Interviewer:This is the fifth of August, 1997, and weíre here today, at Guyís Hospital, on behalf of the International Society of Nephrology through its video legacy program and the Commission for the History of Nephrology to talk with Sir Douglas Black.
Douglas, would you like to tell us a bit about yourself and how you came about to take up medicine? When you were born, for instance.
DB: Itís a terrible temptation to talk about oneself, but Iíll try to do it. I was born in 1913 in Chatton of all places, not here in Chattledon. I was in an area east Fifer or Lancerspan, and I spent most of my youth in Kinermule and Arington, which is near Forefrum, and then I was at St. Thames University, which was the adjacent one. I was one of the sons of Demant, which caused so much trouble in the world.
Interviewer: But for our international audience, all of these places are in Scotland, of course? Youíre really a Scot to the backbone.
DB: Yes. Theyíre all in east of Scotland. It was all one part. Less romantic but more down to earth.
Interviewer: Than the west.
Interviewer: And so you grew up there, and you went to medical school in St. Andrews. I noticed that you went at a very early age. You were only sixteen.
Interviewer: Seventeen. That was the custom then, was it?
DB: Yes, as soon as you got to convocation you went to go in, there was no wasting about.
Interviewer: What was the medical course like in St. Andrews in 1929? A long way, perhaps, from what we have today?
DB: Well it was very much lecture bits. We had very many lectures, probably too many, and we also had nothing very much in the line of visual aids, or as I sometimes in more cynical moments call them, visual hindrances, because they invariably not work. And we were fortunate it was a rather small medical school, I think there were only about thirty of us. This meant that we get to know our teachers very well, and, perhaps to a less great advantage, they got to know us very well, so there was much more in the way of personal element than you get now, certainly in the initial years of the course when youíre doing anatomy and physiology. Obviously you get clinical years, as much then as now, much more small group teachings. Itís then that more intimate contacts tend to develop, and you get to know your teachers and they get to know you.
Interviewer: You see that as a crucial element in teaching?
DB: Yes. Again, I have this slightly unethical belief that you learn your medicine from patients, you donít learn it from books, and you donít learn it from people who purport to teach you, but certainly that was a feature of the medical course then. You had very open access to hospitals and wards, and looking back it seems almost frightening by todayís perspective what we were allowed to do with patients, but perhaps thatís something to come back to, but I remember the house physician having to do system punctures, which I donít think many house physicians do now.
Interviewer: In view of what you did later, did you ever do basic biochemistry and hematology and so on, or was that not part of theÖ
DB: Well I did an interpolated year, but this consisted of a rerun of the previous yearís lectures, plus some embryology, but we got a grounding in biochemistry.
Interviewer: They gave you a science degree for that?
DB: Yes, but clinical biochemistry, of course, had hardly been invented. Quite literally there was no such thing as a clinical biochemistry laboratory, and my old boss, Professor Patch would come out in the middle of the night and do blood sugars and blood ureas himself. I donít know how accurately he did them, there was noÖ. You know, quality control hadnít been invented.
Interviewer: But you fell in love with St. Andrews?
DB: Oh, well it would be difficult not to.
Interviewer: Not just the golf?
DB: No, I gave up gold, actually, when I came down to Oxford, because I found that instead of paying 10 shillings a year for golf, youíd pay twice that for a single round, and my salary at that time was 200 pounds a year, non-present.
Interviewer: I have to explain perhaps that 10 shillings in 50 pence.
Interviewer: Should we say 70 cents? So golfís always been cheap for some, in Scotland of course. So you graduated from St. Andrews, and then went on to your clinical post.
DB: Yes, I did house calls. It was almost standard then to do a physician post and a surgical post, and then I did a year in a pathology laboratory, where I began studying the problem of a rise in the blood urea in hemoptemesis. That in a way was my introduction to nephrology. Even then it was more body fluids than it wasÖ You know the kidney was then very much the culprit in that particular syndrome, and not the victim. Or the other way around, the kidney was the victim and not the culprit. Of course, so much happens in that line, I mean the whole acute renal failure, I suppose, is that story.
Interviewer: Was this studies in humans or animals or both.
DB: These were primarily studies in humans, seeing what circulation was like after sever hemoptemesis, and seeing what kidney function was like by the clearance stats which were relatively newly introduced at that time, but were, of course, going to play a big part later on. And we also got into torsion and things like that later on. Thatís a big element. Very characteristically, we met the problem when it seemed very simple, and by the time we finished with it, we made it very complicated. The secret of academic success.
Interviewer: The secret of academic success Ė thatís a very cynical view.
DB: One of my bosses and a cheerful cynic said ďIíve never lost a good problem by solving it.Ē
Interviewer: Yes, of course, Homer Smith had only polished the clearance concept a few years before you were doing these studies, so you were measuring creatinines and ureas at that time?
DB: We werenít doing creatinine. It was inulin clearance.
Interviewer: Oh, you were doing real Rolls-Royce inulin clearance?
DB: It was a hard way, you know, because inulin wasnít as easy to measure, then as it is now.
Interviewer: No, god no. To boil it up for one thing.
DB: Practically no one does inulin clearance any more.
Interviewer: Well itís polyfructose, almost entirelyÖ
DB: EZTH and so onÖ
Interviewer: No I think inulin clearances are still the gold standard, but in the form of polyfructose, because I well remember having to boil inulin to get it into solution, and these crystals would keepÖ I guess you had that. It was a very impure product at that time.
DB: And again, if we are still talking about the romantic days of biochemical nephrology, then, there were no flame photometers that did both sodium and cobalt and iodide, I think, method, and potassium had another awful method that you had to do.
Interviewer: You did measure sodium, though, and not chloride? Because a lot of people were measuring chloride. Thatís interesting, because you were ahead of the field, I think, at that time to some extent.
DB: Well we had to write papers and did what they told us to do.
Interviewer: Yes, gravimetric methods for doing electrolytes would certainly slow down renal units these days.
DB: It gave you more time to think.
Interviewer: So that work sparked an interest that was lifelong, really, in terms of your investigational career into electrolytes and the regulation of body fluids, compartments, and concentrations, which was a hot field at that point, and you went to work with one of the world experts in that at that time.
DB: Yes, that was Arvy McCanst, not difficult to guess to whom you were referring. I think he would have admitted being a world expert.
Interviewer: Well weíve missed out Oxford. You went to Lesley Whits at Oxford.
DB: Well I did the bulk of the hemoptemesis work. I mean I started it earlier, and of course war intervened, all of those things people canít prevent, definitely canít prevent, and that brought in problems of not hemorrhagic shock but bone shock and so on. I got involved in that at the clinical level, really, and we devised a formula for the right amount of calcium replacement for someone whose state of hemoconcentrations for plasma leakage through the skin.
Interviewer: You judge that by the hematocrit?
DB: Yes. It was either hemoglobin or hematocrit. I think we had formulas for both. Also Alkenon was working at the same time on exactly the same kind of problem in Philadelphia, I think. Thatís how I got to know him; we exchanged correspondence.
Interviewer: Did any of these patients actually go into acute renal failure? Established with having acute renal failure, do you remember?
DB: I reckon most of them, but if we got plasma volume up sufficiently we were rather able to prevent that, and in the wartime context, there was another little lesson about the care of acute renal failure. We had on shipboard way out to India, a case of black water fever, which was then relatively common. We learned a way to cure in course; we donít often use it. A way to cure black water fever was to keep them very short of liquids, and so on, instead of trying to burst the kidneys open by forcing the fluids. These were romantic days. I actually saw wet cupping used as a treatment for acute renal failure.
Interviewer: No, we havenít actually come across that yet in this series of videos, but thatís a new one.
DB: When I went to Manchester the department of medicine was just starting with Robert Platt, and we had got one piece of equipment and that was the equipment for wet cupping.
DB: We never used it, it was a waste.
Interviewer: For those who donít know, what was the difference between wet cupping and dry cupping?
DB: Well in both cases you had a glass bell that you placed over the skin, and you heated so that the air would then contract, and exert a tug. Now in dry cupping you were content to let the skin come up under its own steam, whereas in wet cupping you scarified the skin, so that you got some bleeding as well. I suppose weíve lost track of therapeutic bleeding.
Interviewer: Yes, I think many people will be familiar with seeing that in ďThe Madness of King George,Ē in the movie, which was done to George, among many other barbaric 18th century practices. So you finished with the work on hemoptemesis in Oxford, and then you went toÖ
Interviewer: ÖCambridge. Tell us a bit about McCannes, because he was one of the great figures of electrolyte physiology and management in children and in adults. What sort of person was he? I met him, but only when he was very old.
DB: Well, he was someone who was, obviously, very, very bright, and he had imagination to pick up with great skill things that were important and needed to be done, and which were often quite solvable. I find it terribly difficult to talk about McCannes in isolation because his collaboration with Elster WhittlesonÖ
Interviewer: Fortunately still with us?
DB: Yes. Öa perfect example of complementation in scientific endeavor, because Mac provided the flair and imagination, and scintillating communication skills. Elster had great communication skill, but it was no of the scintillating type, whereas Mac could use his imagination to see what needed to be done. He was very good in the conduct of the experiment. He didnít actually like pain, I donít suppose many people do like pain, but, you know, he could get a little testy when things were going wrong, but Elsie was the stabilizing, sort of common sense element, without which no scientific research would be complete.
Interviewer: I can see they look complete.
DB: Yes, they look a bit like that, but he was an inspired chap to work with.
Interviewer: Iíve heard him criticized by several people that in fact he did things to patients, indeed to his colleagues, possibly including yourself, which would certainly now be regarded as unethical, or even rather cruel. You think thatís an unfair criticism, or itís just that times have changed?
DB: Well, I think partly times have changed. I donít think he did anything dangerous, you know, that would be one of my important criteria. I donít think the ritual of informed consent had made much headway by that time.
Interviewer: I know that in Africa, for instance, there is one experiment that comes to mind. He was feeding urea to malnourished children. I remember specifically one of my pediatric colleagues criticized him, and that does seem, perhaps, justifiable criticism. But he did some pretty heavy things on himself and on his colleagues, I believe.
DB: Yes. I think to me, the most exacting things were not acute experiments, but very, very long-term balance experiments that you did. Not on me, but her was very interested in fitate and bread in the war, and heís responsible for adding calcium to bread. And that meant people being on calcium balances for periods of many months, up to a year, and I remember one lady gave up after two months and McCannes said, ďI always thought she was a bad subject.Ē
Interviewer: What experiments were you doing yourself, or being subjected to?
DB: Well, we were interested then in dehydration, which is a bad word, I think. What we were really interested in as water depreciation, because we werenít really dehydrated, thatís for foods. But at that time it was a practical problem. This in a way, illustrates what I was saying about Mac and his way of getting something practical as well as of academic importance. And at that time there were worries, both about people being in lifeboats in the Atlantic after U-boats had sunk ships, and also people in the desert whose tanks had broken down. So it was important in the first case to know whether they should drink seawater, and in the second case, whether they should drink their own urine, both of which things sound rather horrible, both of which things had actually been done before, at that time. And I think in showing that the overall effect in water depreciation was increased concentration of body fluids, we were able to show, well, Iíve got two of my chaptograms, which I think put the thing in a nutshell. With regard to drinking seawater, he pointed out that this was really much stronger in concentration than anything the human kidney could do, and therefore, one would be making things worse, hardly better. And the even more short way of putting the problem of drinking urine was, he said, ďThis is making the kidneys do again, what theyíve already done. There was nothing to be gained by itĒ But the thing I learned, particularly in Cambridge, was the importance of doing oneís own biochemical work. Not necessarily every single estimation that you make, in the course of what may be a long collaborative research, but certainly the necessity to do it sufficiently to know what the snags are in the method, how to look out for discrepancies and so on. No, I had a very good training, which I have since forgotten, of course, in good laboratory technique. Elsie was a harsh mistress in laboratory technique, and Mac knew the important things.
Interviewer: And there were, of course, other people working in electrolytes and the regulation of body fluid at that time and immediately after. You mentioned that Mac quoted Carl Perfrennius, I remember.
DB: Yes, thatís right. He had a tremendous regard for Carl Perfrennius who was a pediatric biochemist in hunger and PAGE-SDS, and he had obviously been thinking among very similar lines to MacCannes, a thing which always endeared people to MacCannes, and to some extent in animals, Carl Perfrennius had worked out the ill effects of water deprivation. And again, Carl Perfreenius and MacCannes, relatively simultaneously, made an important distinction between water depletion and sodium depletion, salt depletion. It both hit him as one, and certainly in this country, in England, this was brought much more to clinical prominence by H.L. Marett, of the Middlesex hospital, who gave lectures where he rather underlined this thing and translated it into clinical terms to an extent that Mac and Carl Perfrreenius hadnít entirely done.
Interviewer: Do you think Marettís nameís been lost?
DB: To some extent, yes. He did a good job in Middlesex. You know sometimes clinicians donít immediately seize on the importance of biochemical and physiological knowledge. Marett was what you might call a good interpreter, sort of author, or something or other. Thereís a good French word for it, vulgarasator. My French accent is such that whenever I spoke in French, theyíd say, ďSpeak English, please. I canít understand it either.Ē
Interviewer: Well one name, which has endured, of course, is Gandallís.
DB: Oh yes.
Interviewer: I think many people know of him and never saw him. Did you ever meet him?
DB: Yes, Iíve met him, not to any great extent, but I met him in Boston at the childrenís hospital there, and again, he was a great pioneer, and he illustrated something, the tremendous contribution that pediatricians have made to nephrology, because there everything happens more quickly, and so more acutely. For instance, a child can lose a quarter body weight in half an hour, as it were. With adults it all happens more slowly, and pediatricians I think have made a tremendous contribution here.
Interviewer: Yes, I remember Jane Metcalffe, who we sadly lost the other year, who himself went into renal failure, talking with great reverence of Gandall. It was interesting, here was this man of seventy, a very distinguished man, who always refer to Gandall as Dr. Gandall, never as anything else. He obviously still had a great deal of respect, forty or fifty years later.
DB: I think the American medicine of course had stronger roots in German medicine than English medicine ever had, and an image of the higher-up professor, for some degree, I mean I saw that phenomenon, itís Full Ferning and Franz Walhart too, splendid nephrologists, but thereís no doubt about it, amseronical, when I speak like Nodog Bach.
Interviewer: He was quite a man. Did you meet Walhart?
DB: Met him very briefly, I took part in medical student rounds in Germany in 1938. It was a rather difficult time between Germany but one good thing was that we visited Franz Walhartís unit, and saw them conduct a wards round.
Interviewer: He was stillÖ because the nazis got rid of him for awhile, and he returned in 1945, I know, to his unit.
DB: In Ď38 he was stillÖ I think he was originally in Holar, but in 1938 heíd moved to Frankfurt and Mein, and he was still very much in control, not a nazi within sight.
Interviewer: Yes, he was a tough cookie, and he went in 1950, but he went out with a bang, literally, in a car crash, at the age of seventy-something. I donít know if he was driving or not, so thatís maybe a warning for both.
DB: He probably was.
Interviewer: So you had a good time with MacCannes, and learnt a greatÖ that was the foundation, really, of your, that was when you flowered.
DB: Yes, yes I think that made me grow up.
Interviewer: You grew up as an investigator. But then the war took an even more partÖ
DB: Yes, I was in the army for í42 to í46, in Poonya in India, and we werenít working directly then on kidneys or body fluids, but on tropical stew, which, again, was a problem of the day, and, again, I have to admit, we didnít solve it, but at least we did discover that there was an electrolyte aspect to it, which would benefit from replacement of sodium. We made a terrible mistake by not appreciating that low plasma potassium might mean something. If weíd appreciated that we might have been along with Dan and Darrow in detecting the clinical importance of potassium depletion, but alas, we didnít. We thought our results were probably wrong.
Interviewer: You picked it up and didnít do anything with it.
DB: No, you never know when you miss something or other things youíll regret.
Interviewer: You were working with Paul Foreman at the time? Yes, and Jim Robertson.
DB: Yes. Jim Robertson was in the same unit, yet. I donít think he was directly involved in the same work, he was doing something on his own, which isnít a very good thing for people to do.
Interviewer: And heís the other person, like Marett, whose name has gotten lost from the history of electrolytes to some extent. I still have a copy of his excellent little book onÖ
DB: On acid base, yes.
Interviewer: Öwhich he wrote when he went back to New Zealand, and itís worth just bringing him in, because I think he hasnít been remembered as he should, perhaps.
DB: Yes, Jim was a very meticulous worker, and a very good expositor. Heíd been through MacCannesí mill too, of course, and married a dietician. Theyíve had, I think, a very distinguished career in Deneiden, but New Zealand isnít the first one picks up.
Interviewer: Do in 1946 you came out of the army, and were wondering where to go, I guess.
DB: Yes, thatís simply right, and I might have applied for a job in Manchester and got it. I think that was a time series and not a causal relationship, and I had 26 happy years in Manchester. Going into Manchester having been to places like St. Andrews, and Oxford, and Cambridge, going into Manchester and Arddrick, and sort of other places on the fringe of medicine, I wondered, ďWhat sort of place am I coming to?Ē
Interviewer: Why did you go there? I mean, I have to ask this. Was it just that you had a job going.
DB: Oh, yes, Iím a primatist through and through, and I wanted a job and took it. Iíd been there about a year, dean of the medical school met me in the corridor, he was a huge, towering figure of a man, and he said, ďWhen are you moving on?Ē I thought this rather an ominous question from a dean. I fell back on the truthful answer, which I sometimes do, and I said, ďI donít know.Ē Turned out it was 26 years. Very happy time there, because again, you know, the first half of that time I remained some kind of investigator, particularly in potassium metabolism, but after that I got into wider pastures like medical education, even, heaven help me, administration of a unit, and wider issues in medicine, but certainly for the first half of it I managed to retain some degree of investigative integrity, looking at what happened with potassium in the body. We did quite a bit of self-experimenting. We had traced it in the muscle by doing arterial and venous punctures, and seeing with isotopes. I recognized fairly early the contribution that physics could make to medical investigation. I got a talented investigator, Bill Emery, to come up from Hammersmith to work with me. He did a lot of tracing of potassium both in the muscles and in the kidneys. We did have a renal vein catheterization that weíd had simultaneous arterial and venous samples, and we satisfied ourselves at least. And I think possibly others, that a first circuit passed through an organ to pretty well all potassium ions to be replaced with other potassium ions, which is very interesting. What we showed, really, was that potassium in the urine had restriction. It was actually the kidneys and the blood. It had already been stored in the kidneys.
Interviewer: So it was using potassium 42?
DB: Potassium 42, yes.
Interviewer: So you, yourself had a renal vein catheter, and a potassium injection of potassium-42, and an arterial sample.
DB: Yes. Simultaneous arterial and venous sample.
Interviewer: I doubt youíd get that past an ethics committee these days.
DB: Those days, two things saved us. One was we didnít ask an ethical committee, and two was there wasnít an ethical committee to ask. But I think the most interesting thing we did with potassium at that time, I did with a dear friend and colleague, Malcolm Moon, who later went to Hammersmith. We made ourselves potassium depleted to a very modest degree, and again we showed that the kind of potassium depletion that you would get in say diabetic coma was something that certainly must have contributed to the clinical picture, but didnít contribute in any initial degree, because certainly that order of potassium depletion didnít make us ill. We were well able to do our work.
Interviewer: Thatís a good criterion to use. How did you make yourself potassium depleted?
DB: We had exchange resin, a column of it, and we put ourselves on a diet of nothing but milk, which Iíve since looked at as being horrible, but we had three liters of milk a day, and we did balance experiments, and found out about potassium excretion in the urine and so on, and then we put milk through sodium resins so the potassium in the milk was replaced virtually entirely by sodium, and after three days of a potassium free diet, our serum potassium went down, and we lost quite a bit of potassium from the body, and we found that the renal methods for conserving potassium were not quite as efficient as its methods for conserving sodium. I mean Stan and I were doing experiments at about the same time. They were his experiments, and I was the willing victim on a rice diet. There we were able to show how very efficient the renal mechanism for conserving sodium was.
Interviewer: At that time, glucocorticoids were just being introduced, about the time you were doing these studies?
DB: Thatís right. I mean aldosterone hadnít been discovered then.
Interviewer: You didnít do yourself work, with giving glucocorticoids, and look at the depletion?
DB: No, we didnít. We werenít into that one.
Interviewer: You also did some work with sodium. I can remember some readings even as a medical student from Black, whom I didnít know from a hole in the ground on salt-wasting in renal failure, for example.
DB: Yes. Of course, Bill did more of that than I did. He was more of a renal physiologist, but certainly IÖ I was a factory of self-torture because at the same time, Al Veron was doing water intoxication.
Interviewer: It sounds sort of like a chorus of masochists, but I suppose itís better than doing it to somebody else.
DB: Robert Platt was eating urea. You reminded me of that by saying Maxís experiment in Uganda, I think it was, and Caroline. Yes, Robert Platt loaded his blood urea up by about 60 or 70, and Charles Demp thought that he was murdering himself.
Interviewer: This was milligrams percent?
DB: Yes, milligrams percent, or course, Iím not into SI units.
Interviewer: No, I just added that for the record. The Americans of course have not changed, so weíll be all right, but the Europeans think of it in millimoles. Tell us a bit about some of these people, I mean Malcolm Milne, for example. Unfortunately, we lost him. He was quite a character, Malcolm.
DB: Malcolm was a great character. I thought that for a long time that Malcolm had no sense of humor until I discovered how deeply buried it was. Malcolm had a magnificent sense of humor when he had done an X-ray excavation, but again, Malcolm was a nephrologist and a scientist of a class to which I would never myself dream of aspiring. Iíve been very happy in other ways, but you know, deep science isnít my thing.
Interviewer: You enjoy working with him as a person?
DB: Oh yes, Malcolm was a great joy to work with, and tremendously conscientious, and tremendously reliable, of course. Thatís the sortÖ
Interviewer: What about Robert Platt? He was partly responsible. He later became Sir Robert and then Lord Platt?
DB: Thatís right. He went up a few rungs.
Interviewer: Well youíve managed to get up the odd rung yourself.
DB: Well yes. Sheer bullyness, sheer bullyness is young ambitionís ladder. Um, no. Robert was generally a splendid all-round clinician. I mean he was a real general clinician, and his nephrology, again, was profound, but he wasnít primarily a research worker. I think that he could interpret research work very well. I suppose in the nephrological world heís best known for his clinical applications of intact nephrons hypothesis that Neal BrickerÖ
Interviewer: Yes, Neal has always been very, very careful to acknowledge Robert.
DB: Thatís what Robert was really good at Ė detecting a clinical syndrome and then finding a biochemical basis for it, but primarily he was just a splendid all-round clinician.
Interviewer: I was saying to you earlier I still have a copy of his book on nephritis, which I bought as a student, and itís an interesting read still. From a clinical point of view, it canít be better. The descriptions are excellent.
DB: Heís splendid himself, and a very, very shrewd man, in all conceivable ways. He was sure to speak up and get it wrong. I mean there was a very famous controversy between Robert Platt and George Pickering on the nature of high blood pressure, because Robert Platt thought that this was genetically determined. Well, they both thought it was genetically determined, but Robert thought is was almost a Mendelian genetic determination, whereas George Pickering thought it was a multi-factorial inheritance, and thereís no doubt about it to me, that scientifically Pickering was right. It was a multi-factorial thing, because Robert, in order to work out the Mendelian tree had to call in that dubious ghost in the machine, lack of penetrance. In other words some people didnít develop what they should have developed. This was lack of penetrance, and not a cause of their basic genes, lying behind it. Thatís an inelegant function.
Interviewer: Varying penetrance still comes up in the literature.
DB: I was saying earlier, John Swills and the memoir series, you know, anatomized that controversy.
Interviewer: The memoir series, I should remind those who donít know, is a series of books that you, yourself contributed to, which is published by a college.
DB: John Swills, I needed say, didnít reproduce the entire writing because they amount to many, many pages of stuff, but what he did was put the whole thing into perspective, which is always a difficult thing to do. Very valuable when people do it.
Interviewer: But for a young investigator like myself, it was like two Goliaths wrestling in the mud.
DB: Well they enjoyed the battle for longer than the spectators did.
Interviewer: Yes, it went on a little too long, I think, in retrospect. But youíve admitted that youíve not always been always right yourself. Once or twice you made some excathedra pronouncements which turned out to be not entirely true.
DB: Well itís just the trouble with journalism in those days. I mean not now. In those days, I mean Robert Fox who was editor of the Lancet used to ask me to write editorials, and when all the diuretics first came in, particularly in form of Dialex and similar things, it acted on the bicarbonate anion they werenít tremendously effective, and people soon got tolerant of them. I said, wisely and profoundly, ďI doubt if these things will ever replace the well-tried mercurial diuretics.Ē Well it must be twenty years since anyone gave a well-tried mercurial diuretic. So I think itís educative.
Interviewer: One other person you mentioned that you met at Manchester was Darcy Thomson, which I was fascinated by, because I have always been fascinated by him as an individual, and Iíve never met him.
DB: He was a real polymath. I met him at St. Thames. He was professor of zoology and Greek, and he, being Darcy, was able to be professor in two places, and did equally well at being professor in Classical Greek or professor of mathematics, because he brought all of those things together in one of the great works of modern zoology, Proof and Form. He brought together the classical layering of Aristotleís Natural Philosophy, and the mathematical form underlying the shape of shells, and itís been one of the most influential books in modern biology. Greatly appreciated, for example, by Peter Medivar back in Provence. Any book that was appreciated by Peter Medivar was some book.
Interviewer: It was an accolade indeed. I first came across his name in one of Medivarís essays. He was a giant of a man, both intellectually, and, I believe, physically.
DB: They were both that, actually, but Darcy was so bigger than life.
Interviewer: Of course another man that you had contact with was Jeff Burleim.
DB: Yes, Jeff polarized the teaching staff of Manchester University into two groups.
Interviewer: You can say anything you like. If Jeff were watching this, he would love it.
DB: Yes. Those who were frightened of Jeff because he knew more than they do, and those, like myself, who made the same recognition, but at the same time was willing to listen at the fountain. And I like Jeff very much. He was often a thorn in my flesh when he became a member of my staff. Of course, Jeffís idea of an ideal ward was one completely full of renal patients, whereas my idea of a ward where one was going to teach medical medicine, because that was in your contract, was one where there was people with peptic ulcer, neurological problems, or something. Not all renal patients have all of them, although many of them have most of them.
Interviewer: Or probably because weíre all arrogant people. During the time you were in Manchester, nephrology as a specialty, one of the later than many other areas halved itself off gradually from general medicine. You were in on that movement. Tell us a bit about the growth of nephrology and the beginnings of the renal association in the UK and the ISN in the world as a whole.
DB: Perhaps a contentious way of putting it, I never mind that, I think that whereas neurologists rushed into their field, nephrologists had to be dragged backwards towards it, because I think nephrologists tried for a very long time to maintain a very high general physician component, in which they were much assisted by having to deal, just in the nature of their work, with hypertension, and with all the many complications of renal disease. So you really couldnít stop being a renal physician with any degree of safety to your patients, which is what really matters, and, well, I saw things happening organizationally. One very stimulating thing, actually, was the origin of the Renal Association in UK. This started, I think, somewhere around 1950, and, well, two things came together for that. There was a trio of enthusiasts, Dr. Sofie who worked in Guyís, where we are having this interview, and Dr. Olsen Ė misprint there Ė Dr. Olsen worked in Guyís, Dr. Sofie was a gynecologist who worked god-knows-where, again, he was a mistaken expert on ecclampsia, but who wasnít a mistaken expert on ecclampsia, if theyíre an expert at all, and Franklin, whoís really a physiologist from Oxford who worked on veins. Well that trio had an enthusiasm for getting a society on renal medicine, and they met, got Woolson involved in it. At that time, he was director of the Sigma foundation, which, at that time, was a very far-seeing organization, which encouraged scientific meetings on an international basis. It was funded by a receiver firm, and I think Gordon Woolson was one of those magic people who make a unique contribution to things by doing what no one else could quite do, and thatís how the renal association started. And of course, itís grown into other things, a European society, International society, and so on.
Interviewer: Were you personally concerned with setting up the renal society? Did you join it? Were you a founding member?
DB: I think if I remember, I was a founding member. I sit rarely on it, at present, and Hugh de Wardener was president just before me, I think. He did one of the best things for the Renal Association. He persuaded Norman Jones to be its secretary, and that induced tremendous efficiency. Hans Freyer, of course, in association.
Interviewer: Did you have any involvement at all with the first meeting of the International Society of Nephrology in 1960 in Evian.
DB: Old men forget. I forget that.
Interviewer: You may not have, because not everyone was. Of course the impetus came very strongly from the United States and France. Iím not sure that the British werenít a little bit side-lined in that. I mean they contributed, but I donít know that we were the leading players, this country, at that point. But one thing you did contribute internationally to nephrology was, of course, your book on renal medicine at the time, when there was nothing but Hugh deWardeners excellent text, but your book was our early bible in lieu of a comprehensive text on nephrology, and that series of essays that you wrote and edited from the 60s onwards was a read landmark in nephrology I think.
DB: Well, thatís nice. I had a bright idea, of course. I realized that if we were to have a proper textbook of Nephrology, the thing was to get a lot of people to write it. Iíd do the editing and translating everything into English, as required. At that time I had a lot of friends in Nephrology, as I hope I might still have, thought Iím getting a bit detached from Nephrology, but Iíd persuaded a lot of good people including McCants, and Norton, and so on. At that time, the first edition, which was somewhere around 1960, I forget the exact date, I did a chapter myself, and I did that in the next two editions. It went to four editions. In the last edition I thought Iíd confine myself to writing a preface because at that time Iíd gone through other postures like the Department of Health and College of Physicians and so on, so I thought Iíd de-competize myself, if Iíd ever really been competent. But I was lucky, I mean I was able to persuade a lot of fine people to write a lot of fine chapters.
Interviewer: It certainly was and is a good book.
DB: And I tried hard to make it interesting.
Interviewer: Yup. Even if you didnít make money from it, you had fun.
DB: I didnít actually make any money from it. I didnít take my own chapter fee; I didnít take any editorís fee. Those were the days of folly.
Interviewer: So gradually you were wrinkled out of being first an investigator, then a clinician by your academic responsibilities.
DB: Stan Pewt had an article in the Lancet which attracted publicity in, I think, the mid-seventies. He talked about the death of a professor of medicine. I remember a charming correspondence saying he wasnít really dead, he was just stumptified by the effect of being a chair. Of course, there was quite a bit in that. George Whickering, I remember, when I was appointed chair, said to me, ďYour job now is to make it possible for other people to do work, and not be able to do any yourself.Ē He was just about right there, in the second part of that. I wonít say much about the first part.
Interviewer: It happened surprisingly early. The old idea of professor of medicine, the doer, has turned into the professor of medicine as administrator and fundraiser.
DB: Itís got a lot more. In the old days people used to come to me and say, ďCould you possibly employ another senior lecturerĒ if I found one. That doesnít, I imagine, happen now. Iím rather out of touch with academic life.
Interviewer: But of course your post-post-Nephrological career has been stellar, as the chief scientist in the Department of Health. You dived into that, what, in 1972, was it, you left your chair?
DB: Yes. Diving is a strong word. I was plucked into it. One canít start exactly there. I got on the Medical Research Council, and that was a factor, of course, in terminating my own personal research, if you have a monthly meeting in Langdon, a good deal of committee work surrounding gets in the way of the bright idea, and I think I demonstrated an ability to listen with tolerance to committee work, and an ability to see at least two sides and often more in question, and that made me a natural when the Rothchild thing came up to be pushed into Department of Health to try and administer this thing. I must explain the Rothchild principle, this idea, that instead of letting the scientist do the research that they thought would be profitable, you would have wise people in a government department who would say what research needed to be done, and then you would call up the scientists and say this is what youíre going to do. And it was, of course, a terribly stupid principle, well exemplified by Richard Nixon, who was, of course, a good man to exemplify stupid principles, because when he successfully got someone on the moon, he said, ďOh well, thatís the moon. Cancer. Weíll put a lot of money into curing cancer.Ē And I think he put billions, not millions into curing cancer, and as far as I can read, the net result of this was to show that doing occult blood tests was not a tremendously 100% way of detecting cancer. And thatís not a great output from billions, you know.
Anyway, I was put in to implement this thing, and luckily in a way, and this is the only time itís been a lucky thing, research funding became very constrained after that, and this meant that the structure would be undirected, which meant might have articulated the demands of the department of health in such a way that DeMarcy could understand what they were became gradually wardened out, and luckily we had a department man named Pat Naren, who met Jim Carrows, and they were honest with one another, understood one another, and Jim Carrows said, ďIs there another way that things can be done?Ē and the thing sort of died away. Unfortunately itís come back again.
Interviewer: It has indeed.
DB: Actually Cochrane, who was a stimulating epidemiologist, wrote a book of reminiscences in what was the course of a similar thing like this.
Interviewer: A Rothchild wasnít he?
DB: Yes, he did that, but he also did one interview with a chap up in Oxford, and in the course of this referred to me, and he said that as chief scientist in the Department of Health, that nice man was thoroughly miscast, and he was dead right, actually. He went on and kindly said that we did an impossible job. What his criteria was for a possible job, I wouldnít know, but anyway.
Interviewer: Well obviously the colleagues didnít think youíd made a total mess of things. And then you moved on to the British Medical Association?
DB: Thatís right. That was a one year stint, but then it was one of those unlooked-for extensions. I became Chairman of the Board of Sciences and Education, so called, for another three year stint, and then Chris Bull took that on, and then Jack Cowl, and I think we managed to do something with the BME funding, and we had some, I think, quite good reports, and things like that, patient health and so on.
Interviewer: Well of course that was one of the things you were associated with in the United Kingdom, most strongly perhaps, which is the Black report, which was perhaps smothered by the government. Perhaps youíd like to talk a little about that whole business, because deprivation health is very much in the news now.
DB: Itís quite interesting in the way things happen by chance, but this thing started in 1977. David Dales, who was then a labor sector state for health, called me in his room and said, you know, is this link, which is already well recognized, between social past, as he called it, and disease, and he said, ďGet some people together, and look at this.Ē So we got people together, notable ones being Peter Townsend, who was a sociologist interested in poverty, and Jerry Morris, who one of the pioneers of epidemiology in this country, and we looked at it for three years, and then we copped out this report. In the meantime, through causes outside our control, the Labor government disappeared, and the Conservative government came in under a rather dynamic lady called Margaret Thatcher, and the last thing they ever wanted to hear about was anything to do with poverty.
Interviewer: Poverty didnít exist. She abolished it.
DB: Society didnít exist. There was no such thing as society, just individuals. Anyway, they didnít, you know, think that this was much of a problem, really, and certainly not one that they wanted to do anything about, so they thought ah well, now, weíll not bother too much about this, weíll print it out in a very unreadable season, and that immediately spared it from page four to page one headlines.
Interviewer: It was published, wasnít it, on the Friday evening before the major summer holiday? Two hundred copies only were printed.
DB: Yes. Two fifty, something like that. Anyway, the trumpets failed to sound, noticeable, and Peter Townsend wasnít having any of this. He managed to organize a press conference, which we had, coincidentally in the College, slightly nervously on my part, but anyway we had it, and of course came. Now I as unsuspicious at that time, I didnít think there was anything about because, of course, Iíve got a kind nature, but five years later the Health Education Council produced a very similar analysis by a girl called Margaret Whitehead, whoís been active in the field ever since, and exactly the same type of thing happened. David Player, who had commissioned this report, he was actually sacked for it, and the director for the thing at that time forbade him to hold a press conference. Again Peter Townsend, so again we had it, but at that occasion I was quite sure there was ministerial pressure, and of course, there are such things as denials which separate. And on this occasion there was a denial of such force that it made one believe that it must be all true, and sure it was to ministers bent on then directors of Health Education Council who sat as medical advisors, and did his best, and once again leapt from page four footnote to banner headlines.
Interviewer: Yes, well, I mean the attempt to smother it completely misfired, because, of course, Penguin Press published it. It sold tens of thousands. It was a best seller, butÖ
DB: Now letís be optimistic. Last year, 1995, two years ago, the Department of Health, I mean, Chief Medical Officers have always been well aware of this problem quietly burrowed away, trying to get it recognized and even acted on, and Donald Atchinson is going to have another mount in this particular chariot with a view to action now, because the will to action is once again being replaced with a change of government, and Kent Carment, the present CMO brought out a report chaired by Chairman Matters, the DCMO last year, which recognized two very important things. One, that there is a real problem and something should be done about it; and two, that it is a very broad-based problem with roots of really societal rather than purely medical. And that puts two things on the line, as it were, and now all thatís changed, but itís a very important change is that weíve got people like the current minister of public health whoís positively anxious to, you know, look at what can practically be done about this, and thatís a see change. You know reports, and reports, and reports do nothing in themselves, but a will to act does things. Itís going to be a very difficult thing to do, because of its multifaceted nature, but itís well worth doing.