagogy and research. Because of itscollection, library and archive, over the past yearsthe Museum has attracted a number of researchers.The Museum has in the main been inward looking –establishing and positioning itself in the Faculty, interms of teaching. This inward looking developmenthas been a valuable part of the history of theMuseum and has been one of great contributions ofthe previous Curator. This foundation has securedthe position of the Museum in the life of the Facultyand will help me build its future trajectory.

The inward looking and services approach needs tobe complemented by a comprehensive andmeaningful outward looking approach. Thisredefinition, recoding and positioning will, amongother things, attract new audiences to the Museumand address politics of inclusion and exclusion,access, representation and presentation. The futuretrajectory of the Adler Museum of Medicine is basedon positioning it as a knowledge hub and a systemof knowledge for diverse audiences at different levels.This will facilitate the Adler Museum becoming oneof the leading museums in the world that preserveand conserve the history of medicine/healthsciences. In this manner, the Museum will shape andinform the civil citizens (visitors) in a particular way.This future trajectory is underpinned by the notionof change and continuity. This approach will makethe Museum a contact zone, a space of intellectualengagement, a space of public discourse, a source ofinformation for diverse audiences.

Over the past decades, the Adler Museum ofMedicine has evolved. The aforementionedachievements to date are a product of itsdevelopment and the shape it has taken over theyears. This historical evolution is epitomized bydifferent interventions that characterize its variouscurators at different historical periods. These rangefrom establishing the Museum, creating Museum’ssystems and procedures and striving towards soundcollection management to establish and position the

Museum within the Faculty of Health Sciences andthe University community. These indicators point tothe focus area/s of each curator at different times ofits development as determined by the needs and theprevailing circumstances.

ADLER MUSEUM OF MEDICINEEXHIBITION COMPLEX

The term ‘exhibition complex’ is borrowed fromTony Bennett (1995), who used it in reference to the“Great Exhibition of 1851” that transformedmuseums from simple, private spaces, cabinets ofcuriosity, to complex, more public and open spaces.Prior to the mid-19th century, the institutional natureof museums and exhibitions was based on class, asthey were spaces that were visited only by thearistocracy.1 This means that before the mid-19th

century, particularly before this exhibition,museums were private spaces, cabinets of curiosity,not public spaces. The “Great Exhibition of 1851”caused a shift in as far as the institutional nature ofmuseums and their exhibitions were concerned. Thisexhibition, which was not based on class, displayedthe products and the industrial equipment thatcaused the working class to become subjects, notobjects, of the exhibition.

In this article, the term is used in relation to theimages and gazes that a visitor encounters at theAdler Museum of Medicine and represents its masternarrative. The key gazes of the Museum include the“Highlights of western medicine” display. Thisexhibition presents the overview of the evolution of“western” medicine within the context of threeindicators. These are treatment, knowledge anddisease. This three dimensional interpretationframework of the medicine geography asdemonstrated hereunder presents key points in thehistory of medicine.

There are multidimensional approaches that can beused to interpret and present the history of medicine.These include a Marxist approach which is class-based in its interpretation, a social history approachwhich focuses on triangulation approach: social,economic and political contexts a gender approach

From the Curator’s Desk: Into the future: change and continuity

Luvuyo Dondolo

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which is gender-based in its interpretation, and amedicinal approach which focuses mainly on theevolution of medicine. These approaches to theinterpretation of the history of medicine have theirown challenges and the Museum opted for the latterapproach - a medicinal approach that focusesmainly on the evolution of medicine - as illustratedin Figure 1.

This display is also important because it is thestarting point for the Museum’s guided tours andintroduces the master narrative. It lays the base forthe subsequent displays which focus on differentthemes/topics of medicine/health sciences. Thepolitics and poetics of purity, regionalism andnaming/terminology manifest themselves in thispermanent exhibition. For instance, the term‘western’ medicine, which has regional undertones,is exclusive and gives a perception that there issomething purely ‘western’. The term is loaded,politically and epistemologically and more complexthan it might seem. The presentation of the ‘western’medicine geography is pretexted on racial, regionaland superiority knowledge production with itssubtext of ‘us’ and ‘them’ which was a commonfeature of colonial and apartheid discourse.

From this exhibition, the visitor then moves to themicroscopes display. The exhibition presents thedevelopment of microscopes and the changes theyhave undergone over centuries to the most recentand technological advanced ones. Microscopes havebeen central in the evolution of medicine.

Another key image of the Museum is the HIV/AIDSexhibition entitled “Confronting HIV/AIDS”. It givesan overview of HIV/AIDS as a virus, its sociology,development and key highlights nationally andinternationally. This informative display is viewedby various visitors and seems to be appealing tonursing and medical students. The exhibition,however, presents a racialized narrative of theepidemic as it is portrayed as a black people’s virus.Correctly so, statistically there is a high number ofblack people with HIV/AIDS. But South Africansacross the colour line have been diagnosed with itand ought to be presented as such. This exhibition’snarrative - which in line with the dominanthomogenous and monolithic master narrative ofHIV/AIDS in South Africa - perception and viewabout Africans’ sexual behaviour and them as thecarriers of HIV/AIDS, is trapped in the politics andtensions of presentation, display and staging. As

Figure 1: Highlights of western medicine exhibition

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Just as in the case of the exhibition entitled“Highlights of western medicine”, the term“alternative” is complex with many meanings,connotations and possible interpretations. Thequestions arise: alternative for whom? alternativefrom what? Is it incidental that the “AlternativeMedicine Exhibition” is displayed at the back interms of the Museum space and layout or has it todo with the long racial history of space allocationin public places which was experienced in SouthAfrica and in countries like the United States ofAmerica? Most recently, information that wasreleased by Statistics South Africa and the WorldHealth Organization revealed that a high numberof South Africans consult so-called ‘traditionalhealers/isangoma’ regularly, even though South

Africa is perceived to be modernand ‘western’. According toCoombes: “Past policies alsoresulted in the banning oftraditional medicine, despite thefact that over 80% of SouthAfricans depend upontraditional herbal remedies fortheir primary health care”.2 Thisview is also shared by Ilse Truteras she pointed out that: “It isestimated that 70% to 80% of thepopulation in Africa makes useof traditional medicine. Also inSouth Africa, it is estimated thatbetween 60% and 80% of peopleconsult a traditional healerbefore going to a primary healthcare practitioner. Furthermore,African traditional healing isintertwined with cultural andreligious beliefs, and is holistic innature. It does not focus only onthe physical condition, but alsoon the psychological, spiritualand social aspects of individuals,families and communities”.3 Thisarticle is not intended to enterthe debate about the regular useof traditional healers as againstprimary health care, but toillustrate the complexity of theterm ‘alternative’ in the Africancontext.

If this is the case, is that an‘alternative’ or do people useboth depending on theirpreferences or what they deemappropriate at a particular time,Figure 2: Abu Ali Al-Husain Ibn Aboallah Sina (Avicenna) exhibition

part of this exhibition, a timeline has been used todepict the key highlights of HIV/AIDS not only inSouth Africa but throughout the world.

From this exhibition, the visitor moves towards theback of the Museum where an “Alternative MedicineExhibition” is displayed. It is made up of someaspects of medicine from various groups of people.These include the African Herb Shop, Abu Ali Al-Husain Ibn Aboallah Sina (Avicenna) (Figure 2),Scientific Medicine, Chinese Traditional Medicine,Ayurveda, Unani/Tibb Medicine, Tara Rokpa:Traditional Tibetan Medicine, Western HerbalMedicine, Homoeopathy, South African TraditionalHealing and Those whom the ancestors have called:Traditional healing in southern Africa (Figure 3).

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depending on their circumstances and the natureof their illness? The term, therefore, is not merelycomplex with different meanings but may also bemisleading.

Furthermore, the politics of layout or locationmanifest in the exhibition’s location at the backof the Museum which makes it an alternativefrom the western medicine exhibition. Thedominance of western medicine is implicit both inthe exhibition and in terms of space and location.Based on the aforementioned pointers thisexhibition is what I would term the “modernethnographic gazes”.4 The alternative medicinenarrative includes a display about Isangoma. Theexhibition depicts the practice according to itsinformant, the late Mr Maseko. A contrastbetween this display and the medical doctor one isthat to be a medical doctor is a career while to beIsangoma is a calling as not everyone can be one,only those who have been called by the ancestorsand/or possess supernatural gifts.

The “Those whom the ancestors have called:traditional healing in southern Africa” exhibitionpresents the process isangoma undergo fortraining and there is a reconstructed consultation

room. The display attemptsto be balanced, however, thereconstructed consultationroom and the contextualframework triggerquestions. These range fromlack of provision ofinterpretation of mostdisplayed objects whichhave meaning and value;dress code and colours andpatterns of beads; to thesociology of isangoma as apractice. In addition, theabove discussed images ofthe Museum, particularlythe “Alternative MedicineExhibition” and isangomadisplay also demonstratepitfalls of an add-onapproach that is mostlyseen as the easy way toshow change andtransformation without atransformative conceptualframework.

In between the “AlternativeMedicine Exhibition” and

“Traditional healing” exhibition there is anexhibition entitled “Poliomyelitis – The Dread ofYesteryear”. It projects the history of poliomyelitisand the equipment that was used, and thedevelopments associated with it.

The last key images for visitors is based on the tworeconstructed consultation rooms – a doctor andan optometrist, and lastly, a reconstructedpharmacy.

These visitor gazes are complemented bytemporary exhibitions and outside displays in thefoyer of the Faculty of Health Sciences building,and education programmes for mainly healthsciences students and learners of different agegroups. All these constitute the master narrativeof the Museum which is premised at safeguarding– conserve, preserve, research, present andmanage the history and heritage ofmedicine/health sciences.

To date, a lot of work has been done in as far asthe Museum exhibition complex is concerned.However, there is a need to widen the audiences, tocoherently and comprehensively serve all its“imagined communities”5 and to address the

Figure 3: Traditional healing in southern Africa display. Photograph from the AdlerMuseum of Medicine

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politics of display andpresentation. The rationale forthe Museum to focus more onserving the Universitycommunity is understandablebut this is inward looking andneeds to be complemented byan outward looking (i.e.outreach programme,awareness days, mobilemuseum etc.) that considersother members of itscommunities that are not basedat the University. We need toshowcase balanced gazes andengage in outreachprogrammes, particularly amobile museum, that targets thepreviously economicallymarginalized communities,appealing to learners especially.This will assist in redefining andrepositioning the Museum inrelation to its appeal in diversecommunities and itscontribution to socialtransformation in post-apartheid South Africa.

This past, present and futurecontextual framework informsthe notion of change andcontinuity at the Adler Museumof Medicine. Changes relate tothe vision, philosophy,approach and conceptualframework while continuityapplies to what is deemed to besignificant to be carried over tothe present and the future.

THE MUSEUM’S FUTURETRAJECTORY

My vision for the Adler Museumof Medicine is for it to become aknowledge hub for learning,teaching and research fordiverse audiences, and be one ofthe leading museums thatcollect, preserve, exhibit anddisseminate information aboutthe history and heritage ofmedicine/health sciences in theworld by 2020.

Figure 4: Reconstructed doctor’s consultation room

Figure 5: Reconstructed optometrist’s consultation room

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The concept of a knowledge hub depends on itsfundamentals. An effective knowledge hubinvolves people, process and infrastructure(technology, displayed and not displayedinformation or collection etc.). Knowledge is afluid mix of framed experience, values,contextual information and expert insight thatprovides a framework for evaluating andincorporating new experiences and information.It is in this context that knowledge is intrinsicallylinked to human thought and experience (themuseum visitor’s experience).

Furthermore, there are two types of knowledge.These are: (i) Tacit Knowledge which refers tointernal information, thought processes,experiences and accumulated knowledge that isheld within the minds of individuals (‘soft’knowledge); and (ii) Explicit Knowledge thatrefers to codified information such as exhibitions,books, documents, journals, legislation, visualand audio recordings, digital text, email andinternet.6

All these ingredients will assist in positioning theMuseum as the knowledge hub, a system ofknowledge and a space of interaction, publicdiscourse and conversation. This knowledge isproduced in multidimensional ways like displays,non-displayed collection, museum tours,education programmes, and library and archives.

The Museum through its systems of knowledgewill gather, generate and disseminate knowledgeabout the history and heritage of health sciencesfor diverse audiences. The strategic pillars of theknowledge hub with its sources of knowledge

include: infrastructure(displays, collection),governance, library andarchives, and learning andsharing (and research).Through this system ofknowledge the Museum will beone of the leading museumsthat preserve, conserve andshowcase the history andheritage of health sciences.

The key elements in theaspiration of becoming aworld class museum,preserving, conserving andshowcasing the heritage ofmedicine include:

• quality of the visitor experience; • fulfilment of the educational mandate; • deepening social consciousness;• institutional reputation (through excellent,

balanced and quality exhibitions andpublications);

• effective management of priorities andachievements;

• diverse staff of high calibre and a broad range ofskills;

• good governance; • sound collections management ensuring a wide

scope and excellent quality; • scholarship which enhances public discourse.

The Adler Museum knowledge hub will mirror theUniversity’s vision and mission commitment tobecoming a “Leading research-intensive university,intellectual excellence, international and nationalcompetitiveness and local relevance.” This hubmust also function as a space of engagement,dialogue and interaction for different segments ofits diverse communities, advancing socialengagement.

The future of the Adler Museum of Medicine willencapsulate meaningful and comprehensiveinclusion of the ‘other’ through presentation,interpretation, and representation. It hopes to taketransformation beyond staffing equity and add-onexhibitions through to content and contextchanges. This promotion of change will have aclear transformation conceptual framework,objectives and measurable targets.

Coombes in her book entitled History afterApartheid: Visual Culture and Public Memory in

Figure 6: Reconstructed pharmacy. Photograph from the Adler Museum of Medicine

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a Democratic South Africa, particularly a chapterentitled New Histories for Old: MuseologicalStrategies, identified certain museums tohighlight the need for transformation,particularly with regard to their exhibitions andimages positioning in the present (need to beinclusive).7 The exhibitions of the institutions sheidentified and institutions themselves attemptedto address the issue of historical imbalances.However, Coombes fails to show or understandthat the democratisation of museums sheidentified is hampered by the approachunderpinning their exhibitions which is an add-on approach. It is imperative to consider the formand shape the democratisation of museums take.If not taken into account, this might undermineand devalue the initiatives and programmesaimed at redressing historical imbalances. Thus,there is an element of denial, convenient amnesiaand production of “modern ethnographic gazes”about certain aspects of culture, heritage andhistory.

The term ‘transformation’ is used here to denotefundamental changes in the structures,institutional arrangements, policies, modes ofoperation and relationships within the museum.Transformation of our society calls for its re-orientation from the past values and practicesdefined by racism, sexism, inequality and lack ofrespect for human rights towards the valuesreflected in our national constitution.8 The abovepresented Adler Museum of Medicine ExhibitionComplex has made efforts to be inclusive andrepresentative. However, there is still a need for amore transformed museum space with a clearapproach and conceptual framework. This willaddress politics of display, presentation,interpretation, space and location. Thetransformation of museums and their practisesought to entail a complete alteration in both formand substance; and a successful transformationwould be typified by the antithesis of theconceptual framework of the current AdlerMuseum of Medicine exhibition complex.

CONCLUSION

This article critically examined and depicted thecurrent state of the Adler Museum of Medicinethrough a reflection on its exhibition complexwithin a context of a space in transition and at thecrossroads. The crossroads at which the Museum isat is made up of establishing, positioning andrelevancy of the Museum in the Faculty of Health

Sciences, serving its off-campus communities(outward looking), social consciousness through abalanced exhibition complex, and meaningful andcomprehensive transformation. It also highlightedthe dilemma, challenges and politics of spacelayout and design, display, representation andpresentation, dialectics of transformation, tensionsand contradictions that manifest at this space intransition and at crossroads.

It also moved into the future through continuityand change concept. This space in transition andcrossroads needs to move away from demarcatedaspects of heritage and displays, modernethnographic gazes, and add-on approach as atransformative conceptual framework towardsholistic, balanced, sound and more all-encompassing images and social consciousness.Based on its collection, the Adler Museum ofMedicine has social and intellectual capital, andlegitimacy which we should use for both inwardand outward looking. In transforming as we moveforward, this social and intellectual capital,grounded exhibition complex and sound museumservices will not only enhance the credibility of theMuseum but also become key ingredients of thenew era.

REFERENCES

1. Bennett T. (1995). The birth of the Museum: History,

Theory and Politics. Routledge, London & New York.

pp 25-228.

2. Coombes AE. (2004). History after Apartheid: Visual

Culture, Public Memory in a Democratic South Africa.

Wits University Press, Johannesburg. pp 150.

3. Truter I. (2007). African Traditional Healers: Cultural and

religious beliefs intertwined in a holistic way. Drug

Utilization Research Unit (DURU), Department of

Pharmacy, Nelson Mandela Metropolitan University, in SA

Pharmaceutical Journal, September. pp 56-60.

4. Dondolo L. (2007). “Intangible Heritage: The Production

of Post-Apartheid Memorial Complexes”. Presented at the

African Religion Workshop entitled “Empowering the

Youth Through Heritage” at Icamagu Institute in Dutywa

(Eastern Cape), 29 December. pp 98-127.

5. Anderson B. (1983 & 1991). Imagined Communities:

Reflections on the Origin and Spread of Nationalism. Verso

Publishers, London. 2: 3-21.

6. Amathole District Municipality. (2014). Knowledge

Management Plan 2014-2017, East London. pp 12-14.

7. Coombes AE. (2004). Op cit, pp 160-201.

8. Ramphele M. (2008). Laying ghosts to rest: dilemmas of

the transformation in South Africa. Tafelberg Publishers,

Cape Town. pp 13-27.

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This is a biography about Dr Erika Sutter, a Swissophthalmologist who spent 32 years working inElim Hospital, which is situated in an area that isnow known as Limpopo.

Dr Sutter’s life’s work lies in her commitment tosocial issues, foremost of which were theprevention of blindness and the promotion ofcommunity health care and development.

“Her story” is told by a friend, Gertrud Stiehle,who persuaded Erika to confront her past,opening up more personal issues and revealingher interests and motivations. Erika’s previousbooks were more academic, with an emphasis onthe role of others in the community.

The foreword is written by Mamphela Ramphelewho describes herself as “fortunate for havingencountered this remarkable woman as acolleague, a mentor, a friend and a fellow globalcitizen”.

The book also includes a chapter by Frances Lund,Associate Professor in the School of BuiltEnvironment and Development Studies,University of KwaZulu-Natal.

The book (soft covered and A4 in size) makes easyreading and is illustrated with some wonderfulblack and white photographs.

Born in Basel, Switzerland in 1917, Erika is one ofthe last Swiss South Africa Mission fraternalworkers to have stayed so long in South Africa.

As her parents encouraged intellectual andcultural ideas, Erika developed a keen sense ofsocial disparities from an early age. She chose acareer in natural sciences over social work andtheology (her parents were agnostics).

While working in Sweden, Erika committed herselfto becoming a missionary, and joined the SwissMission in South Africa, taking up the post of alaboratory technician in 1952 at Elim Hospital.Thus in spite of being a botanist, after six monthsof medical laboratory training, she found herselftesting sputum for tuberculosis, urine for bilharzia,stools for other parasites, blood samples for malariaand syphilis. In addition, she was responsible forthe performance of all X-Rays.

After a conversation with a superintendent from aneighbouring mission station who commentedthat: “spending a lifetime working in thelaboratory didn’t suit her”, she decided to studymedicine.

Erika Sutter: Seen with Other Eyes Memories of aSwiss Eye Doctor in Rural South Africa

Author: Gertrud StiehleYear of publication: 2014 – published in English (originally published in 2011 in German)

Publisher: Basler Afrika Bibliographien. ISBN: 978-3-905758-33-7. Reviewer: Dr Nicky Welsh

Book Review

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From 1956 – 1961 she was enrolled as a medicalstudent at Wits University. While pursuingopportunities in Basel to continue training inObstetrics and Gynaecology, she received a letterasking if she would take over the Elim EyeHospital. Dr Odette Rosset who had built up theEye Hospital, wanted to retire along with herhusband, Dr Jean Rosset, the Superintendent. As aresult Erika underwent specialist training inSwitzerland, returning to Elim in 1965 as a fullyqualified ophthalmologist.

She worked in an era during which racialsegregation had been imposed under colonialrule, and was systemized by laws after 1948. As acommunity development pioneer she faced thechallenges of political engagement and struggles,striving not to let apartheid interfere with herwork. The Rev Beyers Naude had a profoundinfluence on her.

Furthermore, she sought to address the issue ofpatriarchy in the missionary and medicalsocieties.

Three important projects that she establishedwere:

1. Diploma in Ophthalmic Nursing. Erika addeda training school in eye care for ophthalmicnurses, within her department at ElimHospital. A nursing school for Africans, withofficial accreditation from the South AfricanNational Nursing Council, had been inexistence at Elim since 1933.

2. The Rivoni Society for the Blind.3. Care Groups – for which she is the most well

known.

Initially she tried to practise the best possiblecurative medicine as was the norm in a missionhospital, but, motivated by the high incidence oftrachoma seen in patients from the area, sheembarked on a more community healthapproach. The essence was to mobilise localwomen to form groups in which they could spreadtheir newly acquired knowledge about trachomawithin their own area. They were visited regularlyby a facilitator who had been trained by Erika.These Care Groups are still functional and nowinclude HIV/AIDS in their work.

She remained single all her life, with thesuggestion that the care givers provided asurrogate family for her. She battled withdepression, dealing with a family history ofmental illness, and feelings of neglect by hermother during her childhood.

Brave, dedicated, committed, determined andsingle minded, she sometimes took risks thatmade her unpopular. Notably, she has beendescribed as a better team worker than a leaderby nature.

Erika retired in 1984 aged 67 years, having livedher life in the service of humanity. She movedback to her hometown of Basel. She is 97 years oldnow, and in a cruel twist of fate is almostcompletely blind from glaucoma.

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Letter to the Editors

To the Editors

In the Editorial of December 2014, titled Wanted – Alaunch pad,1 it was Professor Davies’s opinion that ‘asuitable launch pad for a major health project can onlybe found within the existing health service’.

The term ‘local leadership’ refers to what I believe is amajor factor for improving health services, especially ruralservices. His 2009 Editorial2 identified this item: ‘Strongerleadership and greater local accountability’.

In 1977 I joined the Head Office of the Department ofHealth in the ‘independent’ Transkei, to support the newSecretary, Dr Charles Bikitsha, who had been head-huntedfrom general practice in the UK. My aim, which heaccepted, was to promote primary health care from HeadOffice. The Department held regular general meetingswith the medical superintendents of all hospitals, mostlymission hospitals. The official attitude was that thesemeetings were for conveying head office policy andrequirements. Over time I tried to change it to that ofdiscovering their needs and how to support them. Thatwas when I began to see that health service developmentshould be a bottom-up rather than a top-down process,and that local leadership is the key. The top should enablethe bottom rather than try to run it.

At All Saints Hospital, near Ngcobo, we developed aprogramme for the training of district clinic nurses,reflected in a handbook. When based in Mthatha, Icombined the results of such work at All Saints, Rietvlei, StLucy’s and St Barnabas Hospitals and recommended tothe Head of Transkei Nursing Services using such acurriculum to establish a diploma with the TranskeiMedical Council. I saw such a process as an example ofthe positive side of Transkei’s ‘independence’, but sawwhat happened as an example of ‘top-down’ failure. Thesaid Head preferred to stay in line with RSA’s much lesspractical Diploma in Community Nursing.

Today development of all kinds dominates our politics,our news, and our thinking. Increasingly, I have beenstruck by what I shall call ‘the reality gap’ between thelevel at which so many administrative and executiveconferences and meetings of all sorts examine andpronounce on policy matters, and the ‘coalface’ whereissues have to be handled.

It was a pleasing coincidence that there arrived, soon afterthe Editorial I refer to, an SAMJ with Chris Bateman’sarticle: Honing healthcare leaders' competence andattitudes equals facility-level delivery.3

Under his sub-heading The power of one, and appropriateto my point, Bateman reports that the University of CapeTown has recently set up an Academy of Leadership andManagement of Health, and that Marilyn Keegan of theCouncil for Health Services Accreditation Southern Africa

(COHSASA) said that even when given standards athospitals “ … but nothing happens … the missing factoris a good manager or leader”. Anton Le Grange, head ofthe Foundation for Professional Development, is quoted assaying: “We teach them how to be leaders, what asupervisor is, how to present yourself.” Under his final sub-heading: Leading under ‘conditions of complexity anduncertainty’ he reports that the primary aim of the 5-dayStellenbosch course is to explore, analyse and unpack theadvanced topics in current leadership thinking as itapplies to the healthcare system.

Local leadership becomes even more critical whengovernment, central or provincial, lacks functionality andfails in the execution of its responsibilities. I recall thatRobert Kaplan’s book: The Ends of the Earth: Journey atthe Dawn of the 21st Century, published in 1997,4 is adetailed and prophetic account of his backpacking travelsthrough Africa and the Middle and Far East as heexperiences the state of the societies he passes through.Although overpopulation and environmental degradationdominate his conclusions, he has observations relevant tomanagement at the local level under difficult conditions.

Professor Ian Couper of the Centre for Rural Health (CRH)at Wits kindly sent me their Biennial Report (2012-2013).5

It presents a big range of local and internationalorganisations concerned with rural health: theircollaborations and the CRH’s own training and support toregional rural health services. In the Report itself I find thisreference to the question of leadership: that in February2012 CRH hosted a joint workshop, followed byconferences, with Monash University on the developmentof rural clinical academic leadership.

Which is why I conclude with the suggestion that youinvite CRH to make a ‘launch pad’ contribution to theBulletin, to show, more specifically than their Reportallowed, how their own experiences and support of theneed for well-defined local leadership overcame thereality gap.

Dr Ronald IngleRetired, formerly Superintendent, All Saints Hospital

REFERENCES1. Davies JCA. 2014. Wanted — A launch pad. Adler Museum

Bulletin. 40 (2): 1.2. Davies JCA. 2009. South Africa’s Health Service: time for a re-

think. Adler Museum Bulletin.35 (2): 2.3. Bateman C. Honing healthcare leaders' competence and

attitudes equals facility-level delivery. S Afr Med J, 105(2):85-86.4. Kaplan R. 1997. The Ends of the Earth: A Journey at the Dawn

of the 21st Century. Papermac, Great Britain. 5. Wits Centre for Rural Health. Biennial Report 2012 – 2013.

Available from: <http://www.wits.ac.za/academic/health/entities/ruralhealth/10103/annual_reports.html>

38

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Dr Frack had been a member of the 1919 Class, theTin Templers.1

It did not, however, include anything about osteology,for bones would have doubled the size of The PocketGray.2

Direct quotes should be in italics or in invertedcommas

Military medicine, surgery, and nursing were matterstoo important to be left to private charity, howeverwell intended….3

“The tenth edition of Aids to Anatomy appeared in1940…. It had been edited by Professor Stibbe, who,sadly, in 1923 left the University of theWitwatersrand.”4

References

1. Melzer R. 1980. “The Tin Templers;” or the class of1919. Medical School Johannesburg. AdlerMuseum Bulletin. 6(2):15-21.

2. Cotterell E. 1879. The Pocket Gray. Ballière,London.

3. Hutchinson JF. 1990. Medical opponents of the RedCross. XXXIInd International Congress on theHistory of Medicine Abstract Book. p 75.

4. Lucas MB. 1990. Highlights of the Adler MuseumCollections - Serendipity and Gray’s Anatomy: ThePocket Gray. Adler Museum Bulletin. 16(3):18.

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