ISN VIDEO LEGACY PROJECT

DR. STEWART CAMERON
INTERVIEWED BY DR. ANDY REES


SC:

A place into the second year provided I got the right school qualifications so they offered me that and I went to Guy’s instead of Aberdeen and I suppose my whole life, in every way, would have been completely different probably if I’d come to Aberdeen instead of Guy’s but I had no intention of initially going there but I spent the most of the rest of my life there.

 

AR:

Well you obviously had an interesting undergraduate career there.  What is most interesting for me about that is that you chose to do a BSc now that must have been more than exceptional in that era.

 

SC:

It was unusual but it was a program that had already begun. I think we were…we may have been have been the first year or we may have been the second.  I’m afraid my memory breaks down at this point, but the idea was to allow people who wanted to do it, having qualified with their first preclinical studies to go ahead and take a full degree in some aspect of biology relevant to medicine and then come back in after a year or two into the medical stream.  It obviously was a very intelligent and far-sighted decision on the part of London University to do this, and I decided I would like to apply for this.  I can’t remember now whether we were actually invited to or whether I applied, but obviously you had to be in the top three percent of your year.  For me it was a tremendous, tremendously exciting period because from really having had, up to then, what was an extension of school.  This was a small group of highly motivated and probably highly intelligent people and, we were not only invited, we were forced to think for ourselves.  We were asked questions, we were asked to set the agenda, we were asked to do things we had never been asked before.  In terms of education, it was a turning point and I am eternally grateful that I did take the opportunity.

 

AR:          What happened to the rest of them?  Did they go in academic medicine?

 

SC:        A lot of them did.  ????? was among them of course.

 

AR:          And he was the other one, right?

 

SC:

Yes…with whom I worked with for many years…he became a clinician of course.  I suppose the equivalent today would be...now you’d have to take a PhD.  In fact people nowadays do take PhD’s and return to clinical medicine.  So I suppose the stakes have gone up if you get by with a BSc or, in American terms, a BS, at that time and count yourself as academically qualified.  The course was interesting, I mean, part of it involved radioactivity, which at that time in the mid-fifties was quite exciting and new; how you could use radio isotopes to study biological systems and functions.  It sounds bizarre now, but it was a hot topic and some of the techniques I learned in that BSc course in fact I used in the next decade in actual, new, frontline research.  I did studies on several things, one of them I remember on bone with calcium 47 and it was one of the first papers I gave, I think it was around 1961 or 60. 

 

AR:          So at a very early stage you were committed?

 

SC:

Yes, I came out of that knowing I wanted to go into some aspect of…I hate the term academic medicine, it sounds terribly frosty and ghastly and sort of stuffy.  But medicine in which continuous inquiry is the part of the day-to-day bread and butter.  Every time you see something you say: What does this mean? How did it come about? Can I learn something from this? Can I dissect it out? Can we set up a project to investigate this, it might be fruitful?  And of course, you can only get that within in a teaching hospital and within a sort of, to quote, “academic environment”; so yes, in that sense I knew I wanted to take an academic career.  I wasn’t sure to begin with what a particular area that I wanted to be in.  I’ve still got notebooks that I kept as a student with all the papers I’ve read, which is fascinating to look back on.

 

AR:          With comments?

 

SC:

Yes, I critically reviewed papers and things as a clinical student.  The handwriting is oddly different from my handwriting now.  I was attracted by all sorts of areas.  For instance, as I went through the clinical services I got very attracted, for example, by one time going through neurology and even neural surgery.  Particularly, jumping forward a little, even when I got my higher medical qualification in England; it’s the MRCP.  It’s like taking the boards in the states for internal medicine very, very quickly, within nine months of qualifying for medicine, as one could do in those days.   I suddenly thought to myself since I was doing neurology, would I like to be a neurosurgeon and go on to get surgical qualifications because I love to do things with my hands.  I wave them around a lot as you can see.  I think many nephrologists are surgeons manqué. They have the personalities of surgeons…

 

AR:          The best ones anyways

 

SC:        (chuckles) The best, yes…

 

AR:

So carry on forwards slightly…all of this seems very different from my image of Guy’s in the late fifties.  Even looking back from when I went there back in the early seventies. 

 

SC:

It was a very strange place, Guy’s.  It had been a great teaching school and had seen many, many great people going through it, but it had become marooned.  It was a sort of beached whale in the 1950’s. There were one or two absolutely outstanding people there.  Russell Brock who become known as Brock the cardiothoracic surgeon who pioneered many of the techniques in collaboration with people at Johns Hopkins with whom Guy’s has had and always had and has now still close links.  Apart from his group and one or two others, there was really very little going on at Guy’s.  There was a very strong clinical tradition on the other hand.  The degree of responsibility we had a students was frightening.  We were responsible for the official case notes for example.  The house officers and residents did not write in them; the student wrote the notes.  We did many of the tests, simple tests: blood sugars, proteinurias, quantitative proteinurias, blood pictures… Of course if there was anything unusual it would be referred to someone who knew a bit more about it than we did.  The medical/legal implications of this now are quite terrifying, but of course it gave us a tremendous feeling of being a part of the team.  We related directly to the physician in charge of the patient.  We were almost a parallel.  We were a parallel link.  There was a link through the houseman and the house officer and the resident, and there was the link to the student.  When the boss went around, he didn’t turn to the house officer he turned to the student and said, “Tell me about this patient”.  You had to give all your history and your findings without any reference to notes every round.

 

AR:

Good training.  So, moving on to the more academic side of things, I know you hate the term, but the research training.  John Butterfield, I know, is one of the key early figures there.

 

SC:

I know.  It was a rather odd grant. Of course, famous for relay reaction, occupying a small and personal MRC unit within which John Butterfield came to work in the late 1950s and that was the only academic clinical research that was going on.  Of course, there was research within the medical school departments, particularly pathology and things like that…biochemistry…but the clinical research was basically clinical observation.  It was classical stuff; you looked at cases, you recorded them carefully, you followed them up, and then wrote them up.  But this little MRC unit which was almost totally divorced from the rest of the clinical part of the hospital contained one or two extraordinary people.  One of them was John Butterfield and another was Norman ?Veal who was a physicist, who was the isotope man, who I mentioned a little earlier and had quite a big influence on my early research career because I worked with him and under him looking at the use of isotopes and various systems.  But John Butterfield is person who is responsible and may be responsible for you, where you are. (points to I)  John Butterfield was certainly responsible for me being where I’ve gone to.  He made clinical inquiry seem exciting.  He was an unconventional person.  He carried, for a long time he carried his goods around in a sort of trug, a sort of wicker basket you might use in the garden.  I wouldn’t say he is eccentric, but he was very, very different from the average Guy’s person.  At that time the hospital was run by a handful of people and the consultants, the attending physicians of the American term, came in from their west end practices.  Many of them and black coats and black striped trousers, talked for free, in fact at that time, and went away again.  The hospital was structured in a wholly different way from what it is now.  Surgeons, of course, visited and did operations as well.  But the idea that someone there, who was continuously there inquiring, and working on the patients, whose one role…who didn’t’ have a private practice, who didn’t have a practice outside, they were entirely based within the hospital.  Guy’s was actually forced to appoint clinical chairs, only in the late 1950’s, and John Butterfield was appointed initially as professor of experimental medicine; we didn’t dare appoint him as professor of medicine, but the university actually said to the school they would take away their funding if they did not appoint clinical chairs.  I think the people at Guy’s were afraid that somebody would come and occupy the chair and all the consultants would lose their freedom.  That’s what happened in some schools elsewhere in the country.  So that’s a little bit of ancient history. 

The thing that I remember most about the wards at that time is how different they were.  Some wards, especially intensive care units, are almost like labs.  In those days you went in and there was a wooden floor which creaked with cracks between it, God knows what bacteria growing in it.  There was an open coal fire in the ward, in every ward.  We used to see the patient with the registrar, the resident, and then go off and stand around the fire, leaning on the mantelpiece, and talk about the case.  It had sort of an almost Victorian about it now. 

 

AR:

I remember distinctly when I went there in the early in the early seventies you could still then prescribe whisky or gin or brandy, and what would come up but a bottle of Gordon’s gin, a bottle of Johnny Walker, wonderful before Christmas.  But that tradition is gone I guess.

 

SC:

I guess, at that time in prescribing, again, it sounds pretty medieval, and it was.  Prescription was in the old apothecary’s measure.  There were ?minions and drams and apothecary’s answers.  One thing I might, just jumping back a bit, to get into medical school two obligatory qualifications were that you had to have studied Latin, and have a qualification in school level Latin, and you had to have botany.  Clearly it was an eye on ??Nathalica Pier which was almost entirely vegetable at that time.

 

AR:

Well I’m sure we ought to move on.  That was the archaeology.  One of the things that strikes me is how I can’t conceive how the body of Guy’s physicians regarded these upstarts or these curious beings who were completely from a different world or even had a different culture almost, a different cultural attitude towards…

 

SC:

Yes, it was a different culture.  I was able to move within two worlds.  For instance, the first people I worked for was a physician named Will Mann, who died last year…or was it the year before?  Wonderfully cultured man, he in fact ??? is still one of his standard translations of Hippocrates, being a Greek scholar.  Well, Mann was a good enough Greek scholar to be able to contribute to this field.  He and I had a very interesting relationship over all the years when I started off as his houseman right the way through; I was a consultant myself.  And one could see the best of the Guy’s tradition in somebody like Will.  He appreciated that we were very different people, but I’m not at all sure that he was happy with the way things were going.  One thing, when intensive care units, and we take them for granted now because they only came in the late 1950s, middle sixties really, I suppose the first time that anybody every knew that they needed them was the polio epidemics in the fifties and that again takes one back.  But we were discussing the name for our new medical intensive care unit and eventually it became called ?Starling.  And he said, “I supposed it’s a pretty appropriate” Will Mann said, “after all they’re all heart lung preparations anyway.”  The other suggestion, Lazarus, was put down rather quickly. 

 

AR:          So against this background, what about research training?

 

SC:

Well I went to work in John Butterfield’s lab.  I think the principle difference from now is that there was very much less technical help.  Basically, you were free standing.  As a researcher, you made all your own reagents; you labeled your own things with radioactivity; you set up, made up your own buffers; you did the whole thing yourself.  You couldn’t go out and buy most of the reagents, like you can today, and you didn’t have anyone assisting you, so it was a very, very tough training.  You had to do everything from the ground.  You had a row of chemicals on the shelf, animals (if you chose to work with animals, I’ll come back to that in a minute) sitting in their cages, but you had to do everything yourself and you had to learn how to do it.  Obviously there were people around who knew more about it then you.  But basically experiments took much, much, much longer to do, what I think would be the main difference.  Of course it taught you to think.  I remember the sheer terror with which I started off; I didn’t have any ideas, I didn’t know what I was going to do any research on.

            John Butterfield’s main interest was diabetes, so in fact for three years I spent my time basically working in diabetes.  We studied two things really; one was glucose output from the liver, it was a big controversy, a hot topic, at the time-how much glucose output from the liver contributed to maintaining your blood glucose.  The other was of course the binding of insulin to cells, producing its action.  Of course, we had fantastically this new radio-labeled insulin, so we tried to study insulin receptors.  (laughs)  I mean our experiments were so hopelessly crude.  Clearly, we were studying non-specific binding, but we thought that we were studying receptors.  But those are the two topics that I pursued, broadly speaking.  I was always participating in lots of other…it was marvelous.  One of the things I learned from John Butterfield was to have an informal family atmosphere for the unit.  The units worked best when everyone knows and respects each other as human beings.  There was no hierarchy; everyone uses first names.  There is discipline, but the discipline is self-imposed.  If you can create a huge happy family, you have enormously greater productivity than if you have some sort of machine, and I tried to apply that when I set up my own labs in my own clinical unit.  I think it worked.

 

AR:

It was clearly evident in the early seventies, and it actually was one of the most wonderful things about the early seventies.

 

SC:

Well I learned that from John Butterfield basically.  He was the most original person in many directions.

 

AR:

So how come he sent you or you volunteered or whatever to leave ?Dudley ?Huson, go to the States and learn how to be a nephrologist?

 

SC:

Well I sort of had been interested in the kidney.  Having trained in physiology and taking a degree in physiology, I wanted to apply physiology to medicine.  I could see how in cardiovascular disease at that time the physiologists applied physiology and moved cardiology forward hugely and obviously that step had been taken; I’m in respiratory disease to a larger extent, and I wondered what I could do, and I was vaguely interested in what the kidney did.  I read it in my little notebook from my student days and I got papers on the kidney and one or two papers on glomular permselectivity from people in Belgium.  I sort of got interested in this and I thought: well, here is an area where the physiology has not been applied to the clinical medicine.  I know it made no difference to what I did clinically. (laughs)  But I thought well this is an area that I could apply my physiological knowledge and background, and maybe I should turn to kidney.  So I discussed this with John and John had worked in the States, of course, at the Hopkins, and an old buddy of his, Lovell Becker, because he was nearly six foot nine inches tall, that’s two meters and five centimeters for those who don’t speak inches and feet.  He was called Stretch Becker because he’d been a basketball player naturally.  So I went off in 1962, to become a nephrologist in the unit at Cornell in New York Hospital under Stretch.  But actually I was a fellow of Robert Pitt’s.  I still maintained my contacts with physiology.  Homer Smith had just died when I arrived in New York; Pitts was one of his most outstanding protégés.  A very gloomy man if I have to say, I never saw him smile. 

 

AR:

Clear textbooks of physiology, a small green one as I remember; beautifully written.

 

SC:

I still have my copy and it was beautiful.  He was a very good research worker, almost entirely in animals, however; but he released one or two of his fellowships from the NIH, ????? one of the fellows, to the clinicians so they could do clinical physiological works.  That was exactly what I wanted.  In the meantime, I could pursue the clinical ward rounds; I could learn about transplantation, which was just beginning then with rather disastrous results in 62, we’re talking about now.  Acute hemodialysis and news was just coming through about the fact that you could go on repeating dialysis indefinitely, but that had a big impact yet in New York at least, Seattle and Boston; and of course, studying nephritis, which I rapidly became very interested in.  I realized that the immunology in the clinical aspects of nephrology really fascinated me, so remembering back to the studies on permselectivity and after talking with John Hardwick, who had worked on this with John Squire and John ?Suthill in Burmingham in England and happened to be in New York at that time as well.  I decided to look at permselectivity in nephrotic patients and try and see the measurement of differential protein clearances, whether we could assess glomerular function.  Particularly I was interested as a practical clinician; I was always in bridging the gap between.  I’ve always been somebody with a foot in research and a foot in the clinic.  I’ve always wanted to transfer research to the clinic rather than being purely academic.  It was easy to do that in those days, because the two were closer together; the gap has gotten wider since then.

 

AR:         And what about renal biopsies?

 

SC:

It was clear that to become a nephrologist you had to be able to do renal biopsies.  The previous year the CIBA Foundation held their epic symposium in which all those doing biopsies in the world met at the CIBA Foundation at ?Waltham Place in London and this little red book was the hot new bible.  Biopsies have been around ten years since Klaus ?Brun described it first.

 

AR:          And around in London or not?

 

SC:

Yes, Hugh DeWardener had started doing biopsy.  He was the only person really sensible doing much nephrology in London at that time.  I mean, there were other people doing dialysis.  The Hammersmith kept doing dialysis, because that was in the urology department at that time.  The urologists played a much bigger role than I think many people realize now in the starting up of dialysis particularly.  They regarded it as another urological procedure, and in every country, I think, the urologists had a major or even an exclusive role.  But Hugh’s unit in London, and of course there were others like ?Birmingham, I could have gone there; but it seemed much more exciting to go to the States and it was immensely liberating experience.  In those days, if you hadn’t gotten your BTA (Been to America qualification) you couldn’t go on in medicine, especially academic medicine in the UK.  And New York was fantastic.  It was not quite the first time I’d been abroad; we went there by boat.  It was almost the last year or two when the boat was cheaper than the air, on a Fulbright scholarship and an NIH fellowship, and I am eternally grateful for those two institutions for having given me this push.

 

AR:

One of the other extraordinary things is, at least looking back, you went and trained for nephrology in a year and went and set up your own unit.

 

SC:

Yes, I had people out for me.  John Chance is the figure I must mention here.  He was quite a remarkable man who is not famous outside Guy’s, I don’t think.  He’s still with us I’m glad to say.  Very modest man who contributed to many fields, but he took on as a senior physician all the politics for me and let me get on with setting up the unit.  But essentially yes, I was in charge of a unit at an extraordinary early age. 

 

AR:          And your status there?

 

SC:

Well at that point I was a lecturer.  Then I became a senior lecturer in the 60’s then finally professor in the early 70’s.  It wasn’t usual for lecturers who were rather a lowly breed to be running departments, but we set up everything up.  We set up biopsies, we set up acute dialysis.  Eventually a few years later I went and trained with Charlie Shoredon and we did chronic dialysis starting in 1966, and then we started up transplantation with Frank Ellis, who was then the surgeon, and Mick Buick, who stayed with us for many years.  And we ???pinied a lot of things.

            One interesting thing that happened was that Richard White, who was at Guy’s of course the same time I was setting up the adult unit, he was setting up what was one of the first pediatric nephrology units.  Pediatric nephrology didn’t exist; nephrology barely existed.  But then Richard went off to Birmingham in 1965 and I was left looking after the children as well.  I had some general pediatric training but in collaboration with the pediatricians we in fact the kept the pediatric pathology service going and for seven or eight years, I had a wonderful time working hands on frontline pediatric pathology doing some very new things, including founding pediatric nephrology as a specialty; in fact, nationally and in world terms.  I really do relish my attachment with pediatric nephrology, which is still present.  I find pediatricians lovely people to get along with. I found children, although emotionally very wearing to work with; I mean children dying of renal failure is not an easy thing to face up to.  But I think it helped me to be a much better physician.

            I learned from the pediatricians, especially Ronnie McKeith who was a very famous British pediatrician of the time, how to look at what the patient thinks of what is happening to them in the context of their life and their family, which of course is standard pediatrics, but at that time nobody in internal medicine was practicing it.  Of course, it’s supposed to be standard today.  But it made us establish, when we set up our chronic renal failure program, a couple of years later, or at about the same time, we entered a contract with our patients.  I remember saying to them, “we give you the starting ticket but you’ve got to run the race.”  We didn’t realize actually that we were pioneering a pattern of medical care which would take many other medical specialties twenty or thirties years to catch up with.  We just did it because; one of the things is that there were no rules.  We were starting off a new specialty in a new area; people didn’t know what dialysis and transplantation and things like this and the management of children and adults with renal failure should be like, so we invented it.   So we invented a new unit which was a huge extended family, which people liked each other and wanted to work with each other, and in whom the patients had an active role in saying what should happen, and incidentally in which the nurse had hugely increased and in fact illegal responsibilities.  I and ??, who by the next couple of years he joined me from the Institute of Urology where he had trained with Joe ?Yurcas; we were hauled over the coals on several occasions for suggesting that nurses do things like: sticking needles in veins, taking blood, supervising dialyses.  Of course we were so overworked we had no choice but to go down this road.  Effectively the head nurse became the head of the dialyses automatically.  I remember the shock and horror in the early days when people came to visit us, and we sat down and had our weekly meeting and it was chaired not by one of the physicians but by the nurse.  People almost literally fell off their chairs and their jaws dropped when they saw this from some more, less flexible countries, I won’t name which ones.

 

AR:

There were some very interesting and effective nurses who went on to ultimately have very interesting and effective careers elsewhere as well.  It touches at one of the things I wanted to ask; who provided the help?  The nurses clearly, you mentioned the necessity of that; the overwork must have been enormous because there was so many of the procedures in a sense which were technical, technical beyond the normal physicians.

 

SC:

Yes, we were in no better position to do these things than the nurses were, so we all learned together and we rapidly learned they often were much better at it.  So we asked them to do it, but I say the legal end of nursing took a long time to catch up with what we asked our nurses to do.  We were operating in a very difficult no-man’s land in which we couldn’t admit what we were actually doing.  And things happened which were not very happy; we had the hepatitis epidemics, which were sweeping through dialysis units in the late 60s, we got ours, I got hepatitis quite severely and was off for almost a year, were put down to the squalid conditions which we were operating under, because of course the units we were doing the dialysis in corners and holes.  There was no properly dialysis unit.  When we finally got a temporary building, which was supposed to stay up two years, it stayed up…twenty five…thirty?  

 

AR:

The atmosphere there must have been extraordinarily intense with the hepatitis, particularly after the Edinburgh outbreak, where roughly two thirds of the staff who got the disease died.  Clearly the Guy’s outbreak was different.  Nonetheless you wouldn’t have done that in prospect.

 

SC:

We were very lucky; we had a much more infectious disease.  It went through walls.  People just looked into the unit and got it, but touch wood, nobody died.  But I remember when I realized I was yellow, I looked into the mirror and thought, “Is this it? Is this the big one? ”  And of course for six weeks I didn’t know, which was an interesting experience, I just got iller and iller and iller.  It’s a useful experience for doctors to be ill.  I explored that more recently since I retired.  I think all doctors should have some serious illness that teaches them about fear and the loss of control that serious disease brings to patients because otherwise they don’t actually understand what’s going on inside their patients’ heads.

 

AR:

That’s absolutely true.  Probably we ought to move on to less morbid things rather than more something things.  I mean, so by then you’ve got a renal unit, you’ve got a colleague.  Really, one of the things that many people of my generation in Britain, actually and I’ve discovered in Berlin far beyond that, realize was that Guy’s is one of the few places that glomerular nephritis had been rather a black box and then had been complicated by all sorts of terminology became much more simple and straightforward again. 

 

SC:

But we just had to provide, as I’ve said before, it was cartography rather than science.  We took all the elements that were available, looked at the levels of description. I mean, the problem was a very simple one, which I think John Suthill first pointed out to me.  Everyone was talking at different layers.  It was immunological, pathological, clinical, all sorts of descriptions and terminology and everyone was expecting one to one correspondence between these layers and the thing about glomerular nephritis, like many chronic diseases, is it doesn’t work like that.  And of course at that time Boolean logic and Venn diagrams, and everybody knows about Venn diagrams now.  They were new.  I got them from a chap called Wulff, who was a Canadian physician and I suddenly realized the power of being able to use Venn diagrams to illustrate.  It’s such a simple advance conceptually, but it immediately cracked open all the problems of glomerular nephritis really.  They would just have to just simply provide a simple account, dissect out the layers of distribution, show where there were correspondences and where there weren’t, and use the Venn diagrams to show how they were related to each other.  It was a very simple task, of course, in retrospect.  But it was as I say, it was cartography not science.  We were doing new things.  We were studying complement in new disease-mesangial capillary nephritis, which of course the fallout from that, through the studies we did then and later with Keith Peters and ?Good Williams who joined us in 1973 from the Hammersmith with the people of the Hammersmith, actually helped map the complements, of which of course was almost totally unknown.  I think three complement components would be started, two or three and one pathway. And it was actually the study of some of the pathological condition such as nephritis factoring, as it came to be in the MCGN that taught us this.  We were innovating in nephritis and we were extending the map, but essentially the cartography was taking what was already on the shelf and rearranging it. 

 

AR:

It seems to be the cartography is a critical science.  There were a pair of takers in the BMJ, this was well before I went to Guy’s, I remember exactly where I read them and when.  When, when was of interest.

 

SC:        (laughs) Where you when Kennedy was shot?

 

AR: 

Well I was sitting on my bed in my bedroom on a flatted livable, but the curious thing is that, talking, and I can’t remember who it was it was just someone a couple of weeks ago in Berlin, someone from the States say they remember the paper too, which struck me as being extraordinary, from the British Medical Journal.

 

SC:

Yeah, the BMJ actually asked me to write those.  They said, “This is a myth tidy it up for us, will you? You think you could write us a couple of…” I think there were two parts to them

 

AR:

There were, from memory, and again the memory is… It was certainly glomerular nephritis and I think the second one was nephritic syndrome.  You round abused the term acute nephritic syndrome in those, which I have done ever since, I have to admit.

            The other thing that actually rose out of that was you must have got a large number of patients.  Presumable that you got a large number of patients initially because of doing the selectivity studies gave you the urine and then the biopsy gave you the patient. 

 

SC:

It was a very good advertisement.  We offered to do selectivities and we did them, for instance, for the International Study of Kidney Disease in Childhood.  We did all the selectivities for that international endeavor; all the urines and serums came in from the nephrotic children all over the world that were participating in that study.  We offered ourselves, Dick, Richard White, in fact had started this.  We didn’t usually do this for the adults but for the children.  For a long time I traveled around the southeast of England with a biopsy needle doing biopsies in the units and discussing the cases with the pediatricians.  We only realized afterwards how a subtle and method of advertising this was.  It meant that they didn’t lose control of the patient, they didn’t feel they were being taken over, but in fact in the end we got the patient to manage or we advised through them on the management.  Of course things like how to treat minimal changes in nephrotic syndrome were hot news in those days, but now, now people are still arguing.  But optimal treatment is interesting to see forty years later.  But doing the biopsies and doing the selectivities meant we rapidly got really very large cohorts of different brands of nephritis and we built on that during the 70s and we were able by the mid-70s, we had ten year ?followup on quite large numbers of people which taught us some very interesting things and which lead to…a series of almost…it was a coffee grinder basically, it went through all the forms of nephritis and turned out similar papers, which looked at the presentation, the background, the ideological factors, the evolution, the evolution in relation to the initial factors and the biopsy findings and what-have-you.  Some interesting things fell out of that.  By far, the most important one was in the 1975; much to my annoyance, because I was pushing histology as a major determinant, but unfortunately all these graphs seemed to look the same with different forms of chronic proteineuric nephritis.  Then I saw that the ones who did badly were one with the heavy proteineura and the ones who did well were the ones who had minor proteineuria and the graphs again were almost superimposable between the different histologies: ???bal sclerosis, mesangial capillary ?membranous.  Two clumps of lines were exactly the same; the difference was in the degree of proteineuria.  I remember being very annoyed about this but of course in retrospect this was a very, very important finding, which we never properly published, to my regret, otherwise would have been a real landmark paper.  I presented it in several meetings and it got published in monographs and things, but we never actually had a paper or standing journal saying that.  I have seen that slide from one of those papers, flipped through some of the proteineuria discussions in the recent years.  But I think actually that probably was the beginning of proteineuria as a nephroid toxin. 

 

AR:

One of the keys things that you haven’t mentioned was, again, the need for an analytical approach, a statistical approach.  To the long term follow-up of patients.

 

SC:

Yes and of course all those curves that I was describing were, in fact, Kaplan Meier estimates of survival.  Again it sounds ridiculous, but when you look at the papers in the 60’s they’re a boggy mess because nobody knew quite how to describe what happened to cohorts of patients.  Of course, the actuaries first and then the cancer doctors, and then before I have to say the nephrologists, the transplanters had already realized the power of the Kaplan Meier clock, the lifetable, which is obviously now bog standard for absolutely everything that you do.  But in fact nobody had used them in nephrology.  I think the papers that we presented to Priscilla Kincaid-Smith’s meeting on glomerular nephritis in 1971 or 1972 was the first time anyone actually used Kaplan Meier’s.  I think we used them for our survivals of our dialysis patients slightly earlier in a paper we published in the EDTA.

 

AR:          Where did you get the technique from?

 

SC:

I got it from the transplanters.  The paper that I used was not Kaplan and Meier’s paper, which you’ve read it, of course.  It’s pretty dense statistics.  No, I used a sort of ?El Cheapo model which is a paper from Seattle by ?Cutler, he was a very well known physician, and ?Agerer, and they described how to use survivals in general, in medicine in general.  That was one of my biblical references to be in it with Cutler and Agerer.

 

AR:          I remember the name.

 

SC:       (laughs) I ??? with them a lot.  So does nephrology.

 

AR:

Absolutely.  Again, for someone around learning nephrology at the time, it actually has made things comprehensible for the first time understanding how to do things.  Usually the implications of that are enormous not only for the natural history but also for the unnatural history, i.e. the ?cretint history.

 

SC:

Well you need tools, you need descriptive tools.  One of my great authors, I suppose most people of my generation were influenced by George Orwell, whose ?centenary as you know is this year, so all sorts of Orwellianers are coming out on the television and papers.  But he wrote an essay, which is for me is one of the key essays in my education, which is called “Politics in the English Language”, which he exploited as a theme in 1984.  He went back to Roger Bacon who said, “Words are the footsteps of reason”, which is something again I’ve been fond of quoting for the last forty years.  Orwell pointed out that not only did you need words, following Bacon, to shape thought, if the vocabulary and the terminology is not right and is not there, language can be used either accidentally or deliberately to corrupt thought.  Unless you get your terms right, whether they be statistical or verbal you cannot describe something accurately and you cannot move forward.  Any innovator who has invented or reinvented new terms like, just to pluck one word at random that every nephrologist knows, dialysis; it didn’t mean what it means today when Thomas Graham took it off the shelf, dusted it off, and said this is what dialysis means, it means diffusion down the gradient through a membrane, etc.  “Falling apart”, in fact in Greek; might be, my Greek’s not very good, I only learned very little secondhand I didn’t do it at school, but you’ve got to have new terms. 

Whenever there are great periods of advance in science, there are nearly always great periods of coining of new language, I mean molecular biology; think of the terms that we didn’t know about: axons, introns.  Looking back at papers of 1975 for example, none of this is there; a whole vocabulary is being created, sometimes in a very, very inventive and lively fashion.  But the danger is always there; if you use sloppy language, you will have sloppy thoughts.  That’s what Orwell pointed out to me, so I’ve been rather precise in how I used language ever since.

 

AR:

I mean that’s certainly one of the absolute keys, isn’t it?  Nephrology then was beginning to develop into a specialty as well; I mean the beginnings of so many of the things that have been dominant happened then.  What was the international community of nephrology like then, among the people, I mean even just starting with the people in glomerular nephritis.  Presumably it was a small enough group.

 

SC:

Yes it was a small enough group.  I wasn’t involved with the ISN meeting, for example, in 1960; I was still just on my house.  In 1963, I had just come back from the states, so John Chance, whom I mentioned as my mentor, when to Prague for the second meeting at Yeven, chaired at the sad Prague of the communist era.  My first ISN meeting was in 1966 and of course George Schreiner ran that; and the huge expansion of the number of people in nephrology during those five years is something he has talked about.  He was able to find thousands of people around the world that he could write to.  I’m trying to remember the figure of how many people.  There’s a picture of two hundred and fifty or so who were in Avion in 1960; by Washington it was already in the low thousands.  So by the end of the 70’s dialysis and transplantation, particularly dialysis, had multiplied the number of people were needed as nephrologists to do the specialist things we were good at, which was biopsies and dialysis.  Ironically the nurses have taken dialysis away from it and the interventional radiologists and pathologists are in the process of taking biopsy away from us.

 

AR:

So what about the researchers, the people interested in the development of glomerular nephritis that must still have been a very small community.

 

SC: 

Yes it was.  I think Priscilla did a great job getting us together twice in ?Melmount for two meetings in 1971, I think…72?, and 79 to look at the state of the art, and those books were published by John ?Wiley and I think they were landmark publications because they gathered everything together and said, “Where are we?”.  By the end of that decade really, I think we had exhausted the possibilities of the sorts of tools we had in our hands.  Of course very new exciting tools were just around the corner, we didn’t know that then.  The monocolonals were just about to break in the early 80’s and of course that gave us a new impetus, a new interpretation, a new field that we could work on, and things we’d have fun with, and that we did.  Of course at that time I was still heavily involved, in Britain in contrast with many countries, one of the things you know better than I, nephrologists have stayed as polymath; they’ve never specialized.  Most nephrologists in Britain do dialysis, they do transplantation medicine, they do nephrology, they do hypertension, they do pretty well everything; inherited metabolic disorders, you name it.  So ?DeMer from 1966 onwards, we of course had a very busy dialysis and transplant program, which I think was one of the best going. 

The tragedy of the early 70’s of course was that it took us so long to learn not to kill our young transplant recipients.  In those days of course we didn’t transplant or take on elderly diabetics, they weren’t on the scene.  We transplanted exclusively young people and dialyzed most people of a young age, although very rapidly, funnily enough Britain has always had the reputation of being a place where dialysis was rationed.  Notorious paper from Jeff Berline who having fled from Britain emigrated, I don’t know how he would put it, to Brooklyn, said, “Uremia plus being in the UK equals death.”

 

SC:

Well that was one of the things I was going to ask you, because 1971 is when I came to Guy’s first.  At that era, everyone was being dialyzed who it was thought it was clinically possible to dialyze.  Whereas I guess where’d I’d come from, in the Northwest of England, there was still hanging committees, age limits of thirty-five, forty-five, needed wife-two children, single man wouldn’t be dialyzed; I’m probably paraphrasing and almost certainly exaggerating too.  Nonetheless that was the culture.  How did you escape that culture?  Why were you able to dialyze everybody?

 

AR:

We tried to dialyze.  Well one thing was the rationing was occurring further down as we all now know.  Practitioners and general physicians simply were not sending us the older and frailer patients, but we did take on people in their 60’s as early as 1970, which was very unusual for the UK and unusual for the world, and we transplanted them too.  The time when major transplant units in the UK and elsewhere had an upper limit of forty-five; Oxford, to state a specific example, one of the finest transplant units in the world, but Oxford for many years had an upper limit of forty-five for transplantation, similarly did Belfast.  Again, they had wonderful results, very innovative.  They were the first people almost to point out that we were poisoning our patients with prednisolone and we actually had one of the first control trials to demonstrate that was so tragically late as I’d said.  But we didn’t escape from it; we were protected by our colleagues to a certain extent.   We were willing to take on people, but we’ve pushed home.  One of the problems in the UK at that time, which of course was not internationally present, was the tremendous impetus to use the more cost effective home dialysis than ?incented dialysis.  PD at that time didn’t exist of course.  Put people on PD and they died basically.  In the early 70’s, it difficult to remember that now but it’s true.  PD was strictly for acute renal failure.

            So we forced everyone into the home and I think your criteria in the northwest were of course heavily directed towards picking only people for dialysis who potentially at least might be able to go and do it for themselves and not spending too much money before they died, because of the appalling low budget and priority that renal failure had.  I mean, I spent all my clinical career from 1965 to 1995 lobbying for more resources for patients in renal failure.  Somehow we pushed the intake rate from ten per million up to a hundred per million, but it was crisis management all the way.  It’s a blot on the history of nephrology and the United Kingdom and it’s a blot on the National Health Service.  Jeff Berline may have been aggressively overstating it, but he was right in pointing the finger and saying, as is Eli Freedman again from the same institution, who is an old friend, I saw him the other day again in Berlin.  Perhaps we should mention for the record that we are recording this just after the Berlin Congress of the ISN, which was most fantastically successful.

 

AR:         At which, of course, you were awarded the Hamburger award.

 

SC:

Well, that wasn’t… (Laughs) …but yes I got the Hamburger award.  I’m immensely proud of that.  I met John Hamburger first, of course, in the early 1960’s.  I wasn’t in the first meeting he put together with William ?Macht in 1960.  What’s often forgotten is there were two secretaries at that meeting who did a lot of the hard work.  They were two people from Britain who were both French speakers: Joe ?Yurkis and…I’m afraid to say just for the moment I’ve forgotten the other name…

 

AR:         Would it…Hugh DeWardener?

 

SC:

No, no, no, it was somebody else who was not…Bruin Lewis.  He is a general physician, but at that time he was interested in postoperative renal failure ??? ?accent.  He happened to be a friend of Hamburger’s and both of them spoke French, and Joe Yurkis being from Holland, of course, spoke everything, or his family being from the Netherlands.  There I’ll mention them because we have an interview with Joe in this Video Legacy series, I’m glad to say, which I did a few years ago with him, and he’s still around and well, when I last heard from him.  But ?Der ?Rowan setting this up and Gabriel Richer and John Hamburger quite rightly have had enormous credit.  The role of the two secretaries which was huge in getting that first meeting, in getting the ISN off the ground, I think deserves record on tape.  And I think in his history of the ISN, Kidney International the other year, I’m glad to say Ike Robinson took my hints that this ought to be mentioned on the way.

 

AR:

So we really in a sense have covered aspects of dialysis and the dialysis political situation.  What about the technical advances and things?  To what extent did they change the face of…what was it like actually dialyzing people? 

 

SC:

Dialysis was absolutely totally different and in the 1960’s, the first time I learned long term dialysis, we started off with a coil dialyzer of course.  The fifties had thrashed through the Kolff rotating drum still in use in various places, in ?Leeds, for example.  Frank Parsons brought dialysis back to Britain in 1957 against colossal opposition.  Then three or four other units were set up in Belfast, in Glasgow, in Newcastle, in the late 1950’s.  But the coil kidney was coming through, the twin coil, which Kolff donated after he and Bruno Watschinger, who is another person we have on record I this series, had established itself for the workhorse for acute dialysis.  Some people used it a lot; it’s been forgotten now, for chronic dialysis.  But this oxygenator that Fred ?Keel, who was a urologist in Norway, had built and turned out to be a very, very nice dialyzer, particularly because it didn’t require a pump, which made it very safe for using at home.  So we all learned our dialysis on building a Keel.  You take an exploded diagram; I used a slide often and I have it in some of the things I have written, all the layers you had to put together and clamp, and make airtight, watertight, bloodtight before you could even dialyze the patient.  It was quite a horrendous business and that was the first thing.  It was about about that long, about that wide (gestures with hands).  The hollow fiber was a bit bigger than this glass.  The monitoring was very, very crude.  We did all sorts of abominable things to our patients; we’d poison them with copper, filled it with undistilled water, and they took it all in the machine.

 

AR:

One of the things that ?Chiz ?Marg wrote was that he was just as at home with a screwdriver as you were with a stethoscope.

 

SC:        Oh you had to be a plumber.

 

AR:         I could see that.  I could see ?Chiz ?row; he acts like it more than you do.

 

SC:

Ah well, the jubilee clip was one of mine; you know the thing you put the plastic, for fixing plastic pipes to the wall.  I could not only build a kidney, I could build and take down and reassemble a dialysis monitor of the period and I wrote the manual for the dialysis monitor.  At that time of course, there were few manufacturers, most things were homemade.  Our first kidney was made in our hospital workshop for dialyzed use in 1962.  So yes, we had to be very practical people.  That’s why I’m saying that a lot of physicians that drifted in to dialysis in the sixties and the seventies were in fact surgeons manqué.  They like putting in shunts and then later on fistulas and they also liked fiddling with machinery, tinkering with things in basements.

            One of the sad aspects of this has scarred nephrology, to my mind, over a period of its development, is the division between people who do mainly dialysis and people who are in the ivory towers of channelopathies and proximal tubules.  There has been a failure in understanding in many countries between the two groups and it’s taken a long time and a lot of hard work on many people’s part to bring the groups together and weld them into one. 

 

AR:

And in a sense is a problem that is getting worse and worse as there are vast numbers of patients on dialysis now and it is in fact overwhelming the relatively smaller number of patients approaching that.  Of course that might change with better preventative…

 

SC:

Well one hopes, fingers crossed.  It’s been a wonderful thing to see, I mean I live most of my clinical career with no hope really sensibly except for treating blood pressure and treating obstruction, for renal prevention, but then now in diabetes and glomerular nephritis there is real hope.

 

AR:         Well presumably there must have been a real hope in the beginning.

 

SC:

We though that we would cure nephritis with these ghastly poisonous drugs like cyclophosphamide and corticle steroids that we used on people in ridiculous doses to begin with and still use today.  It’s a terrible thing that for forty or fifty years, certainly for forty years, cortical steroids and nitrogen ??? essentially, which were introduced in 1950, were the standard and only admissive personal drugs.  Not only in glomerular nephritis, in immune disorders like lupus, and also in transplantation.  We had the same repertoire of tired drugs with their dangers and difficulties really until very, very recently.  It’s a delight to see we now have a repertoire of drugs that we can choose that do things much more effectively. 

 

AR:          If only we knew how to use them.

 

SC:        If only we knew how to use the most out of them.

 

AR:

Well there were certainly a large number of nasty drugs flying around in the transplantation field there when I first joined, but Guy’s had really one of the very biggest and most productive transplant units in the UK back then.  I don’t know how the numbers vary with other big units in the world.

 

SC:

I think we were one of the biggest, partly because we drained from such a large area, but part of it must be the energy of Mick Buick and subsequently Jeff ?Kauffman  and the others.  Mick as our transplant surgeon had an energy, I mean he made me feel tired, very tired.  His energy particularly in getting, promoting all the information, and getting all the kidneys was largely responsible for the size of our program.  So I suppose we had lots of quantity.  The quality wasn’t so bad either.  One of the things we were able to do, as I said earlier I think we were one of the first people, although the papers never quote it now, to show in a control trial far later than we should have done it; we should have run the control trial a decade earlier.  It’s difficult to remember now, the control trials were still innovation in nephrology in the 1960’s; in fact we published one of the first in 1968 in “Steroids in ?Endothronopaneal Nephrotic Syndrome” just about the same time as the MRC trial came out, I think that was the first one.  So the trial we did in 1979 on “High Dose Versus Low Dose Initial Steroids”, which absolutely and conclusively showed what ?Maureen ?Mageran in Belfast did say, that high does steroids to begin with were lethal and not only didn’t make things better, it made it worse, was ten years too late  I feel guilty knowing all the people we just destroyed during that time ever since.

            Another thing I think we contributed to was when the monocolonals came in, as I mentioned.  It was very exciting because we could study the infiltrating cells and the transplants and in glomerular nephritis in parallel.  Of course there were very few people who were doing both simultaneously, I mean we had the same lab; we were looking at lots of transplant biopsies, lots of GM biopsies, and of course the interstition had been horribly neglected by ourselves and everybody else in the nephritic studies.  ?Drummond ?Renny, an old friend, who had been working with us and with Harry Keenan in the sixties and is now one of the editors of ?Germar.  I remember him saying in the 1960’s to me once, “Hell I wouldn’t know a tubule if you hung one around my neck.”  He was at that point where he and Harry Keenan were on microalbumineria as it happens, in 1967; it was a hot topic in those days and still today.  Anyway, we were able to study the two things in parallel and unite the idea of the interstition being important in both, obviously, transplant rejection but also in nephritis.  This of course was a very old idea.  Hugh DeWardener and Tony ?Risdon had brought it forward in the 1960’s, a paper which still people quote in the Lancet.  Then ?Adel ?Buller was in Germany, again somebody who had the advantage of enormous numbers…he was the one person I used to look at with envy…they had even more patients with nephritis than us.  If we had a big series, he had an even bigger one.

 

AR:         But the difference was those were biopsies, yours were patients.

 

SC:

Yes, I think that’s true.  Although he had lots of clinical data, it was essentially a path-clinological paper, whereas our papers were clinical-pathological with each, balanced.  I think it was very exciting to find that in nephritis the infiltrate was exactly the same as in rejecting transplants because the light bulb went on at that point, because clearly we were looking in the wrong place.  And of course the rest, as they say, was history.

 

AR:

The other thing that was missing before the monocolonal era was the lymphocyte of course.  The lymphocyte was completely irrelevant to nephritis, remarkably.

 

SC:

One of the things we were able to show in fact was there were lymphocytes there.  Other people had done this, of course, before; Bob Atkins and others had done the later big present to the ISN of course, had shown that macrophages were important in the experimental and clinical nephritis and all the old work from the Japanese back to 1950’s, the macrophage suddenly came in.  The macrophage was the sell of the 70’s, and then the lymphocyte was the sell of the 80’s, largely because of the monocolonals.  In fact, I think we were one of the first groups to show that there were lymphocytes, probably up to no good, very early on present in human nephritis.  Other people had shown this in experiments several times, but we, again, with our huge biopsy library, we could go back and they were all lined there apart a few disastrous refrigerator accidents which I think every unit suffers from.  One of the things I learned very early one was keep sera, keep case notes, and keep biopsies forever.  Don’t throw anything away.  Become a squirrel.  Horde it away, because you’ll be able to go back and if a new idea or technique comes in you’ll be able to go back and answer a question in a matter of minutes.  Nowadays of course, you and others are hording DNA.

 

AR:

Hording everything.  I must say, having come through Guy’s and then Hammersmith, I was amazed.  It never occurred to me that people threw things away, and it’s only when you move elsewhere that you realize that people clear freezers out in two years.  Well that’s a nightmare.

 

SC:

Well it’s difficult to get the storage space.  Well we had fun during the 1980’s, expanding.  We had new toys, and again it emphasized one of the fundamental lessons about science in general and medical science in particular, how tech dependant you are on technology.  Where would you be without all the techniques, with the gels, the radioactive this, the chromatography, the blotting, the antibodies, the polycolonal and monocolonal?  Your ideas have to be limited by finally what you can ask.  Science is, after all, the possible.  I don’t know whether Peter ?Mendlebar said that for the first time, but I’m sure it was said by someone before him. 

 

AR:

Who were the big players?  Who were the people who you sort of related to in this big time?  Who were the sort of figures who you as one of the key players of the time looked to as the people who were challenging you, or the rivals.  I know you don’t actually think in those terms at all.

 

SC:

You raised a very good point, because one of the problems about the way science and medical science developed is that now with commercial development, particularly in the last decade with patents, I mean the first reaction thirty years ago to anyone who found anything was to ring up all their friends or write them a letter, there wasn’t e-mail in those days, and tell them what they found.  I only realized once from something Keith Peters said to me, “No, no, we mustn’t give that away, so-and-so will get there first.”  This wasn’t an attitude that I had ever come across, but of course it’s not that Keith invented it, but it’s just that it was becoming necessary for grants, for funding purposes, and now for commercial exploitation, for collaborations with firms.  People no longer discuss their results as long as openly they used to.  They don’t discuss them until their papers are accepted in sale or nature, if it’s really hot stuff.  The sort of stuff I was publishing wasn’t really that earth shattering.  But I do detect a problem there that rivalry is now the name of the game, you get there first, whereas cooperation…  So you’re right, we looked up to people of course, but we wanted to work with them, we swapped samples.  Science is entirely about this, science is dependant on openness.  Back to another one of my gurus, Carl Popper, long before he became fashionable I have to say.  I’m not sure in conscience I wasn’t partly responsible for making him popular.  Peter Mendlebar, of course, as well.  Remember he wrote a book called The Open Society and Its Enemies, which is about the conditions that are necessary for political freedom; they are the same conditions that are necessary for scientific freedom.  There is nothing absolute about science; science won’t go on forever, unless we preserve the ?milia which allows science to continue in an open fashion, we will destroy it.  And I am seriously worried that we are moving in the direction of destroying the absolute basis of science, which involves sharing of ideas.

            So yes, Hamburger terrified me when I first met him.  He was this god who more or less who invented nephrology, who started the ISN, and built a building which is bigger than our hospital just for nephrology, the Palais du Rein, which is still going strong in Paris.  Priscilla, she was a polymath like I was, I guess.  Liked dipping her toe in everything…

 

AR:          She was vigorously combative wasn’t she?

 

SC:

And she was quite competitive.  But we worked in parallel and shared a lot of ideas over the years, and I count her as a colleague.  On the histological side, particularly Renee Habib; she been a very, very, old, dear friend since I first met her in the early 60’s.  We still are in contact.  We shared many things together, debates.  We argued a lot, of course.  Science is about openness and discussion as well, and of course you need differences of opinion.  If they are emotionally charged that doesn’t matter, but once you see people getting emotionally addicted to their ideas beyond a certain point, you know there are guys who have gone over the top and down the other side; they’re going to stop thinking clearly about this.  They’ve lost their grip on the science, and that’s something I think some people haven’t learned in all fields. 

 

AR:

Glomerular nephritis, I’m not sure if that provides a good example of that, in one way or another.

 

SC:        I’m obviously not going to quote any names. 

 

AR:

I wasn’t going to say that, but I was going to bring up was actually how useful, in a sense; you found the experimental contributions that were being made.  I mean they have allowed fundamental things to happen.  There has been a chasm between the two for much of the life of nephrology.

 

SC:

Well the old business about man-doctors and rat-doctors has always been there.  There are some people like Dick Glassik, for example, who’s another of my old, great friends who I’ve enjoyed and collaborated with, who can do both, but it’s difficult to do both, and now it’s becoming increasing difficult to do both.  It’s very, very difficult to be…it’s no longer a rat-doctor, you know, a clone-doctor, as well as working in the clinic.  It’s very difficult to bridge that cap.  There’s a tremendous need for the clinician-scientist to be coddled and preserved.  Don Seldin and other presidents of the ISN, with whom I’ve interacted over the years, has many, many times emphasized the importance of the clinician-scientists, of trying to get a career path, as we have in the United Kingdom, and you’ve played a role in this yourself along with many others, to try and find people who can and think in both terms, who can see the relevance of the clinical stuff, and also operate amongst the fundamental biology, which is probably where most of the major advances are going to occur.  But it’s still extraordinary how from time to time clinical aberrations and clinical observations do throw up clues that are of fundamental importance in basic science.  There are still things in there that clinicians can notice and they if they don’t tell the people who are working in basic science about them, say, “I’ve always wondered why…” and put that to somebody who’s got the technology in molecular genetics to try and sort it out.  If that communication breaks down, we’re going to lose an enormous amount; humanity is going to lose a lot, people are going to suffer more, and intellectually as scientists in a world of ideas we’re going to lose out.  We have to work very hard at keeping that gap from opening.

 

AR:

One of the questions I really wanted to ask, again sticking with experimental models of glomerular nephritis and the like, did you as a clinician or at least as a person primarily interested in the pathogenesis and natural history of human disease feel you gained things from the insights and paradigms of the day, acute and chronic serum sickness.

 

SC:

We did relatively little work.  We did some, which was forgotten, except one thing which I don’t think should have been forgotten was we saw very early on that two mediators were going to be very important; one was PDGF and the other was TGF Peter.  I remember saying in Stockholm in 1989, TGF Peter is going to be the mediator of the 1990’s.  Well it wasn’t, it was nitric oxide, but we were almost right.  But we did so some work with PDGF.  While we are on that, platelets were a very big interest of mine for many years.  This is something Priscilla and I had in common; we were very interested in the role of coagulation in its broader sense.  Coagulation is inflammation and inflammation is coagulation, except they are studied in hematology labs and immunology labs; that was our thesis basically.  We tried very hard both therapeutically and experimentally and clinically to show that coagulation, my main interest was not in fibrin and the cascades but in platelets.  Ironically we stained biopsies again; antibodies came in that we didn’t have.  In 1981, we got an antibody what was then called Platelet Factor Four, and so we went hunting it and showed that it was present around beautifully in a little halo, beautifully around platelet derived antigens within the glomerulus.  What we didn’t notice was this was a chemo-kind.  Chemo-kinds hadn’t been invented. 

            The other thing that I might mention was my desperate attempts to measure macrophage inhibition factor in the late 1960’s.  It taught me one thing that any assay that has to be run in quadruplicate to get even vaguely useful results is a waste of time, because we actually measured it; you got your macrophages to crawl out of a little test tube and you measure the size, if you remember sensitization ?Steptor Cockeigh, ?Zubreski and others have worked with this technique.  God it was awful.  And when you look at the explosion in cytokines that was almost the first time people and me termed…the term didn’t exist.  Lymphokines, I suppose.  But I think macrophages and inhibition factor was probably the first.  It’s interesting that it’s just made a comeback.  There are hot papers on that now.  God, that scarred me.  I never published the stuff, it was just…  Again it teaches you, you need methods of measurement.  Science is measurement; I know who said that, it was Carl ?Luthrid, definitely.  If you can’t measure it, you are nowhere; you are in the field of arts.  Not that there is a anything wrong with the field of the arts, I love them, but it’s not science.

 

AR: 

Well that flags up quite naturally on arts, which you’ve certainly had, but in a rather untypical way.  I’ve accused you elsewhere of being a politician, and I now can give you the opportunity to respond formally.  You have actually headed and been responsible for an enormous numbers of what can only be described as political changes within the world of nephrology over the last thirty years. 

 

SC:

I think that’s true.  I’ve had a hand in a lot of the societies.  I think we just saw the need, we needed to be organized.  I also saw, because I was working, being a butterfly as I’ve always said I was, hopping around from flower to flower; I saw what different people, transplanters, dialysers, immunologists, physiologists, clinicians, and were doing, and I saw the need to try and get them together and do things.  So yes, I’ve tried to make things happen, which is what politics is all about.  Try to make people see that the way you do things is the easiest way, especially if you can make them think it was their idea, then you’ve completely won, and that is I supposed, the fundamental art of politics.

Despite having occupied all these offices, president of this and chairman of that, I haven’t actually sought any of these.  I’ve been more interested in things that happen, but if that’s the way to make it happen, then that’s the way to go.  You have to take the drudgery of being the president or the secretary. 

 

AR:

Considering just a little detail, you were president of the European Society of Pediatric Nephrologists, which was way back, which was 1975 I think. 

 

SC:

Cambridge, wonderful meeting, people still occasionally come up to me and say, “You know Stewart that was one of the meetings I still remember.”  It was marvelous; it was a small group of people.  We were still all friends, we all knew each other.  We were still finding out exciting new things at the time, not that there aren’t exciting things now.  It was the scale, I think.  Of course, being in Cambridge was just marvelous, and the weather was kind to us.  Somehow everything clicked.  I remember that was one of the best meetings that I’ve been concerned with.

 

AR:

That must have been a formidable challenge in a way, must have been the EDTA, I think that was.

 

SC: 

The role I took on there was to do something which was very difficult, which was to try and change it, continue to change it into the European Renal Association without dropping the dialysers.  We needed to make it general.  Of course the American Society of Nephrology had evolved from entirely the opposite direction, it had started out from the salt and water club, you know Bob Berliner and Gerhart ?Gibish and the people working in the physiology in Yale.  I actually have proper credentials for that.  I said to Gerhart in Berlin the other day, and to Don Seldin, that I was a physiologist manqué; not only had I been a fellow at Pitt’s in New York, but I also spent my time in Homer Smith’s hut up in Bar Harbor in Salisbury coast studying things in the dogfish. 

American nephrology evolved from, if one was being critical, Mandarin science, towards clinical middle ground, and tried to incorporate the dialysers.  European nephrology started off entirely within dialysis and transplantation, and had to evolve towards physiology.  So one of the jobs, Vittorio Andrew, which he started, he was the president before me in the ERA, was to persuade this to happen without dropping off the dialysers, because I counted myself as a dialyser, and as a physiology, and a nephrologist.  So I had, if you like, street cred, in all these areas, so that was one of the reasons I was able to do the “politics”. 

With the ISN I think my main aim was to internationalize it more, to turn it into a machine, which it is now, for transferring money and resources from first world countries into third world countries.  Of course I wasn’t alone in this effort.  I was one link, I was a relay runner.  I think Gabriel Richer, whom we haven’t mentioned yet, he was one of the greats of the ISN, ex-president.  He was the first one to run continuing nephrology in what was then, I suppose, although they might be insulted, a developing country in Tunisia, I think in 1985.  I could see when the ISN came to London and we hosted the ISN meeting in 1987 that was the way the ISN needed to go, and I said at opening it.  We had a three minute speech; we were told that Princess Ann, no it was not Princess Ann…wrong princess (laughs).  The royalty was going to talk…

 

AR:         Princess Alexandra.

 

SC:

Princess Alexandra was going to talk for three minutes, and we should none of us should talk for longer than that.  So in my three minutes I remember saying that somewhere on the globe, shows how fast things happen, the five-billionth person had been born within the last couple of weeks, of course we are already through six-billion and beyond, and it was our job to try and see that all benefits of nephrology got to as many of those five-billion people as could; and quite clearly this was not the case in 1987.  The huge expansion in programs of all sorts, Ike Robinson, Bob Schrier, everyone, there’s so many people who played a part in that, but I like to think I was one of the relay runners handing on the baton, after my two years, it used to be three of course.  I must admit running that meeting in 1987 in London was quite a terrifying task.  First of all, it was the awful realization that unlike the EDTA, when you ran an ISN meeting at that time you were on your own.  You raised all your own money, and if you made a profit you could pay it to anybody you chose to, which was usually the national society, which often was a very enriching experience, as it was, for example, for the Greek society in the ISN meeting in 1981; it helped give them enough money to do all sorts of things they hadn’t been able to do previously.  But equally, if you lost money, you went to jail and your house was sold.  So almost the first thing we did was to form ourselves into a limited liability company and that was my first encounter with trustee liability.  Because it was really rather a frightening…I mean, a couple million dollars.

 

AR:          At a time when a million dollars was a million dollars.

 

SC:

This was not something we had handled before.  We’d had the EDTA, the ESPN for instance in Cambridge 1975 was ?penanced.  The other thing was of course, it was for me personally it was a rather arduous trail because two things happened to me during that which shouldn’t happen to the president of any meeting.  I was thinking of this in Berlin with regards to Karl ?Uver Eckhart as secretary and Abel Hartwitz as president.  First of all, the secretary, who is supposed to do all the work, while the president sits back and decides on the strategy, became sick, and I had to do the job of secretary and president.  Then the second blow came when the company we had hired, we were working with, to run the congress, went broke, and we had to change horses in midstream and pick out all the stuff of the middle of the stream.  After that experience I felt I was covered with Teflon, I couldn’t take anything.  I certainly don’t want to repeat those experiences.  As they say, it was educating. 

 

AR:         Well certainly a very effective meeting; again another meeting that is talked about

 

SC:

Yes, we tried…the only thing that didn’t work was our sports afternoon.  We decided to have a half day in the middle rather than at the end, and we thought everyone should go off and do something, so we had a run and we had a cricket match, and I forget what else we had.  The skies opened.  England versus Australia nephrologists; I still have the pictures of the two teams proudly there. 

 

AR:         At the honor of ?latillery ??? ground.

 

SC:

At the honor, yes.  The match was called off.  We runners still went round, slopped our way around.

 

AR:          I’m sure the cricketers drank an awful lot that afternoon.

 

SC:

Yes, the cricketers went off to the bar to drown their sorrows.  I first encountered the ISN, well I went to the meetings in 1966, and I’ve been to all the meetings, but I went on the council in 1978 when somebody said, “Would you like to be on the council?” and I said, “well I supposed I don’t mind,” because I had worked with the EDTA quite a lot, so I had a lot of experience with the EDTA which came in good stead.  So I got on the council then and eventually I ground my way through the executive during the 1980’s, ground a meeting in 1987, which I think was sort of to prove you could stand the heat, and then you were allowed to become president.

 

AR:

I mean, all this international activity emphasizes again the enormous range of people over the years who have been fellows with you from all over the world. 

 

SC:

I’ve always said, and I said in Berlin at the Hamburger award, that’s my greatest privilege has been to work with and help form and shape, about 250 people, clinicians, research people, or both, over thirty years from 1965 to 1995.  And it is a huge extended family, which it is lovely to meet them at meetings and see how they’re all doing, people like your self.  Many have achieved distinction that I expected of them some surprises in both directions but always a warm feeling to know that I can go to almost any country and ring somebody up and say, “Can I come in and have a drink with you?”  It’s a huge privilege.

One of the things I systematically did in our unit was to try and foster.  We had a room, as you know, which was called the Foreign Office, and which one or two of the fellows did not like that; they thought it was patronizing.  I didn’t realize this until later.  But one of the things that I know about some of the fellows that were with us, and we usually had up to five or six at a time doing different things.  And we were perpetually grateful to them because they did a lot of the work in the clinical unit and the research.  We would not have published half the papers that we did if we did not have them.  But they met each other, and I know that some of them formed lasting friendships between Greece and South America…and the Far East…Hong Kong, basically you have people from every continent except Antarctica, and just about every country.  In some cases in some countries we had so many people we helped shape the nephrology in those countries.

 

AR:         So in a real sense, it was a one man COMGAN.

 

SC:

It was.  And we built many of the features.  Basically what the ISN has done subsequently has to try and formalize and fund.  Of course one of the problems was finding money for all these people.  Obviously there were other sources like the Commonwealth Fund, which we used to exploit anytime anyone said, “I’d like to come and work with you”; we knew we had a repertoire of sources that we could try and tap, of course, recently, the ISN fellowships.  I honestly don’t know how many ISN fellows we had through.  My last fellow was an ISN fellow, so I had a special regard for her because she was my last fellow.  ?Paula Fernandez from the northeast of Brazil was the last fellow I had before I retired.  Unfortunately she wasn’t able to get to Berlin because she was stuck at an airport somewhere, but the first one, I’d have to look that up.

 

AR:

            Well one of the things we haven’t touched on, and at least it’s coming full circle in a way, is Aberdeen was not only the place where you were born, but was also the place where you did a certain amount of research as well.  Again, thinking about a far flung part of Britain.

 

SC:

            Yes, another field I’ve been interested in.  John Butterfield said, “This is some scientist at the welcome who needs her PhD supervised, she is called Ann Simmons and she works on uric acid.  Would you like to supervise her PhD?”, and I said, “Well I don’t know anything about uric acid but you know I can provide her with the academic background.”  Because working, she needed a formal academic attachment.  Then that started a collaboration which is still active ‘til today.  We just exchanged very some exciting e-mails about genetic studies in ?familiar ?hyperurosemias, which is a cracking topic at the moment.  The genes are pouring out, we’ve found two, and there’s one ?uromogilin gene curiously turns up in the tubules to be related to a reduced ability to excrete uric acid, and we haven’t yet got any hypotheses.  That was the beginning.  First of all we thought we’d solve uremia; uremia undoubtedly was due to the retention of ?purin metabolites.  It’s amusing to see; actually I’ve seen two papers within the last year, I’m reiterating some of the things, some of the ?carboximides and things, was interested in the 1970’s.  But we had a very long and fruitful collaboration with that. 

            The Aberdeen connection, as you know, was the fact that we wanted to work on the pig.  The pig’s metabolism of uric acid is very similar to human beings, with one exception of course, that it can break down uric acid.  All the piggeries were taken up.  Roy ?Calm had taken up the one we have gone to in the south of England, and so we ended doing this work in the nearest piggery you could find, was 500 miles away.  So we ended up working eight years, ten years, with the pigs in the ?Roud Institute here.  It was a very interesting and rewarding experience working with the veterinarians to see their different approach to things, and we studied the clearance of uric acid in the pigs.  Eventually with Francoise ?Vachamelle who sadly died the other year, we were able to do micropuncture in the pig.  It’s the only time I’ve ever tried to do micropuncture; I won’t tell you what Françoise said about my micropuncture technique.  I did get a few of the pets into tubules, but it’s the largest animal so far.  She was very interested in doing it because of course deep down she hankered after doing micropuncture and ?mad, which was clearly impossible.  We were working with full size pigs, not mini ones, not these little kiddy ones, real bacon pigs; large white and grey crosses straight out of the field.  The piggery, of course, didn’t even own a reliable electrical supply so we had a generator.   We set up the whole lab, everything, the fusion pumps to do the clearance studies, and eventually the micropuncture, in a piggery.  Doesn’t appear in the papers, it appeared in the AGP a long time ago, but it must be something of a first.  But I think that was why Francoise accepted the challenge; she wanted to do a biopsy something as big as a human to show it could be done.  One of the interesting things that emerged from that was we had a great deal of difficulty with the anesthetics for the pigs, for the micropuncture.  One of the sights that I have not forgotten since, which took me back to interest in acute renal failure in the 60’s again, was watching a pig kidney whose cortex was completely ?hischemic with the tubules collapsed, completely impossible to micropuncture, producing quarts of urine.  Clearly there’s a whole outer cortex shut down.  That’s what halothane does to a pig kidney, but eventually we just used vast doses of barbiturates and it bled everywhere.  My job in the main thing was I went back to being a surgeon, I had to open up the pig, and prepare, and set kidney up.  I haven’t done surgery for, I forget, how many years. 

 

AR:          I hadn’t realized you done micropuncture in those experiments.

 

SC:

And then she did the puncture.  Yeah, yeah, it’s in the AGP in 1970, ’79 or something like that.

 

AR:         Must have been obsessed with glomerulus in those days. 

 

SC:

But gout, I’m talking off the record; my family has gout and I had gout and have gout in the past, so there was some incentive for me to study uric acid.  But it’s a fascinating molecule and of course Rick Johnson, he’s another old friend, I wish Rick had come and worked with us but he didn’t, I like him very much, down in Texas.  He’s brought the uric acid back in.  He’s done the things that we should have done properly.  We were sure uric acid was toxic.  We knew it was doing things but we were never able.  We were still trapped in the idea that uric acid was toxic through the formation of crystals.  We were pretty sure that soluble uric acid and some of its metabolites were nasty, that’s why we went for it in uremia, but he’s been able in a series of absolutely beautiful experiments, blocking ?uriches and otherwise with oxynate to demonstrate how important uric acid, I mean, I’m very pleased to see those papers coming out.  And Rick’s also such a nice guy to be with, and also very bright.

 

AR:

One of the things that’s always amazed me is how you’ve managed to do all of these things.  How you’ve managed to find the time, not only the time to do the things that are work related, but also all the other things as well.  How have you managed to find the time to do all these things?

 

SC:

Well you have to work very fast, concentrate extremely hard in what you’re doing, and work very hard.  But of course there is a price.  Families suffer when they’re attached to people like me.  During the 60’s especially when we were, and early 70’s, and we were working virtually single-handed, before we were able to build the unit up to something like a reasonable size, 20 or 30 people.  When you were two of us doing the whole thing, families didn’t exist, and when we got home, “Mommy who’s that man who comes in and falls asleep on the sofa?”  “That’s your father, dear; don’t wake him.”  It’s not a joke; it’s a very real problem from the families of the driven.  The drive comes from inside and you’ve got to be very, very careful not to drive things over the limit.  I was very lucky Margaret, my wife, was able to come to a lot of meetings.  We always managed, even in the early days, to dump the children, and the children loved, “when are you going away next?” they’d used to say.  But it’s something, and yet again I keep mentioning Berlin.  As I’ve said in Berlin, its part of the untold story of people who do a lot.  But I’ve always been interested in trying to related science into its cultural background, to the arts, and to not that it sounds very highfalutin, but basically to see science as essentially one human activity, which is part of a repertoire, which is seamless.  Science is exciting and we’re beginning to get signs that people actually recognize this, and that it has cultural value in itself, and the history of science is as fascinating and interesting as the history of painting and the history of literature or literature itself.  The way people discover things and work out.  Science has dramatically altered how people think of themselves, from the sailors and onwards.  And it’s important that people realize that.  It’s built in, not as something over there or outside culture, but as an integral part of culture.  We haven’t got there yet, but I think there are signs we are getting there.

 

AR:

Well, as usual you are one step ahead of me, because the next thing I was going to ask about was the work in the history.  Again, a broad cultural extension, but…

 

SC:

Yes, it was something that always interested me.  I read general history obviously, and the history of medicine in particular because I am a doctor, and because I’m a nephrologist, the history of nephrology.  And since there was no history of nephrology you have to write it.  In fact on e of the earliest papers that I published in 1964 was a history topic on some histology, on some micro dissection of nephrons Richard Bright and his colleagues did in 1839, so there was nothing new.

 

AR:

And of course there was a later paper on the reexamination of some of the kidneys from some of Bright’s patients using modern approaches. 

 

SC:

Barry.  Every pathologist in Guy’s has taken those out and restudied them.  Barry Hartley’s produced some absolutely wonderful pictures from that most recently, but I think every pathologist who’s been concerned with Guy’s over the last thirty years has had them out.  I think they were first dug up and restained in the 1920’s or 30’s by Arnold Osbourne and his colleagues.  As you know one of them has ?analoid and the two have MCGN, which is an interesting commentary on the sort of diseases that occurred in ?Bermansium in the 1820’s 

 

AR:

Now you’ve always in your primary historical research emphasized forgotten people or under-recognized people.

 

SC:

Well that’s relatively easy.  If you’d like the soft option to go for people who haven’t been written about or have been forgotten, because if you write about Bright you’ve got an enormous amount of baggage, and also it’s not so necessary to do that.  One of the things I’ve tried to show is there’s enormous amounts of exciting stuff out there which nobody’s looked at.  So in a way, we’ve discussed together before this interview, interview’s an awful word, before this chat, why people get remember and why they get forgotten is something that’s beginning to fascinate me in science in general, and in medicine in particular, and in nephrology precisely.  Because there’s got to be an anatomy, there’s got to be some mechanism before all this that we can crack, so we need a few hypotheses to figure out why X is famous and Y has to be dug up and resurrected. 

 

AR:

To what extent do you think it is due to families?  You’ve mentioned elsewhere about families of nephrologists and have cited Homer Smith and Robert Pitts as being part of an extended family, which…

 

SC:

Well I’m Homer Smith’s grandson.  Homer Smith taught my mentor Stretch Becker and Stretch Becker me, and Homer Smith also taught Pitts and Pitts taught me.  I’ve actually wanted to do a formal genealogy to try and draw out; you’d need a computer to do it, a series of stars.  Of course, some people who’ve trained an enormous numbers of people, like Don Seldin, for example, I had the pleasure if interacting with ?ski meetings which they’d run for years between many of the people that Don trained and worked with.  That’s another; it would clearly be a huge starburst from Homer Smith and Don and so many other people, well Hamburger for a start.  It would be very interesting to know.  And many people translated through several labs.

 

AR:

Marriages.

 

SC:

Yes, so it would be very interesting to look at who taught who.  I mean the 19th century for instance; Carl Ludvich taught almost everyone.  Everyone who was anyone in physiology in Carl Ludvich’s labs for about sixty years, quietly, you know.  We all remember him for describing glomerular infiltration in the 1840’s, but of course he went on for thirty years to contribute and invented the ?smokedrum, for example.  Farr, ?Volharden Farr taught in Germany a large number of Japanese and American pathologists, including ?Kimmel ?Stewart for example, who went back and influenced a whole new group of people.  There are always these key people who, ?Volhard himself obviously in Germany, clearly influence vast numbers.  There are always learners, who stand outside this framework. 

 

AR:

In a sense that was behind my question, almost.  Is it the learners are being forgotten or are there people well within the families that have been forgotten? 

 

SC:

Certainly some of the people that have been forgotten have been learners.  I mean, if you train a lot of people you will probably be remembered, because they probably will remember you.

 

AR:          For good or ill.

 

SC:

            If for one reason or another you don’t train people, or your lineage dies out very quickly or you die young and have no chance to establish a lineage, you have much greater chance of being forgotten.  But that obviously isn’t the whole of the story.  I’m thinking about that.  I feel a paper coming on. 

 

AR:         Yet another one. 

 

SC:        Yet another one.

 

AR:

Well, we’ve talked a bit, and it has been a chat.  One of the delights is being able to sit down and talk without interruption for two hours.  What have I failed to ask you about?

 

SC:

            Well I have my crib here.  I will admit I have a piece of paper here, but I haven’t been using it at all.  I’ll just see if there’s anything that really bites me that I haven’t said anything about.  Nope…

 

AR:

            This is rather worrying, we both have our cribs and neither of us have used them. (laughs)

 

SC:

            I think I have said all of what is in here somewhere.  Oh well one thing, and we have mentioned this a little bit, but the ?Rolar unit, that was purely selfish, one thing nephrology can be generally, we touched on the doctor-patient relationship and the doctor-nurse relationship, I was far too selfish when I talked about our unit.  We did that.  But nephrology as a whole pioneered the medical pattern which is now standard in terms of increasing nurse responsibility and patient contracts and cooperation.  I think nephrology should be very proud of that, it’s something that is not being flagged from the housetops.  It was not just we who were doing that, I think it happened more or less everywhere.  The chronic disease, someone being on dialysis for thirty years with you has to change the relationship and the way you treat a patient and I’m proud of that, I think nephrology helped do that. 

 

AR: 

Only it’s very curious, being someone who has moved from one unit to another after twenty years.  I think the most difficult thing was actually the patients, because many of whom I had known for certainly well over a decade.  And many more…

 

SC:

            Well I was sessile; I stayed more or less in one place for my whole clinical career.  I never intended to.  When I trained at Guy’s I thought, “What a dump!”  Apart from John Butterfield and Russell Brock, there’s no way I’m staying here.  Then in 1966 we got off at a renal unit, if we could take on dialysis patients it was obviously an opportunity we couldn’t refuse.  And then I still thought I’d leave; I thought I’d become a professor of medicine quite quickly somewhere else.  But somehow or another I liked nephrology better than being a professor of medicine, so I stayed professor of nephrology all my life.  I actively turned down the idea by coming.  I could seethe, it would swallow me up in administration, obviously I had to do my slog of administration, but this is a problem that people face now. You as ?regis ?professimist know this as much as anybody the huge administration load that talented people have to bear.  I’ve often thought, and I don’t think he’d mind me saying this, I’ve always thought Keith Peters was appointed far too young to do a vast job and that he needed another ten years to explode his huge talent, and I think there were a lot of things that he didn’t get to do.  Of course, not that he’s not brilliantly talented at what he does as a politician in the way you’ve discussed it, for making things happen.  But I’ve always felt that Keith might have done something quite extraordinary with another ten years in the lab, but he got swallowed up into the, what I would call the, admin moor.  If you are out there Keith please don’t take offense to that, I am one of your admirers.

 

AR:

            I absolutely agree he could have done that if he wanted to.  I suspect he preferred to do something else.  But that does emphasis the problem of people who get sucked into doing the next big job out of the default position.

 

SC:

            And they lose their ability anymore to use their minds for day-to-day research.  We’ve discussed the gap between, the fragmentation of science and clinical.  This is another thing, the invasion in both the university and the clinical.  The huge burden of additional duty that now falls on the form filling, the planned statements.  I think we were hugely privileged, my generation; we had a Garden of Eden.

 

AR:         The world was expanding.

 

SC:

            If you wanted to do something, you did it, and then you asked about it afterwards.  Now you’d have to go through…we’ve often said, dialysis if it had to be invented now it probably never would have begun.  I don’t know if transplantation would have gotten off the ground until there was ten year survival in dogs, and certainly some of it killed the first seventeen patients as happened with Kolff during the war, would never have passed any committees today.  It’s so much tougher for people now.  The burden of this vast group of people in chronic renal failure, as well as the burden of administration, as well as the burden of dealing with all these different aspects, a chariot with not one or two horses, but ten horses all pulling in different directions.   I think we were lucky, I think we were privileged.  I really enjoyed my career in medicine, and I’m still enjoying it.  I’m not over yet.

 

AR:

Absolutely.  And on that note, it’s time for me to say thank you Stewart, it’s been a pleasure to sit here with you.

 

SC:        Ok.

 

AR:        Good.

- fin -