Durban

Durban

Durban was the big jump in my career. I left a comfortable position in Cape Town to start a new leading role in an unexplored part of South Africa

Durban is in Kwa-Zulu-Natal. On Christmas day in 1497, Vasco da Gama, a Portuguese explorer, first discovered Durban. It was inhabited by several African tribes. There were a few brief visits mainly by shipwrecked sailors, but there was no development until the early 1820's when Britain looked for a port to trade with the local tribes. They were keen to trade mirrors, blankets, beads and tobacco for ivory, horns and hides. The hinterland is rich in iron and coal and a large port was needed to expand the industrial development,

Durban is now the major port on the East Coast of South Africa.  Since it had been settled by the English, this remained the dominant language and it still maintains its colonial heritage.  It has a large African population and also a sizeable Indian population who emigrated from India. 

The weather is hot and tropical with a monsoon climate.  The summers are very hot and humid: in the summer the rain breaks the torrid heat at 4 p.m. with torrential downpours that would then clear 2 hours later.  The winters are mild and almost nonexistent.  We bought good air conditioner to ameliorate the intense humid heat.

The vegetation is subtropical forest, part of the coastal echosystem and scrubland in the drier areas but with thick rich evergreen foliage. 

We left Cape Town at the end of December, 1967.  When I received the appointment, Maurice Nellen, one of the senior cardiologists in Cape Town, made two suggestions:  to buy a new suit and to acquire a Jaguar motor car.  I went to visit my bank manager and he suggested that since I had only 600 pounds left in the bank, that I buy his second hand Ford Zodiac. It was a perfect offer and the car was in excellent condition.  We sent my old car, the yellow Anglia with its cutback window by train to Durban, with our furniture and household belongings and we embarked in the Zodiac on our 2-day journey. We had 4 children, a small dog, and 2 hamsters.  It was a pleasant drive along the Garden route with its thick foliage and magnificent views, past George, Knysna and Port Elizabeth and we overnighted near East London.  We arrived in Durban the following morning.  The children were exhausted but we had a partially furnished house which we had rented from Brian Gibbs' landlady. Brian Gibbs was my predecessor at Wentworth, but when a new younger chief was appointed, he decided to move to Pietermarizberg where he could earn a little more in private practice.

The house was old but spacious with 3 large bedrooms, two large living rooms and a wrap around verandah.  It was located on the top of the Berea, a tall ridge overlooking Durban and the sea.  We had an uninterrupted panoramic view of the beach, the docks, the bay and the Bluff peninsula. It was cooled by a stiff sea breeze in the late afternoons. It had a large garden with a well-kept lawn, an ideal playground for the children. 

We bought some new furniture and were ready for our new adventure.  The car and our personal belongings arrived two days later and we soon felt at home.  The house was located strategically in a pleasant upper middle class neighborhood. The synagogue and the Jewish primary school were around the corner and within walking distance; the bank was close by and next to it, a large shopping center.  After 3 months, I persuaded the landlady, who was living in a senior citizens home to sell us the house. It was an ideal family home and needed only a fresh coat of paint.  The children were enrolled in the nearby parochial, Jewish school, and they were now set on their new educational trajectory.  Aileen was pregnant and Sharon was born a few months later at Addington Hospital. 

The medical school was very different from Cape Town. The students were predominantly non-white, taught by the senior staff of expatriate English professors.  The medical staff dressed in white bush jackets, with white shorts and immaculately polished white shoes and long socks.  They were anti-establishment but typically colonial.  It was a contrast to the universities in Johannesburg and Cape Town, and quite different from the Afrikaans medical schools in Pretoria, Bloemfontein and Stellenbosch.  In South Africa Medical Services and education were the responsibility of the 4 different Provinces, the equivalent of the States in the United States. The Provincial Administration, was controlled by the English white majority although Dr. Willem Botha, the Director of Medical Services was a little distant from the English controlled medical school.  Ben le Roux, the head of thoracic surgery, had already earned his respect and acquired his trust and support and I entered this small circle.  Sam Disler, the Hospital Director, was also Jewish so that we created a friendly and supportive relationship which in part bypassed the medical school. Sam and I soon became close friends. We had a sympathetic ear in the Provincial Administration for the development of the hospital.

Wentworth Hospital had been built as a temporary army hospital during World War II.  It had a large spread out campus on the top of the ridge of the Bluff, south of Durban itself and overlooking the sea and the local airport. It was designed as a series of long Nissen huts that served as individual wards. The single story wards were joined together by interleading open, but covered corridors like verandahs.  After the Second World War, it was converted into an infectious diseases hospital and specialized in treating tuberculosis.  It needed thoracic surgeons to undertake the tuberculosis surgery and then attracted patients with other chest problems.   Later the Administration added closed heart surgery.  When the new, effective antibiotics controlled tuberculosis, the Administration decided to convert the Hospital into a large single regional center with specialized services for the entire Province for cardiothoracic and neurosurgery and later cardiology.    The single floor hospital had the great advantage that it was easy to clean and undertake simple renovations.  The Administration had also planned a new regional obstetric center, but with a little persuasion it was converted into new operating rooms and wards for heart surgery. 

The medical service was planned on the British system where a single regional hospital such as Papworth Hospital near Cambridge servs a large region without reduplication of facilities.  This meant that we were a large reference centre for the entire Province.

Our offices were new, located in a prefabricated building. Ben le Roux, the chief of cardio-thoracic surgery, and I had two adjacent offices which allowed very close personal interaction and cooperation. Our doors were never closed so that there was a continuous professional dialogue. Ben was a fine honest colleague with an open mind, and soon we worked as a closely knit team.

Ben was a perfectionist and absolutely predictable. He would leave home at 6 a.m. in the morning, swim at the nearby Brighton beach off the Bluff peninsula, return to the hospital at 6:40, shower and shave his body, make rounds at 7 and by 8 he was scrubbed and ready in the operating room.  Surgery was never delayed. Nurses, technicians and patients were all ready before he arrived.  He was a master of order and discipline.

His father had been head of Classics at the University of Cape Town and Ben trained at the University of Edinburgh.  He had been the senior registrar at the Royal Infirmary and Andrew Logan, the chief of surgery, who joined us some years later, would tell that if he left patients unoperated on Friday afternoon they would have surgery over the weekend. Ben simply put together a team of on duty nurses and surgeons, completed all the operations and cleared the wards. All the patients had undergone an operation by Monday morning.  He was a natural leader.

He was a quick and expert, cutting, thoracic surgeon, and between major operations would undertake all the bronchoscopies and bronchograms  while the anaesthetists were inducing the next patient.

Initially he was uncomfortable with open heart surgery, and we brought Andrew Coleman to care for the patients. Andrew was a British trained anesthetist, well trained in cardio-respiratory physiology. He took over the heart-lung machine and the physiological monitoring and care of the patients in the operating room and continued with the post-operative care.  This was a great success and the new combination of good cardiology, precise surgery and careful post operative care produced excellent results. Later Ben was joined by Mike Rogers, an experienced cardiac surgeon who had trained with Donald Ross at the National Heart Hospital in London. He introduced coronary artery bypass surgery and homograft valves. They brought young registrars from Edinburgh and Cape Town and trained a new generation of young surgeons. 

The department had several good and established cardiologists.  Bill Winship came from an old Durban family and was very active in the pediatric department at Addington Hospital.  Ronnie van der Horst was in private practice and a little rough, but he had exuberant enthusiasm, golden hands and, with supervision, he was excellent in the cath lab.  He had trained at Cook County Hospital in Chicago, and understood the anatomical intricacies of congenital heart disease.  Our large volume of patients allowed us to put together many large series of unusual malformations.  He worked hard in private practice but we would spend Sunday afternoons together, and while the children played outside in the garden, we prepared and wrote a series of interesting papers.  He also followed, documented and analyzed the data of children who underwent valve replacement surgery.

Gerald Lapinski was the other adult cardiologist.  He was disappointed at not receiving the appointment of Departmental head and left for full time private practice when they opened a catheterization laboratory at St Augustine's private hospital.     I was left alone with the adults except for Tom Armstrong, an enthusiastic and experienced older physician in practice, but with great vitality and he was always ready to learn new tricks. 

The catheter lab was run by Arthur Skowron, a sharp, intelligent physicist, who ran the lab with an iron hand.  When I introduced the new equipment and procedures he felt that he could not maintain the new accelerated pace and retired gently.

Cardiology needed a new look.  I understudied Val Schrire very carefully after I had turned down the appointment in Melbourne and I came to Durban with an exact plan for developing the department: patient care and service, teaching and research.

The wards were repainted and equipped with new physiological monitoring equipment.  Three patients in each ward had ECG monitors with a slave monitor in the nurses' office.  We bought new ECG machines and built a new wing for radiology, a new catheter lab and meeting rooms. There was no budget for new buildings so we simply built an extended prefabricated wing which was cheaper and did not require extensive budget allocations and delays for approval by the Provincial Council.

CGR, Siemans and Philips, the three major X-Ray companies competed for the new X-Ray contract. They asked the Provincial Administation to send me to Europe to learn about their equipment and see their best installations. I spent two months in Paris, Einthoven, Holland and Stockholm visiting their factories and local hospital installations. It was my first visit to the continent. Paris was difficult because of the language, Einthoven and the Dutch Hospitals in Rotterdam, Amsterdam and Leiden were very exciting because Gotsman, the "eager beaver" soon discovered how the machines worked and updated his radiology and I understood the language. The Elema factory in Stockholm and the Karolinska Hospital fascinated me. It was midwinter and I do not remember seeing the sun. The medical language of the hospital was English, but there were three major sections: cardiology for the diagnostics and catheterization, radiology for the angiography and left heart studies, and a pacemaker group who dealt with the arrhythmias. The surgery was excellent. I also spent time at Elema studying their new pacemaker technologies and the large roll film and cut film changers. It was the most intense learning period of my life and I returned home with new knowledge and interesting ideas.

We chose the Phillips system as the company offered us a bi-plane system for the price of a single plane.  Morris Reznick was an outstanding Phillips representative and technician and after studying the competition: CGR, Siemans and Elema I thought that Morris would provide the most effective service. We planned and ordered a Philips biplane room.  It had a 6/9 inch intensifier in the one plane and a 6/41/2 inch intensifier in the second plane.  The larger intensifier provided a large field to cover the entire heart and was suitable for ventriculography, while the smaller one provided more magnification and was ideal for greater resolution for coronary angiography.  The biplane system reduced the number of contrast injections in children with complex congenital heart disease.  Phillips had not succeeded in synchronizing their bi-plane system.  Morris worked in the lab every Sunday until the unit worked effectively and because of his superb ability he ultimately became the South African, national general manager of their radiology division. We worked together to optimize the photography, experimenting with lens apertures of the camera, and varied exposure settings, using different films and development protocols.  Eventually, we had very high quality pictures and I emerged as an expert on image processing and photography.  We bought a new multi channel, NEP photographic recorder for very high frequency registration of the ECG, pressure tracings and phonocardiograms. We introduced new clinical forms for patient records and a complex filing system and had a complete file of all the patients which we archived in our administrative block. 

We had two major out-patient clinics a week.  On Monday morning patients who were referred from all the Provincial Hospitals would arrive by car, bus or ambulance, and we would see up to 60 patient referrals.  Each patient would be evaluated and returned home with a detailed report and suggestions for treatment.  The patients who needed further specialized investigation would be hospitalized and then undergo catheterization and surgery if needed.  We maintained a flexible bed status so that there were always vacant beds. 

We had a similar clinic at King Edward Hospital which was the main teaching hospital.  These clinics demanded great concentration and were physically hard and exhausting. The registrars would see many of the patients but I would examine most of them and consult on the final diagnosis and treatment plan.

Patients who were seen by their private physicians were admitted as needed, although all the services in the hospital were free.  This was the great advantage of the hospital and the full-time physicians including myself received a small fixed salary.  When I started I received the equivalent of $9,000 a year without any extras. 

We set up training programs for the nurses and technicians and within a short time we had a high powered modern establishment. 

In retrospect it is hard to understand how a young, 32 year old physician, only 10 years out of medical school, could undertake such a major responsibility of running this large unit and making important life and death decisions while building the best infrastructure in the country. I am not sure whether it was good fortune or simply intensive training with mature insight, but the department blossomed and I soon received the confidence and backing of my senior staff, the administration and the local medical practitioners.  The hospital had an enormous drainage area of more than 5 million people and we were the sole tertiary reference center for the entire province. The working schedule was exhausting. I would arrive at about 8AM, make a daily round with the registrars and then continue in the cath lab 3 days a week or undertake an outpatient clinic. Often there was a midday ward round to see the new admissions or follow the very sick patients and then continue in my office with the administrative chores. Then another late afternoon round allowing me to settle in my office with a bar of chocolate and coffee to review the latest research data or prepare a paper. The day finished between 6 and 10PM. I knew every patient personally, and Pam Peters, my secretary, would type the reports and deal with the research material and papers. I used a tape recorder and this saved much time.

The main medical problem was acute rheumatic fever. Acute infections of the throat were common because the children were raised in overcrowded homes, often in huts.  Medical services in the country and small villages were sparse and treatment with penicillin often delayed.  The rheumatic fever ravaged and severely damaged the hearts in the young children and adults. This was a common and unfortunate outcome.  We had many sick children with leaking valves, grossly enlarged hearts leading to severe heart failure.  They would be admitted for stabilization and then undergo urgent valve replacement.  The results were dramatic and these large, dilated hearts would shrink and return to normal size.  The metallic artificial valves were thrombogenic and the children needed anticoagulation with Warfarin. This required careful monitoring of their anticoagulant status with regular fortnightly blood tests. Many of the children lived in remote country districts and their poorly educated parents were unable to maintain optimal anticoagulant control.  We were plagued by stuck valves due to clots on, or in, the valves, or bleeding from excessive treatment.  Ben and I had an emergency service to operate on stuck valves, and a child who would present to the hospital with acute, new symptoms at 10 p.m. would undergo immediate surgery and have a new valve implanted, 2 – 3 hours later.  Ben and I were tireless. 

Mike Rogers had learned how to prepare homograft valves in London, so we bought preformed frames and harvested aortic valves from subjects who had been killed in motor car accidents or died after severe trauma. We would then mount the valves in the frame, sterilize the new valve and implant the appropriate sized valve in the patient.  We soon found it difficult to obtain informed consent from the family to harvest the valves from the deceased donors. The Provincial Administration amended the law to simplify the problem.  The donors were dead and we had at least a 12-hour window for harvesting.  It resembled removing a cornea after death. 

The immediate surgical results were excellent.  The valves had good haemodynamics and the patients became symptom free.  Many young women in whom a homograft had been placed, underwent successful pregnancies since we were able to stop the anticoagulants after 6 months.  Unfortunately, the natural repair and renewal process of the implanted prosthetic valve was imperfect, and the cusps either calcified after 4 or 5 years or developed little cracks and fissures and then degenerated.  This was a slow process which lasted several months. When the patients returned with new symptoms we could prepare them gently for a second or even third operation. 

We studied the pathophysiological changes in the patients in great detail and produced a series of publications to describe the natural history of these new diseases; rheumatic heart disease which had been modified by an operation. This included clinical studies, changes in the ECG and X-ray including careful studies of changes in left ventricular volumes and ventricular function. The key question was; was the ventricular function reversible and would it return to normal? The great confounder was recurrent rheumatic fever which often refused to remain dormant despite adequate antibiotic chemoprophylaxis. The large patient cohort formed an unbelievable human laboratory which allowed us to study in detail the dynamic changes in these patients.

Many patients had severe rheumatic mitral stenosis (narrowing of the valve) and we undertook scores of mitral valvulotomies.  Ben was an expert and after 3 years we were joined by Andrew Logan who had retired from the chair of thoracic surgery in Edinburgh.  He was a tall, bald erect man with large hands and a firm stride. The operation would never last more than an hour.  He opened the chest in the fourth intercostal space, pushed the lung backwards, opened the pericardium, placed a purse string suture on the left atrial wall, opened the atrium, passed his index finger gently into the mitral orifice to assess the size and status of the valve.  An assistant would place another purse string suture at the apex of the left ventricle. He opened the ventricular wall, passed a special dilator (Logan or Tubbs) which looked like an inverted scissors, guided it with his finger into the mitral valve orifice, opened the dilator to a predetermined size and separated the fused mitral valve cusps at the commissures.  He would then withdraw the dilator tip into the ventricle, assess the result with his finger and then make a second dilatation if the first one was inadequate.  Once the valve had been opened adequately, he would withdraw the dilator, tie the left ventricular purse string suture and then remove his finger and tie the left atrial incision. Suturing and closing the pericardium and the chest wall took another few minutes and the patient returned to the recovery room.

 I became an expert in making a correct preoperative clinical diagnosis.  This was based on palpation, (slapping apex beat and right ventricular lift), auscultation (close opening snap, mid-diastolic murmur with presystolic accentuation and loud first heart sound).  The ECG showed right axis deviation and left atrial enlargement, and the x-ray a large left atrium and pulmonary venous congestion.  I learned that a calcified valve and even trivial mitral incompetence were contraindications to operation.   We had no echocardiography and rarely made errors in diagnosis.  Patients had routine phonocardiography and we could assess the severity of the valve obstruction. My training in London and later with Val Schrire and the other cardiologists in Cape Town, all of whom had trained with Paul Wood had turned me into an intelligent clinical cardiologist, with sensitive fingers for palpation and carefully tuned ears for precise auscultation. We catheterized many of the patients to confirm the diagnosis. The echocardiogram had not been introduced and I became expert in recognizing patients with calcification of the mitral valve and trivial insufficiency who were unsuitable for a closed valvulotomy.

Again, this experience was a fruitful basis for research particularly the evolution and regression of pulmonary hypertension. We collected and indexed the patients, carefully, comparing all the clinical findings. The ward rounds were slow and thorough and all the young registrars in training became superb clinical cardiologists.

The Province was also an untapped reservoir of children with unoperated congenital heart disease who needed treatment.  We had a large population and investigated the most complex syndromes.  Ben and his colleagues improved their surgery and we soon had excellent results. Ronny van der Horst documented and classified the patients and with my experience from the Children's Hospital in Birmingham we soon recognized the unusual syndromes like congenital mitral stenosis, cor triatriatum and the "scrambled egg syndrome" where the body cannot recognize right and left orientation of the organs and this causes  the most complex cardiac malformations. Our surgery was good and many patients with severe congenital malformations underwent a successful operation and were returned to normal life

Mike Rogers was good at coronary artery bypass surgery which requires careful and accurate microsuturing.  I now became very experienced at coronary angiography and soon we had a large program of coronary bypass surgery. We were joined by Peter Richardson, a cardiologist from Vancouver who had been a Fellow at the Hammersmith Hospital. He introduced us to the transfemoral percutaneous Judkins technique using special preformed catheters and soon we abandoned the more difficult Sones technique.  John Barlow, the senior cardiologist in Johannesburg, initially, was opposed to coronary artery bypass surgery and Chris Barnard inn Cape Town took a long time to adapt to microsurgery. We were the only major unit in the country with this program and soon we were drawing patients from Johannesburg and Pretoria who were outside our Provincial territory. 

The Provincial administration was impressed by our success and national reputation and opened their coffers to provide money for expansion, staff and medical equipment.  We were a modern hospital, with excellent facilities, working in a third world community. 

I now started to attract medical trainees.  They were all excellent and continued their very successful careers. Justin Silver, grew up in Durban and brought with him from Johannesburg two other young doctors       . Denise Kitchiner and Basil Lewis arrived the following year. Basil was quite outstanding.  His father was a successful furniture merchant in Springs.  He was tall and thin and when he finished the army he came to Durban.  He was a fast learner, dexterous in the cath lab and not afraid of hard work.  We would retire to my office in the late afternoons and put together the research results.  I would leave at 10 p.m. and he would work all night, so that the data was on my desk in the morning.  My mind was spinning with questions and new ideas of pathology, physiology and treatment. We worked in academic isolation punctuated by annual trips abroad. 

The next phase was studying the indigenous diseases in the local population.  Congestive cardiomyopathy was endemic and the commonest cause of heart failure.  We set up a program to study the disease in detail and understand the mechanisms of heart failure due to heart muscle disease.  We did not know the cause of the disease: was it a genetic or viral?   Despite years of subsequent study, we are no closer to understanding the etiology of the disease in the African population. Congestive cardiomyopathy was a very interesting and common disease. The patients would develop heart failure in early adult life and after an intercurrent event would develop congestive heart failure. They had a large left ventricle, with the apex beat far beyond its normal limit. They had a palpable early diastolic apical knock corresponding to a loud third sound, often an apical pansystolic murmur due to functional mitral incompetence and altered systolic timed intervals a sign of a failing left ventricle. The ECG showed left ventricular hypertrophy, usually with marked left axis deviation and ventricular conduction disturbances.The chest Xray showed left ventricular enlargement, often left atrial enlargement and pulmonary venous congestion.  The angiogram showed a greatly dilated ventricle with large end-diastolic and end-systolic volumes and a very low ejection fraction. The left ventricular end-diastolic pressure was elevated and all the direct and derived indices showed abnormal systolic and diastolic ventricular function. 

We were able to treat the patients for many years with simple antiheart failure medications.  Progressive cardiac enlargement, increasing mitral incompetence, atrial fibrillation and ventricular ectopic beats, and deep vein thrombosis carried a poor prognosis. 

These patients provided a wealth of material for studying the natural history of left ventricular dysfunction. We studied the clinical syndrome, using external markers such as the chest x-ray, ECG, physical examination and timed intervals and also by cardiac catheterization, and again produced a series of publications on the subject.  We were fascinated by the derived indices of left ventricular pressure changes and measuring ventricular volumes at angiocardiography.  We looked at both diastolic and systolic function of the ventricle.  Arnold Weissler from Detroit had worked on the left ventricular indices and shown that the pre-ejection period was related to the iso-volumic contraction period and was prolonged in left ventricular dysfunction. The left ventricular ejection time was decreased when the stroke volume fell.  This became our standard for assessing left ventricular dysfunction. Once we had established our techniques, we looked at patients with rheumatic valve disease before and after corrective surgery. Basil made the recordings on our three channel Philips hot-stylus recorder, I measured the intervals with a compass and Ray Everson would punch the cards for the university NCR computer. He wrote the software and we had highly significant statistical correlations.  We were very excited by our results.

Later when we presented the data at a meeting in Philadelphia we met the advance guard of the echocardiographers and Basil and I re-routed our trip to Boston to learn the new speciality from Roberta Williams who was then the rising star at the Children's Hospital. It was an easy introduction to a brand new science.

There were other interesting indigenous diseases such as subvalvular left ventricular aneurysms. Syphilis was endemic and many patients were untreated so that the tertiary disease was common causing aortitis and ascending aortic aneurysms.

Tuberculous pericarditis was common and we saw patients in the early stages with large pericardial effusions often with severe tamponade, but when seen later, had developed constrictive pericarditis.  We aspirated the large effusions and decorticated the constrictions at surgery.  These procedures were always accompanied by careful hemodynamic measurements and angiography and we described in detail the clinical findings and special tests. We wrote the literature in this field. One of my registrars was involved in political activity and had to flee the country.  He was working on the pericardial effusions: the data disappeared to England with him and we never published the final paper.  The hemodynamic studies were very sophisticated.  We placed a catheter in the pericardium for aspirating the fluid, a second catheter in the right atrium together with a flow meter and via a transseptal puncture another catheter in the left atrium.  We constructed pressure volume curves of the pericardium together with the associated disturbances in hemodynamics and blood flow at rest and during respiration.  It was possible to show that the compliance of the pericardium depended on the volume of fluid.  Large effusions were associated with very compliant pericardiae and smaller effusions with tense noncompliant pericardium.  Removal of 20% of the effusion, no matter how large it was, would abolish the tamponade. 

The next program was heart transplantation.  Chris Barnard was forging ahead with great success in Cape Town.  We had so many patients dying from heart failure and I was so impressed by the results of transplantation that I was determined to set up a program.  Botha provided us with a sterile suite and we were ready to go.  Ben went to Cape Town to learn the surgical techniques.  Our first patient was Aaron Hlongwane, a 35-year-old Bantu gentleman with intractable heart failure from cardiomyopathy.  We had a suitable donor and opened his chest.  Unfortunately, we were not certain whether the donor had complete brain death. We closed his chest and I felt such a responsibility for the unnecessary thoracotomy that I treated him personally until he passed away two years later.  He became my personal friend and patient.  The next patient was Martin Hands.  He also had severe heart failure after 3 major heart attacks.  The operation was a great success and he survived for a few months until he succumbed from acute rejection.  We continued the program for another year until it became obvious that the then, current immunological program, was inadequate to prevent long term rejection and we would have to wait until cyclosporine was introduced. Mr Myburgh was our next candidate but we could not find a suitable donor.  We had many other potential candidates.  We waited until October, 1969 when we found a donor for Mr. Dan Stoltz.  He had severe coronary heart disease and intractable heart failure.  We had a potential donor from the neuro surgery department but we waited a few days until we were certain that the brain death was irreversible.  Tensions rose in the hospital as Mr. Stoltz had been so ill and we weren't sure that he would survive.  The donor, Mr. Ian Taylor, had a sudden cardiac arrest.  The neurosurgical team unsuccessfully tried to resuscitate him.  Mr Stoltz had already been prepared and the sterile rooms were available.  Team One took Mr. Taylor to one operating room, to  harvest the heart while Team Two prepared Mr. Stoltz; a rapid induction, his chest was opened and he was connected to the heart—lung machine.  Mr. Stoltz's heart was removed and replaced by the new donor heart.  The new heart was weakened by the prolonged resuscitation and the recovery was very slow.  We worked very hard for the next few days but his blood pressure continued to fall and was unable to maintain a good cardiac output and he died.  The family was shattered by the tragedy, then Ben became very despondent.  The publicity penetrated his iron clad exterior, so that the anticlimax after such a long period of waiting deterred him from further procedures.  Heart transplantation had survived its initial wave of enthusiasm, and would need to wait for new effective immunosuppressive drugs.  Today, heart transplantation is one of the best operations we undertake with excellent ten-year survival.

The transplant program in Durban produced a violent debate in the local press and also at the medical school.  Fortunately, Botha, the Director of Medical Services was very supportive; we survived the local criticism and gained a very good medical reputation. 

We also started a pulmonary program but I was so busy with cardiology that I was unable to develop it to the full. 

We were supported by a good pathology department and our pathologist, Annie Kalachurim, was very enthusiastic.  We had a regular Friday clinico-pathological meeting.  She made meticulous post-mortems and was very careful and observant examining the heart.  Unfortunately, she had difficulty writing papers, so that we had very few publications.  Together we learned a great deal about our local diseases, particularly cardiomyopathy.

The big academic event was the annual meeting of the South African cardiac society in Durban. I was determined that it would be an outstanding event in 1972 and we invited a powerful faculty from abroad. My own interest was Paediatric cardiology so that we brought Alex Nadas from Boston, Brian Barrett Boyes, the paediatric surgeon from Green Lane Hospital in Auckland, George Burch, the editor of the American Heart Journal from New Orleans, because of his deep interest in cardiomyopathies, Morrow, the chief of cardiac surgery at the NIH in Washington and the expert on septal ablation in hypertrophic cardiomyopathy. Electrophysiology was a new emerging specialty so we brought two experts from London.

The meeting was held at the medical school and we had a full turn out of all the cardiologists in South Africa.  My department presented 13 papers.  I was run off my feet, managing the Congress, the program, rehearsing our presentations and preparing the slides and looking after the visitors.

Alex Nadas was very impressed with our work and the range of patients we were seeing, and this formed the basis of a long term professional and personal relationship.  George Burch was fascinated by our cardiomyopathies, our studies on pericarditis and our valve surgery.  In later years he would introduce me as the "crazy cardiologist" who put metal valves into children.  Bryan Barrett—Boyes taught us a great deal about cardiac surgery including the use of deep hypothermia reducing body temperature to 12 degrees centigrade so that one could stop the heart and protect the brain for periods of up to one hour.  This permitted correction of complex congenital heart lesions.  The Congress was a great success and we finished with a safari and a visit to the wild animals in the Kruger National Park. 

          

 

The academic progress was a little slow.  We were finishing many research programs and I was a little impatient with delays in publication.  The journals abroad would keep the papers for a year for review, and we cut corners and published many of the articles in the South African Medical Journal.

At this stage it is interesting to stop for a brief interlude and review my journey in Cardiac Pathophysiology. It started in London with the variability of high blood pressure and its influence by sympathetic and parasympathetic stimulation and inhibition.Then I learned about cardiac output and its measurement with Coomasie Blue dye dilution curves.  This needed an understanding of volumes of distribution and exponential decays and their mathematical analysis. 

Simple cardiac catheterization needed an understanding of cardiac hemodynamics. 

In Birmingham I learned how to measure cardiac output at rest and on exercise using the Fick principle, variations in oxygen uptake and then the distribution of regional blood flow.  Ken Donald and John Bishop had been working on this for a few years when I arrived in Birmingham and I joined their research group.  Ken Donald left for Edinburgh and his personal enthusiasm faded a little.  Melville Arnott the head of the department, believed that the lungs and pulmonary circulation were an integral part of heart disease and Peter Harris, the reader, was preparing a monograph on the pulmonary circulation.  I entered the pulmonary physiology research laboratories where we examined every aspect of respiratory function.  I was soon versatile at all the techniques since the laboratory was very well equipped.  With discussion and reading I understood these complicated interrelationships.  I also understood how each machine worked.  I complemented my knowledge by attending the University of Aston in the evenings where I learned electronics, physics and more advanced mathematics. 

I learned statistics in the department.  I carried my slide rule in my pocket and learned how to use the simple mechanical calculator.  All the statistics were calculated long hand and I made long lists of measurements, their squares, their means and finally calculated long hand all the formulae. 

We then studied pulmonary regional ventilation, blood flow and matching, the diffusing capacity of the lung and respiratory mechanics using the body plethysmograph.  I now understood how the lungs reacted in heart disease. 

In the operating room I came to understand blood volume and cardiac function.  The simple changes that occurred when a patient went on or came off cardiopulmonary bypass were related to the amount of bleeding, the priming volume of the machine, and the distribution of fluids and blood between the machine and the patient.  Many patients were dehydrated and fluid depleted and their blood pressure fell when they went on bypass.  At the end of the procedure it was necessary to monitor blood and venous pressure and transfuse the patient to obtain an optimal blood volume, blood pressure and cardiac output.  This could also be modulated by the function of the left ventricle after surgery.  I had recorded miles of tracings and made a careful analysis of these complex interactions.  Today, this part of the basic training of any young cardiac surgeon.  Later, John Kirklin introduced his method of titrating by numbers when the patient was weaned from bypass. 

 My studies with congenital heart disease showed how the heart developed and dilated or remained underdeveloped because of poor flow, and this we interpreted in the chest x-ray and later in the cine angiogram.  The cine angiogram with its fast rate of exposure showed exactly how the heart contracted and I studied right ventricular outflow tract dynamics in Fallot's tetralogy.  It also showed shunts and chamber and vessel enlargement.  I studied poststenotic dilatation of the pulmonary artery in pulmonary stenosis and aortic dilatation in aortic stenosis and incompetence. 

In Cape Town we were very interested in the chest x-ray which showed chamber enlargement or underdevelopment as part of the cardiac pathology.  I also examined heart volumes as a measurement of cardiac enlargement and showed how it changed after a successful repair operation on a valve or congenital abnormality.

When I arrived in Durban I became a free spirit.  I was my own navigator.  I could determine priorities and set my own trajectory.  I was constrained by the University, the Provincial Administration, my colleagues and the patients.  But the University was distant and did not interfere.  The Provincial Administration was located 50 kilometers away in Pietermaritzburg.  My colleagues in the Hospital were very supportive.  Patients received excellent care and although we worked hard there were a few hours a day in the late evening or early morning to pursue my ideas and thoughts.  It was complete academic freedom and I built a cohort of "eager beaver" doctors who shared my ideas and enthusiasm. 

I had a natural inquisitiveness and spirit of enquiry.  We would discuss the new ideas during ward rounds, teaching or clinical meetings. And gradually the brain storming would take form and create questions which needed answers.

New Ideas –the active incubator.

My first overseas trip was to plan purchasing a new catheterization complex and the four major companies covered  my trip at the end of 1968.  My first stop was with CGR, the major French x-ray company. 

Paris was a strange experience.  The cars traveled on the other side of the road, and narrowly missed being hit by a car as I crossed the road.  The hotel was very elegant, but there were no side plates on the table at meals and one ate bread on the bare tablecloth.  The language was impossible. Their radiological equipment looked good, but the external finish not so good. The only comparable unit had been installed in Pretoria.

I visited the local Hospital where Du Bois had performed the first heart transplant and there I met Carpentier for the first time.

My next stop was Einthoven in Holland. I flew to Amsterdam and here I felt at home with the language. They sent an elegant car to pick me up at the Airport with a very comfortable trip to Einthoven.

This was a very professional visit as I had developed their system with Roy Astley in Birmingham. We planned a biplane room but I learnt all the new technical advances in X-ray tubes, image intensifiers, gantries and cameras and spent two days with Buys at their Beta site in Leiden.

The next stop was a few weeks with Elema Schonander in Stockholm.  It was mid-winter.  There was no sunshine.  I commuted between the hotel and the Karolinska Hospital and I can't remember that I visited the city.  There was snow everywhere.  The Karolinska was a very unusual hospital and all their main meetings were conducted in English.  Mannheim was the Director of Radiology.  And the quality of all their work was unusual.  The chest x-rays showed the most minute details of the lung parenchyma and the angiograms were perfect in positioning, timing and quality.  The Karolinska was then the "mecca" of cardiac angriography due to the excellence of the Elema-Schonander roll and cut film changers which could photograph at up to 12 films a minute.  We bought one of their film changers and integrated it into our Phillips angiographic suite. 

The cardiologists worked under Bengt Jonnson, pacemakers with Holmgren and surgery under Viking Bjiork.  Bjiork was a most intense and restless man physically, moving backwards and forwards at the meetings.  I had an opportunity to understudy each of them and come to know at first hand some of the people (Edgar Mannheimer and Ulf Rudhe) who had studied and written the cardiology of congenital  heart disease. At that time the Karolinska Hospital was the European intellectual centre for the research and care of children with congenital heart disease. It was an unusual educational experience.  I came back to Durban with a new infusion of knowledge and a close understanding of angiocrdiography and cardiac radiology.

My next visit was at the end of 1969.  I spent two weeks in London attending the meeting of the British Heart Society and a fortnight with John Goodwin at the Hammersmith Hospital.  It was interesting to meet with him as a colleague rather than a teacher.  He was interested in hypertrophic cardiomyopathy and the different forms of pulmonary hypertension. We soon became close friends. Celia Oakley had returned from the States and was active and voluble. The ward rounds were active and full of active discussions.

I bought the new monographs in cardiology and then continued to the American Heart Association Annual Meeting in Chicago.   This was my maiden trip to the United States.  It was mid-winter and cold, but I was all eyes and ears at the meeting. It was held at the Hilton Hotel in Chicago. I had never seen so many cardiologists bustling in the entrance halls of the hotel.  The lifts were so congested that each entrance on the ground floor had a long queue with its own individual concierge. The most interesting feature was the front row of the lecture theatres with the giants of cardiology: Friedburg, Katz, Langendorf and Pick who were experts at cross examining the lecturers. 

This was the start of a series of medical pilgrimages abroad.  I traveled once a year for six weeks living on budget of $2,000 which was the maximum that the South African Government would allow for overseas travel.  I managed in cheaper hotels and in London stayed at the British Overseas Club. On my later trips I took Basil Lewis with me as we could share accommodation and also saved on the budget. 

I would always attend one of the major American Cardiology Meetings and then chose a series of institutions where I could learn and observe the latest inovations. 

I went to the Cleveland Clinic regularly, to learn and pick up tips from Mason Sones in coronary angiography and Floyd Loop in cardiac surgery.  Mason Sones was a character. He was the first person to develop selective coronary angiography and showed that a cardiologist could inject contrast medium directly into the coronary arteries without damaging the coronary tree. He also had a special relationship with Philips and he had the latest image amplifiers and patient tables so that they could film the patient in different oblique projections. His technicians showed me the finer points of modern photography and film processing. I advanced my knowledge from the rudiments that I had learnt from Roy Astley. Mason Sones worked nonstop, with clean gloves, no mask and a cigarette between his lips.  Basil would blush at his language.  He had perfect eye-brain- finger coordination and it was a pleasure to watch his dexterity. In the evenings we would review the angiograms, discuss the management of patients and then he would phone their referring physician.  His mind and personality were open and he was always willing to share his ideas. Floyd Loop was another genius in the operating room and taught me all about coronary artery surgery. This was a brand new field and I took all the lessons back to Durban. My old friend from Cape Town, John Viljoen, was head of cardiac anesthetics. 

The Mayo Clinic was equally fascinating. On my first visit I thought that Rochester was located near Minneapolis, but it took a 2-hour bus ride to arrive at the Clinic in Rochester.  This was a small town, occupied only by the clinic and IBM Computers and a series of variably priced hotels and motels.  The patient would arrive in the afternoon, see a cardiologist the next morning as an out-patient, undergo all his tests on the same day without any unnecessary delay and then see his physician again, who was free, on the following afternoon.  Within 48 hours he would wrap up the visit.  If he needed in-patient care, catheterization or surgery he would be admitted under the attending physician, undergo a procedure by an expert on duty, and then the three physicians would consult and decide on treatment.  The clinic physicians were chosen because of their ability to work as a team. I would make rounds with the attending physicians, spend time in the cath lab and later in the echo lab and attend the decision making meetings.  It was also an opportunity to sit and read in a very well stocked library. The Departments of Cardiology, Pediatric Cardiology and Cardiac Surgery were very special.  The Mayo clinic was then regarded as the acme of heart disease in the United States, and the focal point of cardiac surgery. It had the most intelligent and forward looking cardiac staff: Jeremy Swan, John Kirklin, Dwight McGoon, du Shane, Wiedman, Burchell and Wood and many others. This was the start of a regular pilgrimage and although many of the staff moved to other centres, we remained close friends.  Jeremy Swan had a grand vision, leadership, wisdom and brilliance. He touched the lives of several generations of cardiologists from all over the world and later put the Cedars-Sinai Division of Cardiology in Los Angeles on the international map.

The Medical School at John Hopkins under Richard Ross also had a galaxy of excellent cardiologists.  It was less well organized than the other units and the emphasis was on research.  The Helen Taussig Cardiac Center was another major center for congenital heart disease and surgery. 

Boston was the center of cardiology in the United States.  Gorlin was Chief of Cardiology and Bernie Lown, the head of the coronary care unit, but my real center of interest was Alex Nadas at the Children's Hospital.   He was the doyen of Pediatric Cardiology and had raised a generation of younger men.  The clinical material was unusual and Robert Gross who had operated on the first ductus arteriosus was the senior surgeon.  We had a very close personal relationship and I would spend at least a week with him every year.  He was a very fine mentor and would pass me on to his younger colleagues. I spent hours in the clinics, cath lab, and operating room and echo facilities. This was interlaced with interesting discussions and I rarely returned to my hotel before 10pm. Normally I would take home the latest cardiological journals and read and summarise the articles and the day's activities until the early hours of the morning. I was an avarice note taker and would revise the ideas several times until they were well digested.

NIH in Washington was also very interesting.  Braunwald had already left for San Diego, but we formed a close relationship with the pathologists: Bill Roberts, the finest cardiac pathologist I have met and Victor Ferrans who was one of the first exponents of the electron microscopy of the heart  and  who was very interested in congestive cardiomyopathy.  Again, they were very interesting young doctors at NIH all of whom have risen to the top of US cardiology. We had acquired an electron microscope in Durban and this was real tutoring by the expert. 

Seattle was a long distance away on the Northwest Coast, but we visited Hal Dodge and Florence Sheehan to discuss the measurement of ventricular function of the angiogram. Hal was quantitating ventricular volumes and function with Sanders and was now pushing the details of the left ventricular ejection fraction. Later in Jerusalem we used Sheehan's techniques of measuring regional ventricular function. Again Hal was open and showed us all his methods, current research and we spent hours of his precious time discussing his new ideas. This was the basis of our later work on myocardial salvage after thrombolysis in acute myocardial infarction. Greg Brown was undertaking his first studies on quantitative coronary angiography and we spent many hours studying his techniques which we later incorporated into our studies.

Dudley Johnson was developing coronary artery bypass surgery using venous grafts at St Lukes Hospital in Milwaukee and we made several pilgrimages to watch him work. He used multiple grafts and coronary endarterectomy and no patient was too ill for surgery. My whole philosophy changed and he insisted on complete revascularization whenever possible.

Jeremy Swan moved from the Mayo Clinic and controlled Cedars-Sinai Hospital in Los Angeles.  He had an expert team investigating acute myocardial infarction.  He had a large SCORE unit and was paving the way to understand the hemodynamics of myocardial infarction. When I arrived at the airport, he sent my old friend, Don Michael who was then one of his young staff members  with a copy of his research protocols for the next three years so that I could understand his thoughts and future research programs. I was astounded at his openness, but he responded simply: my ideas are public property, even though they are unpublished and I would like you to take them forward. He had a superb group of associates

We also visited Richard Popp at Stanford where the surgeons were undertaking the surgery of myocardial aneurysms.  This was an opportunity to study and discuss the practical implications of regional ventricular dysfunction. 

We were having trouble with the pacemakers.  Cordis in Miami and Medtronic in Minneapolis invited us to visit and this was an opportunity to deepen my knowledge of their new units. 

I lectured at all the Centers about our latest research and would spend much time in the cath lab learning their techniques and also in the operating room.   I spent weeks in Houston with Denton Cooley marveling at his ability to correct complex congenital hearts such as total anomalous pulmonary venous drainage and transposition of the great arteries.

The foreign travel was a wonderful, educational experience and kept me up to date with the latest developments.    

Jewish Durban

The Durban Jews formed a fairly unique community.  The first generation had been poor merchants from Eastern Europe who became successful.  Their children were well educated.  Some followed their parents in their large businesses.  They were self employed. Many had entered the professions:  pharmacists, accountants, lawyers and physicians.  Very few worked for companies or other employers:  engineers or teachers.  The Jew had his profession and his money in the bank and was always ready to move. He was an independent spirit.  Latent or overt anti-Semitism made them feel uncertain and they were ready to move at a moment's notice.  Many with young families were migrating to Australia and Canada while those who could acquire a green card moved to the United States.  There were large enclaves (settlements) in New York, Boca Raton, San Diego, Portland and Irvine.  The older parents with established businesses found it more difficult to move because of their very comfortable income.  

The Jews were Friday Night synagogue goers, who usually worked on Saturday unless there was a simcha and a large Kiddush at the synagogue.  Their children went to the Jewish school and most of the families had Jewish circle of friends.  The children would have non extravagant birthday parties and kept and celebrated the holidays at school.  Purim was a great festival and the Pesach tradition was maintained.

The large Silverton Road synagogue became our center of activity, and for the first time I was able to observe Shabbat.  I was my own boss, controlled my time and Shabbat was not dictated by the needs of the hospital.  We simply transferred the academic activities to Friday afternoons.

David Fine was the temporary Rabbi. A genial man with a good training from Telze Yeshiva in Cleveland. A short time later, Abner Weiss arrived as the new rabbi.  He had a dynamic personality, had trained as a teacher in Johannesburg, and come to Durban North as the Reverend and teacher.  The local congregation was very impressed with his drive, knowledge and ability as an organizer and orator, and sent him abroad to Kerem B'Yavne in Israel for 2 years to learn in an advanced yeshiva, and followed this with 2 years at Yeshiva University, where he took his PhD in Jewish Philosophy. His thesis was on the Maharal of Prague.

He was full of verve, running around with his beard and tzitzit flying, and encouraging everyone who could share his enthusiasm.  I had previously joined the "old man's shiur" in Durban where Rabbi Hertz taught Gemarah in Yiddish.

This new wind of intellectual Judaism swept me in its wake and for the first time I could embark on serious Jewish  practice, participation and learning. 

 Abner Weiss established a series of study circles where he taught simple Judaism and Philosophy during the week and on Saturdays had an extensive learning program at the synagogue.  He was also appointed as professor of Hebrew at the University of Natal in Durban and ran a very stimulating program.  His classes were well attended.  He opened a language laboratory based on the American Foreign Service Hebrew Language Program and I would spend a few hours a week in the laboratory. I copied many of the tapes and would replay them in my car as I commuted to and fro from home to the hospital. Unfortunately the language became on oral experience and I was fluent in conversation but never learned to read and write correctly. Later I used my secretaries to overcome this deficiency.   

The community was revitalized by his enthusiasm and it was interesting how a single person could change the community.

There was a weekly Hebrew ulpan where Mr. Zimmerman the local Hebrew School teacher had been teaching the diehards for many years and later, Mr. Fischer, the local Hebrew book seller took his place.  I joined the group. We  mastered the standard textbook, "1000 Words in Hebrew". In addition, Avi Bakst and I had our own personal shiur with the local lecturer in Hebrew at the University.

General Internal Medicine

King Edward VIII Hospital was a large non white regional hospital which was converted into the main teaching hospital.  It was very well kept and provided excellent primary, secondary and tertiary medical care.  It was overpopulated and a little understaffed by a very good dedicated group of care givers. 

I looked after a small 15-bed unit in the main professorial unit, but gradually the residents filled it with patients who had heart failure, high blood pressure and kidney disease.  It was good to be in the main teaching hospital but my time was very limited.  We had a weekly cardiac out patient clinic of about 60 patients every Wednesday afternoon where I would be joined by 2 or 3 of my medical registrars and staff from Wentworth Hospital. The pathology was varied; the patients were sick and complicated but the management was very rewarding.   

Addington Hospital was a large modern hospital on the beach front.  It received white patients who could not afford the private hospitals.  Again, the standards were very high, but I did not have the time to participate in their programs.

The period in Durban was probably the most productive in my life.  I had started with a tiny department, developed one of the best departments in the country and left it in excellent condition.  It was far from the major academic centers in South Africa, but the traveling, constant reading and full time thinking allowed me to provide a high standard of clinical service and the freedom to think, research and write. 

The Winds of Change

I could have continued in Durban much longer, but the political turmoil, the racial inequality and the undercurrents of revolution made me restless and pushed me towards Israel.  My latent Zionism would at last reach fruition.
December 1971 brought the next major change. Ciba -Geigy the major pharmaceutical company in Basle had developed a third generaion Beta Sympathetic blocking drug with minor innate sympthetic action to prevent toxic side effects from overdosing had asked us to study its effects in man in hypertensive patients and the results were very satsfactory. When the study was cmpleted the company inted me to send a monthe in Basle to explain the results to their scientic and Medical staff in Basle, I asked them to permit me to spend part of the period as a Sabattical at Hadassah Hospital in Jerusalem.Hadassah were very generous and offered me a small guest apartment in the Hospital.  I arrived with Craig who was then 7 years old. I used my time carefully, making rounds of the in-patients,teaching the students and residents and interacting with the Medical Staff. I made agood impression on  the Medical ,Surgical and Anaesthetic staff and after two months the Hadassah and Medical school administration set up a Search Commitee to look for a new Head of Cardiology. I was interviewd and then the formal appointment progam started rolling, I returned to Durban and decided to bring Basil Lewis and Avy Bakst with me to Hadassah. The appointment process continued and finally the final the appintment was ratified.
 I left the in July 1973, Dr. Elliot Chesler arrived from Cape Town to take my place.  He was good but did not stay for a long period and after 3-4 years took up a new appointment as Head of Cardiology at the Veterans Administration Hospital in Minneapolis.

Dr. Abdul Mitha, one of my trainees, took over from him.  The "winds of change" removed the white supremacy from South Africa.  The priorities of medical care changed with an emphasis on primary family medicine and less emphasis on specialized medical care.  Cardiology and cardiothoracic surgery were relocated in a new teaching hospital and Wentworth was converted into a primary care facility. The good work continued but the pace and the priorities changed.

I had learned to lead a department, mentor trainees, navigate unknown territories and provide outstanding medical, care, teaching and research and now it was time to move on to undertake new challenges.