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.
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.
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