Bernard Nicholson, Emeritus Medical Superintendent, Royal Adelaide Hospital
This address was delivered by Mr W E J Ricketts on behalf of Dr Nicholson, who was not able to so do on account of illness, at the tenth Foundation Day Ceremony held at Royal Adelaide Hospital on 13 July, 1988.
During the early hours of 27 October, 1952, Sir Trent got out of bed and sat on a fireside stool overlooking the North Adelaide parklands. Over the previous week or so he had had periods of unconsciousness. But then he sang in a strong voice a full verse of the hymn ‘Onward Christian Soldiers’; returning to his bed he rested quietly holding his wife’s hand. In a little while he passed away.
The life of one of South Australia’s most distinguished adopted sons had come to its close.
At the relatively tender age of twenty seven years, Crep, as he was known to all of us, had been selected from a number of applicants and appointed medical superintendent of the Adelaide Hospital in 1909.
He died but eight months after his retirement from the chairmanship of the Council of the Institute of Medical and Veterinary Science in Adelaide. He had been in indifferent health, since 1950, having suffered a coronary occlusion on 12 June that year. From that time on his life was a struggle against ill health, compelling him to curb his professional activities, a restriction at which he chafed.
There were several important milestones in Crep’s career which successively and collectively formed the power base from which he exercised his influence on pathology services in South Australia.
- medical administration as medical superintendent and then director of the government bacteriological and pathological laboratory at the Adelaide Hospital
- his war service
- his clinical practice as a specialist physician
- his university commitments
- his Royal Australasian College of Physicians and British Medical Association involvements
- the development of the concept of an institute of medical science
- the creation of the Institute of Medical and Veterinary Science
- his membership and then chairmanship of the Council of the Institute of Medical and Veterinary Science.
At the turn of the past century pathology services generally were rudimentary by today’s standards and we should remind ourselves that a pathologist dealt with all its branches. Many a clinician continued to be his own morbid anatomist and clinical pathologist. Bacteriology was regarded then as the more important branch of pathology.
The Adelaide Hospital had become a teaching hospital in 1885. The then professor of anatomy, Professor Archibald Watson, was appointed in that year the hospital’s first pathologist or morbid anatomist. It so happened, that, by 1909, when Crep became medical superintendent at the Adelaide Hospital, Watson was also an honorary consulting surgeon. Watson was a survivor in today’s terminology having been dismissed from the hospital staff in 1896, from the post of pathologist and returned as an honorary consulting surgeon in 1904.
Bacteriology had been practised for some time at the Adelaide Hospital, when Dr Thomas Borthwick was appointed honorary bacteriologist in 1902. He had been appointed to such a post at the Adelaide Children’s Hospital in 1894, and in 1896, he had succeeded in making those services at the Adelaide Children’s Hospital available to medical men and health authorities, as was the pattern across the other side of the world, at a fee of five shillings.
Dr Borthwick had, by 1899, persuaded the Adelaide Children’s Hospital to form the bacteriological department into an Institute of Hygiene and Bacteriology with himself the director.
Turning again to the Adelaide Hospital’s records, we note that some five years of planning was involved in the provision of a new laboratory and facilities, before Dr Borthwick took up his appointment.
Dr R G Burnard, the first resident pathologist, commenced his duties in February, 1906. This, then, was the setting of pathology in South Australia when Crep became medical superintendent at the Adelaide Hospital in 1909.
He had based his clinical practice and teaching on an insistence on tracing the pathological basis of disease processes, having been under the influence of Professor Allen in Melbourne. Eighty years later, we can state that all the branches of pathology are grouped together as being the scientific basis of medicine or the science of disease. So complex are these matters today, and so great is the extent of specialisation, that pathologists from different disciplines communicate – the one with the other – only in the very broadest terms.
This problem of communication is very real. Today the essential problem is how much do other professionals in other branches of medicine need to know so that they have the necessary inklings of what is going on.
The communication problem, between clinical and laboratory medicine, hopefully will be resolved as their practitioners adapt to the opportunities offered by the new communications technologies, yet facilitate consultation and minimise ‘slot machine pathology’.
In those, now, far off days of 1909, clinical medicine was very much a matter for the doctor at the bedside. A doctor depended on his own observations and at times had a scant regard for laboratory or radiology examinations. This style and process had been a salient feature of medicine since before the Middle Ages – indeed almost since time immemorial. It is, thus, a little harsh now to dismiss proponents of such a style but also easier to understand why consultants seemed to be and were singular, eccentric, outspoken or even outrageous in their demeanour. Such ‘characters’ or ‘personalities’ do not exist today and more’s the pity.
I suspect that they not only believed their style of practice to be correct, as indeed it had been for many hundreds of years, but, they may also have had an inkling that laboratory medicine was shortly to develop into many sub-specialties; and thus perhaps they were also shortly to be under siege!
Less than one year after Dr de Crespigny’s appointment in 1909 as Medical Superintendent, Adelaide Hospital, he wrote a report on the then bacteriological and pathological laboratory; which was adopted by the board and forwarded to the government. He had also established elemental clinical pathology in a disused shed at the hospital.
It is an interesting sidelight on hospital administration, in those days, to follow up those board minutes and discover that the chief secretary, on receiving Dr de Crespigny’s report, wished to know if the departments and others mentioned therein had actually been consulted!
The minister was reassured that the board had not done so, as they recognised that, without the consent of the minister, they had no authority to do so and that the policy of the board had always been to do everything though the ministerial head!
With tacit approval, unfruitful discussions were had with the chairman of the Central Board of Health (Dr Ramsay Smith, a remarkable man, about whom much could well be written) and committees and sub committees were formed with Dr de Crespigny’s original report forming the basis of a scheme put forward by the chairman of the board.
The chief inspector of Stock and Brands (now part of the Department of Agriculture), out of which sprang the formal veterinary interest in utilising ‘the public laboratory now proposed’, raised the question of officers of his department performing investigations in this new laboratory.
By August, 1910, the chairman of the hospital board was able to announce that the South Australian Government had approved the centralisation of all bacteriological and pathological work in a laboratory to be administered by a (medical) director under the control of the board of management of the Adelaide Hospital – a scope which intended to cover bacteriological and pathological investigations for
- public hospitals
- the Commonwealth Quarantine Department
- the Central Board of Health
- local boards of health
- meeting the requirements of the Food and Drugs Act
- private medical practitioners
- examination of water and milk
- preparation of vaccines and sera
- veterinary and agricultural work
- original work, that is to say, research.
This was a unique proposal for Australia and almost certainly a world first. Nevertheless we must remind ourselves of what Topley said later, in 1925, on the competing claims of routine service and research. ‘The effect of routine work is disastrous …’
These formal proposals led to Dr de Crespigny becoming the first director of this new laboratory. He held this appointment from 1912 until 1919 including a period of military leave during World War I.
While these proposals were coming to fruition, the university wrote to the board of the hospital indicating it was their understanding that the board intended to establish an institute of pathology under the direction of Dr de Crespigny. The university asked if the board would agree to Dr de Crespigny being appointed lecturer in practical pathology and histology. Professor Watson offered to resign and Dr de Crespigny was appointed (honorary) pathologist and clinical pathologist by the hospital.
This effective partnership between the chairman of the board and Dr de Crespigny as medical superintendent and then as director of the government laboratory gives us an early indication of this young doctor as a successful medical administrator.
His war service indicated, yet again, his sound preparation for duty in that Dr de Crespigny had obtained a Commission in the Commonwealth Defence Force. Whether or no you agree with Henri Dunant and Florence Nightingale concerning doctors in national uniforms, Sir Trent saw his duty clearly to be associated with the defence of the empire. His non combatant role as a doctor was, as we say today, non negotiable.
His posts as registrar, secretary, commanding officer and then consulting physician to the army are all cogent evidence of his skill as a medical administrator and its recognition by the authorities by promotion to such high office confirmed by the award of the medal of the Distinguished Service Order and two mentions in dispatches.
During the immediate post war years he consolidated his professional standing, as a consultant in medicine in private practice, and as honorary physician to the Adelaide Hospital in 1918. He was already an honorary physician to the Adelaide Children’s Hospital.
Sir Henry Newland, writing of this phase of his life, asserted with conviction that ‘as a medical consultant he ranked with the best. A sense of superiority was assumed without conceit and he certainly had the intellectual gifts to warrant it. He was a man of taste and refinement’.
His university appointments culminated in his appointment as Dean of the Faculty of Medicine, University of Adelaide. Thus he was able, for some forty years, to influence directly the content of the medical course, the teaching of medicine, and thereby the practice of medicine in this State. During his middle years, this influence extended throughout the profession. In 1925-26, he was President of the South Australian branch of the British Medical Association and, in 1928, President of the Medical Section of the Australian Medical Congress in Sydney.
The Royal Australasian College of Physicians was created in 1938 and Dr de Crespigny being one of the founders soon became its president. His official college biography refers to his presidency being at a time of great difficulty for the college, with 102 fellows and members on active service in World War II, and many problems of travel and communication between colleagues.
Throughout those busy years he continued to set for himself and for those about him exacting high standards of excellence and thoroughness.
A developing concept of an institute of medical science had continued to flourish, and, although Crep had relinquished the appointment of director of the government laboratory, in 1919, he had never ceased to be concerned with the ongoing development of pathological services in South Australia.
Lionel Bull, who took over from Dr J B Cleland, Crep’s successor as Director of the Central Government Laboratory, having been first assistant and veterinary pathologist to Crep and then deputy director, had had some discussion with Sir Charles Martin at that time chief of the CSIR Division of Animal Nutrition, as to a proposal to establish an institute of comparative pathology.
Through the good offices of Lady Champion de Crespigny I am in possession of an undated, unsigned document attributed to Martin making a plea for greater encouragement of pathology in the ‘School of Medicine’ at the University of Adelaide.
This document ventilates the idea of a pathological institute. It states that ‘Pathology has not been nurtured by the University to the same extent as the earlier subjects of the medical curriculum and it would appear that the very considerable development which has occurred at Adelaide has originated from the hospital rather than from the University’. It carries the imprint of Dr de Crespigny’s views of the significance of pathology in relation to medical student education and the practice of medicine. Others involved having been Sir Charles Martin, Dr L Bull and Prof J B Cleland.
In 1936, the South Australian Government created the Government Hospital Laboratory Advisory Committee to oversee and recommend to the Adelaide Hospital board concerning the administration of that laboratory and to draw up plans for an institute of medical science. At this time a new director of the laboratory was appointed (Dr E W Hurst), it being intended that the director would be the first director of the institute, which would take over the laboratory and maintain and develop its original roles as defined in 1910, but, also engage in teaching, and, as the premier of the day stated in his second reading speech to the enabling legislation it would ‘do all research for the Adelaide Hospital’.
The chairman of that committee was Dr de Crespigny. Conferences with the university had been fruitful, and funds were committed by the university to paying half the salary of the director, the medical bacteriologist and the pathologist, conditional upon these having ample time for research.
At this time special tangible support for the building of an institute had come from three sources in South Australia – Miss Edith Bonython, Mr T E Barr Smith and Mr Norman Darling, who, clearly, were influenced by Dr de Crespigny’s proposals for an institute of medical science. Their letters to the chancellor of the university confirm their responses to his plans.
To match these funds the South Australian government moved without delay to vote an equal amount.
As planning proceeded and costs became clarified, the Commissioners of Charitable Funds and of Endowments for the Adelaide Hospital donated £10,000 and the government came forward with a further sum. For some years a veterinary laboratory for the Stock and Brands Department (now the Department of Agriculture) was in the government laboratory, and it became a division of the new institute.
It is interesting to recall that when the foundation stone was well and truly laid the institute was named ‘The Institute of Medical Science’, yet, in view of the sources of funds and developing concepts and interests, it was named as the Institute of Medical and Veterinary Science in the enabling legislation: this aspect linking human and animal pathology was referred to in the second reading speech when the Bill was before parliament.
The first council was appointed and the Act proclaimed on the same day 9 June, 1938.
On account of the wider pastoral interest, Mr A E Hamilton, an accountant, and President of the Stockowners Association had been appointed chairman but he resigned within a few months and Dr de Crespigny replaced him and presided at the formal opening ceremony on 24 May, 1939 – the anniversary of Queen Victoria’s birthday, if I am not mistaken.
During the thirteen years that Dr de Crespigny was Chairman of the Council of the Institute of Medical and Veterinary Science, its development was continuous although the war years, commencing shortly after its opening, slowed development down, but, to be followed by post war expansion. In 1941 he received a well deserved Knighthood.
Sir Trent maintained a constant personal interest in the development of the institute particularly in the fine tuning of its relationship with the Adelaide Hospital and the university. It had become clear to some that the institute in 1950 was not well placed to respond to the burgeoning demands of routine services and the post war surge in the growth of laboratory medicine. Its activities were predominantly oriented to research and the near absolute truth of Topley’s remarks, in 1925, as to disastrous effect on research by the demands for routine service was evident. The imbalance of these two principal activities of research and service necessitated a significant change of emphasis.
Thus the third director became a full time institute officer and greater emphasis was placed on a prime duty of service especially to (Royal) Adelaide Hospital. In addition a research division was created.
These events confirm Crep’s style of leadership to have been very apropos. His ability to heed advice and act on it enabled the institute to respond to the circumstances facing it, in the early post war years, and enabled those who have successively influenced its affairs to have followed surely and soundly in his footsteps.
In passing one wonders if there is no longer a role for the general physician. The growing edges of all of medicine lie in its special branches, laboratory medicine and epidemiology. There is an ever increasing need for these realistically to be co-ordinated.
This is probably a developing role for the general practitioner to play – a role of clinical/health co-ordinator and a new exercise in medical administration.
I would go further, and state that one could forecast a three point basis for health services in the future
- personal health care with the general practitioner as a ‘good health co-ordinator’
- epidemiology being the pattern of good health, morbidity and mortality
- laboratory medicine as the corner stone in the science of good health and disease.
All other services related to each of these three areas being supportive and not distractive.
This vignette by its very nature closes in 1952 with the death of Sir Trent.
I have examined his career by way of a helicopter view with little time to learn of his modus operandi. As to his modus vivendi he believed in the power of prayer, in eternity and the human soul. His favourite poets were John Donne and William Shakespeare.
A late Victorian professional gentleman seeking, and achieving in himself, and others always the difficult, but never the easy road and always to the highest standards. Influencing events, the details of which mask the magnitude of the changes which were occurring in medical practice by virtue of exponential expansion and specialisation of knowledge and thus of practice. He engendered respect, regard and devotion in those of our profession who worked for and with him.
I believe that he also saw the twentieth century as did one of Donne’s editors, of an earlier age, as an opportunity to recover a sense of vitality and of truth and a reconciliation of instinct with spirituality and heart with head.
He qualified with honours, when medicine was as much an art, as it was a science. Fifteen years before he was born the medical curriculum as laid down by the General Medical Council in the United Kingdom did NOT include pathology and bacteriology.
When he died, he did so with honour and dignity looking forward as a new world of scientific medicine was unfolding before him; with his Institute of Medical and Veterinary Science ready to play its part in the new era of laboratory medicine – no doubt always choosing the difficult road and always to the highest standard.
Mens Conscia Recti ‘A Mind Aware of the Truth’.
Like Donne he acclaimed truth and I can well believe like Donne on truth he exemplified these words
… and he that will
Reach her, about must and about must go
And what the hills’ suddenness resists, win so;
Yet strive so, that before age, death’s twilight,
Thy soul rest, for none can work in that night.
This address is based on that presented at the Royal College of Pathologists of Australasia’s Annual General and Scientific Meeting Official Ceremony in Adelaide in October, 1987. It is a variant of an original paper presented at the III National Conference Medical History in Adelaide, 1986, and published by Melbourne University.
Copyright of the original paper rests with the Medical History Unit, Melbourne University.
This variant is published with that unit’s permission.
References are available on request.