Volume 40 No. 2 December 2014

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 ___________________________ Professor Yosuf Veriava (Chairman)

Department of Anatomical Sciences __________________ Mr Brendon Billings

Health Graduates’ Association _______________________ Dr Paul Davis

City of Johannesburg Arts and Culture Department ___ Ms Alba Letts

City of Johannesburg Health Department ____________ Dr Refik Bismilla

Medical Students’ Council ___________________________ Mr Faheem Meer

Other members _____________________________________ Dr Catherine Burns

___________________________________________________ Professor Tony Davies

___________________________________________________ Associate Professor Sekibakiba Lekgoathi

___________________________________________________ Dr Ann Wanless

STAFF MEMBERS

Curator ______________________________________________ Ms Rochelle Keene

Professional Officer ___________________________________ Ms Cheryl-Anne Zillmann

Professional Officer (Collections) _______________________ Mr Sepeke Sekgwele

Museum Attendant ___________________________________ Mr Gilbert Singo

ADLER MUSEUM BULLETIN

7 York Road, Parktown, 2193

Editors

JCA Davies MB BS (London)

Rochelle Keene BA(Hons)(Witwatersrand)

Email

Adler.museum@wits.ac.za

Adler Museum of MedicineFaculty of Health Sciences

Editorial: Wanted – A launch pad ____________________________________________________ 1JCA Davies

Serendipity and the Journey to a Human Autoantigen _________________________________ 3David J Salant

The Tara photograph album: visualising a therapeutic community _____________________ 13Rory du Plessis

Tomorrow will be Tuesday if it is okay with you: Memories of a surgical _________________ 19internship with Professor DJ (Sonny) Du Plessis

Denis Daneman

From the Curator’s Desk: Looking back and bidding farewell ___________________________ 23Rochelle Keene

Guidelines for authors _______________________________________________________________ 27

Contents

Wanted – A launch pad

Professor JCA Davies

Editorial

1

The proposal, in principle, to establish a NationalHealth Insurance Service (NHIS) in South Africaappears to many to have become trapped inuncertainty and discussions of complex issues ofmarginal significance. Nurses, among others, arereported to have complained that there is notenough information in the public domain abouthow the system is intended to work, and aboutslow progress towards implementation. Thiscomplex situation is not the fault of anyparticular individual or group, but an inevitableconsequence of the ideological conflicts whichare so deeply embedded in South African society.These conflicts, many and various, have retardedthe development of primary, secondary andtertiary education, the establishment of a stablehigh quality health service which successfullybalances the need for prevention and theimperative to provide treatment for establisheddisease, and the provision of adequate housingand infrastructural services for a growingpopulation. Recently, obtrusive evidence of adecline in the economy and destructivecommunity and industrial protest has led towidespread pessimism about the prospects for thecreation of a developmental state.

A suitable launch pad for a major health projectcan only be found within the existing healthservice – this much must be obvious. Equallyclear is the fact that many elements in theexisting service are not performing to maximumcapacity. For example, and for no other reasonthan that I know the area and have workedthere, consider the Limpopo Province.

There are fifty hospitals in the province, almostall of them district hospitals with a necklace ofprimary health care clinics in the surroundingrural area. My estimate is that on average eachdistrict hospital has between five and tendependant clinics. This is no mean healthinfrastructure – fifty hospitals and between 250and 500 clinics. As a result of the almostcomplete absence of medical management andside-by-side clinical teaching, the nursing sisters

and staff nurses who serve in these clinics referfar too many patients to the hospital, therebyinflating the marginal cost to the patients andensuring that the hospital is permanentlyoverloaded and plagued by long queues andexcessive waiting times. Systematic work andsimple fact finding projects are impossible underthese conditions. In the face of the lengthyqueues, the front line staff adopt the routinequadruple prescription of analgesic plus anti-inflammatory plus antibiotic plus vitaminsupplement as the way to please as many peopleas possible by shifting the queue rapidly.

It would be unwise to claim that the MedicalFaculty of the University of the Witwatersrandinvented primary health care, but it is beyonddispute that this Faculty made an important andlasting contribution to the development ofcommunity-based primary health care. Withinthe last decade there have been two editorialsabout primary health care in this journal. Thefirst, in 2006, made two points: “In the hands ofEmily and Sidney Kark, primary health care wasscientific medical practice adapted to a particulargeographic situation” … and: “For two youngdoctors, Pauline and Ronald Ingle, working at amission hospital in rural Africa was not medicalmarginalization but involvement in a complexnetwork of people and ideas, and in parallelproviding medical, surgical, paediatric andpreventive services to the people living withinreach of the hospital”.1 The second was promptedby the publication of a series of six articles aboutHealth in South Africa. Some of the problemsfacing the country’s health services are listed,and they constitute in aggregate a formidablecomplex of problems for those whoseresponsibility it is to set the stage for theintroduction of the NHIS.2

The danger is that the centre of interest is locateda long way from the primary interest of themajority population living in the rural areas orworking in the urban industrial areas. Experiencein the Limpopo Province tells me that the acutely

2

felt need there is for a slick and effective clinicservice backed by district hospitals with dedicatedmedical managers responsible for continuedclinical education of the staff working in theclinics. If the existing health service of thatprovince were brought to peak productivity,improved health would act as a promoter ofdevelopment. Working conditions, and livingconditions for the worker, are not good in thiscountry and contribute to the burden of diseaseand the prevalence of disability outsourced to thelabour-sending rural areas.

The people of this democracy would benefit fromthe development of basic elements of the health

service. They are not getting any benefit from thecontinuing dispute about the pros and cons of theconcepts underlying the public and the privatepractice of medicine. The surviving members ofthe classes which included Emily and SidneyKark, and Pauline and Ronald Ingle might like toexpress their views on the subject.

REFERENCES

1 Davies JCA. 2006. Misunderstanding primary health

care. Adler Museum Bulletin. 32 (2): 1.

2 Davies JCA. 2009. South Africa’s health service: time

for a rethink? Adler Museum Bulletin. 35(2): 1.

3

INTRODUCTION

As a medical student at Wits and later as a registrarat the Johannesburg General Hospital, I becamefascinated by disorders of autoimmunity. “Horrorautotoxicus”, literally the horror of self-toxicity, isthe process described by the great Germanimmunologist and Nobel laureate Paul Ehrlich todescribe our aversion to attack by our own immunesystem. Nonetheless, we now know that themechanisms of central and peripheral self-tolerance that we have developed to avoidself-injury do occasionally break down and lead todisorders of systemic (e.g. systemic lupuserythematosus, rheumatoid arthritis) and organ-specific autoimmunity. Among the organ-specificautoimmune diseases is a condition calledmembranous nephropathy, a relatively commonform of kidney disease that I first became familiarwith when I joined the Renal Unit in Johannesburg.What followed has been something of a personalodyssey. At times, as a result of happenstance,I have had the luck of being in the right place atthe right time. At others times I have benefited fromtrue serendipity.

The opportunity to study immune mechanisms ofkidney disease arose in 1977 when I received anNIH research fellowship at Boston University towork with Dr William Couser, then a relativelyjunior faculty member but considered something ofa rising star. It was only a slight coincidence thathe had recently started working with a wonderfulrat model of membranous nephropathy calledHeymann nephritis discovered quite fortuitously in1959 by Dr Walter Heymann who immunizedsusceptible strains of rats with an extract of ratkidney cortex and noted that they developed all theclinical and pathological features of humanmembranous nephropathy.1

Membranous nephropathy is a leading cause ofnephrotic syndrome in adults, a condition thatleads to total body swelling (oedema) because ofleakage of albumin from the blood plasma intothe urine (proteinuria) when the glomeruli, the

filtering units of the kidney, are damaged.Glomerular injury and nephrotic syndrome maybe caused by various diseases like diabetes,infections like HIV, hepatitis B or C, lupuserythematosus, and other diseases limited to thekidney. However, membranous nephropathy isamong the most frequent causes, especially inadult males in the 4th to 6th decades. It has avariable clinical course. About 15-30% of patientsmay enter a spontaneous remission, up to 30%progress to end-stage kidney disease, and theremainder have persistent proteinuria unlesstreated with potent immunosuppressive agents.2,3

It has been reported that 30-50% of patients withend-stage membranous nephropathy who receivea kidney transplant will experience a recurrenceof the disease in the allograft.2,4-7 The diagnosis ofmembranous nephropathy has relied exclusivelyon kidney biopsy and until recently there was noimmunoassay available for the diagnosis or todetect active disease.

The histological features of membranousnephropathy are characteristic (Figure 1).3 Thereis diffuse thickening of the glomerular basementmembrane (GBM) but no increase in cellularity.With Jones’s silver stain characteristic “spikes” areseen to project from the GBM to extend betweenand surround the sub-epithelial immune depositsthat are typical of this disease. The expansion ofthe GBM is best seen on electron microscopy,which also reveals the subepithelial electron-dense immune deposits, extensive effacement ofthe overlying podocyte (visceral epithelial cell)foot processes with collapse of the actincytoskeleton and disruption of the interveningfiltration slits. Immunofluorescence showsprominent staining for IgG and C3 in a granularpattern on the glomerular capillary walls typicalof an immune complex disease. Most notably, theIgG subclass that predominates in idiopathicmembranous nephropathy is IgG4.

Membranous nephropathy may be idiopathic orsecondary to a variety of conditions. About 80% ofcases of membranous nephropathy are idiopathic

Serendipity and the Journey to a Human Autoantigen

David J SalantProfessor of Medicine, Department of Medicine, Boston University School of Medicine

Chief of Nephrology, Boston Medical Center, Boston, MassachusettsAJ Orenstein Memorial Lecture, Medical School, University of the Witwatersrand, Johannesburg

15 September 2014

4

in most series. Membranous lupus nephritis (class5) is the most common cause of secondarymembranous nephropathy in developed countries,whereas infections such as hepatitis B,schistosomiasis, malaria and syphilis predominatein developing countries. Membranous nephropathymay also be seen in association with various drugsand toxins such as NSAIDs, gold, penicillamineand mercury often used in skin-lighteningointments. There is also an association with varioussolid tumors. Secondary membranous nephropathycan sometimes be distinguished from the idiopathicform by the presence of immune deposits inlocations other than the subepithelial space andthe predominance of IgG1 or IgG3 in the depositsrather than IgG4.8

MECHANISMS OF IMMUNEDEPOSITION

When I joined the Couser laboratory in 1977 it waswidely believed that all forms of immune complexdisease, including membranous nephropathy,resulted from the entrapment of circulatingimmune complexes that activate complement andincite a leukocyte-mediated inflammatoryresponse.9 However, it proved difficult to reproducesuch subepithelial deposits by infusing preformedimmune complexes and membranous

nephropathy is a non-inflammatory diseasedespite the presence of complement in the immunedeposits.10 Much of what we subsequently learnedabout the pathogenesis of membranousnephropathy derives from the Heymann nephritismodel of experimental membranous nephropathyin rats.11 Whereas Walter Heymann inducedmembranous nephropathy in rats with a crudeextract of rat renal cortex,1 it was later discoveredthat the immunogen is located in a fraction of theproximal tubular brush border termed fraction 1A(Fx1A). Rats immunized with Fx1A developproteinuria after 6-8 weeks and an immunecomplex glomerulonephritis indistinguishablefrom human membranous nephropathy.12,13 Thedevelopment of the passive Heymann nephritismodel, in which rats become proteinuric within fivedays after injecting heterologous anti-Fx1A,enabled a more critical analysis of the mechanismsof immune deposit formation and glomerularinjury. In 1978, studies from our laboratory inBoston and that of Philip Hoedemaeker in theNetherlands determined that the subepithelialimmune deposits form in situ as a result ofcirculating antibodies binding to an intrinsicglomerular antigen rather than circulatingimmune complex entrapment.14,15 This wasestablished by perfusing isolated rat kidneys withanti-Fx1A such that the formation and entrapmentof circulating immune complexes was impossible.Based on these findings, we hypothesized that theantigen might be a component of the podocyte cellsurface,10 however, the nature of the antigen wasunknown until 1985 when Kerjaschki andcolleagues in the laboratory of Marilyn Farquhardiscovered the target on the podocyte cell surfaceand called it GP330.16,17 Dontscho Kerjaschki andI happened to bunk together in a room at a GordonConference in New Hampshire where he sharedthese observations with me prior to submittingthem for publication. This engendered mutualexcitement because we had just found thatpodocytes are the primary target of antibody-mediated, complement-dependent injury in thepassive Heymann nephritis model (see below).Antibodies to GP330 were shown to bind andcluster the antigen on the podocyte cell surfacewhereupon the complexes were shed to form thesubepithelial immune deposits characteristic ofmembranous nephropathy.18 The true nature ofGP330 was uncovered several years later as theresult of work in several laboratories.19-21 Theprotein – named megalin – is a 600 kDatransmembrane protein of the LDL receptor familyhighly expressed in proximal tubular brush borderand rat glomeruli.

Figure 1. Pathological features of membranous nephropathy.Left upper panel: Light micrograph of a Periodic Acid Schiff-stained glomerulus showing thickening of the peripheralcapillary walls (arrows) but no inflammatory infiltrate. Rightupper panel: Immunofluorescence micrograph of a glomerulusstained for IgG showing granular immune deposits in theperipheral capillary loop walls. Complement depositscolocalize with the IgG (not shown). Lower panel: Electronmicrograph showing subepithelial electron-dense immunedeposits (white asterisks), effacement of the overlying podocyte(Podo) foot processes, condensation of the actin cytoskeleton(arrows) and new glomerular basement membrane (GBM)being laid down between and around (black asterisks) theimmune deposits. Cap – capillary lumen; US – urinary space.

5

THE ROLE OF COMPLEMENT

Shortly after I arrived in Boston, one of my co-fellows Steele Belok ran some experiments todetermine the effect of various inflammatorymediators, including complement, on immunedeposition in the passive Heymann nephritismodel. The results were largely negative, however,unexpectedly the complement-depleted rats didnot develop proteinuria while all others did. Inthe meantime Steele had identified a guru anddecided to go off to meditate so I decided to followup on this serendipitous finding. As noted above,the only known role for complement in tissueinjury at that time was an inflammatory processinvolving leukocytes attracted by the chemotacticproperties of C5a. We confirmed that rats depletedof complement failed to develop proteinuria wheninjected with anti-Fx1A (Figure 2), whereasdepletion of leukocytes had no effect.22 This led usto speculate that the effect of complement mightbe the result of podocyte injury induced by theterminal complement pathway acting throughC5b-9, the membrane attack complex. This waslater established by studies in the isolatedperfused rat kidney model using C6- and C8-deficient sera.23,24 We found that rat kidneyscontaining subepithelial immune deposits of

complement-fixing anti-Fx1a when perfused withC8-deficient human serum or C6-deficient rabbitserum had normal podocyte morphology and noalbuminuria. Restoration of the complementdeficiencies allowed assembly of C5b-9 andcaused massive albuminuria and podocytedamage (Figure 2). Studies in C6-depleted ratswith passive Heymann nephritis and in C6-deficient rabbits with membranous nephropathyinduced by a planted antigen further establishedthe role of the membrane attack complex ofcomplement in experimental membranousnephropathy.25,26 Subsequent in vitro studiesestablished that sublethal podocyte injury byC5b-9 involves calcium influx, activation ofphospholipases, stress pathways, protein kinasesand transcription factors, alterations in theregulators of cell cycling, disruption of the actincytoskeleton and loss of focal adhesioncomplexes, reactive oxygen species production,DNA damage and overproduction of extracellularmatrix proteins.27 We also found thatthe development of complement-dependentproteinuria in the passive Heymann nephritismodel is associated with dissociation of nephrin,a critical podocyte slit-diaphragm protein, fromthe actin cytoskeleton. This process disrupts anddisplaces the filtration slit diaphragms, therebydestroying the final barrier to albumin leakageinto the urine.28,29

EVIDENCE FOR IN SITU IMMUNEDEPOSITION IN HUMANMEMBRANOUS NEPHROPATHY

Despite these insights into the pathogenesis ofmembranous nephropathy, there was someskepticism about the relevance of these findingsto human membranous nephropathy. This wasbecause megalin is not present on humanpodocytes and no one was able to detectcirculating anti-megalin antibodies in humanmembranous nephropathy. Furthermore, IgG4,the predominant IgG subclass in glomerulardeposits in human membranous nephropathy,does not bind complement C1q.30-33 Thisskepticism was largely countered by theremarkable description of a case of alloimmuneantenatal membranous nephropathy resultingfrom the production of alloantibodies to neutralendopeptidase (NEP) in a mother deficient in NEPand sensitized in a prior pregnancy.34 NEP isexpressed on the podocytes of human kidneyswhere it may serve as a target for thetransplacental passage of the anti-NEP

Figure 2. Left upper panel: Complement depletion of rats withpassive Heymann nephritis (PHN) prevents the developmentof proteinuria without affecting the amount of IgG antibodydeposited in the kidneys (right hand bars). Right upper panel:PHN kidneys perfused in vitro with C8-deficient (C8D) or C6-deficient (C6D) sera do not develop albuminuria, whereas thecombination mutually restores the deficiencies allowingformation of the membrane attack complex C5b-9 and causesmarked albuminuria. Lower panel: Kidneys perfused with C8-deficient serum (C8D – left micrograph) have immune depositsbut well-preserved podocyte foot processes, whereas kidneysperfused with sera that enabled C5b-9 assembly (rightmicrograph) caused severe podocyte (Epi) injury withmembrane vesiculation (arrowheads), foot process effacement,slit-diaphragm disruption and focal detachment. CL – capillarylumen; US – urinary space. Modified from Salant DJ, Belok S,Madaio MP, Couser WG: A new role for complement inexperimental membranous nephropathy in rats. J Clin Invest66: 1339-1350, 1980 and Cybulsky AV, Rennke HG, FeintzeigID, Salant DJ: Complement-induced glomerular epithelial cellinjury. Role of the membrane attack complex in ratmembranous nephropathy. J Clin Invest 77: 1096-1107, 1986.

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alloantibodies. The discovery of additional suchcases, and the demonstration that thedevelopment proteinuria depended on thepresence of complement fixing IgG1 rather thanIgG4 anti-NEP antibodies, largely resolved suchskepticism and showed that the paradigmestablished in the Heymann model ofexperimental membranous nephropathy alsoapplies in human membranous nephropathy.35

IDENTIFICATION OF THE M-TYPEPHOSPHOLIPASE A2 RECEPTOR ASAN AUTOANTIGEN IN HUMANMEMBRANOUS NEPHROPATHY

While the elegant studies of foetomaternalalloimmunization to NEP clearly showed that thein situ paradigm established in the Heymannmodel of experimental membranous nephropathyalso applies in human membranous nephropathy,the nature of the target antigen in idiopathicmembranous nephropathy remained in question.To address this, we conducted a series of studiesusing protein extracts from isolated normalhuman glomeruli and sera from patients withidiopathic and secondary membranousnephropathy as well as serum from subjects withseveral other diseases and normal controlsubjects.36 This was not a new undertaking sincewe and other investigators had attempted similarstudies in the past without any success.Nevertheless, having had some recent success inidentifying podocyte target antigens inexperimental models using modern proteomics,37,38

we decided to try again. Several experiments werea complete failure until one day Dr Larry Beck(then a research fellow and presently assistantprofessor) walked into my office with the westernblot shown in Figure 3. This showed for the veryfirst time a protein band at about 185 kDa thatwas identified by serum IgG antibodies from fivesubjects with idiopathic membranousnephropathy and none of the controls. So why didthis work whereas all other attempts had failed?For reasons unrelated to the explanation, we haddecided to electrophorese the glomerular proteinextracts under non-reducing conditions ratherthan the conventional method using reducingagents to disrupt disulfide bonds. Electrophoresisunder reducing conditions completely abolishedreactivity with the patient sera, which indicatesthat the epitope identified by the autoantibodiesexists in a conformation-dependent configuration.The results were confirmed with several additionalpatient and control sera and deglycosylation

studies showed that all the reactive idiopathicmembranous nephropathy sera identified theprotein backbone of the same glycoprotein.Proteomic analysis of the fully glycosylated anddeglycosylated protein revealed several candidateproteins, including some that are known to beexpressed on podocytes. However, none of theknown candidates was reactive with the humanmembranous nephropathy sera. Among theproteins identified in the proteomic analysis wasthe M-type phospholipase A2 receptor (PLA2R).39

While PLA2R was known to be expressed inkidney,40 it had not been identified in humanpodocytes and had never been implicated inhuman kidney disease, although it had beenshown to be up regulated and expressed by injuredmesangial cells in a rat model ofglomerulonephritis.41 In collaboration with DrGerard Lambeau from the University of Nice whohad originally cloned the human M-type PLA2R40,we performed western blot analysis of recombinantPLA2R with the human membranous nephropathysera, as well as western blot analysis of the humanglomerular extracts with a specific anti-PLA2Rantibody from Dr Lambeau. This clearlyestablished the identity of PLA2R as a putativetarget identified by human membranousnephropathy autoantibodies. This was confirmedby immunoprecipitation of the native antigen inhuman glomerular extracts by membranousnephropathy patient sera and identification withthe specific anti-PLA2R antibody. Confocalimmunofluorescence microscopy with anti-PLA2R

Figure 3. Western blot analysis of a protein extract ofnormal human glomeruli with sera from patients withmembranous nephropathy (MN) and controls (DN –diabetic nephropathy; FSGS – focal glomerulosclerosis). Theupper panel shows specific reactivity of the MN sera with aprotein of ~185 kDa. SDS-polyacrilamide gel electrophoresiswas run under non-reducing conditions. Lower panel showsreactivity with the core protein after deglycosylation of theN-linked sugar chains. From Beck LH, Jr, Bonegio RG,Lambeau G, Beck DM, Powell DW, Cummins TD, Klein JB,Salant DJ: M-type phospholipase A2 receptor as targetantigen in idiopathic membranous nephropathy. N Engl JMed 361: 11-21, 2009. Copyright © (2009) MassachusettsMedical Society. Reprinted with permission.

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demonstrated that PLA2R is expressed on thepodocytes of normal human kidney sections(Figure 4). In addition, the IgG4 antibodies andPLA2R were seen to co-localize in kidney sectionsfrom patients with idiopathic membranousnephropathy but not in sections from patients withsecondary membranous nephropathy due to lupusnephritis (Figure 5). Thus, it would appear that themechanism of antibody-induced clustering andshedding of the podocyte antigen-antibodycomplex that had been demonstrated inexperimental membranous nephropathy mightalso apply in the human disease. Analysis of theIgG subclass specificity of the circulating andtissue-deposited anti-PLA2R autoantibodies wasexamined and found to be predominantly, butnot exclusively IgG4. Thus we were able toconclude that the M-type PLA2R is a major targetantigen in idiopathic but not secondary formsof membranous nephropathy, and that a highproportion of patients with idiopathic

membranous nephropathy have circulatinganti-PLA2R antibodies directed at a conformation-dependent epitope on PLA2R.36

CHARACTERISTICS OF PLA2R

PLA2R is a member of the mannose receptor family,which comprises the mannose receptor, Endo180,Dec-205 and PLA2R. A receptor for Fc on avianimmunoglobulin is another member of this proteinfamily. All family members have a cystine-rich N-terminal domain, followed by a fibronectin II regionand 8-10 C-type lectin-like domains, atransmembrane segment and a short cytoplasmictail with an endocytic signal domain.42 The functionof PLA2R in podocytes remains uncertain, however,it has been shown that stimulation of cellsexpressing PLA2R with sPLA2 induces cPLA2activation, eicosanoid production and generation ofreactive oxygen species.43,44 Moreover, over-expression of PLA2R induces DNA damage andcauses cellular senescence.45 Recently, PLA2R hasalso been found to have tumor suppressor propertiesmediated through the kinase JAK246-49 and itmediates myocardial healing after ischemic injuryby interacting with beta1-integrins.50 Anotherinteresting observation is that other members of themannose receptor family have been shown to existin either extended or bent configurations.42,51 IfPLA2R is also found to exist in differentconfigurations it might explain the conformation-dependent nature of the reactivity of themembranous nephropathy autoantibodies with theantigen. In that regard, we and others (Fresquet etal. Abstracts of the American Society of Nephrology2013) have found that the autoantibodies identify aconformation-dependent (reduction-sensitive)epitope in the N-terminal region of PLA2R that isknown to undergo conformational changes in othermannose receptor family members. Furthermore,this region is known to harbor several non-synonymous coding SNPs, variations in whichmight confer susceptibility to membranousnephropathy52,53 and account for the conformationdependent nature of the target epitope.

GENETIC ASSOCIATIONS

As in many autoimmune diseases, membranousnephropathy has long been known to beassociated with certain class II majorhistocompatibility (MHC) loci, thus suggesting agenetic susceptibility to the disease.54,55 Moreover,shortly after we reported that PLA2R is a major

Figure 4. Confocal immunofluorescence micrograph of anormal human glomerulus stained with monospecificantibodies to PLA2R (arrows) and agrin (to delineate theGBM). The PLA2R staining corresponds to the location ofpodocytes on the outside of the GBM. From Beck LH, Jr,Bonegio RG, Lambeau G, Beck DM, Powell DW,Cummins TD, Klein JB, Salant DJ: M-type phospholipaseA2 receptor as target antigen in idiopathic membranousnephropathy. N Engl J Med 361: 11-21, 2009. Copyright© (2009) Massachusetts Medical Society. Reprinted withpermission.

Figure 5. PLA2R relocates to colocalize with IgG (left panel) inthe immune deposits of patients with idiopathicmembranous nephropathy (IMN – middle panel) but not insecondary causes such as lupus membranous nephropathy(Lupus MN – right panel).

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antigen in idiopathic membranous nephropathy,significant associations were reported withpolymorphisms in the PLA2R1 gene in Koreanand Taiwanese subjects.52,56 Perhaps more strikingwere the results of an independent unbiasedgenome-wide association study from a Europeanconsortium that showed a strong geneticassociation of idiopathic membranousnephropathy with a non-coding single nucleotidepolymorphism (SNP) in PLA2R1 and with theMHC II locus HLA-DQA1.57 Notably, the PLA2R1SNP was in strong linkage disequilibrium withnon-synonymous coding SNPs found in the Asianstudies. Remarkably, although the PLA2R1 andHLA-DQA1 SNPs were both significantly andindependently associated with the disease, theodds ratio of membranous nephropathy wasalmost 80 fold in individuals that werehomozygous for both HLA-DQA1 and PLA2R1variants. This work provided a robust andindependent verification of the significance ofPLA2R, however, subsequent studies have notidentified unique or rare PLA2R1 variants toexplain the susceptibility to membranousnephropathy.58 It is possible that the stronggenetic interaction between the PLA2R1 and HLA-DQA1 loci may indicate that a specific HLAmolecule is required to present PLA2R aberrantlyto the immune system, or another factor, such asa microbial infection leading to molecularmimicry, may trigger the onset of disease.59

CLINICAL AND THERAPEUTICIMPLICATIONS

To date, we have analyzed the sera of more than200 patients with idiopathic membranousnephropathy and found seropositivity to PLA2R in80% of cases. This includes patients from severaldifferent ethnic groups and geographic areas. Noneof our normal and disease controls has beenpositive, and almost all of the cases of secondarymembranous nephropathy have been negative. Ina recent series of 116 Chinese patients, a positivetest for anti-PLA2R was found in one case each ofmembranous nephropathy associated withhepatitis B and SLE, two cases of membranousnephropathy in patients with mercury exposure,and three cases of membranous nephropathy inpatients with cancer.60 Whether these are real orchance associations has yet to be established. Wehave found a good correlation between anti-PLA2Rreactivity and disease activity. In a series of cases ofidiopathic membranous nephropathy treated withrituximab we found that 83% of those that entered

into a clinical remission lost reactivity prior to thereduction in proteinuria, whereas 71% of those whofailed to remit remained positive for anti-PLA2R.61

Furthermore, we performed an analysis of 54 serumsamples from 18 patients with idiopathicmembranous nephropathy obtained at variousstages of clinical disease, and found that the anti-PLA2R titer correlated strongly with clinical statusand proteinuria.62 Similar results were reported byothers.63,64 Table 1 summarizes the results of mostpublished clinical studies that have utilized one ormore serological assay (western blot, indirectimmunofluorescence or ELISA). In addition,following on our observation that PLA2R relocatesfrom the podocyte plasma membrane to co-localizewith IgG in the immune deposits in idiopathic butnot secondary membranous nephropathy, severalstudies have confirmed that finding in largernumbers of patients and several pathologylaboratories are routinely performing tissuestaining for PLA2R to distinguish primary(idiopathic) from secondary membranousnephropathy and recurrent from de novomembranous nephropathy after transplantation.65-

68 Finally, to determine if anti-PLA2R positivity atthe time of kidney transplantation confers a risk forrecurrence, we evaluated 26 patients from theMayo Clinic, 18 with recurrent MN and 8 withoutrecurrence, with serial post-transplant serumsamples and renal biopsies to determine if patientswith pre- transplant anti-PLA2R are at increasedrisk of recurrence as compared to seronegativepatients. In the recurrent group, 10/18 patients hadanti-PLA2R at the time of transplantation ascompared to 2/8 patients in the non-recurrentgroup. The positive predictive value of pre-transplant anti-PLA2R for recurrence was 83%,while the negative predictive value was only 42%.Clearly, further prospective studies are required todefine the value of anti-PLA2R in this setting.

In July 2014, the United States Food and DrugAdministration approved two anti-PLA2R assaysfor clinical use, an indirect immunofluorescenceassay using cells transfected with recombinanthuman PLA2R and a high-throughput ELISA(Euroimmun, Morris Plains, NJ). Thus far, thesensitivity of anti-PLA2R positivity for the diagnosisof idiopathic membranous nephropathy is 60-80%,the higher number representing newly diagnosedand active cases (Table 1), and the specificity is atleast 96%. Moreover, the fact that the antibodiesdecline and even disappear prior to the completeresolution of proteinuria may offer a more accurateguide to the duration of immunosuppressivetherapy.64,69 Additional prospective data from

9

clinical trials of membranous nephropathy willfurther refine the value of this test for the follow upof patients receiving treatment for membranousnephropathy.

SUMMARY

In summary, we have identified PLA2R as a majortarget antigen in idiopathic membranousnephropathy. Approximately 60-80% of patientsfrom all ethnicities with biopsy provenmembranous nephropathy have tested positive foranti-PLA2R. The autoantibodies identify aconformation-dependent epitope in the N-terminalregion of PLA2R on podocytes. This region is knownto undergo conformational changes in other

mannose receptor family members. Anti-PLA2Rreactivity is highly specific for idiopathicmembranous nephropathy. The antibodies aremostly, if not exclusively, IgG4 and the IgG4 anti-PLA2R antibodies co-localize with PLA2R inidiopathic membranous nephropathy but not insecondary forms of membranous nephropathy onkidney biopsy. However, there are still questions toresolve. Is there another antigen in the 20% ofidiopathic cases that have tested negative for anti-PLA2R or are they simply inactive? What are theantigens in secondary membranous nephropathy?How do IgG4 antibodies cause podocyte injury ifthey can’t fix complement? What triggers thedevelopment of anti-PLA2R? How do the geneticvariations in PLA2R confer susceptibility tomembranous nephropathy? Whatever the answer

Table 1. Current status of anti-PLA2R serological tests in patients with primary (idiopathic) membranous nephropathy

Author (Year) Patients (n) Anti-PLA2R (%) Assay Reference

Beck (2009) 37 70% WB 36

Hofstra (2011) 18 78% WB 70

Beck (2011) 35 71% WB 61

Debiec (2011) 42 57% IFA 71

Hoxha (2011) 72- Entire cohort 100 52% IFA- Active disease 35 66%

Qin (2011) 73- Active disease 60 82% IFA- Remission 21 19%

Bruschi (2011) 24 58% WB 74

Gunnarsson (2012) 3 100% IFA 70

Hoxha (2012) 88 68% IFA 67

Hofstra (2012) 117 74% IFA 7572% ELISA

Murtas (2012) 111 60% WB, IFA 76

Svobodova (2012) 77- Active disease 31 65% IFA- Remission 37 22%

Kanigicherla (2013) 63- Active disease 40 75% ELISA- Partial remission 27 37%- Complete remission 23 10%

Coenen (2013) 82 52% IFA 58

Becht (2014) 48 71% ELISA 64

Timmermans (2014) 109 68% IFA 7872% WB, ELISA

WB - western blot; IFA - indirect immunofluorescence

10

to these questions, it is clear that the detection ofanti-PLA2R can serve as a useful diagnostic test incases that are not amenable to kidney biopsy aswell as to follow the response to treatment andpossibly to predict the recurrence of membranousnephropathy after transplantation.

ACKNOWLEDGMENTS

This work was supported by research grantsDK030932 and DK090029 from the NationalInstitutes of Health.

DISCLOSURE

Dr Salant is a co-inventor on a patent“Diagnostics for Membranous Nephropathy”. Hereports serving as a consultant for Alnylam andChugai Pharmaceuticals and he conductsresearch with Alexion, Alnylam and Pfizer.

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13

ABSTRACT

A wealth of photographic material from Tara, theH Moross Centre, exists at the Adler Museum ofMedicine. For the purposes of this article, only onephotographic item will be investigated, namelythe Tara photograph album (the album). Such aninvestigation is faced with a number of difficultiesas the album is undated and lacks anyaccompanying text (no captions, titles, orpreface). Although the album lacks the relevanttexts and archived documents to assist in decodingthe photographs, I argue that the institutionalethos of Tara during the superintendency of Dr HMoross (1947 – c 1969) provides a contextualframework within which one can examine thephotographs critically. Accordingly, this articleseeks to explore Tara’s institutional ethos in orderto provide a historically informed understandingof the production and encoding of the album’sphotographs.

INTRODUCTION

“Psychiatry and photography were born with a fewdecades separating them. Their encounter producedthe use of photography for classificatory andteaching purposes in order to identify, study andclassify mental illness”.1 Such a statement highlightsthe dominant concern of visual culture scholarshipthat seeks to interrogate the clinical andclassificatory genre of photography withinpsychiatry. Recently, however, there has been anacknowledgement that multiple other genres alsostem from the nexus between photography andpsychiatry. One such genre includes the promotionalphotographs that psychiatric institutions display orpresent to the public. The production anddissemination of these images can, for the most part,be linked to the image-making of the institution –the creation of a favourable view of itself.2-5

The archives of Tara, the H Moross Centre, at theAdler Museum of Medicine provide a valuableresource in exploring the genre of promotionalphotographs. The folders of the archive are

brimming with photographs from newspaperclippings, brochures and a photograph album (thealbum). For the purposes of this article, I aminterested in providing a critical exploration of thealbum. Yet such an investigation is faced with anumber of difficulties as the album is undated andlacks any accompanying text (no captions, titles,or preface). Moreover, I have thus far not been ableto locate any documents that make specificmention of the album. One can estimate that thephotographs were taken in the late 1940s and early1950s based on the styles of clothing depicted.

The album is a regal hard-cover book in landscapeformat with twelve A4 black-and-whitephotographs pasted on separate sheets of paperwith the name of ‘Wittels Studio’ signed at thebottom right corner of each photograph. Althoughthe album lacks any captions and text to assist indecoding the photographs, I argue that theinstitutional ethos of Tara during theabovementioned time-period provides a context inwhich one can critically examine the photographs.Said differently, a contextual reading of thephotographs is possible by understanding Tara’stherapeutic tenets, principles and aims.Accordingly, the article seeks to explore Tara’sinstitutional ethos to provide a historicallyinformed understanding of the production andencoding of the album’s photographs.

Tara was established as a provincial hospital of theformer Transvaal province in 1946. The hospital inHurlingham, Johannesburg, catered for the careand treatment of non-certifiable psychiatricproblems, in other words, the minor andrecoverable cases of mental illness.6-8 Thescholarship on Tara has in the most partenumerated the seminal role and pioneeringcontributions of Dr Hyman Moross (1904 – 1979),the hospital’s first Medical Superintendent.9 Thisarticle seeks to contribute to the existing scholarshipby identifying and exploring the institutional ethosand image-making relating to the hospital.

Under the superintendency of Moross (1947 – c 1969),a core institutional ethos of Tara was the provision

The Tara photograph album: visualising atherapeutic community

Rory du PlessisDepartment of Visual Arts, University of Pretoria

14

of and practice within a therapeutic community.10-12

For Moross, the therapeutic community compriseda synthesis of a number of current concepts inpsychiatry that focused on maintaining atherapeutic milieu and harmonious hospitalenvironment while offering a range ofoccupational therapy and associated activities forthe active participation of patients.13 The approachand regimen of the therapeutic community wasbelieved to be ideally suited for the treatment ofpatients who were battling the perplexities of lifeand having problems relating to other people:

the milieu which he enters on admittance tohospital must provide such new livingexperiences and new personal relationshipsas to provoke less anxiety than before, affordmaximal support and gradually enable thepatient to develop social relationships and tolive more effectively with others.14

Tara was equipped with a range of medicaltechnologies and machines that catered for thehospital’s various sections – medical, surgical andneurosurgical. Yet, there is not one photograph thatdepicts either the machines or the aforementionedhospital sections. Instead, the photographs are ofthe picturesque grounds of the hospital, individualsplaying sports (tennis, golf and bowls), patientsrelaxing to the rhythmic beat of a drum, a weavingworkshop, and the impressive collection of books inthe library. These photographs suggest that thealbum was not aiming to record all the facilities andfacets of care and treatment at the hospital. Instead,it compellingly presented a hospital environmentthat promoted the ideals of a therapeuticcommunity. Thus, I argue that the interpretation ofthe photographs requires a conceptual frameworkthat sheds light on the therapeutic community.Consequently, the investigation consists of aninterlinking twofold objective, namely: (1) toresearch the concept of the therapeutic communitythrough historical and critical texts; and (2) toexplore how the photographs require for theirinterpretation a conceptual framework of thetherapeutic community.

Figures 1-3 are evocative of a leisure resort in thearray of sporting amenities and activities depicted.All the images show patients playing sport. Figure 1includes umbrellas and spectators, which contributeto establishing a vividly ebullient scene. While thephotographs portray various outdoor sportingactivities, these very activities operated as a mode oftreatment at the hospital.15 A main concern withinthe concept of the therapeutic community was

developing the use of recreation as a therapeutic toolin hospital practice.16 Thus, what follows is anexploration that illuminates the diverse therapeuticimbuement of sporting activities. On a very directlevel, sport was one form of physical education thataimed to improve the bodily status of theindividual.17 Furthermore, it was also believed torestore “rhythm, co-ordination, appetite and weight;

Figure 1

Figure 2

Figure 3

15

it helps to induce a sense of well-being and inspirespsychological accessibility”.18 Sport was alsoconstructed as a recreational pursuit for thetherapeutic purpose of relaxation. Moreover,sporting activities, whether conceived as recreationengagement or physical education, were valuablefor being participatory and social.19 To this end, itwas argued that on a therapeutic level the patientsbenefited from group engagement.20 Such anargument was based on Moross’s commitment togroup psychotherapy that called for bringingindividuals together into direct and meaningfulinteraction. In doing so, this form of therapy offered:

opportunities for social participation and forincreasing social capacity, at a ratecommensurate with the patient’s abilities.The group situation makes it possible for themembers to enjoy equal responsibility,freedom of thought and uninhibited self-expression.21

The photographs are remarkable in this regard inthat they display groups of individuals interactingwith one another and socialising. The demeanourand behaviour of the individuals are markedlyfriendly and connote companionship,camaraderie and team spirit.

In figure 4, a healthcare worker in a white coat isseated in close proximity to the beds of the patientswhile she rhythmically beats a drum. Her eyesappear closed as if she is somewhat absorbed in apleasurable state induced by the cadence of thedrum. The pose of the healthcare worker isjuxtaposed with the individuals lying on the bed.Whereas the healthcare worker looks naturally andunpretentiously relaxed, the individuals appear tobe adopting poses mandated as part of a treatmentprogramme. The individuals are all lying on their

backs with their arms to the side while a pillow liesbeneath their knees. Such a pose anchors theinterpretation of the photograph as a treatmentsession conducted for therapeutic benefits. Thesessions on relaxation techniques were a coreprinciple of the therapeutic community.

Tara placed special emphasis on relaxationtechniques and treatment. This took the form ofspecial classes in which the patients were taughthow to consciously relax.22-23 The classes werevaluable in improving sleep patterns while alsocontributing to minimising tension in humanrelationships and fostering stress-free interpersonalcontact.24-26 A connected outcome of relaxationtreatments was that the patient learnt to“appreciate the value of relaxation in action. Helearns, for example, that he need not drive a motorcar with a vice-like grip of the steering wheel,urging the car along with braced arm and legmuscles, but comes instead to appreciate howmuch more competent he can be when he iscomfortable and relaxed”.27 One notablerelaxation technique was the use of music that wasdeemed to be beneficial “to the extent that it mayengender satisfying release from tension, and thepleasurable emotions stimulated by it may aiddistressing sensations”.28

Depicted in figure 4 is a poster on a wall that reads“If you are relaxed you are not afraid; if you areafraid you are not relaxed”. While music may besoothing and aid the patient in consciouslyrelaxing, the outcome of the relaxation treatmentprogramme is equally focused on teaching thepatients the difference between tension andrelaxation.29 In this regard, the poster acts as amaxim that calls for the patients to consciouslyassess their stress and anxiety levels in their dailyliving and to manage them through the relaxationtechniques taught at the hospital.

For Moross, a risk of hospital institutionalisationwas that patients could develop an unhealthydependence on the hospital to protect them againstthe pressures of normal life.30-32 As a therapeuticcommunity, Tara instead aimed to encourage therecovery and successful return of patients to thecommunity. This was fostered by the hospitalpromoting social participation and relaxationtechniques that aided the full integration of theindividual into life outside the hospital. Activeparticipation in occupational therapy was anadditional means of supporting the patient to keep“in touch with the reality of daily living external tothe hospital, and … counteract isolation”.33Figure 4

16

Figure 5 depicts a workshop for occupationaltherapy in which a number of women are engagedin weaving. Occupational therapy was thought tooffer diverse therapeutic outcomes. It offeredpatients respite from tensions, anxiety, grief andmorbid or melancholic thoughts by offering themopportunities for meaningful engagement andactive socialisation.34 This respite was contingentupon the hospital offering a wide range of activitiesto appeal to the various preferences of individuals.35

Additionally, the choice of the activity was“discussed and designed by and with the patient,otherwise the activity is regarded as a disciplinaryrestriction and the patient is not likely to benefitfrom it after his discharge from hospital”.36

It is worth noting two features in the photographthat explain the practice of occupational therapy atTara, namely the setting of the workshop and thepresence of the nurse / therapist in the background.By being in the workshops, the patients wereremoved from their wards and entered a workatmosphere.37 This was an intentional mechanismdesigned for the hospital to help the patients to re-enter the work environment of the outside world.The Tara workshops therefore served as a steppingstone in the rehabilitation of the patient. A friendlyworkshop atmosphere was offered where “thepatient is often helped to overcome his inability tomix with others, to make social contacts, and to takepart in communal activities”.38 Central to enablingand encouraging the development of social contactsand co-operation between the patients is the role ofthe nurse / therapist.39 The nurse / therapist acts notonly to guide the patients but to promote confidencein their abilities and skills. “As confidence expands,anxiety, frustration and stress may become moreendurable; the patient may be motivated to recoverand move toward regulating his behaviour bypersonal initiative, judging for himself what needsto be done, making plans for doing it and executing

such plans”.40 Thus, occupational therapy helped toprevent boredom and depression while also assistedin restoring self-confidence and the engendering ofresponsibility.

Figures 6 and 7 are visually striking in theirphotographic composition. What is mostdistinctive is the way in which the imagesrepresent the trope of the picturesque – how thelandscape’s arrangements are cultivated toresemble a painting. Figure 6 depicts an idyllicscene of a bridge over a tranquil and serene bodyof water. The photograph is framed on the rightby a magnificent tree crowned by a thicket ofleaves. The foreground reveals an open andinviting section of lawn that is well-shaded. Thefocal point of Figure 7 is a tree that is dignifiedand gracious in its outstretching towards the sky.The shallow water of the pond appears marble-like in its reflection of the clouds and sky.

In the photographs, the landscape and sceneryare the focal points. In one way, the focus can beaccorded to the central role that the landscape

Figure 5

Figure 6

Figure 7

17

and grounds played in treatment options withinthe therapeutic community. Extensive hospitalgrounds and gardens were fundamental for theoutdoor recreation amenities offered at Tara.41

During leisure time, the gardens may have beena sought after space for rest and relaxation, formeditation, light meandering, bird-watching or aplethora of other activities that suited individualtastes.42

Of interest, though, is that Tara’s representation ofits grounds and landscape has parallels withnineteenth century asylums across South Africaand the West, when asylums sought a countrylocation with ample grounds and an unobstructedview of a surrounding landscape that was bothtranquil and picturesque. Furthermore, substantialportions of the asylum site were cultivated asgardens and farms for the purpose of providingoccupational therapy and exercise for patients –an intrinsic component of the therapeutic regimenpractised at the asylum. Thus, the landscapedesign was not intended for appearances only, buthad an explicit role in the treatment of patients.Stated differently, the location, grounds and designof asylums were intrinsic components of thetherapeutic regimen offered at the institution.43

The landscape tropes of nineteenth centuryasylums became adjuncts to mental healthtreatment in the twentieth century under theconcept of milieu therapy. At Tara, milieu therapywas woven into every facet of the hospitalsystem.44-45 Tara’s appreciation of milieu therapyfurther serves to underpin and underscore theimage of the hospital as being dedicated toproviding an appropriate setting in which patientscould regain their serenity.

A notable feature of the album is that there is nota single depiction of a psychiatrist. Instead, thereare extensive representations of nurses and othermembers of the therapeutic team. This intriguingfocus on members of the therapeutic team otherthan psychiatrists can be succinctly enumerated interms of the therapeutic community. In such atreatment approach, it was extolled that “any staffmember with whom the patient has contact is apotential psychotherapeutically active agent”.46

Thus it was not only the psychiatrist/patientrelationship that mattered, but the patient’scontact and communication with all members ofstaff that held therapeutic value. In figures 4 and5, the hospital’s staff members are depicted neitheras wardens nor supervisors. Instead, they areshown to be intimately engaged with the patients.They serve to constructively support and guide the

patients in the workshop, while in the relaxationsessions they sooth and comfort the patients.

In the absence of any captions or text in thealbum, the interpretation of the photographs canfor the most part be described as a hermeneuticalor interpretive reading. A fundamental feature ofhermeneutics is that it acknowledges that therewill always be the prospect of generatingalternative interpretations that may offer moreconvincing or even divergent interpretations. Thus,while this article considers the therapeuticcommunity as a construct critical to theinterpretation of the photographs, there are otherideological constructs evident in the photographswhich offer further research topics. An absence inthis article has been a critical analysis of therepresentations of race, class and gender in thephotographs. Future investigations may indicatehow the dominant socio-cultural understandingsof race, class and gender are embedded in theimages. Such an undertaking will provide muchwarranted additional avenues of research.

Although the discussion of image-making hasbeen limited to the Tara album, it may serve toenrich further explorations into other forms ofpromotional photography disseminated by Tara.A precursory examination of the archivedpromotional photographs shows a continuity inthe themes, motifs and tropes established in thealbum. Thus, future research efforts may take theform of trying to evaluate and understand moreextensively the resonance of the visual repertoireestablished in the album and its influence onvarious other promotional photographs.

Additionally, future studies may move towardsexploring the image-making of the hospital invarious other media forms. Tara ran a number ofmental health campaigns which included radioprogrammes, open-days and a film produced bythe hospital to enlighten the public on the aimsand work of Tara. It is certain that the examinationof each medium will reveal new approaches andfeatures that will aid in establishing the full scopeand scale of the hospital’s image-making. For thepresent, what can be stated is that the image-making provided an important tool to counter thefear and stigma of mental illness and the public’slack of confidence in mental hospitals.47-49 Theimage-making helped “in the development of amore acceptable image of the psychiatric hospitalwhich may have been preconceived as a dreadfulplace accommodating bizarre 'maniacs' and staffedby strong-armed persecutors”.50

18

ACKNOWLEDGEMENTS

I wish to thank Rochelle Keene for introducing meto the Tara photograph album and providinginvaluable help and support with my research.The photographs are reproduced with permissionfrom the Adler Museum of Medicine.

REFERENCES

1. Manzoli F. 2004. Images of madness: the end of mental

hospitals illustrated through photographs. Journal of

Science Communication. 3(2):2–7, p 3.

2. MacKinnon D. 2003. 'The trustworthy agency of the

eyes': reading images of music and madness in historical

context. Health and History. 5(2):123-149.

3. Topp L. 2007. The modern mental hospital in the late

nineteenth-century Germany and Austria: psychiatric

space and images of freedom and control. In L Topp, JE

Moran & J Andrews (eds) Madness, architecture and the

built environment: psychiatric spaces in historical

context. Routledge, London, pp 241-262.

4. Du Plessis R. 2013. Popularising and promoting the

asylum: photography and image making at the

Grahamstown Lunatic Asylum, 1890-1907. Image &

Text. 22:99-132.

5. Tomes N. 1994. The art of asylum-keeping: Thomas Story

Kirkbride and the origins of American psychiatry.

University of Pennsylvania Press, Philadelphia.

6. Moross H. [n.d]. Tara: The H. Moross Centre. Smith

Mitchell Organisation, Johannesburg, p 7.

7. Gillis L. 2012. The historical development of psychiatry

in South Africa since 1652. South African Journal of

Psychiatry. 18(3):78-83, p 80.

8. Moross H. 1960. Thoughts on the planning of mental

health services for South Africa. South African Medical

Journal. 34(9):171-174, p 172.

9. Gillis L. 2012. The historical development of psychiatry

in South Africa since 1652. Ibid, p 80.

10. Moross H. [n.d]. Tara: The H. Moross Centre. Ibid, p xiv.

11. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part I: diagnostic and

treatment resources and modus operandi. South African

Medical Journal. 41(14):351-355, p 351.

12. Moross H. 1951. Treatment and prophylaxis. In EH

Cluver (ed) Social medicine. Central News Agency, South

Africa, pp. 135-175, p 136.

13. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part I. Ibid, p 351.

14. Ibid, p 352.

15. Moross H. [n.d]. Tara: The H. Moross Centre. Ibid, p 17.

16. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part II. Ibid, p 376.

17. Moross, H. 1951. Treatment and prophylaxis. Ibid, p 141.

18. Ibid, p 141.

19. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part I. Ibid, p 353.

20. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part II. Ibid, p 376.

21. Moross H. 1951. Treatment and prophylaxis. In EH

Cluver (ed) Social medicine. Central News Agency, South

Africa, pp. 135-175, p 139.

22. Moross H. [n.d]. Tara: The H. Moross Centre. Ibid, p 17.

23. Moross H. 1951. Treatment and prophylaxis. Ibid, p 142.

24. Moross H. [n.d]. Tara: The H. Moross Centre. Ibid, p 17.

25. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part II. Ibid, p 377.

26. Moross, H. 1951. Treatment and prophylaxis. Ibid, p 142.

27. Ibid, p 142.

28. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part II. Ibid, p 377.

29. Moross H. [n.d]. Tara: The H. Moross Centre. Ibid, p 17.

30. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part I. Ibid, p 353.

31. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part II. Ibid, p 378.

32. Moross H. 1951. Treatment and prophylaxis. Ibid, p 136.

33. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part II. Ibid, p 378.

34. Ibid, p 375

35. Moross H. 1951. Treatment and prophylaxis. Ibid, p 142.

36. Ibid, p 142.

37. Ibid, p 142.

38. Ibid, p 144.

39. Ibid, p 140.

40. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part II: psychiatric

occupational therapy. Ibid, p 376.

41. Moross H. [n.d]. Tara: The H. Moross Centre. Ibid, p 18.

42. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part II. Ibid, p 376.

43. Du Plessis R. 2012. The influence of moral therapy on

the landscape design of lunatic asylums built in the

nineteenth century. De Arte. 86:21–38.

44. Moross, H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part I. Ibid, p 351.

45. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part II. Ibid, p 380.

46. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part I. Ibid, p 352.

47. Gillis LS. 1962. Social and community psychiatry in

South Africa. South African Medical Journal. 36(8):141-

148, p 143.

48. Gillis LS. 1961. Who is mentally healthy? South African

Medical Journal. 35(8):141-146, p 146.

49. Moross H. 1960. Thoughts on the planning of mental

health services for South Africa. South African Medical

Journal. 34(9):171-174, p 173.

50. Moross H. 1967. A therapeutic community in the setting

of a psychiatric teaching hospital. Part II. Ibid, p 378.

19

At 16:00 on 31 December 1973,six young men gathered outsidethe office of the Chair of Surgery,awaiting their instructions fromProfessor du Plessis, who for thenext six months would be knownto them as “Sir!” in his presenceand, occasionally, God, butmostly DuP everywhere else.Kenneth Polonsky, Richard Conn,Warren Carel, Raymond Polak,Brian Greis and I. We had atleast three things in common:first, we were all good students,good enough to secure thenumber one internship at Wits atthe time; second, we had allapplied for DuP’s Job as our firstchoice; and third, we were all scared three-quarters to death by the challenges of the next sixmonths. A real band of brothers-in-the-making.

The door opened, in we went and there he was!DuP’s reputation as a tyrant was well known, aswas his exceptional prowess as an academicsurgeon, teacher, mentor and role model. He‘welcomed’ us to his ward with words that wentsomething like: “I didn’t ask you to apply for myjob, you did. So here are the rules!” Just a few ofthe many will suffice:

We would have every second weekend off startingafter ward rounds on Saturday (about 14:00) toMonday morning at 05:00-06:00 when we wouldput in the intravenouses for the day. At all othertimes, we were responsible for our own patients.

We would wear a tie and a clean white coat onthe ward every day, be clean shaven, wear ourhair above the collar and above our ears, neverleave the operating room dressed in surgicalscrubs.

We would avoid fighting with thecharge nurses because he wouldtake their side every time sincewe were just passing through.

And on Wednesdays andSaturdays we would pour tea forthe consultants, giving him a cupwith two fingers of tea, the resthot water, no milk, no sugar.

And many more such rules.

Did the rules scare us even more:not at all, we knew them beforehe spelled them out for us and wecould not have been any moreanxious and excited. After all, we

were now doctors and this was our first “job.”

Rather than provide a blow-by-blow account ofthose sixmonths, I have chosen to highlight theexperience through a series of cases, events andinteractions that have stuck in my mindthroughout the next 40 years. DuP was the mostdemanding individual I have ever worked for orwith. He demanded only one thing of himself andeveryone around him: maximal effort.

THE BENT FINGER

On the first day of the internship, I was exposedto DuP’s aura: we were scrubbing in on my firstcase, DuP on the right, David (Dave) Coombs, thesenior registrar, in the middle, and me on the left(and when I say scrubbing I mean just that!Finger tips to elbow). DuP asked Dave how theman in the surgical infection ward, we’ll call himMr Ferreira, was doing. Dave said the man wascritically ill and very likely would not survive.DuP simply pointed his bent index finger at Dave

Tomorrow will be Tuesday if it is okay with you:Memories of a surgical internship with

Professor DJ (Sonny) du Plessis

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

Professor DJ (Sonny) du Plessis

20

and me (he would do that often as a form ofbenediction) and said that we were not to let himdie, period, the end, no debate. In this way wewould demonstrate excellence in patient care tothe doctors who had looked after Mr Ferreira in aprivate hospital and, quite frankly missed thediagnosis of bowel gangrene due to anintususception. For the next six weeks I becameMr Ferreira’s ‘bodyguard,” treating another crisisevery few days, multiple episodes of septic shock,massive GI bleeding, the complications of evermore desperate therapeutic approaches, such ashyperbaric oxygen therapy, a supposed adrenalcrisis and much more. I may have been hisneophyte bodyguard, but Mr Ferreira became my‘teacher:’ in addition to being the textbook ofsurgical complications, he taught me how to stayawake for days in a row, and resilience, tenacityand commitment to the individual patient. I hadleft DuP’s ward when Mr Ferreira returned sixmonths later to have his bowel reconnected. Onward rounds, DuP said to him that he was luckyto be alive. Mr Ferreira replied that luck hadnothing to do with it, rather that a young intern,Daneman, had simply refused to let him die!

On a subsequent occasion, the bent finger waspointed at me as DuP was completing theremoval of a massive parathyroid adenoma.Daneman, he asked rhetorically, what are yourplans for the next 24 hours? None, Sir! I said.Well, you’ll be sitting by this woman’s bed duringthat time because in 6 hours her calcium is goingto fall through the floor and you are going to bethere to prevent and treat it. Yes, Sir! Almost to theminute he had predicted what would happen.These were lessons in observation and experiencethat were unrivalled.

RUNNING ON EMPTY: THE TRAVAILSOF EXHAUSTION

The last time I checked there were still 168 hoursin a week and in DuP’s ward we were spendingmore than 110-120 of those hours on the ward.The first thing that happened was leg aches andpains, likely shin splints, from being on our feetso many hours a day, but those went away in afew weeks. More scary to me were the thoughtsthat crept into my head after being up for anumber of nights in a row: If only the patientwould die, I could go to sleep. It did not affect mypatient care but I began to question mysuitability for clinical medicine. After a few daysof these dark thoughts, I told one of my co-interns

about it. He said he had exactly the samethoughts and felt he was the only one. We had ashort discussion and these thoughts neverreturned. Almost 40 years later, I recounted thisstory to one of the other interns and he said, whydidn’t you talk to me about it, too? For all theseyears I thought I was the only one … It wasalmost 40 years later when reading SamuelShem’s brilliant book, The House of God, a quasi-fictional look at internship at a famous hospitalin the USA, that I read about the author’s similarexperience which resonated with my own.

On a lighter side, every time I got into bed I wouldfall into such a deep sleep that I could not easilydistinguish between the telephone, my pager orthe alarm. Thank goodness for my wife,Meredyth, who would answer the telephone whileI was fumbling with the alarm. I think she savedmy skin on many occasions. She had a lot ofpatience that year: pregnant with our first child,she would wait until my weekends off call todiscuss baby naming. I would lie on the bed whileshe read the names. After a few minutes shewould shake me awake and say, what is the lastname you heard? I would say, sheepishly,‘Aaron?’ the first in the alphabet! Our first son isNicholas.

The exhaustion of internship taught us how tocatnap whenever the opportunity arose, and itdid so every Wednesday during pathology rounds.The interns, registrars and consultants gatheredwith the pathologists to review the pathspecimens of the previous week. The lights wereswitched off and a pathology registrar would readthe name of the first patient, Mr Jones, forinstance. This was a cue for a short history fromthe intern responsible and a cue for the others todoze off. When the first case was finished, thepath registrar would say, Mrs Smith. The awakeintern then would jab Mrs Smith’s intern awakeand he would give the synopsis and so on for anhour. We were a very finely tuned unit in thisregard. And there was never any snoring.

There is nothing heroic about working 120 hoursa week, and functioning in a state of nearexhaustion throughout. To those of ourgeneration who belittle the work demands andwork ethic of today’s interns and residents withrestricted work hours, I would say only one thing:we were abused in the past, simple as that. Itbecame a badge of honour to have survived theinternship, then registrarships of the day. It hastaken another 30 years for sanity to prevail.

21

RESPITE: PASSING THE TIME, ANDGAS

Of the six month surgical internship, fourmonthswere on the professorial ward, one on the traumaunit and two weeks on anaesthesia, with a twoweek vacation. For me these were the middle twomonths. The anaesthesia service required earlyrising (but later than on DuP’s ward), all morningin the Operating Rooms (known as ‘Theatre’), areview of the next day’s cases, and off by 15:00-16:00 on most days. After DuP’s ward, this was apiece of cake except for the intense need eachafternoon to catch up on sleep: was it the residuefrom sniffing gases all morning or from sleepdeprivation of the ward?

The use of the word ‘Theatre’ to describe theoperating rooms may sound a wee bit arcane, butgiven the histrionics of some of the surgeons, theshouting, throwing of forceps, scalpels, etc.(NEVER by DuP!), it is often quite appropriate.Theatre was where interns could expect the mostabuse. Somehow we were always to blame foreverything that was not perfect in the surgeon’smind.

The trauma service bored me to tears. Fuelshortages had ‘fueled’ temporary laws thatreduced speeds on both city streets and highwaysso that motor vehicle accidents all butdisappeared (simple cause-and-effect for anyonelistening). There was a trickle of victims ofviolence so that being on call one-in-two was nottoo onerous.

Quiet, until one Sunday evening at about 10:00when my pager went off to call the EmergencyRoom (Casualty). I had been relaxing at Resdoc,the residence across the street for interns atJohannesburg General Hospital. The charge nursesaid, you better come quickly because one of theother interns has been stabbed! He was stable but…. I asked a few medical questions, then said, washe stabbed between Resdoc and the hospital. Thenurse said yes, and I asked then how was I to getto him safely? A nightwatchman was dispatchedto ensure my safety, but the truth was that thisintern was attacked in a dark and lonely spotwhile ‘making out’ with one of the nurses on hismedical unit. An attacker came across the twoand stabbed my colleague twice with his‘knobkerrie’ – a piece of wood carved with around handle at one end, the ‘knob’, and asharpened end at the other extreme. The nursehad a broken tibia, heaven only knows how she

sustained such an injury: medicine teaches us toseek the mechanism of the injury. Perhaps weought to have consulted the Kama Sutra. The twominor scratches on my colleague’s abdomenprecipitated an abdominal X-ray, and the findingof air-under-the-diaphragm meant penetration(by the weapon, that is). What followed was teamwork at its best: a trauma surgeon came quickly,and we scrubbed for surgery. At the same time,two other interns, both close friends of the victim,ran errands such as getting blood typing andblood on hand in case he needed transfusion,taking blood specimens to the lab and bringingback results. The two scratch marks andabdominal air were just the opener: he had, as Irecall 22 separate internal injuries that requiredattention: to bowel and liver predominantly. Hesurvived very well, and has had an illustriouscareer. Perhaps he too ponders from time-to-timehow that broken bone occurred.

LESSONS LEARNED ANDUNLEARNED

There was nothing haphazard about DuP’s ward:there was one mantra: Perfection, and nothingless. Do things the way your registrars perceivedwhat DuP wanted and everything would be fine,and mostly it was. DuP operated on an obesecolleague who had a benign intestinal polyp. Theoperation was successful but the patientmaintained a low niggling fever postop and didnot feel quite right. DuP visited the ward,examined and reexamined the patient every day,eventually pinpointing the source: a small abscessdeep in the adiposity of the abdominal wall.There had been just something amiss with thispatient that caught DuP’s attention and he didnot rest until he found the cause of the patient’s,and his, discomfort.

DuP had little time for idle conversation butalways explained in detail to each patient whathe was going to do in their operation. For thoseabout to undergo radical surgery formalignancies, e.g. radical mastectomies for breastcancer or major bowel resections for carcinoma ofthe colon, he would always say something like “ifwe don’t do this surgery it might becomemalignant.” A nice cop-out, but it was the samefor most surgeons at the time, and patients rarelyquestioned the professor. That is until Mr Selkirkwas admitted for an abdomino-peroneal resectionof a low bowel carcinoma. DuP explained themassive surgery in detail, one team working on

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the abdominal side, another on the anal sideleaving him with a colostomy and a host of long-term challenges. What followed was anattitude-changing revelation to me:

Patient: Professor, do I have cancer.

Professor: Not now, but it might becomemalignant if we do not do this surgery.

Patient: Cut the crap, Professor. You know I havecancer, I know I have cancer. Otherwise whywould I agree to such a disfiguring operation? Solet’s stop kidding ourselves and get on with it.

Intern (me) to himself: this has been a sentinelmoment in my medical career! Disclosure wouldmean just that in future: telling the truth as weknew it. I hope DuP also took something from thisencounter.

One more lesson: near the end of my six monthsurgical internship, DuP admitted Mrs Collinsfrom his clinic for assessment of probablestomach cancer: she had many worrying signsand symptoms all pointing to this diagnosis. Butafter a week of intense investigation, I made adiagnosis of pernicious anaemia, a medicalcondition on a surgical ward! Good grief! I toldthis to our registrar, relatively new to the ward,on evening rounds on a Tuesday. He said in frontof the patient: Get her off the ward before DuP’srounds tomorrow! I said I had arranged amedical unit transfer for after rounds thefollowing day so that we could discuss theoutcome with DuP. What followed was a mostunprofessional shouting match between theregistrar, incandescent with rage at theimpertinent intern, and the impertinent internrefusing to budge. I prevailed to the joy of MrsCollins that evening. On rounds the next day,DuP and his entourage of consultants, trainees,nurses and others, stopped in front of Mrs Collins’bed. The impertinent intern said: Mrs Collins isthe woman we admitted from your clinic lastweek for evaluation of likely stomach cancer. Herdiagnosis is, in fact, pernicious anaemia basedon the following …. I finished my concisedescription and waited for the tirade, but nonecame. Rather DuP said, that is fantastic, andspent the next 30 minutes or so providing abedside dissertation on pernicious anaemia andits masquerading as stomach cancer and itspotential for malignant transformation. Thecontrite registrar said only that it was a goodteaching session. Hopefully he learned that DuP

loved the diagnostic and/or therapeuticchallenge and need not be feared as long as thehousestaff was doing a good job.

MOVING ON

Just as abruptly as it started, so abruptly did thesix months on DuP’s ward end. We took him andhis consultants out to dinner (he loved prawns),he gave the six interns each a copy of Verney’sbook, The Student Life, which was about SirWilliam Osler. In it he put the same inscription:With happy memories of an excellent HouseSurgeon with a most promising future, followedby See page 131, a different one for each of us. Onpage 131 of my copy he had underlined thefollowing: The value of experience is not in seeingmuch, but in seeing wisely. For each of us it was ahint as to what we needed to pay more attention.

After it was over, I said to my wife, if I say Ilearned a huge amount about excellence inclinical medicine during those six months andhad undying respect for DuP, nod in agreement.But if I say we had a wonderful time, give me aswift kick in the ass!

What happened to that ‘Band of Brothers’: the sixnervous novices all left South Africa for furthertraining and to avoid the crushing burden ofapartheid. And none returned. Raymond Polakbecame an academic surgeon, specializing inliver transplantation in Chicago; Brian Greis wentinto private practice in obstetrics andgynaecology running fertility clinics in Chicagountil he retired relatively early; Warren Carel isan anaesthesiologist in Philadelphia; KennethPolonsky did internal medicine andendocrinology at the University of Chicago, spenta few years as Chair of Medicine at WashingtonUniversity in St Louis before returning to Chicagoas Dean of the Faculty of Medicine; Richard Cohnbecame a paediatric haematologist/oncologist,moving to Sydney where he now is Chief ofPaediatrics at the University of Sydney teachinghospital. And I left for Toronto, specializing inpaediatric endocrinology, and joining the Facultyof the University of Toronto and the medical staffof The Hospital for Sick Children, where I am nowDepartment Chair and Paediatrician-in-Chiefrespectively.

And I bet each and every one of us speaks of thosesix months on DuP’s ward on a not infrequentbasis. Yes Sir!

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In April 2004 I became the Curator of the AdlerMuseum of Medicine, coming from a long stint at theJohannesburg Art Gallery: 25 years to be precise (1978– 2003). The first article I wrote for the Bulletin, inDecember 2004, was about this journey, substitutingpill boxes for paintings. I was bold enough to write alengthy list of things I wanted to achieve during myterm as Curator, something I advise people not to dolest they set themselves up for failure! But as I lookback on ten years at the helm, I am delighted withwhat has been accomplished by this small team ofcommitted people who make up the staff of theMuseum. And here I pause to pay tribute to them:Cheryl-Anne Cromie, professional officer, who hasstood by my side from the beginning and has been themost tremendous support in every way, running theMuseum with me in a partnership which has beenenviable; Sepeke David Sekgwele, who worked at theMuseum as a volunteer prior to being made amember of staff and who has concentrated on themanagement of the collection and the developmentof its electronic database. His knowledge of the contentof the collection is unequalled. And finally GilbertSingo who has served Wits for 26 years and themuseum for 25 of those years, and who has thelongest institutional memory of us all! This small teamhas accomplished wonders and I am so proud to haveled them for 10 years – they have made my stay atWits valuable and rewarding, and they have beentremendous colleagues and friends. We have sharedso much together both in terms of work and ourpersonal lives – it will be hard to say goodbye to themand I wish them all well for the future.

On reflection, what do I see as the highlights of thelast ten years? I think we have turned the Museuminto an interesting, vibrant space at Wits MedicalSchool, one which is well used by the Faculty andthe students in many ways: for functions andimportant events; as a formal venue for meetings,lectures, presentations, seminars and a myriad ofother events, as an informal venue for concerts, artexhibitions, shavathons, prize-givings and manyother uses by individuals, other Schools within Witsand external institutions.

Undoubtedly the most daunting challenge wastaking the decision to scrap the Museum’s existing

electronic database in 2004 and, with the assistanceof a trusted Museum colleague, Dr Mike Raath, whohad been on the Museum’s Board and understoodthe problem, we created a new database for thecollection. Progress in capturing the artefacts hasbeen excellent, and over 40 000 have now beencaptured out of a possible 50 000 – 60 000 items.

Reconfiguring the Museum’s archives was anothermajor task which was begun in May 2004. We hadfiles and papers by the thousand strewn all over theMuseum where any flat surface was to be found,including the floors. We probably discarded twothirds of the material in the archives as betterinformation and images were easily available onthe internet. We also began the process of rebuildingthe archives with relevant and important materialrelating to the subject matter of the Museum, itscollections, as well as the Faculty of Health Sciences.In this we were greatly assisted by people such asProfessor Tom Bothwell and Professor Yosuf Veriavawho passed on the extensive archives of theDepartment of Medicine to the Museum, as well astheir own personal archives.

At the same time, and as donations of hundreds ofbooks were received sometimes on a weekly basis, wealso decided to weed the Library, adding further tothe volume of unpacked material all over theMuseum. And just as we thought we may just get ontop of things, we were required to vacate largestorage areas at the NIOH/NHLS and move into onecomparatively small storeroom in the basement of a

From the Curator’s Desk:Looking back and bidding farewell

Rochelle Keene

Moving to the new storeroom

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building! This is any curator’s nightmare cometrue – and so it was! In the process of moving, wewere compelled to deaccession and get rid ofuncomfortably large sections of the collectionitself. This process, incidentally, formed thecontent of several papers I presented atconferences of the South African MuseumsAssociation as we attempted to get to grips withconstructive and ethical guidelines for the processwhich would stand up to peer review and scrutiny.

While these processes were ongoing, we foundourselves daunted by the tasks we had set ourselves.The Museum was actually in a shambles and wehad largely created the chaos ourselves! Wefrequently consulted each other and otherarchivists, librarians and museum professionalsbefore making decisions. It took us many years andmuch soul-searching and consultation before wesaw the light at the end of the tunnel.

The Museum has received many wonderfuldonations over the last ten years, all of which aredetailed in the Annual Reports. We have receivedgifts great and small, which have included theAsher Dubb history of medicine stamp collection,a collection of history of medicine stampsbelonging to the late Professor Asher Dubb, whichwas donated to the Museum by his wife, ProfessorVivian Fritz; the first stethoscope (c1946) owned bythe late Professor Phillip V Tobias when he was amedical student; two Parklane Clinic theatre scrubsused during the first surrogate grandmotherdelivery donated by Dr J van der Wat; and a massminiature X-ray machine from Anglogold AshantiHealth (Pty) Ltd, to name a few.

The Museum also embarked on a project toacquire contemporary South African artworksand the Board of the Museum commissioned asmall number of artworks for the foyer whichhave included three major installations. ChurchillMadikida was the first artist who did aninstallation in the Medical School foyer, usingobjects from the Johannesburg Hospital to createa hospice-type installation entitled Status II, 2006,an exploration into the theme of HIV/AIDS onwhich the artist had focused for a number ofyears. The second was a sculpture by WalterOltmann entitled The double helix, 2007; and thethird was a series entitled Biko Series II, 2008 byColin Richards.

The Museum has been fortunate in havingsignificant artworks donated to it. This includeda major series of photographs by world renowned

photographer David Goldblatt relating toasbestos mining in South Africa and Australia,and the health consequences of this, whichhighlight the devastation asbestos mining hascaused to the people involved in miningoperations, their families, and the environment.Two of the important photographs: Blue asbestoson the tailings dump of the Owendale AsbestosMine. Northern Cape, 2002, and Tailings dumpafter reclamation. Owendale Mine. NorthernCape. 2007 are displayed in the foyer.

An art space was established in the Museum onthe mezzanine level. Selection of artists to haveexhibitions in this space has been limited tothose producing work which are of specificinterest to health science students, schoollearners and the general public in a museum ofthis nature.

Some of the intentions of this initiative are toenhance the foyer of Medical School by theinstallation of appropriate contemporaryartworks by South African artists; to open theMuseum to a wider audience, thereby increasingits visibility and that of Medical School and toenrich the perspectives of health professionsstudents through seeing cogent and poignantwork by artists of high caliber in order to enhancetheir understanding of contemporary art-makingin this country and encourage creativity anddifferent perspectives among them.

An active exhibitions programme has beenestablished and maintained over the years, withtwo major researched exhibitions, accompaniedby important publications, being produced. These

Churchill Madikida: Status 11, 2006 (detail)

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are: Health and health care under apartheid, anexhibition initially conceived and researched by DrJane Doherty which was subsequently revised andgreatly enlarged by Assistant Professor SimonneHorwitz, Department of History, University ofSaskatchewan, Canada and I. The exhibition wassubsequently shown at the University of CapeTown, Stellenbosch University and ConstitutionalCourt in Johannesburg (2010 to 2011).

The second major exhibition, ConfrontingHIV/AIDS, is a permanent exhibition which wascompleted in 2013 and provides a visually andintellectually stimulating account of the HIV/AIDSepidemic by introducing the disease, listing itsclinical stages, looking at the history and spread ofthe disease, particularly in South Africa, and attreatment. The text was prepared by Professor MariaPapathanasopoulos, Co-Director: HIV PathogenesisResearch Laboratory and Genotyping Laboratory,Department of Molecular Medicine andHaematology, School of Pathology, Wits; AssistantProfessor Simonne Horwitz, Department of History,University of Saskatchewan, Canada and I.

A third major exhibition, Poliomyelitis – thedread of yesteryear, which opened in 2012, whichI researched. The exhibition was opened byProfessor Barry Schoub, former Executive Directorof the National Institute for CommunicableDiseases, National Health Laboratory Servicesand Wits Professor of Virology who contributedextensively in advising and assisting me duringthe research process.

Several permanent displays were changed andinformation updated. Consultation with expertsin various areas took place and the Museum wasextremely fortunate to work with a number ofthese specialists over the years. The panels ofalternative modalities of health care andtreatment were updated, redesigned and installedin 2008. We were extremely fortunate in havingthe much acclaimed South African photographerJodi Bieber allow us to use one of her images forthe traditional southern African healingshowcase, and Fiona Simmons for herphotograph of a sangoma in another display ofsouthern African traditional healing.

Many of the temporary exhibitions madefascinating viewing for all visitors to the Museum.These have included African Genesis, an exhibitionof hominid and associated fossils from the Cradle ofHumankind World Heritage site in which the worldfamous Mrs Ples and the Taung child, never before

shown together, with dinofelis (sabre tooth cat),were exhibited. This unique exhibition, madepossible through collaboration between the Schoolof Anatomical Sciences, the Adler Museum andthe Transvaal Museum, Northern FlagshipInstitution (Ditsong) (2006); Rural health care: AllSaints Hospital, Umtata, Eastern Cape, anexhibition of photographs taken by Dr PaulineIngle in the 1960s and 1970s containing imagesof patients, health education and activities, ruralsurgery and medicine highlighting issues in ruralhealth care (2006); Are your rights respected? Anexhibition presented in collaboration with GALA(Gay and Lesbian Archives) in which the originalartwork produced by Tommy Motswai and VusiMalindi for a comic which looked at issues ofsexual violence, STIs, HIV and different sexualitiesin the deaf community (2006); HIV/AIDS: Ninelives, an exhibition donated to the Gay andLesbian Archives initially displayed at theConstitutional Court and now on loan to theMuseum (from 2004).

The 50th anniversary of the Adler Museum wascelebrated in style on 18 October 2012 withFaculty and Museum staff, past and presentBoard members, alumni, early donors and friendsmarking the Golden Jubilee of the Museum witha celebratory tea. Dr Joseph Teeger, a 1951 WitsMedical School graduate and former Boardmember, addressed the guests. An exhibition onthe highlights of the Museum was compiled bythe Museum staff for the occasion. The Museumcontinues the ideals of the Museum’s co-founders,Drs Cyril and Esther Adler, to preserve the historyof the health sciences in southern Africa.

Further exhibitions relating directly to the teachingprogramme of the Faculty included: History oftuberculosis, researched and conceptualised by

Health and health care under apartheid exhibition

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Professor Mary Edginton and sponsored by Sandoz(2006); Asbestos: wonder fibre – serial killer,researched and designed by Jemima Cantrell of theNational Institute for Occupational Health andProfessor Tony Cantrell (2008); and Malaria inContext, researched by Professor Maureen Coetzee,Director, Malaria Entomology Research Unit, Schoolof Pathology, Wits; Dr Basil Brooke, Vector ControlReference Unit, NICD/NHLS & Malaria EntomologyResearch Unit, School of Pathology, Wits; ProfessorJohn Frean, Deputy Director, NICD/NHLS & Schoolof Pathology, Wits and Dr Liz Thomson, GeneralDirector, Medecins Sans Frontieres/Doctors WithoutBorders (MSF) South Africa which I curated. Theexhibition was sponsored by MSF. It encompassesthe history of malaria, a clinical description of thedisease, its prevention and treatment and itseconomic implication (2011).

Co-operation with other entities has led to theMuseum’s involvement in the annual Yebo Goggaproject, an initiative of the Life Sciences Museumand Biodiversity Centre, School of Animal Plant andEnvironmental Sciences; Body Knowledge: Medicineand Humanities in conversation, a medicalhumanities conference arranged by WISER (WitsInstitute for Social and Economic Research); HealthScience Week with Sci-Bono Discovery Centre,Newtown and the Health Professionals Art Societyshow which are annual exhibitions of artworks inall media by members of the society. There have alsobeen a number of important loans from thecollection to other museums, outside organisations,artists and film companies which have increased thevisibility of the Museum and its wonderful collection.

Collaboration within the Faculty and within theUniversity has resulted in a number of interestingexhibitions which have included Wits90 Treasuresarranged for the 90th anniversary of Wits and held atthe Wits Art Museum and most recently 20 Years ofDemocracy, arranged for Faculty Research Day in2014. It has also resulted in collaboration in researchprojects such as the History of Nursing Education atWits published in 2012.

The AJ Orenstein Memorial lecture has gainedprominence as a major annual Faculty event andattendances at this prestigious lecture have risensharply since 2004 when it was delivered by the lateProfessor Phillip V Tobias and was aptly titled At myWit’s End? After 60 years at Medical School. Recentspeakers have included Dr Sydney Brenner, Nobelprize winner (Physiology or Medicine 2002) in 2005,and Professor Jirí Dvorák, FIFA Chief Medical Officerand Chairman F-MARC, who was visiting South

Africa for the Football World Cup in 2010. Thecomplete list can be seen on the Museum’s website.

The Adler Museum Bulletin is now in its 39th year ofpublication and remains, to the best of ourknowledge, the only journal which publishes papersin the field of historical research in the field ofmedicine and allied health sciences on the Africancontinent. The Editors have wisely been recording theimmense contribution that the Faculty of HealthSciences and this Medical School has made, throughits graduates and alumni, locally and internationallysince 2004. They have received and solicited anumber of personal histories from distinguishedgraduates, many of whom have made contributionsof global significance in order to ensure that as muchof this history is recorded and preserved, therebyperforming an important role within the Faculty.

A notable event in 2013 was the publication of OurGraduates 1924-2012 which I researched andproduced. The publication contains a detailedchronology of events relating to the history of theFaculty of Health Sciences and the Medical Schooland a list of graduates which includes all under- andpostgraduate students in all disciplines and in allspecialties taught by the Faculty from 1919. Thesummary of graduates from 1925 to 2012 at the endof the publication has enabled the Faculty to gaugein numbers the contribution it has made over theyears in terms of the training of health professionals.

Guided tours for school and other groups are anincreasingly popular feature of the Museum’seducation programme and worksheets, devisedwith the assistance of school educators, are wellused during school visits. These are constantlyupdated and become part of the portfolio work ofschool learners.

A common but unsatisfactory and insufficientyardstick in monitoring the performance of anymuseum is its attendance figures. It is pleasing tonote that attendances have risen from 5 190 in 2004to 10 140 in 2013: for a small and highly specialisedmuseum with limited resources, this is an excellentachievement and is testament to the efforts of thestaff of the Museum.

There are so many people who contribute to theprogress of the Museum that one is reluctant to startlisting names. They are always mentioned in theMuseum’s Annual Report which is published on itswebsite for all to see. In closing, I wish the newCurator well for the future and trust that thisprecious Museum will go from strength to strength.

´

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Adler Museum Bulletin publishes papers in the field ofhistorical research in medicine and allied healthsciences. The Museum welcomes original contributionsand letters for publication but reserves the right toedit, abridge, alter or reject any material. Manuscriptsshould not exceed 5 000 words. Longer articles may bedivided into parts and published in successive issues ofthe Bulletin. Authors are responsible for the factualcorrectness of their articles. All articles are sent forrefereeing. Authors wishing to reserve copyright tothemselves should stipulate this at the time ofsubmission of a manuscript.

The Bulletin publishes in English, but welcomessubmissions from contributors for whom English is nota first language; language and editing assistance willbe provided.

Each contributor will receive one set of page proofs forchecking. The cost of any additions or alterations tothe text at proof stage may be charged to the author.Authors will receive a copy of the Bulletin free ofcharge and a PDF file of the printed version of theirarticle.

Online access: Back (from 2007) and current issues arenow accessible on the Museum’s website.

The full names of the author, name of the institutionto which the author is/was affiliated and a shortbiographical note should appear below the title of thearticle. The author should also supply full postaladdress, email address and contact number whensubmitting a manuscript.

Authors are asked to submit a copy of the text on discwritten in MS ‘Word’ or saved in ‘Rich text format.’ Donot format the text or use headers and footers.Manuscripts may also be emailed toadler.museum@wits.ac.za. Photographs, if emailed,should be in jpeg or jpg (pc) format, preferably300dpi, or may be sent as high quality black andwhite photographic prints.

References are listed at the end of the manuscript andshould be indicated in the text by superior numbersand listed at the end of the paper in numerical order.Do not list references alphabetically. References shouldbe set out in the Harvard style, and only approvedabbreviations of journal titles should be used.‘Personal communications’ and work that is ‘in

preparation’ may be cited in the text, but not in thereference list. However, formal theses anddissertations, even though unpublished, may be listedprovided full details are supplied, including theinstitution where the master copy is lodged. Do notindent or otherwise format each entry. Note that this isa reference list and should not be formatted asfootnotes.

Reference examples

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.

Discs should be sent to:

The Editors, Adler Museum Bulletin, 7 York Road,Parktown, 2193, South AfricaEmail: adler.museum@wits.ac.za Enquiries to the Curator: Telephone: (011) 717 2081;Fax: 0865532483

Guidelines for authors