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.