Brian T. Collopy graduated M.B.B.S. Melbourne and holds Fellowships of the Royal Australasian College of Surgeons, the Royal College of Surgeons of England and the Royal Australasian College of Medical Administrators. He is a past Director of the Department of Colon and Rectal Surgery at St. Vincent’s Hospital, Melbourne and Associate Professor of Surgery at Melbourne University. He has had a long-standing interest in the assessment of the quality of care and with the award of a Kellogg Fellowship, and subsequently a WHO consultancy, he studied and advised on health care practices in Europe and Asia, as well as North America. He has conducted numerous studies addressing the quality of care at the hospital, inter-hospital and national levels, has authored or co-authored over 150 papers published in peer-reviewed journals, and has spoken extensively on the subject.
Amongst a variety of roles in relation to the quality of health care he was President of the Australian Council on Healthcare Standards (ACHS), which conducts a national hospital accreditation program. With ACHS he developed clinical performance measures, which are now used in a number of other countries, and provide the ACHS with a unique national clinical database. Other offices include being Chairman of the Advisory Council of the International Society of Quality Assurance (ISQua) and the Advisory Committee on Elective Surgery (ACES) in Victoria.
He was made a Member of the Order of Australia in 1993 and received a Fellowship of the Australian Medical Association in 1996.
Currently he is the Director of CQM Consultants, formed to assist health care organisations to assess the quality of their care. In this capacity he has guided tertiary referral hospitals on performance measurement and assisted organisations such as the Department of Health in South Australia, the Royal Flying Doctor Service, Correctional Health Services, and New South Wales Mental Health. He has also assisted the Hong Kong Hospital Authority to develop clinical performance measures.
He has just retired from membership of the Victorian Civil & Administrative Tribunal (VCAT), but continues as a Clinical Advisor to the ACHS and as a member of the Superannuation Complaints Tribunal (SCT). A number of his activities, such as the clinical indicator development for hospital accreditation, a follow-up protocol after bowel cancer surgery, and the categorisation of urgency for elective surgery waiting list patients, were world-first achievements.
In the Melbourne General Cemetery in Carlton a monument to the surgeon Dr James Beaney, who died on 30 June 1891, towers over those surrounding it. There is also a set of memorial tablets to him in England in the Canterbury Cathedral and an historical museum in the city of Canterbury known locally as the ‘Beaney’. For the former he had left a sum of £1000 for the restoration of the cathedral, and the museum was originally developed from £10,000 he provided in his will for the establishment of ‘The Beaney Institute for the Education of the Working Man’. At Melbourne University there was a Beaney Prize in Surgery, which for many years was awarded annually to the final year medical student who was outstanding in the surgical examination. It is now awarded as a scholarship to a graduate engaged in surgical research at one of the three clinical schools attached to Melbourne University. There is a similar scholarship in pathology. He was the first benefactor to the University of Melbourne Medical School, which had been founded in 1862.
Few people who have viewed the monument would have known what a colourful and controversial surgeon Dr. James Beaney was in his dress and adornments, in his surgical beliefs and writing and in the considerable litigious events in which he was the central player. Certainly none of my surgical colleagues or teachers could match him for those characteristics, nor it appears could any of his contemporaries in Melbourne in the second half of the 19th century.
In addition to many years spent in surgical practice in a University teaching hospital and in a major private hospital I have been involved, at a local, national and international level, in the assessment of the standards of patient care and in the development of formal measures to enable such assessments. Many of my activities in this area have been published in peer-reviewed health care journals, but this is the first time I have written about an individual medical practitioner.
It was while researching the history of hospital infection rates (for comparison with current data) that I came across a newspaper article from 1886 strongly criticising the report of a Victorian Parliamentary committee, which had found no fault with the infection rates or with patient management practices at the Melbourne Hospital. The chairman of the committee was James Beaney, and the accusatory article made it quite clear that he was protecting his own interests. That encouraged me to learn more about him.
Seeing Beaney’s name reminded me also that some years beforehand a colleague had given me a small book he had found in his late father’s possessions. It was a monograph, published in Melbourne in 1876 by an F. F. Bailliere, and had a long title: Lithotomy: Its successes and dangers. Being a verbatim report, from shorthand notes, of an inquest, held before the City Coroner with a preface and commentary by an MRCSE. Its author, listed as MRCSE, is believed to be this extraordinary surgeon James George Beaney himself. It was said to have cost £700 to produce, a significant sum at that time. The book was never sold but copies were distributed throughout Melbourne. The monograph, as its title implies, is a report of an inquest, held late in 1875, into the death of a patient upon whom James Beaney had operated. It provided an account of the conduct of the inquest and the brilliant defence of Beaney by a young barrister named James Purves. An assessment of James Purves in Sir Arthur Dean’s book A Multitude of Counsellors – A History of the Victorian Bar (1968), in which he described Purves as ‘Undoubtedly the greatest advocate the Victorian Bar has produced’, increased my interest to learn more about the particular episode, the players involved and the circumstances, both social and professional, of that period in Melbourne.
The accuracy of the account of this particular inquest is verified by reports in the newspapers of that time, particularly those in the Argus and The Age, in which the details of the inquest corresponded closely with those in the monograph, and also by a review of the limited ‘proceedings’ available from the Public Records Office.
I have considerably expanded on the court dialogue in the 1875 inquest and provided information on the various players in a drama, which was lacking in the monograph. I have provided reasons why the inquest was held, a principal one being an indiscreet shop window display of a surgical specimen, organised by Beaney. Without this display an incensed and unknown surgeon, who claimed further knowledge of the operating circumstances in the particular case that was the concern of the inquest, might not have been provoked to make a public response. I have also described the equally extraordinary place that Melbourne was then. While lacking the modern forms of communication, information sharing and transport, the pace of change in Melbourne was frenetic, as this ‘faraway’ city grew into one of the grandest in the English-speaking world of that time. The growth was due, of course, to the immense amount of gold extracted from the mid-Victorian fields at Ballarat and Bendigo, not far to the north of Melbourne. This should help the reader understand how the idiosyncratic James Beaney could be accepted (or tolerated by some) in the city at that time, obtain a senior surgical position in the Melbourne Hospital and develop such a large private surgical practice.
An aggressive attitude existed between many medical practitioners of that period in Melbourne. This had something to do with the fact that, prior to 1867, all doctors in the Colonies had qualified overseas (usually England, Scotland or Ireland). Many were adventurers who came out to seek their fortune at the gold diggings or elsewhere. Not finding their pots of gold, they reverted to medical practice.
Back then, they often found they were competing against charlatans, with bogus degrees, who used bizarre, and frequently dangerous, treatments on patients who had little medical knowledge. The Medical Act of 1865 in England had had a minimal effect in reducing false claims of cure and the advertising of non-existent medical skills. Criticism of the ‘healing profession’ was rife, and it was common, even for legitimate practitioners, to have their credentials questioned. They had to be alert and wary and, as a result, were often defensive and frequently aggressive.
A further stress factor was the enormous amount of litigation surrounding surgery in that period of limited knowledge and an absence of modern diagnostic and support services. An example was the case in 1871 of a woman who suffered injuries to her knee and hip. A Dr. Van Hemert, a well-known and respected Melbourne practitioner, missed a fracture of the neck of her femur (thigh bone) and was sued. In the resulting court case James Beaney gave evidence for the plaintiff, who won her case. At a subsequent special meeting of the Medical Society of Victoria, a motion was passed declaring the decision unfair and wrong. Dr. Beaney arrived at that meeting late and was not permitted to explain the reasons for his damming evidence. He had apparently resigned from the Society the year before. The Medical Society’s motion could not, of course, reverse the court decision. Dr. Van Hemert was reported to be ‘broken in spirit’ and left the country. He would have avoided the mishap if x-rays had been available, but Professor Wilhelm Roentgen of Bavaria did not make his remarkable radiological discovery until 1895.
The advent of anaesthetic agents in the 1840s had led to a rapid increase in the number and complexity of surgical procedures by that time, as with the patient ‘asleep’ and not screaming, the need for surgical speed was reduced. An example of the speed required in the absence of general anaesthesia was evident in a report of an amputation of a leg, above the knee, performed in the Hobart Hospital in the 1840s. The time from the first incision to removal of the limb was just three minutes.
With anaesthesia, various operations upon body cavities and organs could then be performed. However, these new procedures, as well as the more traditional operations, were associated with high complication rates and consequently also high mortality rates. The anti-bacterial drug era was still many decades away and as post-operative infection was an enormous problem reference to sepsis is included in this narrative.
The relatively small number of surgeons in Melbourne then were frequently called upon to give evidence for or against their colleagues and the proceedings were generally made public by an unsympathetic press, which took delight in disclosing the shortcomings of those who “wielded the knife”. The pen and the tongue were powerful weapons. A loose comment from one’s colleague, when picked up by a journalist, could cut short a promising medical practice, providing another reason for resentment and mistrust to abound in the colony’s healing profession.
The first word, lithotomy, in the monograph’s title, refers to the operation for removal of a bladder stone or stones by cutting into the bladder. Hippocrates, over 2000 years ago, had recognised the risks to life associated with lithotomy, and part of his oath included: ‘I will not cut for stone, even for the patients in whom the disease is manifest; I will leave this operation to be performed by practitioners.’ This was probably the first mention of specialist surgeons, the appropriate specialist branch of surgery today being known as urology.
Mention of operations for bladder stone can be found in Arabian, Greek and Roman history. Early descriptions also indicate that there could be a ‘low’ and a ‘high’ approach to the stone, the former being lithotomy via the perineum (as was the approach in the case relevant to the monograph) and the latter being suprapubic (lower abdominal). The low or perineal lithotomy, as will unfold for the reader, could be performed by a median approach, i.e. a surgical incision made in the midline, or by a lateral approach. It was doubtful whether there was any clear advantage to avoiding the midline.
The significant understanding quickly reached by the barrister defending Dr. Beaney about the intricacies of lithotomy and its consequences will be evident to the readers.