Wednesday 8 May 2013

London


London

London had been the epicenter of my dreams. South Africa, until 1952, had been part of the British Commonwealth and my school career had been focused on England as the mother country. We had specialized in the history of England: the Angles, Romans, Saxons and Normans, the history of the mediaeval kings, the industrial revolution and the developing 19th and 20th centuries. The school textbooks were British with a South African bias, we were steeped in British literature, prose, and poetry, Dickens and Shakespeare and even the weekly news magazines arrived a fortnight later. Our medical textbooks were English and not American. Rhodesia was a British Colony and nearly all the government officials and doctors came from England. England was the governing country with its inherited monarchy and London its capital. What could be more normal than coming to London, the city that had borne the brunt of the German blitz in World War 2.

The decision to move to London was natural and the appropriate place to prepare for the MRCP examination and I started with a 10-week course in Internal Medicine at the Royal Postgraduate Medical School in London. 

We found a pleasant apartment off Clapham Common and moved to London.  The apartment was small, on the third floor, a pleasant view over a small park and we shared the bathroom with the other three apartments in the building. It had a “pay as you use” gas heater and a bath cost one penny of gas. Our first new acquisition was a black and white “Pye” television receiver with a 15 inch screen.

Unfortunately, Clapham Common was in the south of London and the hospital was in Shepherd's Bush to the north of the river Thames.  The traveling was tough along the congested roads and I had to cross the traffic bottlenecks at the Chelsea or Battersea Bridges. I explored all the alternative routes to avoid the long delays at the traffic lights but eventually I settled for early rising and I often left home at 6 a.m. in the morning.

The Hammersmith Hospital was an old district hospital which had been updated when the government decided to create a new Royal Post-Graduate School within the University of London.  It was a tertiary hospital with young super-specialist departments.  A new research building had been added and since I have left many renovations have been undertaken.    

The medical course of advanced medicine was challenging.  The Hammersmith Hospital had a large department of Internal Medicine and each sub-specialty had its own ward and specialist staff.  It had attracted the best physicians and researchers in the country and the teaching was excellent.  There were many formal and structured lectures but the basis was the problem based learning of medicine and discussion of clinical cases in small groups of 6 or 7 students with experienced teacher facilitators. Each teacher was an expert in his field and took us to the cutting edge of what was then the, most advanced knowledge. Each subspecialty fascinated me, and diseases of the heart and chest in particular. After my exposure to the pneumoconiosis of the mines in Rhodesia it was an eye-opener to hear the older Prof. Scadding show his patients with sarcoidosis and anthracosis, Fletcher explain the new classifications of obstructive airways disease and chronic bronchitis and John West, the young pulmonary physiologist, demonstrate on the blackboard, his new concepts of ventilation-perfusion inequalities in the normal and diseased lung. My mind went into top gear and I bought all the new text-books to learn and relearn these new concepts.    I became a regular visitor at HK Lewis in Gower Street which had all the new and many second-hand books, and subscribed to their lending library to extend my reading. Simply scanning the books in the shop was a delightful sensation.

I had planned to sit for the Edinburgh MRCP in Tropical Medicine but missed the date for registration. I waited another month and then sat for, and passed the Membership of the Royal Faculty of Physicians and Surgeons in Glasgow.


I made many new friends who had come from all parts of the world and we would supplement the formal teaching by attending lectures and clinical presentations at the other main teaching hospitals in London.  In June, I had no problem passing the  London MRCP specialty examination in Internal Medicine, which then was an entry level examination and a gateway to advanced clinical studies. It was also a major stumbling block for poorly prepared postgraduate trainees and had a high failure rate. I took the examination at the Royal College and went to the clinical examination with an older colleague from Cape Town. He had been the top student to graduate in the Medical School in Cape Town ahead of me and had already been unsuccessful twice. It was a cold winter morning and he had a small Morris Minor car. By the time we arrived he must have lost a litre of sweat. He was unsuccessful a third time.

The examination was a personal triumph after I had waited impatiently for the results but I was now set for a career in Cardiology and planned to continue to Cardiac Surgery.  I had made a good impression on John McMichael, head of the department of Internal Medicine and I was appointed as a Senior House Officer at the Hammersmith Hospital.  The salary was a pittance: 600 pounds a year. 

I knew the physical layout of the hospital well but since I had been studying full time, it was refreshing to return to patient care.  The work was very challenging and I entered a new world of eclectic, academic medicine and research. It was very different from the heavy clinical services in Cape Town and Gatooma.  John McMichael was an expert on hypertension, Jack Shillingford, specialized in cardiac physiology, and Patrick Mounsey, a great physician, and an expert in physical examination.  The other cardiac firm was run by John Goodwin, who received all the patients with cardiomyopathies, older children with congenital heart disease and patients with valve disease and was the primary consultant for a large and expert cardio-thoracic surgical department. The units had an extensive drainage area serving most of Southern England.  Both units were very active and I had stimulating registrar colleagues like Colin Dollery who became the Dean of the Medical School, Brian Pentecost who became the President of the British Heart Foundation, Dennis Boyle who became Professor of Medicine in Belfast and Celia Oakley who would become the doyen of London cardiology .  All the other senior house officers in my year became university professors or medical school deans.  The hospital was an incubator for the brightest graduates in Britain. 

It was a little difficult to come down from my former independence as a general practitioner in Rhodesia, and function as a simple house physician, but the work was so interesting and the scientific investigative spirit so good, that I became lost in the work.  In the ward we studied the diurnal variations in blood pressure. McMichael had built a simple finger plethysmograph which recorded the forefinger blood pressure every 10 minutes and it showed clearly  the sudden emotional rises and fluctuations in blood pressure when the physicians or nurses approached the patient. I also worked in the hypertension outpatient clinics which were a little depressing since most of the patients had severe malignant hypertension with end organ failure and disease of the kidneys and eyes and concomitant cerebral hemorrhage. Hexamethonium was the most effective treatment, but the era of oral therapy with reserpine had started. Reserpine had been extracted from plants in India and formed the basis of the first group of oral drugs. Methyldopa was also new on the market.  Oral diuretics and beta blocking drugs would enter the therapeutic pharmacopeia a few years later. McMichael was also interested in the fundamentals of heart function and was investigating the cardiac output using right heart catheterization and dye dilution curves using Coomasie Blue whose concentratons could be measured non-invasively with an ear oximeter. The haemodynamic laboratory was housed in a small prefabricated building. Medical research did not need expensive buildings or large research grants. It needed ideas, an enquiring mind, planning, enthusiasm and perseverance. The most interesting research was the new novel technique of using radioisotopes for diagnosis and physiological investigation.  The research center had its own nuclear reactor (cyclotron) and the hospital manufactured its own short acting isotopes.  I learned the mathematics of radioactive decays and we studied the regional flow of blood through the lungs at rest and at exercise.  Normal subjects had a reduced upper zone blood flow at rest which disappeared on erect bicycle exercise: this was accentuated in Fallot's Tetralogy and reversed in mitral valve disease.  Colin Dollery was full of enthusiasm, he was restless with a scintillating mind and new ideas but he had patience and soon taught me the appropriate mathematics. We used slide rules, logarithm tables, and semilogarithmic paper to plot the graphs.

I also worked in the dialysis unit at night.  We had the first Kolff dialysers which were the size of a washing machine and I had to wash the filters and tubes after each treatment.  There was no disposable equipment.  My most important patient was the wife of a famous film producer, and when she was discharged well, the husband gave me a present of 5 guineas on a handwritten check from the Coutts Bank. 

The young doctors on the hospital staff were hungry for knowledge and experience and we would meet every evening to make clinical rounds. Each registrar would present and discuss the most interesting patients in his ward.  There was also a daily post mortem session at 12 noon attended by the staff of Internal Medicine and a weekly clinical conference for the hospital on Wednesdays.  I was very active and showed a patient every fortnight. This taught me to formulate my ideas, produce and edit presentations, to speak to a large audience and parry the difficult questions from the Professors in the front row.

I also looked after the hematology in-patients and was very stimulated by Prof. John Dacie.  When I had time, I would try and join the ward rounds of other firms, and spend time in the respiratory laboratories.  This gave me a very good and extensive knowledge of internal medicine. The other specialties were very active and Radiology in particular; Robert Steiner was a scintillating clinical radiologist and his X-ray meetings outstanding. He was an an experienced clinician: a radiologist who could make a brilliant clinical diagnosis and guide treatment from a simple X-ray of the chest.

Spring and summer in London changed our life style from the foggy winter in Liverpool. The long balmy summer days encouraged extensive travelling, I had overcome my fear of the large city and we explored it's every nook and cranny. This was the gracious London, which had grown out of the swamps and the winding ox-bow Thames river, rebuilt after the great fire, with the unusual architecture of Wren and Indigo Jones and with the finest museums and art galleries in the world. We were quite at home and we spent our free Sundays visiting the museums and interesting sites. I have now made many visits to the city and know it intimately. We explored the surrounding countryside and I fell in love with the rolling plains and perennial grassland.

 We bought our first large television set, read all the newspapers and learned about current affairs and politics. We were assimilated into London life.

Bernadine my first child was born at the Hammersmith Hospital.  I had been on weekend call and Aileen had come to join me for lunch on Sunday.  As I was taking her home she complained of pain in her abdomen and attributed it to moving the furniture in the morning.  We returned to the hospital and it was clear that she had incipient labor pains.  She was admitted to the maternity ward and next morning delivered a beautiful bouncing baby girl. 

There was great excitement in the ward and after two days I took her home.  Bernadine was born in November and the winter was settling in London.  We would take her out, all wrapped up in blankets, to walk around the Clapham Common pond.

The year in London was a pivotal year in our lives. I had been educated in the British environment in South Africa. London was the epicenter of the British Commonwealth and there was a natural empathy with British tradition and thought. This had now been fulfilled and once again we were ready to move on.






                                     


London

London had been the epicenter of my dreams. South Africa, until 1952, had been part of the British Commonwealth and my school career had been focused on England as the mother country. We had specialized in the history of England: the Angles, Romans, Saxons and Normans, the history of the mediaeval kings, the industrial revolution and the developing 19th and 20th centuries. The school textbooks were British with a South African bias, we were steeped in British literature, prose, and poetry, Dickens and Shakespeare and even the weekly news magazines arrived a fortnight later. Our medical textbooks were English and not American. Rhodesia was a British Colony and nearly all the government officials and doctors came from England. England was the governing country with its inherited monarchy and London its capital. What could be more normal than coming to London, the city that had borne the brunt of the German blitz in World War 2.

The decision to move to London was natural and the appropriate place to prepare for the MRCP examination and I started with a 10-week course in Internal Medicine at the Royal Postgraduate Medical School in London. 

We found a pleasant apartment off Clapham Common and moved to London.  The apartment was small, on the third floor, a pleasant view over a small park and we shared the bathroom with the other three apartments in the building. It had a “pay as you use” gas heater and a bath cost one penny of gas. Our first new acquisition was a black and white “Pye” television receiver with a 15 inch screen.

Unfortunately, Clapham Common was in the south of London and the hospital was in Shepherd's Bush to the north of the river Thames.  The traveling was tough along the congested roads and I had to cross the traffic bottlenecks at the Chelsea or Battersea Bridges. I explored all the alternative routes to avoid the long delays at the traffic lights but eventually I settled for early rising and I often left home at 6 a.m. in the morning.

The Hammersmith Hospital was an old district hospital which had been updated when the government decided to create a new Royal Post-Graduate School within the University of London.  It was a tertiary hospital with young super-specialist departments.  A new research building had been added and since I have left many renovations have been undertaken.    

The medical course of advanced medicine was challenging.  The Hammersmith Hospital had a large department of Internal Medicine and each sub-specialty had its own ward and specialist staff.  It had attracted the best physicians and researchers in the country and the teaching was excellent.  There were many formal and structured lectures but the basis was the problem based learning of medicine and discussion of clinical cases in small groups of 6 or 7 students with experienced teacher facilitators. Each teacher was an expert in his field and took us to the cutting edge of what was then the, most advanced knowledge. Each subspecialty fascinated me, and diseases of the heart and chest in particular. After my exposure to the pneumoconiosis of the mines in Rhodesia it was an eye-opener to hear the older Prof. Scadding show his patients with sarcoidosis and anthracosis, Fletcher explain the new classifications of obstructive airways disease and chronic bronchitis and John West, the young pulmonary physiologist, demonstrate on the blackboard, his new concepts of ventilation-perfusion inequalities in the normal and diseased lung. My mind went into top gear and I bought all the new text-books to learn and relearn these new concepts.    I became a regular visitor at HK Lewis in Gower Street which had all the new and many second-hand books, and subscribed to their lending library to extend my reading. Simply scanning the books in the shop was a delightful sensation.

I had planned to sit for the Edinburgh MRCP in Tropical Medicine but missed the date for registration. I waited another month and then sat for, and passed the Membership of the Royal Faculty of Physicians and Surgeons in Glasgow.


I made many new friends who had come from all parts of the world and we would supplement the formal teaching by attending lectures and clinical presentations at the other main teaching hospitals in London.  In June, I had no problem passing the MRCP specialty examination in Internal Medicine, which then was an entry level examination and a gateway to advanced clinical studies. It was also a major stumbling block for poorly prepared postgraduate trainees and had a high failure rate. I took the examination at the Royal College and went with an older colleague from Cape Town. He had been the top student to graduate in the Medical School in Cape Town ahead of me and had already been unsuccessful twice. It was a cold winter morning and he had a small Morris Minor car. By the time we arrived he must have lost a litre of sweat. He was unsuccessful a third time.

The examination was a personal triumph after I had waited impatiently for the results but I was now set for a career in Cardiology and planned to continue to Cardiac Surgery.  I had made a good impression on John McMichael, head of the department of Internal Medicine and I was appointed as a Senior House Officer at the Hammersmith Hospital.  The salary was a pittance: 600 pounds a year. 

I knew the physical layout of the hospital well but since I had been studying full time, it was refreshing to return to patient care.  The work was very challenging and I entered a new world of eclectic, academic medicine and research. It was very different from the heavy clinical services in Cape Town and Gatooma.  John McMichael was an expert on hypertension, Jack Shillingford, specialized in cardiac physiology, and Patrick Mounsey, a great physician, and an expert in physical examination.  The other cardiac firm was run by John Goodwin, who received all the patients with cardiomyopathies, older children with congenital heart disease and patients with valve disease and was the primary consultant for a large and expert cardio-thoracic surgical department. The units had an extensive drainage area serving most of Southern England.  Both units were very active and I had stimulating registrar colleagues like Colin Dollery who became the Dean of the Medical School, Brian Pentecost who became the President of the British Heart Foundation, Dennis Boyle who became Professor of Medicine in Belfast and Celia Oakley who would become the doyen of London cardiology .  All the other senior house officers in my year became university professors or medical school deans.  The hospital was an incubator for the brightest graduates in Britain. 

It was a little difficult to come down from my former independence as a general practitioner in Rhodesia, and function as a simple house physician, but the work was so interesting and the scientific investigative spirit so good, that I became lost in the work.  In the ward we studied the diurnal variations in blood pressure. McMichael had built a simple finger plethysmograph which recorded the forefinger blood pressure every 10 minutes and it showed clearly  the sudden emotional rises and fluctuations in blood pressure when the physicians or nurses approached the patient. The hypertension clinics were a little depressing since most of the patients had severe malignant hypertension with end organ failure and disease of the kidneys and eyes and concomitant cerebral hemorrhage. Hexamethonium was the most effective treatment, but the era of oral therapy with reserpine had started. Reserpine had been extracted from plants in India and formed the basis of the first group of oral drugs. Methyldopa was also new on the market.  Oral diuretics and beta blocking drugs would enter the therapeutic pharmacopeia a few years later. McMichael was also interested in the fundamentals of heart function and was investigating the cardiac output using right heart catheterization and dye dilution curves using Coomasie Blue whose concentratons could be measured non-invasively with an ear oximeter. The haemodynamic laboratory was housed in a small prefabricated building. Medical research did not need expensive buildings or large research grants. It needed ideas, an enquiring mind, planning, enthusiasm and perseverance. The most interesting research was the new novel technique of using radioisotopes for diagnosis and physiological investigation.  The research center had its own nuclear reactor (cyclotron) and the hospital manufactured its own short acting isotopes.  I learned the mathematics of radioactive decays and we studied the regional flow of blood through the lungs at rest and at exercise.  Normal subjects had a reduced upper zone blood flow at rest which disappeared on erect bicycle exercise: this was accentuated in Fallot's Tetralogy and reversed in mitral valve disease.  Colin Dollery was full of enthusiasm, he was restless with a scintillating mind and new ideas but he had patience and soon taught me the appropriate mathematics. We used slide rules, logarithm tables, and semilogarithmic paper to plot the graphs.

I also worked in the dialysis unit at night.  We had the first Kolff dialysers which were the size of a washing machine and I had to wash the filters and tubes after each treatment.  There was no disposable equipment.  My most important patient was the wife of a famous film producer, and when she was discharged well, the husband gave me a present of 5 guineas on a handwritten check from the Coutts Bank. 

The young doctors on the staff were hungry for knowledge and experience and we would meet every evening to make clinical rounds. Each registrar would present and discuss the most interesting patients in his ward.  There was also a daily post mortem session at 12 noon attended by the staff of Internal Medicine and a weekly clinical conference for the hospital on Wednesdays.  I was very active and showed a patient every fortnight. This taught me to formulate my ideas, produce and edit presentations, to speak to a large audience and parry the difficult questions from the Professors in the front row.

I also looked after the hematology in-patients and was very stimulated by Prof. John Dacie.  When I had time, I would try and join the ward rounds of other firms, and spend time in the respiratory laboratories.  This gave me a very good and extensive knowledge of internal medicine. The other specialties were very active and Radiology in particular; Robert Steiner was an unusual clinical radiologist and his X-ray meetings outstanding. He was an an experienced clinician, a radiologist who could make a brilliant clinical diagnosis and guide treatment from a simple X-ray of the chest.

Spring and summer in London changed our life style from the foggy winter in Liverpool. The long balmy summer days permitted extensive travelling, I had overcome my fear of the large city and we explored every nook and cranny. This was the gracious London, which had grown out of the swamps and the winding ox-bow Thames river, rebuilt after the great fire, with the unusual architecture of Wren and Indigo Jones and with the finest museums and art galleries in the world. We were quite at home and we spent our free Sundays visiting the museums and interesting sites. I have now made many visits to the city and know it intimately. We explored the surrounding countryside and I fell in love with the rolling plains and perennial grassland.

 We bought our first large television set, read all the newspapers and learned about current affairs and politics. We were assimilated into London life.

Bernadine my first child was born at the Hammersmith Hospital.  I had been on weekend call and Aileen had come to join me for lunch on Sunday.  As I was taking her home she complained of pain in her abdomen and attributed it to moving the furniture in the morning.  We returned to the hospital and it was clear that she had incipient labor pains.  She was admitted to the maternity ward and next morning delivered a beautiful bouncing baby girl. 

There was great excitement in the ward and after two days I took her home.  Bernadine was born in November and the winter was settling in London.  We would take her out, all wrapped up in blankets, to walk around the Clapham Common pond.

The year in London was a pivotal year in our lives. I had been educated in the British environment in South Africa. London was the epicenter of the British Commonwealth and there was a natural empathy with British tradition and thought. This had now been fulfilled and once again we were ready to move on.






                                     

Birmingham


Birmingham  -  An era of scientific cardiology

The medical school in Birmingham had adopted the new Medical School in Rhodesia and since there was a strong affiliation with the country I decided to move Northwards

Colin Dollery, my senior registrar at the Hammersmith Hospital had trained in Birmingham and persuaded me to apply for an appointment at the Queen Elizabeth Hospital in Birmingham.  He felt that their scientific approach and standing was even better than the Hammersmith Unit. 

I went to visit Mellville Arnott, the head of medicine and applied for a vacant post, and although there were two other MD, PhD candidates at the interview, I was successful. The medical school at the University of Birmingham had also adopted the new medical school in Salisbury, Rhodesia, and I think that he felt that I would return and join the nucleus of the new staff.                         

Birmingham was the market town of the English midlands and grew because of civic investment, scientific achievement, commercial innovation and the steady influx of migrant workers. It became the metropolitan hub of the United Kingdom's manufacturing and automotive industries. Initially it was a city of canals, then of cars, and most recently as a major European convention and shopping destination. Today, Edgbaston and the city centre have been renovated or rebuilt and it is now regarded as a post industrial metropolis,

Aileen and I were uncertain of our future but I was impressed by Melville Arnott's forward outlook and moved to Birmingham at the end of 1960. We travelled in midwinter at the end of the year. The heavy winter storms had affected the roads and we battled against the snow on the M4 highway and finally arrived at our new apartment.  I had become an expert at navigating new territories and was very facile with my road map.

We had rented the ground floor flat of a two storied housein Grosvener Road.  We had a large back garden but had to share the bathroom with a pleasant young couple.  The apartment was on the edge of the Harborne Shopping Center and a 5 minutes drive from the hospital. 

Birmingham was a different experience. The Queen Elizabeth Hospital was a large and impressive modern teaching hospital. The building was relatively new and different from my previous hospitals. It had several firms of general medicine, but I was part of the academic professorial medical unit.  The National Health Service provided the standard clinical staff: registrars, senior registrars and consultant appointments to care for the patients, but in addition there were university Readers, senior lecturers and lecturers.  The extra staff allowed more time for teaching students and research.  The department had its own wards, and an additional new 3 floor research building.  The top floor was devoted to respiratory physiology and the ground floor to research rooms in cardiology.  It was comfortable and spacious and my own room on the third floor, faced south, collected the sun, and had a view over the green University lawns which were bisected by the main railway line from London.

I became the main registrar of the unit, but in addition was allocated to study the diffusing capacity of the lung. I shared the service with John Burgess who later became the Chief of Cardiology at the Montreal General Hospital. The major part of my work was to provide a clinical service and look after the patients in ward east 1B, but there was ample time for research.  It was a period of renaissance of diseases of the lung and modern pulmonary physiology. Julius Comroe at the University of Pennsylvania had revitalized pulmonary physiology and it was a blossoming specialty. Birmingham, with its cold smoggy weather, and a large population of industrial workers who were heavy smokers had a high prevalence of chronic bronchitis and emphysema, which were associated with severe respiratory failure and cor pulmonale.

Mellville Arnott had built a well equipped and modern laboratory for respiratory physiology and it was equipped with all the latest equipment. He believed in clinical measurement: His physicians had a stethoscope in the right pocket of the coat and a slide rule in the left. 

I worked together with John Burgess, who later became the Chief of Cardiology at the University Hospital in Montreal.  He subsequently became president of the Royal College of Physicians and Surgeons in Canada. We were supervised by John Bishop, one of the Readers.  He was a very quiet man and in the afternoons would disappear into his office to write his monograph on Cardiac output at rest and on exercise. He had worked for many years with Wade and Ken Donald on cardiac output and regional blood flow at rest and on exercise and was summarizing the data. They had been very productive with a long list of important research publications.  I spent the afternoons in the laboratory and developed new methods of measuring pulmonary capillary blood volume and I started to prepare a PhD. Thesis. John Bishop, my supervisor, was a perfectionist and made me repeat my studies an infinite number of times and eventually I began to lose my enthusiasm. He was a little dry and I thought he was unenthusiastic. I did not realize that he was a tough taskmaster. I did a study on the distribution of ventilation during rest and exercise using the nitrogen meter and was surprised to find that the paper had been published with thanks for my technical contributions.   I learned all the other new techniques of respiratory physiology such as the body plethysmograph to measure the work of breathing and the use of the mass spectrometer for measuring several inspired and expired gases simultaneously. The physical work was interesting and the mathematical analysis exciting.

I participated in many other studies and Natie Segal, another young lecturer introduced me to the cath lab where they were undertaking studies in regional blood flow at rest and during exercise in patients with mitral stenosis.  The pace of research was too slow for my temperament, and although I was very busy, felt a little frustrated.  I was influenced by the dynamic cardio-thoracic surgeons who had a much more enthusiastic group of registrars. Leon Abrams was the junior cardiac surgeon and had brought in a new generation of registrars.  Subramanian from Bombay was full of ideas in the dog lab as well as Jack Norman from Houston, Texas.   We studied left heart bypass in dogs, passing a transseptal needle and catheter from the left femoral vein into the right atrium, puncturing the inter atrial septum and leaving the catheter in the left atrium.  We drained the blood from the atrium into a small receptacle and pumped it back into the femoral artery, providing a left heart assist device.  We were forty years ahead of our time.   Leon Abrams had just started open heart surgery.  Pon d’Abreu, the chief of cardio-thoracic surgery suggested that he operate in the evenings when the operating theaters were free and I was commandeered to help as the assistant open heart pump technician.  My own heart beat quickly when I first saw patients' hearts beating in life together with a good view of the underlying pathology and I learned at first hand the management of cardio-pulmonary bypass, cardio vascular physiology and the management of changing blood volumes.  We studied in detail the need to reinfuse blood at the end of the operation.  I learned a great deal about blood volume and manipulating venous pressures to correct and maintain a normal cardiac output.  

I read extensively, and we had a good library of the contemporary journals, and again gained a wide knowledge of cardiac and respiratory physiology and rheumatic and congenital heart disease.  Leon Abrams worked at the Children's Hospital on Tuesdays which was a quiet day on the medical unit and I would spend the afternoons with him in the operating room and then spend the evening looking after the children who had undergone open heart surgery.  The pediatric registrar who was undertaking the catheterizations at the Children's Hospital was appointed as a consultant in Wolverhampton and Roy Astley the head of radiology asked me to take his place.  My program was now overcrowded so we arranged that I would come to the Children's Hospital twice a week in the late afternoons.  I was now in the adult medical wards in the mornings, respiratory lab in the afternoons, children's catheterizations twice a week in the late afternoons, and two nights a week in the operating room.  I loved this pace, and although I finished some research in the department of medicine, enjoyed the freedom of the Children's Hospital.  Roy Astley was a pediatric and gastero-enterological radiologist, intensely interested in cardiology and prepared to give me all the training, encouragement and help that I needed. Clifford Parsons, the pediatric cardiologist, recognized my enthusiasm and pushed me forward.  Leon Abrams was one of the few surgeons in England in 1962 who was undertaking successful open heart surgery in children.  This was a fertile field for research.  Roy had a collection of more than 1000 children who had been catheterized and 250 patients had undergone successful surgery.  On my free nights I would stay in his office until the early hours of the mornings studying the angiograms and making clinico-pathological correlations.  My best friend was the security guard who would bring me a fresh cup of coffee at midnight when he came to check the lights in the office. When I was in the operating room, I would make careful sketches of the operative anatomy and procedure and summarize the data.  I learned at first hand the precise surgical anatomy of every patient who had undergone surgery.    

I soon had a series of research projects ready for publication. My first presentation was the Value of Venous Angiography in Newborn Babies to diagnose a patent ductus arteriosus.  This was very important as the babies developed severe heart failure, the usual continuous murmur was not present and the babies could undergo lifesaving surgery for closure of the ductus.  The meeting of the British Cardiac Society was held at the famous St. Andrews Golf Course club house  in Scotland.  I was attacked roughly by one of the older cardiologists from Edinburgh. John Goodwin from Hammersmith came to my rescue.  I was excited by my first public presentation. In retrospect, the diagnosis today is made by a simple echocardiographic scan.


I had arrived in the middle of winter and the first new disease that I learned to treat was severe respiratory failure.  This occurred in Irish workers who were working in the coal and iron mines or in outdoor construction.  They were heavy smokers and the dust inhalation diseases had damaged their lungs.  Colds and influenza rapidly spread into their lungs and they were admitted with severe respiratory and heart failure. They were blue and swollen and we called them "black nephrotics".  Many required artificial ventilation, and at that time we only had the Cape Ventilator which was an artificial cuirass similar to the machines we had used in the earlier poliomyelitis epidemic.  The patients were treated in the open ward and developed resistant staphylococcal and pseudomonas infections.  We had no appropriate antibiotics and many died, and I soon learned the epidemiology and spread of the hospital acquired disease and this formed the basis for my first paper in Thorax together with Lionel Whitby, the Head of Microbiology.

Peter Harris was the other Reader in Internal Medicine and together with Donald Heath, the senior pathologist had just published their book on the pulmonary circulation and I joined them in the laboratory studying sections of the lungs in patients with pulmonary hypertension.  Donald Heath, in particular, was an unusually intelligent pathologist who would spend hours making autopsies and studying biopsies under the microscope. My co-registrars were enthusiastic eager beavers and we had intense scientific  discussions and arguments.

In the cath lab I learned a great deal about cardiac physiology although no one trained me formally in the art of catheterization and although I was also doing the catheterization in the Children's Hospital, it was not until I returned to Cape Town where Walter Beck taught me the formal art.  Since then, I have always taught my young doctors personally and maintained a strict routine and discipline.

At the Children's Hospital I analyzed nearly 1350 children with congenital heart disease who had undergone cine angiography.  Most of them I knew personally and I correlated the angiography with their clinical history and physical findings.  In patients who had undergone surgery, I had detailed operative reports and in most of the patients I had been at the operation myself and had made detailed drawings of the anatomy and the operative procedure.  I read the literature in great detail.  I put the material together and published a series of papers in the British Heart Journal.  I was interested, in particular, in Fallot' s Tetralogy.  We had always referred to the four basic abnormalities of the anatomy:  ventricular septal defect, pulmonary stenosis, overriding aorta and right ventricular hypertrophy.  It was clear that these patients had a defect of septation, so that the  patient had a underdeveloped outflow tract of the right ventricle and pulmonary artery and at the base, nonjunction of the body and outflow tract of the right ventricle.  The severity of underdevelopment of the outflow tract determined the severity of the disease.  This was also the basis of the surgical repair with infundibular resection, pulmonary valvulotomy, and enlargement of the outflow tract using a patch.  Later, when I returned to Cape Town and analyzed 100 patients who had a correction by Chris Barnard, I analyzed the outflow tract reconstructions in detail. 

When I completed my two years as a medical registrar at the Queen Elizabeth Hospital, I was invited to become the professorial senior registrar at the Children's Hospital.  Most of my time was devoted to cardiology, but I was responsible for the student teaching programs and caring for the patients in the professorial unit.  Douglas Hubble was an untiring endocrinologist who specialized in the adreno-genital syndrome and other congenital abnormalities of sexual development and Otto Woolf who was interested in behavior abnormalities and lipid disorders and two neurologists Brewer and Wood.  I also had to read the electroencephalograms.  My co-registrars were also enthusiastic. These specialties did not interest me and I devoted as much time as possible to cardiology. 

Roy Astley continued his support, but I had to hire my own secretary to do the typing of the research manuscripts and when the hospital photographer felt that he was being overworked, I photographed and printed my own slides and pictures. 

It was a very interesting period but I felt a little stifled by the other staff who did not share my enthusiasm.  My other "hunting partner" was Dr. Singh and we sit together in the evenings and wrote a series of papers together.  Finally, I prepared most of the material in a massive 1000 page, 4-volume thesis for my MD degree.  The typing was very hard, with text, pictures and references, and I used all the secretaries in the hospital typing pool to finish the work.


I realized that I lacked a firm scientific and mathematical basis and I enrolled in night school at the Aston College of Technology where I learned mathematics, statistics and electronics.  This gave me a really good foundation for the research in the laboratory.  Statistical analysis was very primitive; I would write the data on columns on paper and then come to the hospital at 5 a.m. to use the hand operated desk calculators to calculate the sums and the squares and the sums of the squares and work out r and p values for statistical significance and use a slide rule for logarithms and Fourier analysis.  A single table would take a week of calculations.  Today, it would take two minutes, on an excel chart followed by the SPSS statistical package.

 English medicine was parochial.  We had few departmental meetings and our major research meeting activity was the medical society meeting in London.  Each month on Fridays we would be hosted by a different medical school which would exhibit its current research, and we would have the opportunity to present our own research data.  It was a very important forum to learn what was developing in the other medical schools, and the senior professors would sit in the front row deciding whom they would choose as their senior registrars and consultants.  The British Cardiac and Thoracic Societies were elitist groups, but the meetings were small and discussion was critical and intense.  The English were very humble and intelligent.  Few senior physicians traveled across the Atlantic to the American meetings.

My family life in Birmingham was very rich.  We had little money and some secondhand furniture but our little yellow Ford Anglia with its cut away back window allowed us to whiz around the country.  Every Sunday afternoon we would visit all the surrounding towns and we soon learned the geography of the British Midlands as far as the Welsh border.  The country was delightful in summer, the fields were green, and hedge rows formed borders of the country lanes. We emerged from the smog of Birmingham into the clear skies of the surrounding countryside and dusk would fall at 9 or 10 o'clock in the evening.  We would take along our homemade sandwiches and have leisurely picnics.  Often, I would take a volume of English poetry.  Bernadine, our oldest daughter, grew rapidly and then Debbie and Craig were born at the Queen Elizabeth Teaching Hospital.  The deliveries were a little difficult, but Aileen emerged with a smile and a new baby.  As the family grew, and my salary increased a little, we moved to a three-bedroomed detached house on Hagley Road, the main road out of Birmingham to the west, but only 25 minutes drive from the Queen Elizabeth and The Children's Hospital. The main shopping center was in Quinton, and I can remember Aileen putting the two girls in a perambulator in winter and covering them and taking them to the shopping center.  They were clothed in heavy pink coats, their heads were covered with white knitted "goose caps" and each daughter had sparkling pink cheeks. 

We would take our holidays in Cornwall, hiring a stationary caravan at Falmouth and spending the days exploring the Cornish coast with its rocky outcrops and inlets with beaches and craggy inland terrain.  After spending two weeks at the seaside, we would return revitalized.  We would also travel around the southwestern corner of England exploring the country in Somerset and Dorset.        

I felt that I should continue to the United States where the scientific spirit was much more dynamic and I was appointed as the chief resident of the University of Minneapolis Hospital.  My financial resources were running very low and I had been helping my mother and brother in Cape Town.  I had cold feet.  I did not know how I would survive in the unknown United States and I chose the easier way out by returning to Cape Town with Aileen and the 3 children. 

Birmingham crystallized my future career.  I had seen much clinical material, had been exposed to the most advanced open heart surgery and taught the bases of clinical measurement, research and writing.  My inquiring mind had been sharpened and I met the leaders of research.  It was a wonderful apprenticeship.                                   




The Return to South Africa


The Return to South Africa

Returning home

I had completed four years of intensive training in England and my savings were depleted. The research for my MD thesis was complete and the documents carefully prepared and bound  and I had to present myself for the oral examination in Cape Town. I had been elected as the Senior Resident in Medicine at the University of Minnesota Medical Centre with a valid license to practice in Minnesota but the coffers were empty and I was afraid to take my family to this brand-new unknown space.

Val Schrire had a vacant appointment available for a senior registrar at Groote Schuur Hospital and I returned home to Cape Town to fill the position.  I did so with mixed feelings since I was a little disappointed in not travelling to Minneapolis. 

We embarked from Southhampton and this was a complicated adventure.  I drove our yellow Ford Anglia in advance, loaded with our steel cabin trunks to the docks in Southamton and prepared them for shipping and then returned to Birmingham to close the house, and bring Aileen and the children; there were no snags. It was a pleasant October 1964 and the winter cold had not settled on England.

We returned home in the "Pendennis Castle" that was a little more modern than our previous ship, the Athlone Castle. Again we had an inner berth but the weather was good. This time the voyage through the Bay of Biscay was quiet; there were no violent storms and the sea was calm. The 3 children were a little overwhelmed and I was not sure that they understood the magnitude of the change. They enjoyed the fresh sea air on the ship, but Debbie developed diarrhea.

Our family met us in Cape Town.My mother had found us a pleasant apartment in Sea Point: Heylon Court off Arthurs Road. It was a comfortable third floor apartment off the main road in Sea Point. It was very central, a two-minute walk from the main shopping center and two blocks from the beach front and I would take the children to play on the swings and swim at Saunders Rocks Beach.  Our Ford Anglia Car arrived and we were able to travel around and renew old memories. It was good to return to Cape Town and the Cape Peninsula, with its sparkling summer weather and cloudless skies.


 Sea Point is one of the most beautiful places in the world.  The sea is cold so that the summers are cool.  It has a long well developed promenade which runs for several kilometers along the seacoast, interspersed with little inlets of beach.  The seafront has a long array of multi storey apartments and is well developed like Nice or Cannes.  It lies below the backdrop of Table Mountain and Devils Peak and is protected from the powerful southeast winds. 



Groote Schuur Hospital

It did not take long to return and readapt to my old Alma Mater at the University of Cape Town.

I sat for my MD examinations. The research studied 1350 catheterizations of children and infants with congenital heart disease, their follow-up and the correlative anatomy in the patients who had undergone surgery or who had died.     The examiners were surprised by the length of the thesis: 4 volumes of 150 pages each: One volume comprised the text, two were diagrams and pictures of the angiograms and the fourth contained an extensive bibliography.

In January I started to work at Groote Schuur Hospital.  This was the premier teaching hospital in the Cape Province.  Although new buildings had been added, the increase in services and patient volume had long since outgrown the physical structure.  The Cardiac Department was located on the ground floor (A20) and was very cramped and short of space.  I received a desk in the archives room: It was surrounded by shelves filled with brown envelopes containing the files of the catheterization tracings, ECGs and clinical reports of each of the patients. But it was very central and friendly, as the nurses, secretaries and technicians were moving in and out to use the files. Of course there were no windows but I enjoyed the weekend sun in Sea Point, Later I received my own office in the anaesthetics department.  All the physicians' offices were small cubby holes but the catheterization laboratory was of fair size with the latest modern equipment.  It had a Sieman's X-ray System but with automatic exposure control and a 35mm Arriflex Camera System and Closed Circuit Television.  This was in contrast to Birmingham were I had to view the image through a mirror and take several trial exposures determine optimum photographic exposure. 

The style of work was different and the cardiology very professional.  The staff had been trained by Paul Wood, so that the department had an English tradition.  The cardiologists were excellent clinicians, and skilled in history taking and physical examination.  They understood the heart sounds and murmurs and could interrogate the pulse and jugular venous pulsations and were experts on the ECG and interpreting the x-rays.  Wally Beck had trained with Jeremy Swan at the Mayo Clinic and although I had four years of experience in England, he taught me how to catheterize systematically.  He was a little tough since I had "wandered around the heart" randomly for several years and now he taught me how to undertake systematic and organized navigation studies. Vogelpoel, Swanepoel and Nellen, the other three consultants were in private practice and held part-time appointments at the Hospital.  They had researched and written the literature on phonocardiography at the Heart Hospital in London and I inherited their enthusiasm. They were fine human beings who invested much of their time and effort in their hospital activities with a very small financial return. They were totally immersed in Cardiology and were always full of new ideas and willing to share their knowledge. It was a happy family with a great team spirit. They would help each other in the cath lab and the classical dialogue was. "Come on Morris, let me help you with the cut down in the arm", or "Let me help you Louis, turn the catheter clockwise and with a little push it will enter the pulmonary artery".    The patients were hospitalised on the fourth floor wards as part of the "Brock firm" in Internal Medicine and on Wednesday mornings we would do grand rounds with all the attending physicians. I was responsible for presenting the patients and my previous experience was of great value. I was well honed in speaking and running meetings and I think that I contributed greatly in making the rounds succinct, while maintaining depth of thought and dialogue and a little tension and interest in the discussion with good audience participation. Val Schrire and Beck were both in their element with profound thrust and parry and counteracting the conservative approach of the general physicians. The Internal Medicine Grand rounds were held on Thursday afternoons and I always found an interesting patient to arouse enthusiasm in the audience of about 200 staff physicians and private physicians in the city.  The participants were wide awakewith suggestions about diagnosis and treatment.It was an interesting and stimulating learning forum for the residents and junior physicians                                                        

In the late afternoons I would "invade" the adjacent ENT outpatient department after the surgeons had finished their clinics and move in our high frequency Elema Ink Jet Phonocardiogram and bring the patients from the wards or the outpatient departments to undertake the non-invasive studies.  I would examine the peripheral pulse tracings, the jugular venous wave forms and record simultaneous heart sounds and murmurs which confirmed the bedside diagnosis.

I was very busy with the unending clinical program but I found time to read, undertake clinical research and to write and summarise the data.

I was responsible for most of the Hospital ECG reporting and at night would take home a box of about 50 ECGs to keep me busy. 

Val Schrire insisted on teaching me clinical cardiology for a second time. He realized that I was a good scientist, but lacked sharp clinical skills.  I would spend Fridays with him in his busy outpatient clinic.  Apart from 30 regular outpatients, another 10 patients would arrive by train from Port Elizabeth in the Eastern Cape for a second opinion.  The patients undertook this 8 hour overnight journey and would arrive in Cape Town on the 6 a.m. train, transferred to the hospital by a mini bus, and then find themselves in the cardiac clinic in in the bowels of the teaching hospital.  Val would take their history, examine every patient meticulously, record the ECG and then screen their hearts on a fluoroscopic screen.  This often frightened the patients; the dapper, gray haired professor with owl eyes would appear with red glasses, take them into a dark room and then start to turn them around into the different oblique positions to diagnose cardiac chamber enlargement. He would dictate continuously on his tape recorder and his overworked secretary would run backwards and forwards to type the letters. Every patient would have a full letter, hand drawn diagrams of the physical findings and screening, a precise diagnosis and details of management.  In addition, he made a copy of every report which he bound into books and kept a card file index with all the diagnoses. He passed a knitting needle through the card file and lifted out the cards according to their diagnostic categories.  He antedated the Hollerith cards which we used for the first computers.  All the clinical material was documented and retrievable. At the end of the clinic, patients who needed further investigation were hospitalized; the others were returned home on the Friday night train. There was no time for frivolous conversation and although our dialogue was intense it was confined to diagnosis, differential diagnosis and management.

Val was meticulous and would have me examine every patient and record my findings as a diagram on a sheet of paper.  I was soon an expert on the split second sound and the opening snap.

The most important activity of the department was the daily catheterization conference in the late afternoons.  We would meet in the X-ray room around a multichannel Screen. I would present the clinical details of the patient and then the catheterizing physician would present the pressures, flows and angiograms and we would discuss the minute details of the pressure wave forms and other information.  Everything was analyzed in detail and diagnosis was very accurate.  Once a week we had a surgical meeting with the cardiac surgeons where we again discussed and analyzed the details of the patients.  There were many differences of opinion but the final conclusions were a team effort.

The clinical material was extraordinary.  We received patients from the entire Cape Province and we were the sole tertiary cardiac reference center. There were unlimited patients with congenital and rheumatic heart disease and Chris Barnard, a very adept surgeon  understood the intricacies of the anatomy and physiology of congenital heart disease. 


We had many enthusiastic medical students and I immersed myself in the bedside teaching programs and would devote a much of my time teaching them cardiology and internal medicine. 

Cardiology was a fast developing and innovative speciality.  The transvenous artificial pacemaker was now established treatment and I undertook the first implantations in Cape Town. The system was imperfect.  The electrodes would bend and cause insulation failure.  Body fluids would penetrate the battery casing, and damage the electronics and the mercury batteries had a short life span of less than a year.  I spent every Sunday morning in the catheter lab replacing defective units. Val Schrire was a skeptic and felt that pacemaker implantation was a lost cause so that I found myself  running the entire service by myself,an exciting new learning experience.

It was clear that simple ventricular pacing was inadequate when the patients conducted some of their own beats and there was competition with the pacemaker. We tried to develop the first radiofrequency demand pacemaker and I worked with Barnard's assistant Dr Bosman and an electronic engineer Mr Astrinski who prepared the material for a Ph.D, thesis. He was the human guinea pig and only towards the end of the studies we discovered that he had right bundle branch block and the pacemakers occasionally failed to sense his heart beat. 

The DC defibrillator arrived and we received the Lown American Optical Model.  It was another unusual and exciting new experience to convert patients with atrial fibrillation to sinus rhythm with an electrical shock to the chest.  I needed an anesthetist to sedate the patient for the procedure so that when I was monitoring the surgical patients during Chris Barnard's open heart surgery operations, I would be accompanied by the anesthetist and perform the procedure in the induction room ante theater to the operation room. 

Chris Barnard insisted on having a cardiologist present at every operation and twice a week I would spend the morning in the operating room.  Again, it was a great learning experience of pathology and cardiac physiology, but a little time consuming.

The epidemic of coronary artery disease and its management in specialised intensive care units was evolving.  The large sedentary population smoked heavily and  had high blood lipid concentrations.  The Malay population and many of the Colored people had familial hyper cholesterolemia and coronary artery disease and heart attacks were very prevalent. 

We had always managed acute myocardial infarction conservatively with bed rest and treated it like the "3rd stage of labor" by watchful expectancy in the general medical wards. Day in Kansas City and Bernie Lown in Boston had developed the first intensive coronary care units.  The patients were segregated in a special intensive care ward with a higher standard of nursing, and monitored by the newly developed cathode ray storage oscillographic tubes which allowed persistence of the ECG on the screen.  Most patients died suddenly of ventricular fibrillation or complete heart block.  Both arrhythmias were now treatable, either by a direct shock to the chest or the implantation of a temporary pacemaker. 

Dr. Burger the Hospital Director and Prof. Brock the head of the department of medicine took sabbatical leave and Reeve Sanders, the deputy director, listened to my suggestions to open a new coronary intensive care unit..  She gave me permission to convert the library at the end of the medical ward into an intensive care unit, and use the immediately adjacent office of Prof. Brock as a bedroom for the physician at night.   We brought in 4 beds from the ward and set up an improvised monitoring system We placed the American Optical cardioverter in one corner next to the nurses desk and wired a plug net to each patient and connected it to the new communal monitor with a four way switch. Every 15 minutes we switched and monitored each of the patients on the single shared monitor cardioverter. 

The continuous ECG monitoring opened our eyes.  We suddenly realized how frequently arrhythmias occurred after acute myocardial infarction, and learned Lown's new dictum that ventricular premature beats were harbingers of ventricular fibrillation and could be suppressed by intravenous Lidocaine.  Ventricular fibrillation in the intensive coronary care ward nearly disappeared overnight.  We also learned and understood the basis of electrical conduction disturbances and the different forms of heart block. We learned that in inferior infarctions it passed through phases of first and second degree block before the complete block appeared.  Atropine and a temporary pacemaker could prevent these problems. 

Two of our first patients developed psychological problems from over enthusiastic intensive care and sometimes unnecessary meddling in their treatment.  The pendulum soon swung in the opposite direction and our treatment became more rational.  We published our initial results:  mortality before intensive care was 34% and had now decreased to a startling 14% with care. 

Prof. Brock returned after 6 months sabbatical leave.  He was an elegant, tall Oxford trained physician and instead of exploding, which I had expected, he said quietly "my office has a lived-in look."

The concept of the coronary intensive care unit had been proven.  We moved the library to another room, acquired new equipment with individual monitors for the patients and even closed-in the adjacent verandah to add another two beds.  The greatest tribute was when Prof Brock, himself was hospitalized with an episode of atrial fibrillation. 

The intensive care unit was one of my major contributions to the hospital. 

I was a very "eager beaver" in the cardiac departmentand found time to put together and analyse the clinical material and publish and present the data.  Val Schrire was meticulous in his record keeping and kept all the surgical data on large charts, very much like the modern Excel Charts on the computer.  The data was readily available and I studied the changes in chest x-ray before and after the different surgical operations of mitral or aortic valve replacement. Schrire also recalled all the patients for a control cardiac catheterization one year after the operation, so that I was able to study the outcomes after repair of a ventricular septal defect and also Fallot's Tetralogy.  This was a very interesting continuation of my work in Birmingham as I could study the response of pulmonary hypertension and the different methods of right ventricular outflow tract reconstruction.  I looked at residual obstruction, different kinds of patch insertion to enlarge the right ventricular outflow tract and the presence and degree of pulmonary incompetence.  The paper was accepted for publication in  "Circulation".  This was probably the best paper I have written and since has been confirmed by the current studies with MRI. 

Schrire was very supportive of publications and the department was geared to writing papers.  Sylvia and Bill Piller, two of our technicians, prepared all my pictures, slides and diagrams.  We would draw them on waxed, semitransparent paper and use preformed stencils for lettering.  Eventually, we moved into colored slides and filled the histograms and pie diagrams with cutouts of colored paper.  Today, this is done in a simple Power Point presentation.

Val Shrire encouraged me to present the research data at the local medical congresses.  The first congress was in Port Elizabeth as part of the South African Medical Congress and I prepared papers from the results of a series of patients who had undergone cardioversion for atrial fibrillation and another group in whom we had implanted pacemakers.  I flew to Port Elizabeth in a 2 engined  Dakota "Skymaster".  This was my maiden flight.  We flew along the southern coast of South Africa over the Garden Route and beyond the Port Elizabeth docks. It then made a sharp 180 degree turn over the port in a strong southeasterly wind.  The "Skymaster" had long vertical windows so that one could see the sea below and the roll and yaw as we entered Port Elizabeth. It was an unbelievable end to the flight.  I thought I was leaving my heart in the sea.  I recovered the next day and the lectures were well received. 

I also found time for invasive research. I had become proficient in catheterizing neonates. It is possible to transect the umbilical cord which has a patent but constricted umbilical vein and artery for the first week after birth. A catheter is then passed through the umbilical vein which in the foetus returns the blood from the placenta to the baby. The catheter passes through the ductus venosus into the inferior vena cave and then to the right atrium. It can then be passed into the right ventricle and pulmonary artery and via the patent ductus arteriosus into the descending aorta. If it is withdrawn back into the right atrium it can be passed through the patent foramen ovale into the left atrium and then through the mitral valve into the left ventricle. We had a large population of premature obstetric deliveries and the children were born with immature lungs which developed hyaline membrane disease with severe respiratory failure. Boet Heese, the new Professor of Paediatrics. had established an intensive care unit to treat the low birth weight premature babies and we were ventilating them with artificial ventilation on the Bird Ventilator and using the umbilical artery to measure the arterial and mixed venous oxygen saturations and partial pressure of oxygen. This was an exciting research opportunity to study the pulmonary circulation and pulmonary fuction and observe, that because of prematurity, and the low oxygen PO2, ductal closure was delayed and a large shunt flooded the lungs, and caused severe heart failure with death. I devoted many nights to studying these premies, but when I started to analyse and prepare the data for publication, the paediatricians decided that the data was their property and despite my long vigils and careful monitoring I had no priority to the data. Val Schrire was very upset and recommended that I turn my attention to other research. It took a long time for my pediatric colleagues to analyse the data and I had already left for Durban before the publications appeared and of course my name was dropped from this research. The paediatricians lost from this little interpersonal "tiffle".

Christian Barnard was an interesting, enthusiastic and exciting person. He came from Beaufort West, a small town in the arid, Karroo semi desert, one of the important sheep raising areas in the Cape Province.  His father was an Afrikaans pastor and he was educated in the local country school. He had studied medicine in Cape Town and then started to specialize in internal medicine before he continued in cardio-thoracic surgery.  He spoke English with a strong Afrikaans accent and used all the local South African English idioms. He was a highly intelligent, but restless and impatient person. He had had excellent training with Wangesteen and Lillehei in Minneapolis which was the center of open heart cardiac surgery in the United States.  The results of surgery in rheumatic heart disease were good and  apart from closed mitral valvulotomies, we started to repair the valve by suturing a buffering pledget of Dacron to support the posterior leaflet of the mitral valve. I nicknamed it the "cigarette operation."   These procedures had good initial results but failed later because of continuing rheumatic activity in the valve. 

Chris Barnard invented and introduced his own valve.  It was made by his wife in a simple homemade factory.  Unfortunately, it was thrombogenic and the patients developed clots and sent minor emboli to the brain.  This caused small strokes with gradual mental deterioration and it was sad to see how mental status and cognitive function could change in highly intelligent patients.  His lack of success with the valve caused deep interpersonal conflicts in the department.   He was fortunate to have Rodney Hewitson, another experienced thoracic surgeon as an assistant.  Rodney was a fine and expert but phlegmatic thoracic surgeon, and he would open and close the chests of the patients and even take over the operation when Barnard became too excited or bored.

I had a good symbiosis with Barnard.                                      The open heart surgery equipment in the operating room was very simple as we had a very limited budget.  We had a gravity controlled venous outflow cannula to drain the vena cavae into a large open drum which acted as the oxygenator and then the blood would be filtered through a homemade system to remove oxygen bubbles and then the blood was  returned to the femoral artery  through a   simple Sigma finger Pump.  The heat exchanger was also simple.  We had no budget for disposable equipment and would scrub and wash the components of the system after each procedure.  This was in strong contrast to our modern systems which are totally disposable.  I also had two sessions a week at the Children's Hospital with a different anesthetic and postoperative team. Terry O'Donovan joined us from Johannesburg. He was a brilliant surgeon but some years later left for New Orleans where he established a reputation as a vascular surgeon.  Barnard was an expert in the surgery of congenital heart disease, the surgical treatment was meticulous and we had very good operative results.   

Barnard became bored with cardiac surgery and went back to Minneapolis to learn vascular surgery but was too impatient to make the meticulous vascular anastomoses.  He then decided to learn how to undertake renal transplantation and went to join Richard Lower at the Medical College of Virginia in Richmond where they were also doing experimental heart transplantation.  He returned and after a preliminary series of renal transplantations became bored and tired as the operation consisted of two vascular anastomoses and reconnection of the ureter. 

His restless mind was focused on heart transplantation. He returned to the laboratory and performed a number of successful animal transplants and was ready for his first human patients.  I had a patient, Mr. Louis Washkanski who was diabetic, had undergone several major heart attacks and was referred for assessment and pacemaker implantation.  Barnard chose him as the first recipient and in November 1967 we had a suitable brain dead donor Denise Darvall and undertook the first successful human heart transplant.  Washkanski developed a chest infection and died 2 weeks later with a large lung abscess.  I remember sitting with Barnard in the post mortem room, and he broke down and wept.

The press swooped down on Groote Schuur Hospital like eagles on their prey.  We had no concept of television and publicity and the American and British channels appeared from nowhere.  Barnard was unprepared for this sudden invasion, he had no concept of public relations and gave as many interviews as needed.  Overnight, he became a world famous surgeon with articles in Time and Life magazines.  Washkanski's death was a tragedy but instead of resting on his laurels, or backing down, he moved on to a second and then a third transplant. 

The basic problems became apparent: defining the moment of death in the donor, preserving the donor heart, the precise method of surgery, immunological incompatibility, a good immunosuppressive regime, and avoiding superimposed infections in a immunosuppressed patient.  The Government was very proud of this homeborn Afrikaner whose father was a Protestant Minister in Beaufort West, a small town in the semi-desert of the Little Karoo.  They poured money into the department.  The Chamber of Mines gave an immediate donation of one million rand and work was started on a new research building.

Living in Cape Town

My social life expanded.  Our apartment was a little small and one of my patients, a builder had an empty house on the High Level Road in Sea Point.  He was waiting for approval to build a high rise block of apartments.  He renovated the bathroom and kitchen and we moved into this classical, large gabled, South African house.  It had a pleasant back garden for the children and Bernadine started attending a small kindergarten.  Eugene was born at Groote Schuur Hospital and had his own bedroom.  Traveling was a little difficult as I had to drive through the city center to the hospital and I devised many alternative routes to bypass the 7 o'clock traffic jams in the morning.  Returning in the late evening was much easier.  I returned to my old friends.  I spent one to two days a week at the Children's Hospital and renewed my friendship with my old friends, Vincent Harrison and Ivan Nurick.  Sunday was the day off, and we took the children to the beachfront or for drives along the coast.  Aileen was an excellent mother and the children had a warm and happy childhood.

I needed my own house, but our financial resources were very limited. Rondebosch, an up-ended suburb near the hospital and the University, had a golden mile where the more privileged upper class whites lived. and we found a cheap new house at the poorer end of the road.  We moved to Kromboom road.  The house was a single storied detached villa with three bedrooms, a large living room, extensive grounds and a built-in garage .  It was close to both hospitals along two major highways, so that traveling times were short, and it was easy to pop in at night for emergencies.    The children grew and developed and we had a comfortable family life.  They had their pets: a dog, hamsters, and we spoiled them with toys.         

I was still restless, since I was now number three in the department and Val Schrire made it clear that Wally Beck was his natural successor.  I applied for an  appointment to head cardiology at a new department at Monash University in Melboure, Australia. They invited me for an interview.  The flight from Johannesburg to Perth took 26 hours in a 4-engine propeller jet Dakota with stops at Mauritius and the Cocos Island Archipeligo.  When we arrived I could not shake off the smell of paraffin from the galleys and it was a wonderful escape to emerge from the plane from the small Cocos Island atoll.  They had built a refueling airstrip in the middle of the ocean.

From Perth I took the Ansa Airline to Melbourne and was met by a welcoming committee.  The interviews were quite hard.  Who is this 30-year-old "squirt" who wanted to be the first professor in the new university of Monash in Melbourne.  The hospital was impressive but the older cardiologists seem to feel that I was going to be their "boy".  I looked for housing:  they were built of wood and the prices far beyond my pocket.  I was appointed to the post, and returned home.  I felt unsure about emigrating once again to the Antipodes, far from Europe and the United States.  I tried to gain support from Schrire but he refused to give advice.  Again, I was unwilling to relocate the family, and I turned down the offer.  Monash University was a little angry as they had paid my fare.  They appointed the local man who since, built a great department. 

Now Schrire made it clear that I had made a mistake and I applied for another chair in Leiden. 

The University of Natal in Durban had created a new department of cardiothoracic surgery in Durban and Ben le Roux, the professor wanted a dynamic new head of cardiology.  After much discussion, I was appointed and we took a short holiday to explore Durban.  I had never been there before, the Hospital was unusual. Dennis Gibbs' had worked at Wentworth Hospital and since I was coming, moved to Pietermaritzberg as departmental head.  I rented his house.

We returned home in time for the first transplant, but we were packing our bags and preparing for the move to Durban.

Cape Town had been a fulfilling experience. I had become a compleat cardiologist; I had learnt a new approach to clinical cardiology which would serve as a basis for the rest of my life and become the cornerstone of my future teaching career. I had learned to formulate research, undertake the projects, assemble and analyse the data and to write. I had polished my oratory and could speak and present my thoughts clearly without prompting and I had gained new confidence as a writer.

I was now ready to become Head of a Department.