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.