Graeme Milbourne Clark was born in Camden, NSW in 1935. He finished his secondary education as a boarder at Scots College in Sydney in 1951. Clark then went to the University of Sydney graduating with honours from an MB, BS degree (1957). Fresh from medical school, Dr Clark worked at the Royal Prince Alfred and North Shore Hospitals as a resident medical officer (1958-59) before specialising as a registrar in neurosurgery and otolaryngology (1961). Clark then left our sunny shores for England, where he worked as senior house surgeon at the Royal National Throat, Nose and Ear Hospital (1962) and senior registrar in otolaryngology at the Bristol General Hospital (1963).
Clark returned to Australia and the Royal Victorian Eye and Ear Hospital as assistant and then senior ENT surgeon (1963-66). He held this position concurrently with ENT surgery positions at the Alfred, Austin and Repatriation General Hospitals (1964-66). Not satisfied with the treatments available to profoundly deaf patients, Clark returned to the University of Sydney to embark on further study. He completed both an MS (1968) and a PhD degree (1969). During his studies, Clark also lectured in physiology at the University of Sydney and remained as senior honorary ENT surgeon at the Eye and Ear Hospital, Melbourne.
In 1969, Clark accepted the William Gibson chair of otolaryngology at the University of Melbourne (1970-2004). Whilst professor of otolaryngology, Clark established the Cochlear Implant Clinic at the Royal Victorian Eye and Ear Hospital and was the surgeon in charge (1985-2004). In 1984 Clark founded the Bionic Ear Institute and acted as its director until 2005. Clark was made laureate professor at the University of Melbourne in 1999, professor at the University of Wollongong in 2003 and distinguished professor at La Trobe University in 2008. He is now distinguished researcher at the ICT for Life Sciences.
Interviewed by Professor Stephen O’Leary in 2011
Contents
My name is Stephen O’Leary. I am the William Gibson Chair of Otolaryngology at the University of Melbourne. It is my very great pleasure to welcome Professor Graeme Clark, the first holder of this chair, back to the Royal Victorian Eye and Ear Hospital, to conduct an interview for the Australian Academy of Science.
Childhood is an inspirational time, so what influences from your childhood developed your passion to help people today?
Well, lots of factors. I think childhood is a very important time in anyone’s life. I must have been a fairly hard child to manage for my dear mother. I was hyperactive. I wanted to do many things.
I was into cubs, scouts and sport of all sorts, and I read widely. I was fairly hyperactive, I suppose. My mother was very creative and she inspired me with art and music. My father was the pharmacist, the more pragmatic person, who quietly was influencing me as a potential doctor, I think. So they were strong influences.
When you were a child, were you interested foremost in helping deaf people or were you more interested in how things worked?
Yes, well, I must have been interested in how things worked. At the age of ten I was doing biological experiments in my mother’s laundry. Also, having read the life of Louis Pasteur, I wanted to emulate him in some ways. Even in my vegetable patch! The tomatoes all seemed to have some disease, so I made a hypodermic syringe in my father’s chemist shop, and tried to transfer agents, like viruses, from one tomato plant to another. So there was for me an experimental aspect to it all as well.
Can you reflect upon your days in boarding school and any influences there?
Yes. Boarding school was a very influential period as well. I was shy and I was sent away from home to a boarding school in the city. It took adjustment and it was very lonely for a while, but it was a very maturing experience. It was a school where you had to play sport, unless you had lost a leg or something like that. I had to be one of the boys by being reasonable at sport.
I can remember playing rugby union at Scots College Sydney. Not being a solid boy, it was always a trauma to have to tackle charging boys. I remember one time I was in the under13As on the back line. The house I was in had all the best players, some of whom represented the state later. They wanted to win in both divisions, the firsts and the seconds. So they put me, this under-13A boy, on the wing where I could not do much and occasionally score a try. On one occasion, the opposite house back, a burly young fellow, broke loose and came charging down at me and there was only me between him and the goal line. I thought, ‘Oh no, what am I going to do?’ I was terrified. I thought, ‘I’ll make it look good. I’ll make it look like I’ve done a tackle.’ So I shut my eyes and I grasped the air and it just so happened that, at the moment I grasped the air, he jumped and I caught him around the ankles. He fell like a stone and I was a hero. They were the sorts of challenges that you had as a border.
I had three teachers who were outstanding. One, Rhys Jones, had written a book for schoolkids and he taught us logic. Instead of doing Shakespeare, for one whole year we learned logic and how to summarise. I will never forget how important summarising and logic were for me later in my career. The second person was Fred Pollock, who was a maths teacher. He trained at least four boys to top the state in maths. He gave us a basic understanding of the importance of maths. We had another one, Hoey Simmons, a doctor of philosophy, who had actually made a small contribution to the periodic table, and he was a very inspiring chemistry teacher. I don’t think we realise the important influence that teachers at that level have on us and on our lives. They were very memorable teachers.
Graeme, at what stage did you decide to dedicate your life’s work to treating deafness?
I think it was when I became aware of my father’s hearing loss. I came to realise how difficult it was for him as a pharmacist in the small country town of Camden. He would have trouble hearing his customers, and would have to say to them, ‘Speak up. What would you like?’ and they had to do so, and the whole shop would know what they were wanting. I was embarrassed, and I decided then that I would like to do medicine, and to be an ear, nose and throat doctor. Actually, an eye, ear, nose and throat doctor out at Orange in New South Wales. I didn’t quite achieve that. That was the first desire to be an ear doctor. But, during that time, when I was in Dad’s pharmacy, I got to see what the doctors were prescribing, and I thought, ‘I could make those ingredients up,’ and medicine itself became a goal. I did switch my desires during the course and wanted to be a cardiac physician and then a general surgeon, but I am glad that I returned to ear, nose and throat surgery.
At what age were you when you decided that you may like to make a career out of medicine?
I was ten when I wanted to be an ear doctor. When our local Methodist minister asked me what I wanted to be when I grew up, I was reported to have said that I wanted to be an ear doctor. That floored him, because boys of my age all wanted to be C-class steam train drivers. That was the very macho thing to do. So it was from an early age, and I think it was Dad’s influence as well.
When you went to medical school, did you still want to become an ear doctor, or had some other specialty, like cardiology, taken your interests?
When I went into medicine at Sydney University, my first goal was to get through medicine. I just enjoyed medicine for its own sake. It was an exciting, new era. Early on I didn’t focus on: ‘I’m directing my route to becoming an ear, nose and throat doctor.’
Except that, when I got to thirdyear medicine, I got really excited by physiology. I remember taking the whole textbook away on holidays by the sea, and reading the whole book. I got firstclass honours in physiology. One of the main questions was on the ear, strangely enough. I was offered an opportunity to do a bachelor of medical science degree, which I turned down, because at that stage I wanted to be a clinical doctor and then to turn around and do research.
Something happened in those first few years that drew you back to ear, nose and throat surgery. What was that?
Different circumstances, in a way. Firstly, I wanted to be a cardiologist for personal reasons and for the fact that, at that stage, our thinking was that physicians were the ‘thinking doctors’ and surgeons were the ‘doing doctors’. I wanted to be a thinking one. I wanted to go to London to work with Professor Wood, who was the leading cardiologist then and that fell through. In Sydney the opportunities for medicine weren’t there. All the good jobs were taken. I then settled for general surgical jobs, for which I was very grateful.
After that, I was keen to do surgery. I did my primary anatomy and learned all about the anatomy of the body. Then those jobs in general surgery were all taken, so I got ENT jobs. But I also had a father who had a friend in Melbourne who was an allergy ENT doctor, and that provided an opportunity to pursue my career in Melbourne. From there on, I came to love ENT. I might add: at the Prince Alfred Hospital in Sydney, as a general registrar in surgery, it always seemed odd what the ENTs were doing in the darkened rooms, and curiosity got the better of me. But it was a very exciting stage for ENT. Microscopic surgery was just coming in. I was there with Sir George Halliday, the leading ear surgeon in Sydney. Microscopic surgery was opening up a really fascinating world. We could look down the microscope and see what was going on inside the ear. This was very different from general surgery and opening up the abdomen and taking out infected appendices.
Something happened to draw you away from your flourishing clinical practice to do a PhD. What was your motivation for that?
I suppose that, deep down, I had never been drawn away from the ear. During medicine, when I had the opportunity to do a bachelor of medical science degree, I thought of doing hearing neurophysiology research with Professor Peter Bishop, a leading visual physiologist. But that didn’t appeal as vision was not my long term goal. I basically wanted to get through medicine and then decide whether and where to do ear research. So that was the first thing. Then I duly entered the clinical stream of training to be an ear, nose and throat surgeon and qualified with fellowships in both general surgery and ear, nose and throat surgery.
After returning to be a senior ENT surgeon here at the Eye and Ear hospital, I still was not satisfied. I had a ‘fire in the belly’ to do research, and it wasn’t satisfying enough just to do my routine clinical work. I then had an opportunity to go back to do research in Sydney. I remember writing to Sir John Eccles, who was a Nobel Laureate in neurophysiology, and asking him what would he recommend. This was when I was 31, and he said, ‘I think you’re too old to embark upon a career in research’. I did not take his advice. Some years later I had a dinner with his daughter and told her about the event and she said, ‘I’m glad that you didn’t take my father’s advice; I never do.’ But that was how I got into doing research.
It was a challenge to leave practice to go and do research for a PhD. It meant a significant drop in income. I had to take a young family to Sydney, and live really quite poorly. So much so that, when our second hand car broke down, I couldn’t afford another car, and had to go everywhere by public transport. It turned out to be a blessing because it meant that there were opportunities to think and to think research. In fact, one of my mentors at Sydney University, Professor Liam Burke, said that he spent most of his time thinking about research projects, which I learned to do.
Can you give us a bit of background on the plight of hearing impaired people when you started your ear research for a PhD? Why were you undertaking this research?
The plight of hearing impaired people was evident to me when I was a surgeon at the Eye and Ear Hospital and at the Alfred Hospital. I had four consultant jobs when I started and a little bit of time to do private practice. During that time, their plight was really evident. But we didn’t see them for treatment, because they were always told, ‘Nothing can be done,’ and they just merged into the woodwork. It was very difficult for them to be told that. I don’t think, as an ENT doctor, I fully realised how it affected these people.
It was obvious with children. When I did research at Sydney University, the deaf school was just across the road, and the children were signing. To me, it didn’t look like a very good way of communicating. The difficulties that I now know exist for a deaf person weren’t so obvious. I was just focused on doing the research, trying to help deaf people like my father, and getting a basic understanding of research. At the time I did this, Merle Lawrence, a well known physiologist in the United States, wrote in the journals saying that it would be not possible for people to develop speech understanding with electrical stimulation of the auditory nerve. Most people said that it was not possible to provide the sophisticated stimulation of the nervous system that would lead to hearing speech.
Could you elaborate for us on what people with even strong hearing aids, missed out on that guided your thinking to alternatives and, ultimately, to the cochlear implant?
Yes. People miss out on so much, and they will tell you this. They can’t communicate in groups, it reduces their social life and it leads to loneliness and despair. I know that in my father’s case not only did it create difficulties for him in his shop, it was also very fatiguing and he had to think very hard about what customers were saying. It also meant that, in social situations, he couldn’t participate. There were times when Mum would entertain, and Dad would be seen as dumb, because he really couldn’t communicate in the conversations. So, at a personal level, it really had quite a profound effect, which you don’t see in a clinical situation. With children, it is even more profound. Only when I started taking an interest in this did I go to deaf schools and see what was happening to deaf children and how it was affecting their language. It was then that I came to realise what an enormously profound effect it has on children.
When you started your research, did you have any inkling of how you might be able to help? I’m thinking particularly now about the ultimate development towards the cochlear implant. Were thoughts about cochlear implantation in your mind when you started your research, or did they come later?
When I started, I read a seminal article by Blair Simmons, which I managed to squeeze in through my surgical rounds, sitting in the park near Royal Melbourne hospital. I read that he had implanted one profoundly deaf person and he had heard some sounds. He could not get speech understanding. But, for some reason, that lit a ‘fire in the belly’ and made me want to do research. I did look at research options in Melbourne before leaving practice, but having had an association with Sydney University and physiology, I went back to a very significant department run by Peter Bishop.
As your PhD evolved, you no doubt became aware of other people working in the field. Can you tell us about the evolution of your thoughts on cochlear implantation at that time?
Yes. At first it was a learning experience in how the ear functioned. We are not taught, even when doing a fellowship in general surgery, a lot about the ear. So firstly I had to learn about how the brain functioned. It was clear, from early work that was just emerging from Nelson Kiang, Jerzy Rose and others that the ear was functioning on a place-coding basis. It wasn’t just getting timing information. That was a very important lesson that I learned when I did neurophysiology. I was surprised that many of the clinicians who were starting to take an interest in this area hadn’t really based it on a lot of fundamental research. I feel very strongly that good clinical research should always be underpinned by experimental researches. So, I guess, that’s the way I went. I went to see how to do the research experimentally and how that would affect the clinical outcomes and to try and keep the two in balance.
Even when you were doing a PhD, the idea of place coding was in your mind?
Well, it emerged. The first thing that I did and aimed to do with my research was to see whether or not the single channel system would work. That was the system that was being promulgated in the clinical domain. In other words, would timing alone through a single channel implant be enough to convey speech? It may seem surprising now but, in 1966-67, neurophysiologists weren’t sure which code would work. Coding frequencies, for example, whether a simple place code or a simple temporal code was the key and what frequencies they applied to. So my first challenge was to see whether electrical stimulation could reproduce the temporal coding sufficiently well to allow a single-channel device to be used. When I found that it didn’t, I realised that one had to do studies to look at place coding. I could see too that it was going to be essential to select out important frequencies of speech and try to get them to be perceived through place and temporal coding – these two systems for coding sound.
Chair of Otolaryngology: telethons and tin cans
What was the next pivotal event in your career that allowed you to carry these ideas forward?
The next pivotal event was to get somewhere to do the research. That was difficult because most people said that it wouldn’t work. In fact, a good 95 to 99 per cent said this, and that meant no job. I hadn’t the training in basic physics to be appointed as a neurophysiologist and it wouldn’t have really helped. It was only due to the appointment to the first chair in otolaryngology that I had the opportunity to combine the basic research with the clinical research. Then I was able to try to see whether we could move to the next stage and validate whether place coding was important. And whether I could select out the important elements of speech to try to get them through what I like to call a ‘bottleneck’ between the outside world and the brain.
Can you reflect on what it was like setting up a department here, at the Royal Victorian Eye and Ear hospital?
It was seven or eight years before I got my first patient. And it was a very challenging experience to start up a new department from nothing, with no money – only $6,000 for two years from the Dean – and to be told that I would have to raise all money myself. Also, the department hadn’t been completely fitted out. It hadn’t been completed. I had to find money to build more rooms and labs in this department. So all of those things were pressing on me.
I was fortunate to get money to complete the building because, at that stage, I had only operated on a dog. I realised that maybe this was the way to get some publicity. It is interesting to be operating on a dog and that got front-page news in the papers. I found out that the Premier, Sir Henry Bolte, was an animal lover. So he welcomed me when I went down to ask for funds. We had a long chat in his office about dogs and horses and so on, and had a whisky. I kept drinking whiskies and I started to get drunk – it was the first time I had ever had that experience. I had trouble walking down the stairs afterwards – these were the backstairs. I actually had to sit on the bottom step for a good hour before I was sober enough to drive home. But I got the money! So that’s why we now have a department that is complete.
They were just some of the challenges in getting funds to do the work. But at the same time one had other things to do too. There was teaching to do – undergraduates but not much for postgraduates at that stage. Then along came the opportunity to establish the country’s first course in audiology. That was a very politically challenging exercise because lots of other people wanted it. I felt that it should be within the department of otolaryngology – that is a whole story of intrigue – but it came to be. There were lots and lots of fundraising activities. No money came from the National Health and Medical Research Council because all of the reviewers said that it wouldn’t work, and it wasn’t worth funding. So I had to get soft money. Sometimes it would be $100 or $200 from speaking at a Lions or Rotary luncheon. I could see that it was going to take a lot of luncheons to get enough money to do some substantial research. Then there were meetings and lots of other outside activities.
I have been told that you’ve been seen here on a street corner in Melbourne shaking a can for donations.
Yes. I don’t know how unique that is, but that came a little later. It wasn’t enough to get $100 for luncheons. That was not going to get us very far very fast. The big opportunity came when I got $2,000 from the Apex Club of Melbourne, and it got on to the ABC News. Sir Reginald Ansett saw this news item. He was establishing Channel 0 at the time and wanted a telethon. He always watched the opposition news and he thought, ‘That’s what I would like to have for a telethon for Channel 0.’ I got contacted by the senior people from the great man and summoned to his office and he agreed to underwrite three telethons to raise money. This gave us the opportunity to start the research and develop a prototype. Reg Ansett supported it, but we also had to raise funds ourselves.
I went around Melbourne putting up posters for gala concerts. Also, as a group here in the department, we raised funds through shaking tins, including down there in Collins Street. I had a competition with my PA. She always stood outside George’s and I went down to the other more-elderly ladies who were walking from Myers along Swanston Street. We had a competition to see who could get the most money and I won hands down. We had to be part of the fundraising effort. I always remember getting advice from Gus Nossal saying, ‘You will have to spend half your time raising money to make this thing work.’
Can you tell us a little more about what it was like to build a team and to develop the first cochlear implant that went into a patient?
It was a team effort. It was a multidisciplinary activity, varying from physiology to anatomy, pathology to surgery and then, later, to audiology and speech science. I think it must have been one of the most multidisciplinary research activities ever undertaken in this country. Personally, I felt that it was important to be across all disciplines. I have felt and learned that it is important to inject ideas into a team, so the team can set out to do good things. But, unless there is a clearly stated goal and unless one is prepared to go in and work with the team and, when there are difficulties, to help them get through those difficulties, it’s not going to be as effective.
There also needs to be a good spirit for working together. In those days we had Christmas parties – and still do. Everyone was young. We were all excited. There was a general sharing that we were going into the unknown. There were many times when I didn’t have enough money to support some of the staff members for more than a few months. I didn’t share this too much with them, but it was pretty worrying for me. We were playing a risky game and I think they all shared this. The work might not lead anywhere. But that is the way youth thinks. So we all worked together as a unified group.
I remember Jim Patrick, came to me in 1975 and said, ‘What’s the future for me, if I come and get a job here?’ I said to Jim, ‘I can’t promise you anything, but maybe one day, if it does work commercially, you just might get a job in industry.’ Well, he is the senior research scientist in Cochlear Limited now. But Jim looked back on those days and said that they were the most exciting and happy days of his life.
On the floor, in the laboratory, it was happy times. But externally there was criticism, was there not?
There was criticism externally, indeed. I was criticised from all directions. I suppose that you could divide the criticism into three categories. Firstly, there was criticism from the traditional scientists of the day. The good neurophysiologists that we had trained here in Australia did not think that it was possible, just as Merle Lawrence had said. Sometimes they picked up this negativity from surgeons in America, who hadn’t done the basic research. There was this general awareness: ‘How can you make the ear work with electrical stimuli when the research scientists had shown how sophisticated and complex it was? ’ It was not an unreasonable criticism, but that was the first and it affected all of my research grant applications. That’s why I have a whole file of unsuccessful applications.
The second criticism came a little later from my respected ear, nose and throat colleagues. Again it was a reasonable criticism. They said surgery would be dangerous and it could even lead to meningitis. Surgeons had embarked upon stapes surgery at that time. Stapes surgery, although not terribly well broadcast, did have risks and there were some people who died from meningitis after having stapes surgery. So it was almost a nono to operate on the inner ear and here I was, planning to put electrode wires into the inner ear. So they had concerns.
Then there was the third group. I always felt that we must work on adults first, for ethical reasons. But after working on adults who had hearing before going deaf, I started to work on children. This led to further hazards and problems. The Signing Deaf community said that I was doing something wrong and maybe even evil to operate on children when they should have been learning to sign. So there were many criticisms.
How did that feel personally? Was there a vulnerability for your reputation, for your position?
I am sure that it had an effect on my reputation. I tried not to think too much about it and to focus on the work rather than to be too concerned. But I know, from feedback, that there was a lot of criticism. My good friend and colleague, Professor Gerard Crock, and I both shared the problems of being the first professors of our specialty in a clinical domain. He would tell me that some of my colleagues had been to the vice-chancellor suggesting that I might take a new job or leave, as a reflection of the personal concern they had.
Some people were certainly critical, but you did have some supporters.
Yes, I had some wonderful supporters. In fact, they helped encourage me to keep going in spite of all the difficulties and criticisms. The people who were severely or profoundly deaf, who needed the device, were supportive in the hope that we would be able to do something for them. But there were others who helped or had children who had a hearing problem and wished to help as well. They helped in fundraising. It was great to feel that there was good support, and I thank them.
How did your family deal with what, at the time was public criticism? How did your wife and family deal with that?
It can affect the family. It was really my wife rather than the children. The children were a little young and I don’t think they were too aware of what was going on at that stage. My wife was an enormous support. I could go back and discuss all the difficulties with her. She was very wise, helpful and supportive, and I can’t thank her too much
Did you draw strength from any other people or sources?
Yes, I did. I had a Christian faith. Interestingly, I wasn’t doing this for personal ambition. I was doing it, firstly, to see whether it was scientifically possible but also, with prayer, to see whether I was able to be used to do some good to help deaf people.
First operation: nerves and bedlam
It was in 1978 that the first multiple-channel cochlear implant was put in. What was it like when it was turned on?
It was a very turbulent experience. We were going into completely new ground. I think it was the first fully implantable device and it was being put in against a lot of criticism. The Eye and Ear hospital was very supportive. But they also went to see their legal advisers to make sure that they were covered legally if anything went wrong. It did mean quite a lot of extra effort. I was a little bit obsessive, trying to make sure that we didn’t get any infection, using filters in the theatres at times when the theatre infection rate was a little bit higher than it should have been. But the staff were fantastic.
Then the day came, 1st August 1978. Just beforehand I had been away for a weekend to recover and refresh. I came back on Monday morning for a Tuesday morning operation and I couldn’t believe it: engineers and staff were still running around putting all the finer things together. It was a bit of bedlam. Rod Saunders, our first patient, had been admitted and was being prepared for surgery. I went to see Rod and tried to reassure him that all would be well. He didn’t take in too much as he was well sedated with Valium and was quite relaxed about things.
The surgery started and we took quite a lot longer than we would now. We took every step fairly slowly and did a few unnecessary steps that wouldn’t really have been needed. But I wanted to do everything to prevent an infection. One mistake with that first operation would have stopped the whole thing. So I couldn’t afford to make a mistake.
Then I was operating on Rod. I was a little bit put off by the fact that the side I had chosen was the side he had had a craniectomy on. It was not in view, but I had to be so careful not to enter the cranial cavity. We then were able to put the electrode in without too much difficulty. The staff at the theatre were wonderful. I know that the sister was on tenterhooks. She thought that Brian and I were very relaxed. Anyway, Rod recovered. He went back from the theatre to the wards. I had a somewhat restless night. In those days, although I had done some neurosurgery, ENT surgeons didn’t want to get near the brain. It might lead to haemorrhage. And there was I, pressing onto the dura (the sac surrounding the brain). So I was a little concerned that night that all would be well, and that Rod would recover well the next day.
Then three days later there was a code blue in the hospital. I rang the switchboard and asked, ‘Where is the code blue for?’ They said, ‘On the 4th floor.’ It turned out to be where Rod was. This worried me a little. I flew up the stairs like a prime athlete. I got there and it was bedlam. It was Rod. He had collapsed. I thought, ‘Oh no!’ Fortunately, when I examined Rod, I knew that he had only fainted. Being an ear, nose and throat surgeon I had many patients faint in front of me when I was going to wash their sinuses out with a long trocar. So I knew well that Rod had fainted. Anyway, all was well. Sister had taken off his dressing and he had just collapsed. But such was the tension around the ward and their concern for this patient that it did cause quite a disturbance. Anyway, Rod recovered from that. The wound healed up well and Rod was sent home and asked to come back within four or five weeks. A little bit longer than it is now.
First sound: God Save the Queen!
I positioned the coil over Rod’s implant so that we could stimulate it in the hope that he would get some hearing. We didn’t even know whether he would hear anything at all. When everything was lined up, he heard nothing. So day one was very disappointing. We all went home pretty dejected, I can assure you. We said to Rod, ‘Come back in a few days time and we can check a few things out and see if it will work.’ Anyway, he did. He came back and the same thing happened: it didn’t work. I thought, ‘Oh no, how terrible!’ Because he had had a head injury, I thought maybe the crack in his bone had cut through the nerve, even though had I tested it out beforehand by electrically stimulating it to see whether he heard. One last time – third time lucky – he came back. In the meantime engineers had checked the system and found that they had, believe it or not, a loose connection. So it worked! It was a wonderful experience when Rod heard, out of the tinnitus background of his head noises, this different sound. As we turned the electrical current up, it got louder and louder. So we knew that his system had worked.
That was only the first challenge. It was great that it worked. Then the next simple tests were to see whether he got different sensations for different sites of stimulation. This whole procedure was based on the premise of multichannel stimulation. In other words, would those electrodes give different pitchlike sounds, or had we wasted this whole effort on multichannel stimulation? Fortunately, he did have different pitch sensations that we needed to explore later.
The other thing that we did was to see whether he could respond to tones and stimulus rates, which was part of a single-channel system. We did this by giving him the melody or the rhythm of the National Anthem: God Save the Queen. In those days, when we played God Save the Queen, everyone stood to attention. That doesn’t happen now, but it did then. When we played God Save the Queen to Rod, he stood up and pulled all the leads out of his equipment, so we don’t have a recording. Nevertheless, after that, we settled him down and played him our alternative, Waltzing Matilda, and I have a wonderful recording of Rod singing Waltzing Matilda. Very interestingly, in his description, he said a lot about the psychophysics that we later learned. The song was a higher pitch than he could sing and he got rhythm not by the tone but by the variations in intensity and loudness. So, as happened later, the patients often were very good research subjects.
That was a next step forward, but it wasn’t enough. It didn’t show that device was going to give speech understanding. So, for the next two months, until the end of the year, we had to do a series of psychophysical tests to see just what he could hear, what he could make of sensations and whether I could bring it together as a speech processing strategy. At the last minute – almost at the end of the year – we did. Rod heard real speech sounds using electrical signals alone. When he did, I was so moved that I went into the next-door lab and burst into tears of joy because I knew then that all this effort probably had been worthwhile.
Who were the key people who worked with you to do the intellectual work?
The three of us who worked on it were Joe Tong, with whom I worked very closely, Bruce Millar from Canberra and me. We met and talked often about it. In addition, Jim Patrick and Ian Forster helped with the electronics, but it was the three of us who worked through the questions. Bruce Millar, who had been one of the students and postdocs of Bill Ainsworth, with whom I had worked at Keele University, was now a very good speech scientist. I had supervised Joe initially on developing models of how cochlears function. It was only when we had implanted a patient that I was able to work with Joe and develop an engineering type approach to psychophysics. But we really complemented each other.
I had personally been helped by having taken study leave, when the telethon was on, to work with a speech science laboratory at Keele University in the UK. My project was on formant analyses of fricative sounds like ‘v’, ‘s’, ‘th’. I had felt that one of the keys to all this was to understand speech, and in the Department we knew so little then about speech. I had this feeling that the key was not physiology alone, which is what I had set out to do, but it would be speech science. It turned out, for me, to be a very helpful approach. I came back from Keele in 1976 with a very strong interest in formants, which are key elements of speech. None of us knew much about formants. When I examined audiology students on formants, they said it was a very strange and unfair question. Of course, it is not now.
Providing proof for the sceptics and patient number two
At this stage there was real promise with the implant and no doubt you had something to say on the international stage. What was it like coming into the cochlear implant field with your new data? Were you well received? Was it a collegial experience or was it more competitive in nature?
The first indication of success came at the end of 1978, just before the Christmas holidays. I asked our audiologist, Angela Marshall, if she would do an open-set test. Even then, people weren’t fully au fait with the importance of open-set testing as an indication that this would lead to running speech using electrical stimulation alone. Having been appointed as the senior examiner in audiology, I was well aware of the testing. But it wasn’t really until the next year after the holidays that I was able to carry out a series of more objective tests to establish my initial findings to satisfy the critics.
I needed an audiologist and Angela was on the teaching side. However, being the chief examiner, I had an inside running into who were the best audiologists. Lois Martin shone that year and, without all the niceties that you go through these days, I knew that Lois was a really likely person. After her examination, I remember running down the street to offer her a position. You wouldn’t do that today, but that is the way it happened. Lois did a great job to help develop tests and evaluate Rod in the next months. One had to not only show that this was true but also double-prove it, because the sceptics still wouldn’t believe it. It must have been about mid-1979 when the initial results were being presented. Someone said when I had used film, I had altered the sync between the lip-reading and the speech, such was the scepticism. So it did need quite a lot of proof. But that is one thing that we did do.
I was convinced that right way was to operate on a small number of people – in this case, at first one – and do this testing thoroughly. Not to skimp the testing. That proved, I believe, to be the right approach because then one could show the sceptics what the results were scientifically. But it did take quite a lot of time. It was not until July 1979 that I was prepared to operate on a second person, George Watson, to show that it was valid for other patients. Some people said that what we had done was: ‘You’ve just worked out some unique code for Rod’s brain. It doesn’t necessarily apply to others. Therefore, what’s the good of developing it for commercial use?’
Commonwealth money and commercial involvement
At the same time, when I went to the press to say that we were getting some interesting results, I got approached by 3M. They are a well-known company who were interested in medical technology at that stage. 3M were interested, but they didn’t pursue it. They wanted to do something simple like the House single-channel implant. I wished they had offered money. I had to get money from some source and I turned to the Commonwealth Government of Australia. I was very fortunate that they had a new public interest scheme that was prepared to fund new, potentially interesting and commercially relevant research projects. That meant that they were prepared to fund our research back in 1979, after the initial results on Rod had come through. They did a wonderful job. I think they are an exemplar on how to fund this sort of research: one year at a time. They give you some money. They say ‘Please state what your objectives are and we’ll help you as much as we can that year. If you then meet your milestones, we’ll give you some more money.’ That is how I was able to afford to pay for Lois and to start the gradation between fundamental research at university and its commercial development.
Soon after these initial exciting results, we were planning to do its commercial development. This was carried out in an incredibly short time through Teletronics, the pacemaker firm, with Paul Trainer as CEO. It was then made as a commercial device in 1982.
I remember that well because I was a medical student and I was sitting here, watching the surgery. The whole focus changed when there was commercial involvement. How did that change the focus of your research?
That is a very important and fundamental question that nowadays is even more relevant than it was then. I have personal views on the subject about fundamental research and commercial research. Firstly, having been criticised for not doing pure enough research, it is odd that I am now someone who advocates more pure research rather than applied research. But there was a fundamental difference and I don’t think that should exist. I think Louis Pasteur summed it up nicely when he said, ‘There is only two sorts of research: good research and bad research.’ We should not be talking about pure and applied research. But I felt a commitment to bridging that divide. I knew that we hadn’t succeeded in giving perfect hearing and we still haven’t. There was more research to do. On the other hand, there was a responsibility and a need to get the device out into the marketplace as soon as possible. The first people that came wanted help. I felt a need to direct some important areas of research with Cochlear Pty Ltd or Nucleus Limited, as it was, towards the commercial outcomes, but at the same time to keep the research going here at the University of Melbourne.
The research wasn’t funded by anyone at that stage and, therefore, we had to apply to the NHMRC for research funds. That is a different ball game, as you know. To get funds for fundamentally supported research doesn’t always lead to a more direct, immediate outcomes. So, on the one hand, we had to do basic research with funds that we didn’t really have because we had no telethon and, on the other hand, we had to try to help Cochlear to get it into the marketplace. In those early days, Cochlear wasn’t involved in the hearing field at all and, being an ear, nose and throat surgeon, I had to advise them and even establish contacts with a number of people who were leading ENT surgeons to help get them started. So initially there was a very close relationship between me personally, the research here and Cochlear, as it became. But, as the company grew, it needed to be more industrially relevant. It had to have a wider audience.
How do you view the role of an academic in relating to a more mature industry?
It was a learning experience for me as an academic. It was something that I now realise that academics need to be involved in. It was new for me and it was new even for the University of Melbourne. We took out patents through the University of Melbourne. It was not the first time but near the first time that the University of Melbourne had taken patents out on a development. So it was a new and learning experience but one, I think now looking back, that can benefit both. It can benefit the university and it can benefit research to have that collaboration. But it is not easy when it gets to a mature situation, because companies then can feel themselves mature. But I’m not sure that that is true.
Cochlear implants for children
Arguably, the next pivotal event in the development of the cochlear implant was to bring this treatment to children. Can you tell us about what challenges that brought?
That brought lots of challenges, some of which I didn’t realise. I always started with the idea that I particularly wanted to help deaf children. That was my real special motivation. They have such a lot of life ahead of them, and it has such a profound effect on their language. The challenges were, firstly, solved in a way by our operating on adults. I was not prepared to experiment with children with things that could be tackled and established on adults. The main difficulties with children were to give them proper language, to decide at what age to operate, and also to decide whether we could diagnose the hearing at a level where we could safely say, ‘There is going to be no loss of useful hearing if we do a cochlear implant.’ The other challenge was that, at the time, tactile stimulation was seen as a good alternative. There were vibrotactile devices and electrotactile devices that were seen as just as good. So why do a cochlear implant on a child? One had to address all of those difficulties.
The first question was: ‘Could one operate on a child under four?’ which seemed to be the right way to go to give them the best result. At that time it wasn’t clear how to do that. It wasn’t clear how to diagnose a hearing loss accurately. In my office, in the 1980s, I sat with Professor Dan Ling, who was a well known audiologist. The consensus was that you cannot accurately diagnose a hearing loss in a child less than four years of age with the behavioural tests. In which case, one should be careful about operating on children.
Fortunately, one of the research projects I was supervising was Field Rickards’ PhD way back in 1971. Field and I would go and work in the lab until all hours of the morning. We were trying to see what the brains of the experimental animals would do with a modulated, varied signal. It was amplitude and frequency modulated. Then, after some while, Field felt that the best way to go was to do a Fourier analysis on it. I was for looking at the frequency variations, but I think Field was right. We used amplitude modulation to decide what the thresholds were at the low frequencies. Now, that needs a little bit of explanation.
(At the time) auditory testing was not effective in children for the low frequencies, for different reasons, and it was crucial to know those frequency losses before doing a cochlear implant. At about the time we were ready to operate on younger children, our findings were starting to be accepted. I was surprised at how reluctant our whole group was in using these ‘steady-state evoked potentials’, as they are called, for doing that analysis. So that was one problem.
The second question was to determine whether we should use tactile stimulation instead, and I really tried to have a bet both ways. While developing the research for cochlear implants for children, I also encouraged research on tactile stimulation. That had its own problems. The first problem was that vibrators for converting speech into stimulation were too heavy, too big and too power hungry. They could never really be used effectively in a child’s life. The second problem was that electrical stimulation of the skin stimulated the pain fibres, and that wasn’t very useful either.
I had a private grant from an industrialist to do this research, and on the last day of the work, when it looked as though it was going to go nowhere, I offered my arm sacrificially to doing the experiments. I noted that, when the electrical stimuli stimulated the medial cutaneous nerve of my forearm, it was pleasant enough and not painful. That meant putting two and two together and stimulating the nerves on either side of the fingers as being more acceptable. I found this true when I tested it out on our young son, who was also a sacrificial subject.
We achieved a commercial device through collaboration between our Cooperative Research Centre (CRC) and Cochlear Pty Ltd and named it as the “Tickle Talker”. It gave the best results of any around the world, and looked like it might be the right way to go. But at the same time, perhaps for other brain processing reasons, the cochlear implant results started to get a little better and better. It took quite a long while though before it became clear that language was being benefited by the cochlear implant in children. It’s easy to look back and say, ‘It all happened quickly’, but it didn’t.
The educators of the deaf played a key role in helping to develop the language in children and also in its assessment. It wasn’t really until these educators said that this implant was the best thing that they had ever seen in helping to get language for children that I came to realise that this was so. We had done a lot of testing with psychological and educational tests, but the tests are somewhat stereotyped and not personal. So when the educators said that this was something they hadn’t experienced before, I really thought it was time to make further announcements and to do further work.
Some of those announcements were not well received by all sectors of the community. How did the conversation with those people develop?
I remember it well. It was very traumatic in some ways. It was surprising to me in the first instance. Having done this work for adults, having shown that it was safe, having shown that it would work; I was really being enthusiastic now about helping children. But in trying to give signing children hearing with a cochlear implant the Signing Deaf Community, in particular, said that I was bad, or even worse. It affected the team. I had to encourage them and give them moral support, while all this criticism was going on. It was really quite traumatic and quite unfair in some ways. It came mainly from the signing community. I had been involved with this debate ever since I had been setting up and chairing the Deafness Foundation of Victoria in 1970. I knew there was a real issue with the educational method. But to have it brought home so personally was really a challenge, and it continued on. It got a little less as the years went by.
How did your family take that?
Fortunately, the family weren’t too involved in this. Sometimes I might ask some of the children what was going on, and they weren’t as clued up as you might imagine. In fact, sometimes they didn’t know what dad was doing. But Margaret was very supportive, as she was with the other work.
How about the children that received a cochlear implant? How did they influence the conversation with the deaf community, or how did they influence opinion within the deaf community?
The children that had it early enough have now grown up and they are wonderful. They have grown into self-reliant, mature individuals. One boy, if he is not a soccer player, wants to be a lawyer. Sophie Li is another great advocate for what impact implants have made in their lives. All of children that I know have not deteriorated or rejected it. They have found that it has added to their lives, and they have become very mature individuals. In many cases, even competing well with hearing children.
Have you had conversations with any of the children that received implants about how their cochlear implants were viewed within the deaf community?
In the early phases, yes, one did discuss with them how they were treated. Initially, they were seen not as outcasts, but they were not treated with welcoming arms. They were seen as being on the opposite side. That was in the early stages, but that changed. When it became clear that they could communicate so well with hearing people, that criticism changed. I must say that it surprised me how well these children do with language when they are operated on at a young age. It blows my mind. I went and saw some of the children out at Mount View Primary who have been taught to communicate in a fairly normal situation. They are so lovely and normal that I don’t think there is any need to be concerned. In fact, seven years ago we made a film of this group of children and, just recently, we made another film of the same group showing them seven years later, and they are just inspirational.
Advice for budding scientist-doctor
Can you reflect on being a researcher and a clinician? Have you any advice for young people, who aspire to follow in your footsteps, on how they could develop their careers?
It is a very important question: to what extent can a practising clinician, a surgeon in this case, be accepted as a basic scientist? It is not easy to be both. I remember Peter Bishop, professor of physiology at Sydney University, said that it was almost impossible to be both. Particularly today you have such big demands doing basic research and such big commitments doing clinical work. I think it is still possible to do both, but it means that one should be a basic scientist and at least be accepted into the basic scientific community, perhaps in a niche area, but certainly in a clear area where one is able to make a contribution. At the same time, specialise in one area of medicine. I don’t think it is possible to be a general surgeon or clinician. And it is not even possible for people in practice full time. So I think it is possible, but it is not easy. One of the difficulties too is that, in practice, one has to be on call for patients, whereas, in basic research, you have to give so much time to writing papers and grant applications.
How do you feel that your research training has enriched you as a clinician?
I believe that my research training has enriched me enormously. At first, when I went as a clinician to a very high powered neurophysiology lab and wrote my first paper, I couldn’t see my writing for red ink. I didn’t realise how exacting basic research scientists view their research. I learned to respect them because they spend a lot of time doing that. On the other hand, when I then applied that training to my research, at first my attempts to be more rigorous weren’t treated terribly seriously, but they are now. I think it has helped me to try to be more rigorous with my clinical research as well. I now see that they both complement each other. A much respected senior colleague of mine, who trained in medicine at Sydney University and went into a research career, he too, says how enriching his medical training was to his research background. I think the same applies. For me, I have tended to see most things through a neurophysiological filter as well as a surgical filter.
What do you think we need to do as a nation to help young doctors who want to go into research?
I think we have to make opportunities for them and we have to provide the funds for them to do this. They might need to do research halftime and clinical work halftime. There need to be more opportunities for them to develop their talents, and we need to reward them and to pick the ones that want to do it. But I must say that they have to have “fire in the belly”. I have tried to encourage some, over the years, to do research, but, if they are only half hearted, it is not good enough. Research, as you know, is a demanding career.
What has helped you to maintain the fire in the belly? When you become a successful leader in research or as a professor or a clinician, there are many things that weigh upon your time. There are many political and administrative concerns, and one is always fighting for money. So what is it that kept you passionate through all of these challenges?
I was amazed when I got involved there were so many other distracting areas like politics, fund-raising, interaction with colleagues and various bureaucratic delays and challenges. They can be very frustrating. My response has been single-minded, pig-headed and focused on trying to keep the distractions aside and to focus on the main game.
Professor Graeme Clark, thank you very much for your time today. Your single-mindedness has brought hearing and the gift of communication, language and speech to thousands of people around the world. We thank you very much for this great gift and we thank you for your contribution to Australian science.
Thank you for your comments and encouragement. I do thank not only you, but colleagues and Australians. Australians have a lot to offer, if we can get the adequate support that we see sometimes in other countries.
© 2024 Australian Academy of Science
