foundation chair in hygiene. At the outbreak ofthe American Civil War she organised the NationalSanitary Aid Institute and chaired a registration com-mittee for the training and deployment of nurses.

Although Elizabeth remained single throughout herlife, she adopted a 7 year old orphan.* When Elizabeththought that her various American enterprises wereable to fend for themselves she settled in the south ofEngland in Hastings. In 1875 she became professor ofgynaecology at the London School of Medicine for

*Kitty Barry lived with and helped "Auntie" Blackwell through-out her long life. She returned to America in 1920 and died in1936.

Women and she took an active part in the agitationagainst the contagious disease acts, a nasty piece ofVictorian legislation which permitted the detentionand forcible examination of women suspected ofhaving venereal disease.

Elizabeth Blackwell lived on to see many otherwomen follow in her footsteps. By 1889 there were3000 registered women doctors in the United States,and today thousands of women doctors graduateworldwide each year. Elizabeth continued writingthroughout her life and visited America for thelast time in 1906. She died in Hastings in 1910 aged89.

Death of a heart surgeont reflections on press accounts of the murderof Victor Chang

Deborah Lupton, Simon Chapman

Victor Chang-portrayed as asecular saint

Centre for Applied SocialResearch, School ofBehavioural Sciences,Macquarie University,North Ryde, New SouthWales, AustraliaDeborah Lupton, MPH,senior research officer

Department ofCommunityMedicine, University ofSydney, WestmeadHospital, Westmead, NewSouth WalesSimnon Chapman, PHD, seniorlecturer

Correspondence to:Dr Chapman.

BMJ 1991;303:1583-6

On 4 July 1991 Australia's most prominent heartsurgeon, Dr Victor Chang, was murdered in a bungledextortion attempt by gunmen in a suburban street ofSydney. The murder generated massive news coverage,far in excess of that accorded to any ordinary murder.For days almost all the Australian media ran lengthylead stories on the killing, on Chang and his work, onthose who mourned him, on speculation about hismurderers, and on their eventual arrest. Aspects ofChang's work had long attracted wide publicity, givinghim great prominence in Australian public life. Hismurder was thus not just the murder of a man or of anydoctor, but the murder of a very public medical figure.

Chief among the themes which dominated Chang'spublic profile were his work with transplantation andartificial hearts. The identity of some of Chang'spatients and their medical problems, recovery, andgratitude to him had been widely publicised. Some,including politicians and media baron Kerry Packer,already had public identities-their status as Chang'spatients simply added another layer to their publicpersonae. Such publicity positioned Chang as thesurgeon chosen by Australia's richest and most famous.Others, like teenage heart transplant recipient FionaCoote, became national celebrities as a consequence ofbeing treated by Chang. Background articles thataccompanied the news stories of his death and itssequelae concentrated much of this public profile.

Chang's death as newsWhat was it about the combination of Victor Chang

the man, his background, his work, his patients, andthe circumstances of his murder that the Australianmedia instantly identified as a major story? This paperexamines in detail the press reportage of Chang'smurder. The manifest content of the reportage was"the murder of a heart surgeon," but, as we willshow, the rhetorical devices employed to depict andeditorialise Chang's death were redolent with symbolicimagery and subtextual meanings. Examination ofthese devices reveals much about wider ideologiesconcerning the social importance of doctors (par-ticularly surgeons), medical technology (especiallytransplantation and artificial organs), the body asmachine, and the heart as an elite and highly symbolicorgan. The huge media interest in Chang's m-urderpresents an opportunity to examine the processes bywhich such ideologies are reproduced in popularculture and an opportunity to reflect on the interestswhich they both serve and, as a corollary, deny.

Events are considered newsworthy if they concernelite persons or nations, are dramatic, can be person-alised, have negative consequences, and are part of anexisting newsworthy theme.' Chang's murder fulfilledall these characteristics. As a heart surgeon he was amember of an elite occupation that enjoys one of thehighest social standings in Australian society. Hisdeath was 'highly dramatic, involving elements oftragedy (the sudden and violent death of a kind andbrilliant man capable of saving other's lives), of amystery (who were his killers, what was their motive?),and suspense (when were the murderers going tobe apprehended?). Because Chang had a wife andchildren, as well as many colleagues and patients wholiked and respected him, his death could also beportrayed in personal terms. His death had negativeconsequences because it robbed Australia of an experi-enced, successful, and innovative heart surgeon whocould save lives; his work developing an artificial heartwas cut short. Finally, the story could be slotted intoseveral wider newsworthy themes: the heroism of heartsurgery, the tragedy of violent crime directed againstinnocent individuals, the sudden death of a lovinghusband and father, and the success story of the rise toprominence, wealth, and social standing of an Asianimmigrant who arrived in Australia as a youth with apoor command of English and achieved rags to richessuccess in a strongly egalitarian society.

All of these themes can bear more detailed analysis.We have chosen to explore the first, the heroic natureof heart surgery, in greater detail, discussing themanner in which the popular press "made sense" ofChang's murder and placed it on the cultural map ofmeaning as an obvious news story. Little is random inthe process whereby particular events are deemed byjournalistic cultures to be newsworthy and to traversethe pathway from arcane, behind the scenes scientificor medical event to publicised media release and on toselection, headlining, and publishing or broadcast bythe media. A vast literature about media analysiscontends that the way in which phenomena are bothselected and represented in the mass media facilitatesthe reproduction ofcertain ideologies that serve variousinterest groups. We have adopted this approach tounderstand why Chang's death received the massivemedia attention it did.

Doctors as heroes in the mediaIn Australia doctors enjoy the highest social status,

although media reports of overservicing, doctors'

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strikes, and medical fraud have tarnished this imagesomewhat of late.2 The image of the family doctor as acrusty yet benevolent middle aged man who is a pillar ofsociety predominates in the popular culture. Thecasting ofDr Sharp senior in the high rating Australiansoap GP is clearly drawn from such an archetype.Both the popular media and pharmaceutical adver-

tising have been instrumental in perpetuating thisimage of doctors for the population at large andreflecting it to doctors themselves.`8 Often in drugadvertisements "physicians are depicted looming largein the background of a patient's life ... symbolicallyprotecting or encompassing the patient." and by theirplacement in photographs, "physicians' status andauthority are affirmed. They are usually positionedhigher in the photograph than others, high physicalplace symbolising high social place."I Many drugadvertisements are oriented to technology, withphysicians shown as "manipulators of technologybehind the scenes.... The tendency is to showbrightly-coloured, high-tech imagery, such ascomputer simulations. "I

Doctors in American television dramas are portrayedas successful, benevolent, knowledgeable, andauthoritative, with almost mystical power to dominateand control the lives of others.3 They are commonlydepicted as miracle workers, able to solve all patients'problems and transform their lives,6 or as "LoneRanger" or "Superman" figures, able to restore orderand justice from chaos.9 Australian press reports of thedeath of Victor Chang presented images of doctorswhich conform to these stereotypes.

Chang as humble saviourOne of the dominant themes in accounts of the

murder was the portrayal of Chang as a hero, saviour,saint, lifesaver, able to bring people back to life fromdeath. Despite his wealth and status Chang wasportrayed as caring, unassuming, and hard working.Reports likened his death to that of John F Kennedy(Sydney MorningHerald, 5 July 1991). Articles referredconstantly to his brilliance and great talent. Headlinesspoke of"A genius, a saint and a father" (Australian, 11July 1991), "An energetic man of vision" (MelbourneAge, 5 July 1991), "A humble man full of ideas"(Australian, 5 July 1991), "A brilliant giver of life"(Sydney Morning Herald, 5 July 1991), "A man in amillion" (Sydney Daily Telegraph Mirror, 5 July 1991),"Dynamic and a multimillionaire-a born optimistwho was living a medical dream" (Sydney SundayTelegraph, 7 July 1991). Chang's murderers were saidto have "robbed others" of life and Australia of one ofits finest researchers, and "the nation" was said to begrieving about his untimely death; "Nation mournsVictor Chang" (Sydney Morning Herald, 5 July 1991).The following editorials are illustrative. The first

uses the words rare talent, elite, ability to give newmeaning, international, brink of perfecting, and dream-all of which connote importance and an almostmessianic quality and support the image ofChang as noordinary man.

Death robs the world of a rare talentThe death of Dr Victor

Chang has robbed a worldfar wider than Australia ofa man of rare talent. Hewas a member of an elitecompany of internationalsurgeons with the ability toextend and give new meaningto lives threatened and dis-torted by cardiovasculardisease, the scourge of

modern man.... From dawnto dark and beyond he toilednot just with his patientsat St Vincent's Hospital butin his research and develop-ment work. He was on thebrinik of perfecting an arti-ficial heart, a dream of manybrought close to reality bythe ceaseless, questing talentof Victor Chang.

(Sydney Daily Telegraph Mirror, 5 July 1991)

Such rhetoric is evidence of the exalted status ofheart surgery in modern Western society. Heartsurgery is commonly presented as heroic, dramatic,life saving, miraculous. It is probably the most reveredform of medical endeavour, for its results seem sodramatic for those who are certain of death. It appearsto offer them another "lease of life."

How the St Vincent's team worked:heartbeat that moved mountains:insiders could feel the magnetism

In the early days of the surgical gown he had worn toheart transplant team there the theatre. All the surgeonswas always a kind of electricity were excited. There was aat the weekly meetings when- feeling of high drama whichever the surgeons had come was explained as Dr Changstraight from an operation. It went through the events ofcame from Victor Chang. The the early morning hours,charge he felt after a trans- including the mid-operationplant would excite the room crisis when Scott's heartof 30 or more people. Victor stopped beating. The surgicalChang endured 12 hour shifts team brought him back to life,with enthusiasm and tireless and eventually a completeenergy.... The morning of recovery. That was the10 year old Scott Campbell's mission at the core of Victoroperation in September 1984, Chang's life. To use his skillsDrChangcame to the meeting to restore as many people asfull of energy but looking possible to health. He said itstired and blood-stained. He job satisfaction was unbeat-was still wearing the green able.

(Sydney Sunday Telegraph, 7 July 1991)

In this editorial hyperbole such as "heartbeat thatmoved mountains," the couching of the heart surgeryprocedure in a dramatic, breathless style, the use ofsuch words as electricity, charge, energy, high drama,crisis, and mission give a sense of urgency andexcitement.

Personalisation was another stylistic device wherebypress accounts reproduced the figure of Chang assaviour and hero.

Another story was accompanied by a photograph ofChang in the operating room wearing a surgeon'sgown, with a large theatre light like a halo above hishead.

Patients mourn a friend and saviourDr Chang's most famous

heart transplant patient, MsFiona Coote, was still tryingto come to terms with hisdeath last night. "I can't graspit. It's just so senseless. Henever hurt anyone...."Ms Coote was only 14 andcritically ill when she hadthe first of two heart trans-

plants. Now 21, she hasbecome the most obvioussymbol of Dr Chang's suc-cess, going on to becomea model and television per-sonality. "Victor was not onlymy doctor but my friend, andI just can't believe thatanyone would want to harmhim," she said.

(Australian, 5 July 1991)

The assertion in these reports, reminiscent of Biblicalparables of the miracles performed by Christ, was thatwithout Chang these people would have died long ago.He was their saviour, and it is a tragic irony that hehimself is now dead. Importantly, those who did not

BMJ VOLUME 303 21-28 DECEMBER 1991

Patients stunned by brutal wasteGeoffrey Monk's heart saved Mr Monk's life.... Mr

condition left him only two Monk could not believeweeks to live in 1984. But Dr yesterday that the man whoVictor Chang gave him a new twice saved his life was dead.heart and a new life. It was the "Australia has lost one of itssecond time Dr Chang had greatest," he said.

(Sydney Morning Herald, 5 July 1991)

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survive a heart or lung transplant-Chang's "failures"-received no mention in the press.Within clinical medicine the specialties of brain and

heart surgery rule supreme as the elite of medicalendeavours, a value that is reflected in popular culture.A bright child's parents jest that he or she will grow upto be a heart or brain surgeon. The reasons for theelevated status of heart surgery can be traced to twodominant ideologies. The first venerates high tech-nology; the second concerns the symbolic status of theheart as a body organ.Why is biotechnology so revered? Part of its status

may be due to the symbolic mastery over the forces ofnature that technology seems to promise.2 Medicaltechnology symbolises human mastery over mortalityand is based upon centuries old notions of the body as amachine with replaceable parts. "High technologycomes the closest ofanything in our secularised societyto being consistently vested in the mantle of the sacredand imbued with its mystique."9 Heart surgery isespecially conducive to this imagery; the heart is oftenconceptualisedin mechanistic terms; it"pumps" blood;it has "tubes" and "valves" that may become blocked,and "chambers"; it "fails." When the body is con-ceptualised as a machine, the use of transplants is seenas a logical step: if a part is worn out then it might wellbe replaced with a new one.The heart is a particularly important organ in

Western nythology, symbolising the seat of theemotions, distinguishing humanity from the beasts.Campaigns such as Heart Health Week exemplify thedegree to which the heart is seen as an organ apart, notrelated to other systems of organs but an entity untoitself. Heart disease differs symbolically from otherdiseases: unlike wasting diseases like cancer, it is oftenpopularly viewed as a "positive" disease, the outcomeof heroic achievement and able to be beaten by heroicdetermination.9 10 The prominence given to the heartattack of media mogul Kerry Packer epitomised thepopular concept of the successful and driven executiveat risk from heart disease, despite the inverse class biasof heart disease in most Western societies.

Press fanfareThe combination ofthese two ideologies has resulted

in developments in heart surgery being portrayed inthe press with fanfare, but its ultimate efficacy or costeffectiveness has been questioned little."' 12 Thedepiction of such innovations has taken on an arche-typal format:

Journalists regularly clone the heart transplant story,producing perfect replicas ofprevious reports. They stress thedesperation of those waiting for a heart, and the fear that timewill run out. The fatal alernative is made plain. The operationis depicted as offering the Chance of a new life or future, anopportunity to vanquish death. Grief and joy are voiced, andthe press conference following the operation is an aria ofhope.... Transplant reporting is also almost invariably of the"milestones in medicine" kind. It mobilises the drama offlight.... Above all, medical skill is hymned.... [Heartsurgeons] are medical alchemists, offering the ultimatemedical cure."'

Similarly, illness- as portrayed in television dramastends to be acute, rather than chronic, requiringimmediate action and biomedical technology."3 The

Because ofthe heart's symbolicstatus, heart attacks ofmediamoguls such as KerryPackerepitomise the popular concept ofthe successful executive at risk

Australian press is no exception to this model. VictorChang's murder provided a good source ofnewsworthymaterial, in which notions concerning the importanceof heart surgery and transplant technology weretrumpeted;unquestioningly. The very language used indescribing heart transplants and artificial hearttechnology in public discourse shows the preference ofour society to develop remedies based on technology

rather than to alter social institutions or people'sbehaviour.What sort of ideologies are reproduced or per-

petuated by these press accounts ofthe Chang murder?Although overtly- referring to the death of a surgeon,these press reports provide a vehicle for the publicdemonstration of modern society's reverence towardsmedical technology and surgery. Chang's personalqualities-his capacity for hard work, his charmingnature and caring attitude to his patients-althoughlaudatory, were not alone the stuff of saints. It wasChang's work as a heart surgeon that elevated himto such a position-his dramatic ability to bestowmiraculous recoveries on desperately ill and oftennamed people, to provide them with a tangible solutionto a life threatening condition. Heart surgery providesthe promise of the chance of cheating mortality, albeittemporarily.

Secular saintTo place these contentions in context, it is instruc-

tive to consider what the press reaction to the murderof a leading preventive health practitioner might havebeen. It is unlikely that the murder of a pioneer of carsafety engineering, highway design, or enviromentalsanitation, or of someone who influenced the shapingoffood laws or tobacco control legislation would-evenif the individuals had the personal and biographicalattributes of Chang-occasion the glowing tributes ofsainthood and miracle worker bestowed upon Chang,nor that such individuals' deaths would be portrayed inthe press as national tragedies.The reason for this is simple. In the face of the

miracles wrought by heart surgeons, preventive healthis a poor cousin. Exhortions to the public to avoid heartdisease by exercise, avoiding smoking, and makedietary changes are banal, dull, often depersonalised,and frequently tinged with moralism and puritanism.Success in prevention is defined in terms ofan absence,of something not happening. Prevention offers fewdramatic scenarios to the media: its huge successes(such as the dramatic reductions in road deaths,immunisation at school entry, tobacco advertisingbans, increased cervical smear rates) often do not reapchanges in health status for decades. By contrast,success in clinical medicine is resplendent withdramatic elements. After treatment, patients withbiographies, families, and loved ones move from illhealth to something better. Pain is relieved, bleedingstops, the sick rise from their beds, the lame walk, theblind see, frowns turn to smiles. Prevention canwait; treatment cannot. Treatment always relates toidentifiable individuals, preventive policies areanonymous.Chang was portrayed as a saint because he is the

nearest secular society has to such a thing. He saved atiny number of lives in a highly dramatic fashion,compared with the less obvious results of preventivehealth endeavours. The Australian National HeartFoundation estimates that between 1968 and 1988 thefalling death rate from heart disease in Australia"saved" 115 144 lives.'4 Analysis ofthe dramatic declinein deaths from coronary heart disease in the UnitedStates between 1968 and 1976 attributes 54% of thedecline to lifestyle changes (principally reduction insmoking and blood cholesterol levels) and only 3 5% tocoronary artery bypass surgery.'5 In such a context theemphasis ofthe press on the use ofhigh technology andsurgery to "cure" heart disease arguably negates orseverely detracts from the messages of public health.Holding out heart surgery in such glowing terms asthe solution to heart disease can only damage theimperatives of preventive health. What need is there togive up smoking or take up exercise if one's heart can

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simply be replaced by a better one? Why live aparsimonious and careful life if the miracle of medicaltechnology provides an alternative?Technology steps in after the damage has been done,

at a far greater cost to society but at much moredramatic level. As long as these values are held in oursociety, as long as popular culture continues both toreflect and to reproduce these values, public healthpractitioners will be seen as spoilsports, not saints.

1 Galtang J, Rougue M. Structuring and selecting news. In: Cohen S, Young Y,eds. The manufacture of news: social problems, deviance and mass media.London: Constable, 1973:62-72.

2 Bates E, Lapsley H. The health machine: the impact of medical technology.Ringwood- Penguin, 1985.

3 McLaughlin J. The doctor shows.Journal ofCommunication 1975;25:182-4.4 Chapman S. Advertising and psychotropic drugs: the place of myth in

ideological reproduction. Soc Sci Med 1979;13A:751-64.

5 Turow J. Playing doctor: television, stotytelling and medical power. New York:Oxford University Press, 1989.

6 Gerbner G, Gross L, Morgan M, Signorrielli N. Health and medicine ontelevision. NEnglJMed 1981;305:901-4.

7 Krautzler NJ. Media images of physicians and nurses in the United States.Soc Sci Med 1986;22:933-52.

8 Karpf A. Doctoring ihe media: the reporting of health and medicine. London:Routledge, 1988.

9 Stein HF. American medicine as culture. Colorado: Westview, 1990.10 Helman C. Heart disease and the cultural construction of time: the type A

behaviour pattern as a western culture-bound syndrome. Soc Sci Med1987;25:%9-79.

11 Pfund N, Hofstader L. Biomedical innovation and the press. Journal ofCommunication 1981;31: 138-54.

12 Hall JP, Heler RF, Dobson AJ, Lloyd DM, Sanson-Fisher RW, Leeder SR.A cost-effectiveness analysis of alternative strategies from the prevention ofheart disease. MedjAust 1988;148:273-7.

13 Turow J, Coe L. Curing television's ills: the portrayal ofhealth care. JoumalofCommunication i986;35:36-51.

14 National Hpart Foundation. Heart facts report. Canberra: National HeartFoundation, 1988:13.

15 Goldman L, Cook EF. An analysis of the comparative effects of medical- interventions and changes in lifestyle. Ann Intern Med 1984;101:825-36.

Changing the hideous face ofwar

B J S Grogono

Halifax, Nova Scotia,Canada B3H 1G3B J S Grogono, FRCS,retired orthopaedic surgeon

Correspondence to:Mr B J S Grogono,5854 Gorsebrook Ave,Halifax, Nova Scotia,Canada B3H 1G3.

BMJ 1991;303:1586-8

Besides the thousands killed in war, millions arecrippled or hideously deformed. During the first worldwar the British army developed improved medicalservices to cope with the enormous number of casual-ties from the incessant bombardments and furore oftrench warfare. Under the guidance of Sir RobertJones' 2 a comprehensive management of injuries wasestablished. After initial treatment in the field clearingstation the wounded soldier was transferred to a basehospital for more definitive care and the extent of hisinjuries was assessed. He was then sent back to"blighty," where he received skilled treatment, finallyarriving at a rehabilitation hospital. The centre atShepherd's Bush, London, managed severe skeletalinjuries, nerve lesions, and orthopaedic problems;hand injuries and amputation received special atten-tion. A young army doctor, Harold Delf Gillies, sawthat specialised management of facial and maxillaryinjuries was needed. He was a New Zealander who hadspecialised in ear, nose, and throat surgery and couldsee the urgent need to segregate the soldiers with thesewounds from the rest of the casualties.3The young captain Gillies was not familiar with the

classic work ofTagliocozzi,4 who had described the useof pedicle grafts for the repair of amputated noses inthe sixteenth century, but he did encounter Charles

Auguste Valadier, a dental specialist to the officers ofthe imperial staff, who repaired jaw defects by usingtissue, such as bone, from other parts of the body.Gillies and Valadier operated together, and it was thisbaptism into the realm of faciomaxillary injuries thatinspired Gillies. He was lent a book on these injurieswritten by a German surgeon, Lindeman; he visitedHippolyte Morestin, the most famous plastic surgeonin Europe; and he persuaded the medical authorities ofthe need for special centres for treating faciomaxillaryinjuries. The authorities included Sir Alfred Keogh,director general of the army medical services, andSir William Arbuthnot Lane, one of the most distin-guished surgeons in England.

Within a year the Cambridge Hospital at Aldershotwas opened and Gillies was assigned special duties asplastic surgeon. So that soldiers with facial injurieswere sent to ' Is new unit Gillies bought £10 worth oflabels sayin, "Faciomaxillary injury-CambridgeHospital, Aldershot" and sent them to the fieldhospitals in France to be pinned to the casualty's chest.

In January 1916 the first naval casualties arrived,followed shortly afterwards by 2000 injured soldiersfrom the battle of the Somme. Day after day, nightafter night they came with half their faces or jaws shotaway. Suffocation, sepsis, gangrene, and haemorrhage

4

(Left)MajorHD Gillies as a medical officer, working with theRed Cross, 1915; (right) SirHarold Gillies teaching at Rooksdown House, 1944.Photographer unknown;from R Pound, "Gillies, surgeon extraordinary."I

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