The Mary G. McGeown Unit at Belfast City Hospital is named for Mary Graham McGeown, better known to most of us as Mollie "McGowan" (pronounced as), who was Consultant Nephrologist here in these hospitals from 1962-1988, and who developed the services for kidney patients in Northern Ireland. Mollie McGeown, to use the name we know her by is now Professorial Fellow at the Queen's University of Belfast and has previously had a career as President and now Honorary Member of the Renal Association of Great Britain and Ireland, is an Honorary Member of the European Dialysis and Transplantation Association, an Honorary Member of the European Dialysis and Transplantation Nurses Association and of the British Transplantation Society. She is a member of numerous other societies, some of which have given their distinguished honors to her, has published widely in the field of renal disease and has been involved for three decades and more in the field of renal replacement therapy and treatment of kidney disease.
NM: Mollie, I notice that you were born in 1923, so you are now 74.
MM: Yes. I was born in Lurgan in Northern Ireland in July 1923. I lived my early life on a fairly remote farm about four miles from Lurgan and about a quarter of a mile from the nearest neighbor. It was in a late 18th century longhouse, which had been in our family for many generations by my time, all under one slate roof, with the out-buildings connected onto the same roof but not actually connected to the dwelling place.
NM: So your early life was really on a farm. Your mother was left relatively early with having to run it herself.
MM: My mother was left a widow at the age of 37, actually in 1929, at the beginning of the Depression, when my father died of lobar pneumonia. He did not receive sulphonamides. My brother was then 22 months old and I was not quite six. She'd been a nurse and had no knowledge of farming but we had to earn a living on the farm. And it was hard going in the 1930s for a solitary woman in those circumstances. I was taught early that life was work as well as play!
NM: Though you were in a farming family, you do have a medical background in your ancestors.
MM: Yes. My mother's family had many doctors and in fact I was No. 26 in the line of doctors in our family. One of the earliest woman doctors who qualified in 1910 was a second cousin of ours. So there was a tradition of medicine in that family. My father's side were almost all farmers.
NM: You decided fairly early on, I think, that you wanted to be a doctor. Is that right?
MM: Yes. I had a long illness in my childhood, chest infections related to having whooping cough which persisted and there were several periods when I was off school for about ten months or so. At least two years were like that. So my schooling was interrupted. But doctors were prominent family life because of this and of course they had to be paid for in those days. So it seemed a career was pursuing.
Perhaps, I should say that I went to a public elementary school which was about a half mile away across our own lanes. It was a one-room school with two teachers and 35 pupils in all varying up to the age of 14 or so and I spent the first years from 6 to 11 when I went to the local grammar school in Lurgan. By 1939, I was ready to matriculate and do medicine at Queen's University but I was four days below the age limit for admission and this rule was never relaxed, so in that sense I was a bit precocious. And so I went back to school. This was just at the outbreak of war and the yard man who had been my mother's stalwart, had found a much more lucrative job in the local airfield and he wanted to be relieved of his job. So I became his substitute in the yard. I could muck out the pigs and milk the cow and feed them and even look after to farming sows and litters and so I was a land girl. And I loved that and would willingly have given up medicine for farming except for the fact that my brother who was four and a half years younger had already declared he wanted to be the farmer. So the University was the next step.
NM: Your mother must have been sorry to lose you really but she, I think, was a pretty formidable character. She kept things going.
MM: She certainly was and not only formidable in the hard-working sense but had a sense of other things - she read voraciously and she loved art. She indeed had painted as a young woman. She loved going to auctions and antique shows. These things have been my interest later in life.
NM: Yes. Anybody who knows you knows about going into antique shops or to auctions with you, so it is certainly something you inherited from your mother as well as your love of medicine.
So you got into University to study medicine more or less at the beginning of the Second World War and of course at that time there was a distortion in people being admitted because many people had to go and serve in the armed forces.
MM: Yes. The wards were depleted of medical staff below the level of consultant and the senior doctors often were carrying on almost single-handed. You must remember that in those days nursing and non-qualified personnel were not allowed to do the minor tasks that were assigned to them today. So medical students at that time played a bigger part in hospital life than they do nowadays. We were valuable pairs of hands to take blood or for any purpose - to aspirate chests, to do lumbar punctures and in casualty to do minor operations and short anesthesia. So we had all these practical tasks and we played a role that we felt was important and so we became adept at taking histories and talking to patient and we soon lost our diffidence with them. This was a great skill that was instilled on us early on.
NM: So really the sort of medical studentship that you are describing is what now - much of it - takes places in the early postgraduate years of training.
MM: We did most of the things that SHOs (senior house officers) do nowadays. In fact more to some extent.
NM: I think that's food for thought really that that's the sort of responsibility you had to carry. Now, I think you graduated quite well.
MM: Yes. I got honors in 1946. We graduated in five and a half years because the course had been curtailed by six months because of the wartime need for doctors.
NM: And was University life very austere in those days or was there still time for a certain amount of fun and the sort of life University students expect?
MM: Well, we thought - I certainly thought - that it was a very outgoing form of life compared to living in a remote place where I saw my school friends only at school and rarely occasionally otherwise and here I was living with people in somewhat luxurious surroundings. It was the first time I'd encountered indoor plumbing and electricity - they didn't come to the farm until much later when I was grown up. We had a lovely library with lots of books and a log fire and we changed for dinner. A totally different spectrum of life began for me. Apart from those material luxuries, there was lots going on in the University. There was the Debating Club, and for those sports-minded - there was lots of things to do and of course it was great fun living in hospital as a student. I loved the resident-patient relationships when we doing all these tasks. They weren't really work to use - they were fun almost.
NM: I'm sure that sounds very encouraging to students entering medicine nowadays - that it still can be fun.
When you graduated you clearly had proved your point academically. What was it like as a young woman in a relatively male-orientated society, trying to get jobs in hospitals?
MM: It soon became very difficult because the wards were flooded with young doctors who'd come back from the War - some of them hadn't completed their houseman training and therefore they were slotted in as senior housemen and they were all working for higher degrees so they'd have gratuities and they were ahead of us in the rat race in that sense. Not only that but when it came to applications for jobs the magic: "have been in the forces" was an important pull to getting a post compared to those who had never been in the forces.
NM: So that wasn't particularly due to being a woman. It was an indirect problem really. But you obtained house jobs, I think, both in medicine and then in surgery.
MM: There was no problem in getting a first job provided you were within the upper 60% or so of the class - no problem at all and I was in a teaching hospital as a house surgeon which I will mention in a minute because it played a very important part in my subsequent career - six months in surgery, six months in medicine and then six months in pediatrics which up to that point had been my favorite subject.
NM: Yes. I think you enjoyed that when you are a student didn't you?
MM: Yes, very much.
NM: And not difficult to understand you might have pursued that as a career.
MM: Yes, I saw myself as a pediatrician - not as a general practitioner which was my earlier vision of being a doctor but as a hospital doctor, probably in pediatrics.
NM: You clearly felt you were up to the challenges of hospital life?
MM: I hope so. After all I had enjoyed so much being a resident pupil and so I felt that that would go on in a modified way perhaps.
NM: Your job a surgical houseman, I think, was really quite important for you wasn't it?
MM: Yes. It was my first introduction to urology which was really only becoming a subspecialty of surgery in those days and the Head of the Department, Cecil Woodside, was particularly interested in kidney stones. He must have achieved some international reputation in this field because he was to have received a medal at a congress of urology to be held in 1939 in Barcelona. But in fact this congress was postponed, in fact never held, because of the War and I later inherited his medal and the proceedings of this congress which did not in fact take place!
NM: A virtual congress in that case! I think you found him to be a meticulous operator who obviously impressed you?
MM: Yes, he was a beautiful surgeon with very good hemostasis and was predictable - he did an operation methodically and so I found being his assistant was quite simple and straightforward, unlike some of the other surgical people I had assisted during my studentship years, who were totally unpredictable.
NM: Yes, many of us find this with our surgical colleagues that they vary one from another but there are these very excellent surgeons. And I think he and you took up the idea of stones in quite a big way.
MM: He was very keen on stones as an important cause of illness in our province and elsewhere and he always had a number of patients awaiting operation for stone disease and he wanted them very fully investigated and their family histories gone into and ultimately arrangements made to follow them up at a stone clinic which he was hoping would be formed but it did not exist at that particular time.
The other point that was relevant to how I got to know him was the fact that he wanted to introduce to the hospital the newly formed Classification for Hospital Diseases and he, as a senior surgeon, thought that it should be started in his ward and after the first three months it was beginning to flow and he made an exception that I could stay for six months instead of the usual three. And so of course I got to know him better and became more interested in this problem of renal stones, though I still wanted to be a pediatrician at that time.
NM: Well clearly you had to move on and you did some pediatrics and then when you came to the end of your pediatric houseman time, where did you think your career was going to take you?
MM: Well I felt certainly into medicine rather than surgery. Medicine attracted me much more but as a student, the most impressive of our lecturers had been Professor Biggart, later Sir John Henry Biggart and he as a lecturer was a very charismatic man - a very impressive lecturer - and he gave us the message that, "... you would never be a good physician unless you understood at least the rudiments of pathology..." So I thought, "I'll set a good foundation to my career as a physician and learn some pathology, and hopefully get my M.D. at the end of it." So I went in October 1948 to his Department as an Assistant Lecturer.
NM: This must have been very courageous. He was a man of formidable, not to say, dominating personality, who created a lot of Northern Ireland medical strictures and I think you must have had some courage to go and get a job in so distinguished a Department and with such a Head.
MM: Well it didn't strike me as courageous at all at the time. I just thought it was the obvious thing to do having listened to his lectures.
NM: He must have been taken by your approach! You then did an experimental project, I think?
MM: Yes. It fitted in with what was going on in the Department. Previous holders of assistant lectureships had got doctorates for how to establish valve disease by intravenous injection of horse serum and I extended this work by studying vasculitis by producing bacterial endocarditis with strep specimens isolated from human patients. At that time the first few patients who'd been treated with penicillin for subacute bacterial endocarditis were beginning to come through and so I was put to study them in some detail and the widespread lesions in their bodies and so on, and at the end of that I got an M.D. with Distinction.
NM: So you got your qualification with distinction and now you'd got an M.D. with distinction and you are also doing through this time general pathological work.
MM: Yes, we took part in the general postmortem work and studied in common with everybody all the cases that went through the Department. So at the end of this time I had a good grounding in general pathology as well as an M.D.
During this time I got married to Max Freeland, who was a senior administrative office in the University. He was recently widowed and had two small boys. I knew Professor Biggart liked to know the personal life of his staff so before announcing it in public I went to see him one afternoon and told him that I was about to get married to Max Freeland and he was very kind and congratulatory and so on. About 15 minutes later we met at the tea table and he said, "So you're getting married Mollie?" I blushed, of course and he said, "I suppose you know that you will have to look for another job as I don't have married women on my staff?" I would have been even more nonplussed if I'd hadn't realized that I had not intentions of becoming a pathologist!
NM: Yes, you came up the reality of difficulties of women entering medicine in that era.
MM: For the first time - that afternoon!
NM: And I think that was fairly shortly followed by the difficulties in trying to get the career you wanted.
MM: Well, as soon as the M.D. results were reported I went to see the Professor of Pediatrics, Professor Fred Allen and said, "Please sir, can I join your staff as a trainee and work for my DCH?" And he said, "No! You're married and you're a woman." He had plenty of young doctors all back from the War all working away for the DCH and he didn't want a woman.
NM: So there you were - you'd done everything which could be asked of you. You were being blocked by really a glass ceiling almost as to where you could go to, what did you do?
MM: Well, my husband just dried my tears and said, "Why don't you learn some biochemistry. It's bound to be important for developing medicine." And so, prompted by him, I went to see the Professor of Academic Biochemistry in the University, Professor Harrison. He didn't exactly welcome me but said if I stayed for three years and worked for a Ph.D. in the Faculty of Science, then he would consider me and so I was another three years away from clinical medicine but there didn't seem to be any option, so I joined his Department.
NM: This meant going back to basic research really - a somewhat different subject but at the end of three years what had you got to show for it?
MM: Well, I'd taken part in the Departmental research which was into the phosphate esters in milk which was related to DNA work and my particular contribution was the synthesis of ribulose and deoxyribulose, the sugar moieties of DNA and RNA. I was greatly thrilled when I had a letter in Nature and later the work was presented at an international congress of biochemistry in Paris in 1952 where the major topic was DNA.
NM: And you got a Ph.D. I think?
MM: And I got a Ph.D.
NM: That would be in what year?
NM: So between '46 when you graduated and '53 which is seven years later, you'd done your postgraduate training, you'd got an M.D with Honors and a Ph.D. So you hadn't been slouching about in that period of time! Interestingly, it is difficult to see how with the modern rather structured training program you could have slotted it in at all.
MM: I am aware of that. When I listen to what goes on in the ward still and hear the difficulties that young nephrologist, I realize I wouldn't have got anywhere in their system.
NM: It's certainly food for thought. Now, by this time you really did need to get into a clinical line and I think you had some help here?
MM: Again my surgeon, Mr. Woodside, suggested that I should approach Professor Bull, who'd just come to Belfast as the first full-time Professor of Medicine and he hadn't yet completed his staff. so I made an impromptu attempt to meet him and told him what my problem was and he said quite reasonably, "Well I do have a lectureship in Medicine but you haven't done any clinical medicine for five years or more, so you're not really going to be able to teach my students but the MRC might give you a fellowship if you could think of a suitable research project." So I remembered the council of Woodside and said, "Kidney stones" and he said, "Do you know anything about them?". And I said, "Well, a little clinically." He said, "Go bash the books in the library and work out a research project and come back to me." Amazingly, the MRC accepted my project and it supported me for five or more years later and was in fact the basis of how I came into nephrology.
NM: So you'd eventually got somewhere near there - can you tell a little bit about Graham Bull because he is one of the historical figure in renal medicine?
MM: He had come from Cape Town in 1948 to Hammersmith, just at the time when they had received a gift from Willem Kolff of one of his original rotating drum kidneys. It had a wooden bath and so on. He had developed there at an amazingly young age and got a professorship in Belfast. He was regarded as some as cold and forbidding and very strict in his outlook on medicine in general but I did not find him cold. I found him helpful in every way, perhaps because at the very beginning he did depend a little on me - he was setting up a new laboratory and I had considerable laboratory experience by this time and I expect he thought I could help with the practical aspects and indeed I did just that for many months before I really got started on my projects related to stone disease, though I did set up a stone clinic in those early months.
NM: And were you beginning to take part in the activities of the clinical side of the Department?
MM: Yes, he said, "You'd better get back to clinical medicine hadn't you?" and I said very enthusiastically, "Yes please." So I used to attend his ward rounds and take part in with outpatients. Later on he developed a system of helping all the surgeons with their electrolyte problems which were considerable in those days because nobody understood it but him and he suggested one day that it was about time I helped him with this load. So I was taken down the corridor a few late afternoons while he looked at the problems and prescribed for them and in no time at all I found that this was my daily chore.
NM: So you were getting a wider basis in basic renal medicine?
MM: Yes, particularly slanted to electrolytes and of course my own topic, calcium and phosphate.
NM: I can see two strands developing here - one was your own research work and the other was the work on renal failure which would have been already involved. What about the first one? That was your actual research.
MM: Well, I proceeded to read everything I could about calcium and phosphate and the parathyroid glands and then began to set up some laboratory research aimed to discover why calcium in particular is held in solution in urine. I wasn't sufficient a physical chemist; I had a fair grounding in biochemistry but not in physical chemistry and I didn't get as far in that as I thought I would be able to. I tackled phosphate metabolism and I got a good bit further with it and I have a number of publications which I still feel were worth doing in those early days. Indeed, phosphate metabolism is still a cause of concern and is still a largely understood problem of why some people get kidney stones.
The other point that I worked on was the heredity of stones and there were some papers in connected science and so on which were related to that - taken up by people who were studying heredity later.
NM: Did this you lead you into studying the parathyroid?
MM: Oh yes. All the patients at the stone clinic were assessed for hyperparathyroidism and we discovered that it was astonishingly prevalent among these patients. And I just about reached that point when Woodside died. His successor, Earnest Morrison, was a bit like him in the sense that he was a very neat surgeon, very good at hemostasis. He was already interested in neck surgery and he was very keen to embark on parathyroid exploration. So I chose some likely candidates from my stone clinic and he explored them and he wanted me to be there as another pair of eyes because parathyroid adenomas are small and they are not easily seen against the other tissues of the neck. So I used to attend all his surgery of neck explorations and indeed of the ones that followed him for quite a while. This cooperation with a surgeon enabled me to publish my laboratory findings on stones and he and I were invited as a twosome to surgical meetings. This in fact led to me being elected an Associate Member of the British Society of Urological Surgeons. I was the first woman to be so and probably the first non-surgeon. So that looked good on my c.v.
NM: Your testing for parathyroids must have being quite interesting in those days. Did you have a high hit rate?
MM: Very - over 90% positive explorations.
NM: They are now measuring urine calciums and things.
MM: With Mary Clarke, a recent chemistry graduate, I made an early attempt to assay parathyroid hormone. This proved impossible with our resources. Mary went on the work at the Royal Postgraduate Hospital in Hammersmith and later with John Potts in Boston. She is now Associate Dean of the Harvard Medical School.
NM: Did you also get interested in renal tubular work at this time?
MM: Yes, well the phosphate stuff was renal tubular and indeed had relevance later to my interest in phosphate in patients who are dialyzed which I feel has not been given the importance it should have been.
NM: So by now you'd had a fairly widely experience in stones and in managing electrolyte problems which was really quite a big field in those days and so little was known about it. Maybe less on surgical wards than on medical wards but not much anywhere really. Also you had a lot of biochemical basis in both the kidney and stone formation and outside that. So you had a wide grounding in many of the elemental parts of renal disease. What about the work which was being done on renal failure at this time? Remember Graham Bull was well known for having been involved in dietary management of this.
MM: Well, when he came to Belfast he had a distaste for Kolff's equipment - it was difficult to use, the patients often got sicker while they were on dialysis than they'd been to start with and got convulsions and certainly got rigors. He and his colleagues in Hammersmith had developed this conservative method of management of renal failure which became famous as the Bull-B?.......... diet. So he proceeded to set that up for patients with renal failure in Northern Ireland. Of course they all were sent to him. So as time went on I was involved in their treatment and became very aware of all the disadvantages of this treatment in that the patients were very thirsty, they were nauseated, they developed sore mouths and there was the ever-present danger of developing hyperkalemia as time went on if you did not have dialysis as a resort to improve their potassium balance. We isolated the patients and we fed them high carbohydrate pure fat diets but this was very unpalatable for these nauseated sick patients.
NM: We're talking now about the later part of the '50s?
MM: Yes, the second half of the '50s. That was really worldwide, apart from a very few centres. The only form of treatment available for acute renal failure. There were three other centres in Britain who had those - Glasgow, Leeds and Hammersmith - at this stage.
NM: Glasgow with Arthur Kennedy.
MM: Leeds with Frank Parsons. But Frank was a bit later. To begin with there was Hammersmith and Glasgow and then Leeds followed on and then soon after that the RAF establishment at Farnborough.
NM: So you were one of very few units at this period who were really looking at the management of renal failure, both acute - only really acute.
MM: But they were only a few (patients) to whom it was really feasible.
NM: Now by 1958 you had how many children?
MM: Well I had two stepsons and two little boys of my own, born in '56 and '57.
NM: So you were running a fairly busy household, I think, with four boys prancing around the place, you were doing research, and you were developing a fairly wide interest in the clinical field of renal disease in really some of the quite difficult areas of it. Bull was quite well known really worldwide. Did you manage to meet people?
MM: We had a lot of visitors because of his knowledge of acute renal failure and electrolytes. People like Merrill came to visit us and I remember he was charming but wasn't really interested in either stones or phosphate metabolism which is what I was working on at the time.
Jan Brod was another, who has had a connection with Northern Ireland in that he had worked here when he was in the free Czech forces during the War and had become a friend of the Physiology Department. He continued to visit and on one such visit I was detailed to amuse him for a couple of hours while everybody else was busy and he was very interested in my subject. We met him later socially at Bull's house. Bull was a very hospitable man.
About a year or more later, the first nephrological meeting was held in East Berlin and Bull, of course, was invited but it wasn't possible for him to go and he wrote and suggested to the Secretary that I could go in his place. He had sent me on various meetings abroad before this, under similar circumstances, on condition that I wrote a report for the South African Society of Scientific and Medical Research, who had covered my expenses. So I was keen enough to do that. So I went to East Berlin for this first meeting. Brod, who happened to be the Secretary of it, wrote and said, "Would you like to come to Prague afterwards and give a talk on your research?"
The East Berlin meeting itself was very interesting because East Berlin was still, in 1958, largely in ruins and the Congress was held, if you could call it "Congress", in the Hotel Adler in what had been the back quarters, the servants quarters, of this hotel. There was only about 20 people, few enough to sit around a boardroom table. And I remember that one of the other participants was a man called ?Blint, a biochemist with a colorful private life, whom I had encountered before. The gyrations of him and his ex-wife and research fellow in his Department enlivened the meeting somewhat.
The meeting was in English but it followed the German tradition in that they described the philosophy of the research before they did the methods and results, so it was in that sense a bit confusing for me. Afterwards, ?Brod and I went to Prague and I had a delightful meeting. It was the beginning of a friendship which lasted until he died.
NM: Yes, of course, he was one of the people who didn't go back to Czechoslovakia after the revolution.
MM: He was out on holiday when Dubchek fell and he didn't go back. And in fact he was only back, I think, once toward the end of his life. So he was exiled from a city he loved very much. He became Professor of Nephrology and Head of a big department in Hanover and from 1972 onwards he had yearly meetings which were attended by the great and the good in nephrology in those days.
NM: Now, of course, you really needed to get yourself back, I think, into full-time clinical practice after being involved with research a lot of the time.
MM: An opportunity for this came about rather unexpectedly. A patient that Bull and I had treated was the son of an obstetrician, a prominent man in the Province, who had acute renal failure following a road traffic accident. Of course, we had no artificial kidney, and it looked as if he was going to die without artificial kidney treatment. So we sent him to Hammersmith for treatment there. Ironically, on the journey he began to produce urine and of course made a full recovery. However, this led to questions in the Stormont House of Parliament about did Northern Ireland need an artificial kidney. While Bull was no enthusiast for this, Mr. John McGaw, who was a general surgeon with interest in urology, working at the City Hospital, which had recently been elevated from the workhouse status, which it had occupied, saw this as an opportunity to improve the status of the hospital. He went to see to ask him could he think of how he would go about this idea and Bull brought me into the conversation and indicated that I was looking for a post in clinical medicine, which was true. I said I'd seen an artificial kidney once but I knew really nothing about it but Bull broke in with my experience with electrolyte problems and the conservative management of renal failure and so it was decided that I was the one to set up the service. It was not, of course, at the consultant level because of the usual lack of finance, and indeed, it was four years before the post was finally advertised as a consultant post and I was appointed in 1962.
NM: There are one or two points of history there. In those days, Northern Ireland had its own Parliament, really before the days when what we call "the troubles" began and their influence on some of work which you did in later years.
MM: Yes, indeed. We had a lot of post-traumatic acute renal failure related to "the troubles" later.
NM: And the second thing, of course, is you mentioned the workhouse. Now I think British people know what a workhouse hospital was. Perhaps you could give us your idea of what it used to be like.
MM: Well these hospitals were mostly from the early 19th century and from the days when unemployment led to starvation virtually and this was particularly bad in Ireland during the 1830s and 1840s, when the potato crops failed and there were serious famines. In fact millions died of starvation. The only resource was the workhouse. These were supported partly by Government and partly by the local philanthropists from the great landowners. The City Hospital had been commenced about the 1820s and it was largely a fever hospital to start with and for the totally impoverished, starving poor. It continued, with some improvements to become a somewhat better hospital and it was during the war years that it became prominent as a general hospital and so McGaw was the Senior Surgeon during this post-war period when it was developing.
NM: So when you had your consultant appointment you moved to the City Hospital which was really not the major teaching hospital then in Belfast. I know it has become now a very prominent teaching centre.
MM: Well its equal with the Royal Victoria Hospital but it was not at that stage but in fact from 1959 onwards my clinical work was based at the City Hospital, though in fact I set up what amounted to a travelling dialysis service until some premises were converted in the City Hospital.
NM: So it's 1962 and you'd been in practice really from 1946 to '62, bringing up your family and getting yourself trained in all the biochemical and other research projects. You were really very well equipped, rather enviably, but interestingly, you forged an entirely individual task through medicine. One you couldn't replicate in the sort of rather structured life of today.
MM: That's certainly true as I am aware seeing young doctors in nephrology who are trying to make their training fit the rigid structure of today.
NM: So you're really into the dialysis era, and really quite early, just at the beginning of the '60s we're talking about now. How did you go about getting it all developed?
MM: After the momentous interview with Mr. McGaw and Professor Bull, I went with Mr. McGaw, first of all to Leeds to see the rotating drum with Frank Parsons and he emphasized the difficulties in use. He prescribed exactly the same thing as Bull to dialyze the patient.
NM: Did you find it as something really you wanted to be enthusiastic about at first?
MM: At the end of that interview I was not enthusiastic and I phoned my husband and said, "This is not my pathway." And he said, "Well, why don't you continue with the visits and go and see the next one." This turned out to be Ralph Jackson at Halton, where they had Kolff's new model kidney, the twin coil. Jackson was a very benign, gentle sort of person and he assured me that my background was ideal. All I needed was the equipment, a room where I could isolate my patients, a technician, which he said were very easy to find; a technician who would be able to service my equipment and weigh out salts and such like and be a "general dog's body". It would be perfectly easy! When I got the equipment and had become familiar with it, he would send for me and I could see a patient or two being treated at Halton and it should be really well within my capacity.
NM: Halton, of course, is an Royal Airforce hospital. It's part of the military establishment, so naturally it had good equipment.
MM: It had good equipment and of course loads of well-trained technicians of various sorts who were at Jackson's call.
NM: But hospital life was rather different?
MM: Hospital life was totally different. I went back to City Hospital and ordered a twin coil kidney from America. It was made at that time by Travenol in Chicago and Mr. McGaw wanted to do some conversion of his ward to facilitate his urology ideas and a bit was to be cut off to provide two single-patient rooms, a room for dialysis and an office-cum-store, which was to be the new renal unit. I recruited a technician from the Biochemistry Laboratory, who would certainly know how to weigh out chemicals and such like, simple tasks.
NM: It's interesting how these doyens of renal medicine at that age were keen to get urologists to do this work. In Manchester, Sir Robert Platt got the urologists to run the artificial kidney too because I was the houseman for that service. I think they thought it wasn't the work for gentlemen physicians to be doing!
MM: He comes into my story later.
NM: Now, your equipment eventually arrived, you got everything sorted out and, of course, you were well experienced in how to use it, no doubt?
MM: By the time I got my premises and was fully equipped, I was already in possession of some experience but in fact how it started out was that there was to be a postgraduate course that McGaw was giving at the City Hospital and he wanted this demonstrated for the public benefit of the City Hospital. So my technician, Morris, and I set the machine, following the booklet that came with it and used red ink for blood and McGaw and ........................ were duly impressed. Then Eliahou, Haskel Eliahou, from Israel, had been spending a year with Bull and he was just about to go back to Israel and he was very keen to see my new equipment in action because he supposed that he might, having trained in renal medicine, be expected some day to set it up in Tel Aviv. And so I persuaded the research professor of surgery to tie up the ureters of a dog and Eliahou and I and my technician dialyzed the dog once it was sufficiently uremic, and succeeded in keeping the dialysis going for a few hours - sufficient to show a satisfactory fall in the animal's urea, and , of course, we duly dispatched it at the end of the session. Eliahou went back to Israel where he subsequently became well-known for his treatment of acute renal failure.
NM: So you'd began to get things together. Did you want to get some practical support and nursing support?
MM: The technician I mentioned went within a year to Canada for a much higher salary than I was earning and Jack Lyness followed him from the Biochemistry Laboratory and he indeed stayed with the unit and became Head of what was quite a large technical staff until he retired in 1996 and he certainly was important in the development of the service. He trained all the technicians who came after him and was a real expert in all the variants of dialysis equipment that came later.
As to nursing, we took a nurse from wherever we could get one - wherever, when we were travelling service, the patient happened to originate. So the nurses knew nothing about it. In about 1963 I succeeded in persuading Matron that we really needed dedicated nursing staff and the first nurse was Kay MCGuire from the urological ward next door, who'd helped me many times and she was first staff nurse and it took many years before we got her upgraded to a sister but she became head of what became a very large nursing team and was instrumental in setting up a nurse training program for dialysis which was very important to us as early as the development went on and she became eventually Senior Nursing Officer until her untimely death in 1987.
NM: So you really had a very stable team over 30 years working with you.
MM: Many nurses stayed for long periods of time because they found the work interesting and there was a camaraderie and sense of purpose that was common to the whole service.
NM: What about your first patient.
MM: Well, the first patient was about a week after the dog treatment. This was a man who came in with uremia and McGaw said, "Well, you treated a dog last week, you can't let my patient die without trying." So we set it up in his urology theatre, the technician and I. For the first time, this was a really go. My stepson, John, had just got his driving licence so we stationed him in the courtyard with my car and when we needed anything from the lab which we did, or needed to send blood or dialysis fluid for checking, I shouted from the window and he came to get the specimens. Everything went smoothly except that I spoiled one of the dialysis fluid baths and he had to rush off to the medicine department to get another batch of chemicals weighed before the technician went home. But the patient survived, came out of his semi-coma and survived for another week, when he died of what appeared to be a cardiovascular accident. So that was patient number one.
The next patient was a professorial patient who had post-partum renal failure and she recovered after many dialyses after about 36 days of almost complete anuria. I saw her about 20 years later actually in the same ward when she came in with renal trouble and she had another baby a couple of years after that particular episode and had returned to teaching.
The next one was an incompatible blood transfusion who belonged to another hospital and she required many dialyses. The difficulty there was to get compatible blood for her and the lab reckoned that they had cross-matched 250 units of blood to get the 15 units that I needed for her several dialyses.
NM: It was quite a lot of blood you needed in those days.
MM: Yes, because blood was the priming agent for the twin coil.
MM: Well by new you were a world expert having been through three dialyses with your equipment, so you must have been able to tell almost anybody. Did you think you needed more experience?
MM: Well, I never got an opportunity to go to Halton after all this so you might say that we were self-taught.
NM: Did you know much about Willem Kolff?
MM: Not at that time, though I subsequently got a present on retirement of his first publication in 1944, where he described his artificial kidney treatment in his earliest patients in the first issue of Acta Med Scand. published after the War. My first acquaintance of him personally was in 1966, when I was involved in the planning of what became Renal Unit 1 and also for the new Tower Block of City Hospital, where I'd succeeded in establishing a claim for part of the top floor and as part of the planning for this I was allowed to go to America and see Scribner's Unit and managed to visit a few others on the expense sheet that I was allowed.
MM: Well, we don't want to know about that. I'm sure it was all very official though! That included going to Cleveland. Kolff was at the Cleveland Clinic. He was very kind to me. He gave me his time and access to all his research. At that time he was particularly involved in the development of ?capillary kidney with Doug Corning, which later became the important form of disposable kidney, as you know. He also showed me a calf that had survived several months and had growth on an artificial heart that he had devised. And indeed at a much later meeting he gave me one of the hearts that had actually been used for a calf, which is here with me.
NM: Well, now you are getting into an entirely different branch of renal medicine. Electrolytes is rather an esoteric, intellectual field and dialysis, while it might not be quite intellectual, is certainly a workaday field for those involved with it and you were involved with the detailed and the work. So you began to meet all the other people pioneering this treatment.
MM: Well, one of the problems at this stage, was that I was still working single-handed and there was always the problems of how I was going to be covered if any patient with acute renal failure, or indeed as if soon became chronic renal failure who might need dialysis, turned up. This was a recurring problem and I'd tried to indoctrinate Bull's research fellows so that they could step in and keep things going until I got back, if such an eventuality arose. But, yes, it was very necessary to travel and see what was going on elsewhere. This was a period of rapid development, first of all in the dialysis field, the problem of course was how to do imperative dialysis for the many patients who now turned up from everywhere with chronic renal failure and who would not recover their own renal function if given a dialysis or two. We tried various methods of trying to make the tapered plastic canula remain patent and by intermittent heparinization and such like devices, but this was a continuing problem and led to the end of many such patients.
In 1960, Scribner and his colleague, Quintin, had developed a teflon arteriovenous shunt, teflon being a non-clotting device and it could molded by softening it with heat and then making it more or less fit the configuration of the patient's forearm and the ends of the canula could be tapered to go into the artery and vein and you could connect the ends intermittently with a connector which is a standard piece of mechanical coupling which could be adopted for this purpose.
NM: Did you make these yourself?
MM: We had to make them ourselves and it was really quite a tricky procedure because if you made a dent in the tube as you bent it, it led to clotting, so you discarded it and it could take hours sometimes to get a nice one that you felt was fit to use on the patient.
NM: Were you the only person in Ireland who was practicing dialysis?
MM: At this time Dublin came into it. They had received an artificial kidney in about 1958 and had done their first dialysis shortly before us. I came to know them because we had a family holiday in Dublin and my husband was visiting one of the University staff he knew there. His daughter and her boyfriend came in during the course of the evening. He was a medical student and he said, "At our hospital in Jarvis Street, we've already started artificial kidney work." And I said, "Well, who does it?" So he said, "Oh an anesthetist called Joe Woodcock." So I phoned next morning and Joe said, "Well, we haven't got any accommodation. I've really nothing to show you. You've got a twin coil kidney, so have we. Come and meet me at the Gresham in the bar."
NM: The Gresham is a very well-known hotel in Dublin I think?
MM: Yes, a well-known hotel. And we had a very interesting discussion. A few months later the urologist from the hospital, Tony Walsh, was involved in a law case in Belfast. He phoned me and came home to see me and that was the beginning of a long friendship and that indeed has continued to this day, with the exception of Joe, who died earlier this year (1998). I often went to Dublin and stayed with them and they with us and in 1961 when I was expecting my third little boy, they phoned and said that they would hold themselves available for emergency dialysis while I was having my maternity leave which was in fact three weeks. I thinks this beats the Internet any day!
NM: So within the very small group of people practicing you had just these two groups in Ireland - one in the north and one in the south and obviously I think that friendship as you say has kept together and in fact in terms of Irish medicine the two are very unified aren't they?
MM: Yes, there is a great deal of common interest and comings and goings between the two services.
NM: We're talking now about the early '60s and by then you really needed proper premises.
MM: Yes, we were really outgrowing the limited amount of space we had and we hadn't any other equipment but the original twin coil kidney and so the next bit of it, apart from the arteriovenous shunt development, which was a necessary part, was that you could not continue to use twin coils because of the cost and because of the amount of priming blood. There had already been developed in Sweden the Kiel kidney which is a glass plate dialyzer which could be rebuilt using only sheets of ?cubophane, which turned out to be a better dialysis membrane than cellophane and did not require priming blood because the blood compartment was less than 200 mls, so you could get away with saline as a priming medium. We had no finance but Hepple, who was a patient of Stanley Sheldon's at the Royal Free - he was an engineer - had made some Kiels for the them and for his wife who wanted to do home dialysis as one of Stanley's home dialysis patients. Hepple was good enough to make a couple of Kiels for me without payment at the time, hoping someday I'd pay him. There were fairly crude in spite of working on them and honing them with various levels of glass paper. They were still difficult to build be one snagged the membranes on them but they were useable.
The other problem with this method of dialysis, of course, was the huge volume of dialysis fluid that was needed. We had only the 100 litre tank belonging to the twin coil kidney. That was solved for the time being by Jack Lyness, the technician, sleeping four nights a weeks on the couch in the surgeon's room and being awakened every time the dialysis fluid ran to a certain low level, and he made up a fresh batch of fluid. He did that for six months. I was on continuous night-time call - on the dialysis nights I never made any arrangements that would take me outside the range of my telephone and by that means we managed to dialyze a slow trickle of patients.
NM: These patients you were dealing with, of course, were thought to have acute renal failure.
MM: No, by this time when we started with the shunt and the Hepple kidney dialysis, we were treating chronics. We could not keep out of chronic dialysis because there'd be patients who'd arrived with advanced renal failure whose diagnoses were not clear. Were they in fact acute on chronic or were they truly endstage or were they acute ones who would recover? And one was not justified to wash your hands as say, "I can't treat them. There not acute." So inevitably one became involved in chronic renal failure treatment.
NM: So really it was just a progression from which there was no alternative. Once you had treatment to manage patients with uremia, then gradually some got better and, of course, for the others who'd not got better you had the problem of their continued management.
MM: Yes and this was in fact where these early patient who were treated with the Hepple kidneys came from - people that we had hoped would get better but did not. Some of those in fact went on to have transplants in the next year or two.
NM: This is one of the things that irritates administrators - that medicine seems to find new things to do and doesn't tell them about it before it happens.
MM: Well, if they had been in our shoes they might have thought differently. Many the fight and argument there was on that sort of issue.
NM: And then, of course, it was necessary in a very fast moving field to keep up with the times wasn't it? Were you able to get away and to see some other units and to go to meetings?
MM: I didn't have many opportunities to see other units except on that big trip around America which I told you about and later in London because in 1965 a meeting was called at the Department of Health to decide the knotty question as to whether it was justifiable to provide regular dialysis treatment for patients with chronic endstage renal failure. This was chaired by Sir George ?Gutber and people like Lord Platt, whom you mentioned, and Hugh de Wardener, and Sheila Sherlock, and Stanley Sheldon, Arthur Kennedy from Glasgow, and Frank Parsons, of course and others who were already involved in acute dialysis and, to some extent, a few had tried chronic dialysis, including myself from Belfast, attended this meeting. The decision was that chronic dialysis had certainly reached that stage. It should be part of the National Health Service and it should be available widespread, not just in a few isolated centres. Then the question arose as to how patients would be selected for treatment and Lord Platt, who must have been about 60 by then said, "If I developed endstage renal failure, would you treat me?" And nobody dared to answer.
NM: He was 65. He was born in 1900. I think the question would have stayed unanswered for quite a long time!
So by now it is nearly 20 years since you qualified. It's 1965-66 and you'd gone through from being what might be called a meandering course through some of the highways and byways of science, medicine, then renal medicine, then to the primary phase both of acute renal failure and with regular dialysis or chronic dialysis, as it was called. So we come through from renal medicine - nephrology - being a subject for the intellectual specialist, to being one for the practitioner.
MM: True. If I may take one moment or two to talk about that momentous meeting. It was decided at that time to set up a working party and it was emphasized by Lord Platt and Co. that we would have to be prepared to meet every month or six weeks and spent the day thrashing out all the details of how dialysis would be set up across the U.K. They thought that each hospital region should have at least one dialysis centre and that the rules for treatment - who should be accepted - and all about the equipment and supplies, all this should be planned centrally. Hugh de Wardener was to be Chairman of this meeting and some of the younger actual practitioners like Frank Parson, obviously, and John Goldsmith from Liverpool - I'm trying to think of the Manchester representative...
NM: It was Geoffrey ?Beline.
MM: Sorry - it was Geoffrey Beline
NM: And David Kerr.
MM: Yes, David Kerr. But Geoffrey used to travel with me, and John Goldsmith, travelled in the train from Liverpool - I went over on the boat to Liverpool and he used and they used to travel with me and so I got to know them particularly well.
NM: It must have been quite an experience?
MM: It was.
Hugh de Wardener had already set up a regular dialysis ward with Kiel kidneys and had centralized dialysis setup so that you could a treat a ten bed unit from one massive dialysis fluid manufactory, if you like. I went to see that and he said, "Why don't you come and stay with me the night before. We start at nine a.m." And so this became a regular rule and used to stay with him the night before each meeting. And there I learned many things besides details of dialysis. He was the most interesting conversationalist. He had already made his name, of course, for his very readable textbook.
NM: This was a friendship, I think, which has perpetuated?
MM: Yes, I'm still in contact with him and his wife after all these years.
NM: It is interesting that people from this pioneering generation have kept up relationships, friendships, and correspondence. Over a long period of time you must have seen all the changes in nephrology and medicine through really a quite dramatic period.
MM: Yes, it helped to cement our friendships. We met the same difficulties sometimes in differing ways.
NM: While you were so busy did you get time to keep up your international contacts?
MM: I did. It was essential to so. If you didn't attend national and international meetings, working in an isolated place as the only specialist, there is no way to develop. One congress I remember in particular, which was very important in later years, was the first ISN Congress in Avian and Geneva in 1961. I happened to be staying in the same hotel as Paul ?Doolen from the United States Navy, who was working at Bethesda at the time. He told me they were doing intermittent peritoneal dialysis for chronic renal failure with some success. So I spent all the time I could with him, picking his brains. He had been able to get a canula made specially to suit him and he sent me some examples of it later. I was able to use this with a makeshift dialysis fluid made from intravenous fluids available in the hospital and we did occasional patients, both with acute renal failure when we were overwhelmed with patients and also for a limited amount of chronic renal failure in borrowed premises of the professorial ward at the Royal Victoria Hospital. That nucleus of patients was transported to the next stage of the hemodialysis which was Renal #1, which I think I haven't mentioned so far, which was built to allow us, not only to undertake more hemodialysis on a regular basis but also to involved us in transplantation. This unit was based partly on the chorion epithelioma unit in London, which was used for immunosuppressed patients in the same way, for the same purposes as we wanted to isolate our patients. Unlike the very expensive Nuffield unit in evolved in Edinburgh by Woodruff which had airlocks to every patient room and took up an enormous space, we were able to build a unit which had much the same purpose and worked, as far as I can tell, nearly as well. The individual patient rooms were between clean and dirty corridors and off the clean corridor was a dialysis room for the regular dialysis patients and the transplant room. There was also a transplant theatre which was used for biopsies and other purposes of minor surgery and inserting canulas.
NM: This was obviously the first renal ward in Belfast. Was it developed along with the many which became available through the Working Party which provided money for some of these facilities?
MM: It was.
NM: There was special money set aside but it was very limited in Belfast and indeed elsewhere and this plan was already in being before the Working Party had really made its report. So in fact this had been part of the earlier battle for more facilities.
NM: In the British context, the battle for financial support for renal replacement therapy seems never-ending and I think it is getting so all around the world.
You mentioned a couple of things there - the Working Party which developed these facilities, and really quite early. We are talking to the very early to mid '60s here which was almost before things were developing in many other parts of the world, including the United States. And yet things slowed down. Of course, one of the things that slowed it all down was that these were units where dialysis was to be practiced, and of course, there was the hepatitis problem wasn't there? Did you have that difficulty?
MM: Yes, indeed we did. This came soon after our second phase, Renal 2, which was a unit of regular dialysis beds for 10 patients which followed on the first renal one which was opened in 1968 and we had just opened Renal 2 and an early patient developed jaundice. This patient had come to us just before and had tested hepatitis antigen negative on admission but after he became jaundiced we discovered he had been transfused before he came to us and though we never were able to trace the blood that he had been given, we suspected that this was the source of his hepatitis. At any rate, the new ward had isolation facilities of two cubicles and its beds were widely apart and we were already practicing the things that were later recommended by Rosenheim in that we had individual patient dialyzers, we logged the use of the proportioning systems for the dialysis fluid, and nurses wore gloves and gowns, and took all the precautions that later were regarded as essential. Nevertheless, we developed four positive patients. It was difficult to see where the infection was carried between patients 1 and 2,3, and 4. We asked the helped of Dr. Sheila Polakoff, who had advised the Rosenheim Committee, which was the important Committee in London, which advised on what to do about dialysis, which was already decimating several units, as well as patients. Indeed Manchester was one of the places who suffered. Sheila Polakoff said it was unwise to continued to dialyze in these isolation cubicles and her advice we bought two portable cabins which were installed alongside the Unit. We had volunteer nurses who looked after these patients and, again, from the technical staff, Jack Lyness was the one who stepped into the breach and looked after these patients.
Of the four patients, one of them survived, later to go on to home hemodialysis and eventually had a transplant and survived until last year. One died after a failed transplant which never functioned and two died, while free from jaundice, had recovered to an extent and never got a transplant.
The important thing was that Sheila said that we should not admit any new patients for six months after the last positive patient and this meant that many patients who had otherwise have got into our ward, which still had lots of space, were refused admission until six months after the last patient.
NM: So some would obviously have died in that time?
MM:Yes, there was a considerable patient mortality which I do not like to try to assess.
NM: Certainly the problem of hepatitis slowed down the development of dialysis in Britain and moved it towards home hemodialysis, didn't it, and this has been well-recorded.
You also mentioned transplantation one or two times. Now transplantation eventually became one of the things Belfast seemed to have a particular ability to perform. Tell us about how you got involved with that.
MM: I was entranced by the notion of dialysis being the handmaiden to keep patients with chronic renal failure alive until we could get a transplant for them from the very first report of Roy Calne use of azathioprine in Boston in 1960-61. It was already clear for sometime before this that transplantation was technically possible in the human since it was being carried out for occasional identical twin transplants and indeed we tried it once in 1962 but it was a technical failure.
NM: How did you do that? Did you do it in Belfast?
MM: We did it in Belfast and indeed McGaw was the urologist, and a vascular surgeon who had no particular training - he just decided he and McGaw were going to do this. I would have liked to have sent my patient to Woodruff, whom I was already in contact with at this time. They wanted to do it in Belfast but unfortunately it failed. Obviously, whole body irradiation was not going to be the answer but after the Calne electrifying report on the use of azathioprine and later added steroids this seemed to me to offer hope and that became my dream - that transplantation would be possible on dialyzed patients awaiting a transplant. And it would be cadaver because I had looked industriously over the early '60s for living related donors in patients' families and while it sounds a good idea, it is not in fact that easy to find a suitable donor. So we were keen from the beginning to enter into the transplant field.
NM: As you say, you were here in Belfast and there were only a few places in Britain where transplantation was even contemplated. Did you get a chance to visit some of these early units?
MM: Well there was Woodruff's unit but before that I'd tried Chapman in Hammersmith because I had had a lot of contact with Hammersmith in that it was the supplier of our external examiners and I knew McMichael and Chapman and and a few others, and Malcolm McMillan. So I wrote to Chapman and said, "I want to set up transplantation in Belfast. How do I go about it?" And he said, "Forget it. You are too far from where things happen." Woodruff said, "Well, I'm willing to take your patients if you send me a living related donor." This of course in those days was ABO match, and indeed I sent him one in 1963 but it failed after about three weeks because the patient got a mycotic aneurysm of the graft artery.
In 1965 Roy Calne came back from the States where he had done his signal work and was back as, I suppose, senior registrar, slot in the Westminster. I wrote to him and he sounded very cordial and invited me. When I arrived he was down in the animal theatre operating on a dog. The secretary took me down and he looked a bit nonplussed. I was a woman and I wasn't even a surgeon so what was I doing there?! However, he turned out to be very kind and helpful and I told him my story and that I had patients who were needing to be transplanted and could he do anything about them? I had one in particular in mind at that time, who had become blind from bilateral detachment of the retinas while on hemodialysis and his morale was dreadfully low, as you can imagine, at this stage. He agreed that as soon as he got himself settled in ...............Hospital, where he'd just been appointed Consultant and Professor, that he would take my patient, John O'Neil, to his unit and indeed he did so. He had a cadaver transplant in April 1966 and John survived on that transplant until the Autumn of 1996, still on the same cadaver graft.
NM: That's a 30 year single graft survival.
MM: Indeed when he came back a couple of times to give lectures in Belfast, he was very intrigued to meet with John again and have his photograph taken with him.
NM: You obviously used all the facilities you could - you used Hammersmith, you used Edinburgh, you were in touch with St. Mary's when Roy Calne was there. You must have been feeling that you wanted it that set up yourself.
MM: I was. This was all, in a sense, setting the scene for making impossible to deny transplantation in Belfast. Here we were having patients of ours transplanted. The immunosuppression was carried out afterwards in Belfast and we had shown we could prepare and we could carry out treatment after transplant. We just needed a surgical slot in the middle - this was the message I was trying to get through.
NM: So how did you manage to break the deadlock over this because obviously there was some skepticism about it all?
MM: I met Stanley ?Pate at a meeting in London and asked him what they were doing at St. Mary's. This was quite crucial too because I had my first regular hemodialysis patient - this was in January 1965 and I had a young woman who was home from hospital, well rehabilitated on regular twice weekly therapy. I told him this story and he said, "We're accepting patients from across London when we have a space for a particular ABO match." And I said, "Well, what about my Dorothy? Would you consider her?" And he said, "Write to Tim Mowbray and tell him your story. And Tim said he would take Dorothy and in April that year she was saved a cadaver transplant in London, which in fact supported her for nearly seven years. She, in fact, developed acute venous thrombosis during a plane journey to visit relatives and through that she lost her graft and she never did well afterwards.
That was the beginning of a series of patients who went to St. Mary's and this improved our ?treatment of patients slightly. The second one died of peritonitis because they couldn't find a cadaver kidney and they hadn't hemodialysis at that time. The third one was a young man of 21 whom I'd tried to find a live donor for, unsuccessfully, went to London and had a cadaver transplant in August 1965 and who is still alive with the same graft, functioning well to this day. So he's over 32 years transplanted.
NM: Nobody would have known in those days that there were going to be such successful transplants. The fact that they came back transplanted must have a been fair electric feeling for people involved in the field.
MM: Yes, it was a tremendous reward for the staff, who were struggling with a difficult enough situation in all directions. So that actually was very important; also important to getting transplantation set up when Renal 1 was first being designed. Roy Calne was helpful in the selection of a surgeon. The best deal I could get was two sessions of a surgeon's time to be used ad hoc on retrieval of kidneys and we used cadaver kidneys, needless to say, because I'd done so much better with cadaver kidneys over those early years, than with the living related few, who had all in fact failed, one way or another. So Roy Calne agreed to look at the three candidates who'd said that they were willing, already consulted of course, to spare some time to us and it decided that Stewart Clark, who was a general surgeon with vascular training was the most suitable. The one who'd had some transplant training, Starzl, withdraw because he possibly thought this job was a fairly dead-end and had a post already and the other was a urologist, Joseph Kennedy. In the end we decided we needed both of them. One man could not provide a rote! So with Roy's blessing we set these two. John Alexander volunteered to be on-call for our work and continued close association as anesthetist and the Head of the Intensive Care Unit until his retirement in 1996.
I managed to get tissue typing setting up by a man called Sam Nelson, who later went to UKTS during its early days and he soon recruited a science graduate, Derek Middleton. Derek is now the Head of a very large tissue typing service for Northern Ireland and has established an international reputation for his Department.
So we had this small group of clinicians. We set to and worked out in detail how we would retrieve kidneys and the details of the operation. All the details were thrashed out with the entire team, everybody having input. So we developed the "Belfast Recipe for Transplantation".
NM: Yes. Many people think of the Belfast Recipe as being purely the immunosuppression. In fact it was a whole approach wasn't it? Did you used to go out with the retrieval team?
MM: In the early stage, yes. We had of course no transplant coordinators for many years.
NM: You coordinated quite a lot of this yourself. If I remember rightly, I think you used to go into theatre with the surgeons to make sure they did it properly!
MM: That too, yes!
NM: And I think the tradition remains in Belfast that the physicians stay very close to the patients throughout the procedure.
MM: Yes close to the procedure and indeed I would say at the first hundred transplants there was virtually always a physician in the theatre during the transplant operation.
NM: Did you ever do the operation yourself?
NM: You had the team, you had surgeons, you undertook training, you were willing to help and you had the immunogenetics from really quite experienced people who had become well known in the field. You had, of course, dedicated nursing support and a lot of physician time went into it. You did very early on develop quite a daring immunosuppressive regime. Could you explain how you came to do that?
MM: Well, in every transplant during the '60s a great amount of steroid was given to bolder up azathioprine which was the usual immunosuppressant. Cyclophosphamide was used but didn't take on in one or two centres. They amount of steroid that given was huge. I had some experience of steroid therapy, and particularly of the side effects like osteoporosis, when it was used at the end of the '50s and early '60s for all sorts of complaints, particularly asthma and the serious damage it did to patients' skeletons. So I was very concerned and wanted to use less steroid. Then I compared what was happening in Cambridge with what happened at St. Mary's and St. Mary's used a great deal less steroid than did Cambridge, or indeed, Edinburgh. So I decided that I would work out something that I felt I could cope with and, in fact, we were the first to use 20 mgs of prednisolone from the day of operation. And we dispensed with the usual, then thought necessary, intravenous therapy on days 3, 5 and 7 of the booster doses of steroid. When patients did develop rejection we used much lower doses than were in general use.
In 1973 I did a survey of what was being used in the various units in the British Isles, and found that we used rather more azathioprine but a great deal less steroid than the majority of them. This was in fact important to our patients because we had a strikingly low incidence of serious post-transplant infection which was in fact the major cause of death in patients in the '70s who received transplants.
NM: Yes, of course you were dealing with a much younger group of patients then than we are challenged with now and the cardiovascular risks were less in that group and infection was a major problem but I think that also once the patients were discharged they were seen personally and very frequently.
MM: Yes, follow-up was an important part of our recipe and indeed they were seen meticulously. The follow-up was entirely by physicians unless they developed some surgical complication, which again was unusual.
NM: So all of your patients have always really been in contact with your unit throughout their post-transplant course.
MM: The other thing that we had which was our major advantage was that Northern Ireland is a relatively small geographical area and so the patients were able to attend for follow-up frequently at the beginning, twice a week indeed for the first three months, and thereafter at decreasing intervals with time.
NM: Yes, so really what you've got is very integrated longitudinal care with the same team involved all the way through from endstage renal failure, dialysis and transplantation and post-transplant management. All these ingredients may well matter in the long-term outcome.
The results you were obtaining in Belfast were really quite important and I think you published them didn't you in the Lancet?
MM: Yes, the results of the first hundred transplants were published in the Lancet in 1976. When we had a first year cadaver grafts survival of 80%. Just thereafter the UKTS in its Annual Report showed a graph of the results of the 30+ units who were transplanting in the U.K. under its banner, and ours was the top result and some units were achieving 40% one year cadaver graft survival or even less. So there was a wide discrepancy. This led the British Transplantation Society to feel that this should be investigated and they set up a small group of four, who went to the top few units and the bottom few units and did an exhaustive survey of the methods that were used - all the details - the surgery, the selection of patients, the tissue typing, everything about the whole procedure, and of course the immunosuppression. This had a considerable effect on the transplant practice thereafter in the British Isles and in particular it led to the general acceptance that unnecessary large doses of steroid were being used for immunosuppression and low dosage steroid to some extent was followed by all units - certainly lower than previously - after that report.
NM: You mentioned the British Transplantation Society Survey, in fact it was quite difficult to find many reasons which stood out within the sort of study they did of individual components, and it rather pointed, I remember, to the whole approach which you adopted, being as important as its parts.
MM: I think that was accepted by those who studied the report in detail.
NM: So this was an important and, I remember, striking development and many people at first didn't really want to believe the results you were producing but they were there despite enormous amounts of analysis I think they stood the test of time.
Now, transplantation, therefore, you couldn't do at all yourself, and though it had been shown to be very successful with this team in the general approach, you must have had colleagues working with you at the time?
MM: Yes, apart from the surgeons who were appointed to work with us in 1968. From then on I had my first full-time salaried colleague, Joseph McAvoy, who was a first class honors graduate and a very brilliant young man and who worked until 1975, when he followed the "brain drain" abroad because of our troubles (Northern Irish conflict involving IRA, and loyalist extremists) and indeed and indeed a number of colleagues from the hospital emigrated around about that time.
NM: This was one of the acutely difficult times in Northern Ireland.
MM: Yes, young people like him felt that they did not want to bring their families up under the environment that we were living in.
NM: So you had then to find other colleagues and you'd done that both locally, and of course, you also had a fair stream of international fellows into the Department of Medicine. Some of these worked with you.
MM: Yes, originally people came from Professor Bull's Department to get some practical knowledge of how to manage acute renal failure but from 1964 onwards they began to come to work specifically in my unit. An early one of importance was Stefan ?Taraba, who was a Hungarian who spent 1965-66 with me and afterwards went to work with Merrill and ?Okun in Boston and with ?Semelweis in East Berlin, where he was internist and head of the dialysis service there. He eventually returned to Budapest and set up his second dialysis service. He was very influential in the development of nephrology in Hungary in general until he died in 1990 - a great loss to Hungarian medicine.
NM: You had also, I believe, some of the early Greek distinguished nephrologists.
MM: There was a whole series of Greeks starting with ?Hans Metaxas, who became Professor of Medicine in Thessaloniki and Tony Billis, Nick Papadimitrious, who returned to Athens to practice nephrology and are practicing there still.
In the early '70s we had Soyannwo. In fact they were a little earlier than that perhaps. And also Dimitri Oreopoulos, the last of the Greeks who worked with me. Soyannwo returned to Nigeria, where he came from. His wife, in the meantime, got a degree in business studies and the two of them did very well there and he became Professor of Medicine but eventually they went to work in the Middle East. Oreopoulos went from here to Toronto to work with ?Appl.................... He developed ...................................... continued on with peritoneal dialysis to a great extent and made it more useable and developed it into a system that has been used worldwide since. Oreopoulos has also done signal work in obtaining dialysis in the management of renal failure in geriatric patients, so he's certainly made his mark on world nephrology.
NM: So even though you were living in an island within the British Isles, you had quite a bit of world nephrology come through here over those years and you must have given a lot and learned a lot, I think.
MM: We of course had many local graduates who went through the unit and many of them would like to have had nephrology posts here but there were none available in those days and they went all over the world and of course we trained Indians, some went to America, some went back to India. Quite a number of Canadian nephrologists from places like Nova Scotia and Ottawa and so on had a spell of training with us. So there was a lot of contact with other places.
NM: And when it all started, of course, there was you, then there was you and one other, and now though you have left the unit. How many physicians work there now?
MM: There are six now, plus two who are in dialysis centres outside Belfast.
NM: So from a farm in Lurgan to the work of six people in a relatively short period of time.
One of the things which nephrologists have to learn over the years is that you can't just work in your own unit and expect everybody to come and knock on your door, though some do. And you have to go out and make sure that the case for your patients is heard. Was that the same in Northern Ireland as elsewhere?
MM: Yes, it was a very important thing to make the unit known, both locally and of course nationally. If it wasn't accepted that the work was needed and was producing good results then the resources clearly would not been forthcoming. So getting the right sort of publicity was important. In this our patients helped us directly and indirectly. Some of them were quite eager to have personal publicity though I personally discouraged that. I did not feel that was the right way to go about it. But there was one journalist in particular who gave us sympathetic articles on the work of the Renal Unit which certainly should have been helpful and I believe they were helpful.
The an important development was the Northern Ireland Kidney Research Fund. This was set up by a Mrs. Josie Kerr and her husband, Walter, and later her friends and relatives. She had been a W.I. - Women's Institute - President and knew a great many people and had also worked in UTV (Ulster Television), so she had a wide knowledge of people and was a very persuasive personality and she wanted to help us by collecting Green Shield stamps to buy a dialysis machine, which I think had been done in Birmingham at that stage. She soon set up the Northern Ireland Kidney Research Fund with the help of these other people and this has developed to the extent that there is a group of workers, a branch of this organization, in all the cities and larger towns in Northern Ireland. Over the years they have not only supported our research, never in fact, the routine provision of treatment which should be through the National Health Service, but for research, and for new developmental equipment which would not be provided for some time. Like for instance our first renography equipment came from them but never dialysis machines. Over the years they have provided £4 million worth of help and there is a substantial sum invested so that we can have a continuity of research fellows.
The first one was James Douglas and he now is the Head of the current nephrological service. He was followed by Kieran Doherty, now Head of Research and instigator of the new 40-bed renal unit now being built at the City Hospital.
NM: It's interesting that, not only your patients, but your nurses have made a contribution too haven't they?
MM: Yes, Kay McGuire, whom I mentioned earlier was instrumental in setting up nurse specialist training in dialysis and transplantation. This was a great help in recruiting staff. It was difficult to recruit nursing staff in the early days but the lure of getting a qualification and the possibility that this expanding service would have permanent posts for the girls, and the atmosphere that she generated, were of great value to us in developing of the nursing side.
Moreover, she and Jack Lyness took part in the planning for each of the developments as they came along. Their cooperation was essential to, for instance, putting in nightshifts. Our equipment and dialysis procedures all improved as we introduced shorter shifts and multiple shifts. The nursing cooperation was a vital part of these developments.
NM: I think they took part in the British and European nursing forefront didn't they?
MM: They did, particularly Kay who encouraged her nurses to give papers and again that required time and effort and finance, but it was worth putting finance into because they were such an integral part of the development of the service.
NM: You yourself, of course, and later your colleagues, had continually to contribute reports on your work, nationally and internationally and that led to your having really two sorts of appointment. One was the appointments and presence in the Renal Association and the professional scientific community to show what you'd done, but also important jobs to do in relation to the development of the service for nephrology and for transplantation in Britain. With regard to the second, where of course you became personally involved with the United Kingdom Transplant Support Services, you really spent an extended period chairing their Management Committee.
MM: The UKTS, as it was commonly called, and later UKTSS, began in 1972 with which was again was a Government meeting, to decide whether tissue typing should be provided within the National Health Service, to support the growing transplant community. It was decided that this was indeed essential and those present included all the people who had attempted transplantation up to that time. It was decided that this would need to be a computerized service to match the prospective recipients with any donors of renal concern then and since, mainly with cadavers to match the tissue types. And also to provide a centralized distribution service for the organs once harvested because in the early days we had to do this ourselves. An extreme example which I like to quote is that we took a kidney from Lurgan in 1965 and we sent it in what had been my large family stew vacuum flask to Paris. Lurgan was my home town and the kidney was received from a heart-dead donor, not a heart-beating donor and was sent in two plastic bags in this flask to Paris where it survived, which was quite a triumph in those days.
NM: Did you get your flask back?
MM: I did eventually, yes!
NM: So the need for all this and the development of the UKTS services, I think, meant bringing together a very disparate group of people. The actual scientists themselves, the need for organ exchange, the rules for organ exchange had to be determined and agreed by the physicians and surgeons involved and were in their way pioneering development for which there were no ground rules.
MM: There were no ground rules and we had to make our own ground rules. As regards UKTS, it was eventually set up in Bristol in spite of the claims for the specialized knowledge of London because it was a computerized service and more particularly because Geoffrey T......... had space in a new laboratory just having been developed. So it was set up there and was crucial to the development. This was to be organized by a management committee with subcommittee for tissue typing and data processing and I served on those subcommittees for 8 or 9 years. Tony Barnes, who was a surgeon from Birmingham, was the first Chairman and he did a 10 year stint as Chairman, then I followed him in 1983 and followed through for 9 years until UKTS was replaced by a special health authority.
NM: That of course increased its own authority and I think you worked rather hard to achieve that independence.
MM: That's certainly true. By then in the mid 1980s UKTS in Bristol was bursting at the seams because, not only was it kidney transplant that was involved, but heart-liver, heart-lung and cornea. They developed the Cornea Bank there and later a subsidiary one in Manchester. So they were really pushed for space but no more space was going to be provided because the DOH was unhappy about the management arrangement which they said had been set up without proper legal authority and we suggested the special health authority. This was not considered possible because special health authorities were supposed to deal only with England, whereas UKTS dealt with Scotland, Wales and Northern Ireland as well. However, in the end they capitulated and in 1990 it was superseded by the UKTSS and it has an executive committee chaired by a civil servant. Just recently a surgeon has now become Chairman of it. So it still is crucial to the general arrangements for removal of organs and their tissue typing, and of course the distribution of sera for tissue typing which became from the earliest days an important and crucial part of that service.
NM: I think it's not wrong to say that the development of UKTSS has underpinned the evolution of good transplant practice in Britain and of course it continues to evolve.
You've mentioned of course you were involved with the Working Party which set up dialysis practice. You were involved also with the one which has really I think been the most crucial in developing harmonized transplant practice - if we can speak about. And of course also through your work with the Renal Association, which I think is a group of your professional peers, you became involved with developing services across the whole U.K. for patients needing renal replacement therapy and in the scientific work that one has to do.
MM: Well, in Northern Ireland we were in an especially favored position to do surveys of the need for treatment, both for dialysis and transplantation and in common with Scotland and several other centres, I took part in these surveys. We have a circumscribed population and a circumscribed border so we know the population and its demography that we are dealing with and so we took part in this at the end of the '60s and the beginning of the '70s. I did a three year survey which gave broadly similar results to the one carried out in Scotland at that time. Later it was repeated in the mid '80s. There was also a survey of diabetics with renal failure which was a little later and again Northern Ireland's records and a prospective survey was carried out for the purpose of diabetes. This also proved important when you, yourself chaired the London review of renal services following the Tomlinson Report, where the knowledge of the prevalence of diabetes and how prevalent it was in non-Caucasians was very important to the planning for the southeast of England.
In 1982 a chance meeting on a plane with Professor Terry Lappin, who was then a non-medical scientist working in hematology led to a discussion on our joint interest in anemia of renal failure and erythropoietin. We got support from the Northern Ireland Kidney Research Fund and a science graduate was funded to work on the assay of erythropoietin (EPO). The research and the assay and the structure of EPO continued as a joint project for the two departments, culminating in 1989 when Dr. Peter Maxwell localized the site of production of EPO in the proximal tubule. That research project produced four doctorates of medicine, and two doctorates of philosophy.
NM: Some of the work you did with UKTS and with the BTS - British Transplant Society, and the Renal Association, has led to change in legislation, hasn't it, which I think has remained at increasing public confidence in the role of transplantation in particular as practiced. Could you tell us a little about that?
MM: About the middle of the '80s there was concern in the British Transplantation Society about rumors that the private sector in London were using kidneys that had been imported from abroad for financial recompense. These at first were rumors but the British Transplantation Society took it sufficiently seriously to set out recommendations for living donors and in particular, of course, with emphasis on living related donors. They were so anxious about this, they and the Management Committee of the BTS pressured the Department of Health to undertake legislation to prohibit the purchase of donor organs. But the DOH was reluctant to undertake this because of the pressure of other legislation.
However, in early 1989, there were specific reports in the press of the use of Turkish donors for kidneys in the private sector and this led to rather rushed legislation which was not well thought out but at any rate in July of that year a human organ tissue Act was signed by Her Majesty the Queen.
The details of how this would be applied were set out in a series of regulations and we were told of the advantage of this was that it would be possible to change these as needed if there were development in the scientific or clinical field that justified change. However, in fact, this has not proved to be so. At any rate, the Act prohibited the use of unrelated donors except under specific circumstances laid down by the Act. It laid down the degree of relationship that would be accepted for a living related donor and how tests for relationships should be carried out. This particular section has been the cause of major problems in the field and has not yet been fully resolved. The unrelated live transplant was to be regulated by a new committee called ULTRA - the Unrelated Living Donor Transplant Regulatory Authority - and this was to be chaired by a non-medical scientist of eminence who is currently Martin B.................... and was to have about 11 other members who would be representatives of the surgeons, nephrologists, tissue typing, ethics, the nursing staff and one or two lay members. I was part of the first series of ULTRA membership and spent six years from 1990 to 1996 as a member of ULTRA. The workings of this meant that the physician or surgeon undertook the looking after each individual unrelated donor that was proposed under a set of regulations and considered all the aspects and this would only be permitted to go ahead if the Subcommittee headed by one of us with two other who were non-medical approved of it.
NM: It is really quite a stringent regulation to prevent any questions of donation being clearly for financial recompense, insofar as that can be ascertained at the time. That has resulted in a rather tightly defined and small group of unrelated transplants taking place in Britain or with the permission of the Authority on an individual basis.
MM: Which are mostly, in fact, spouses.
NM: Mostly spouses nowadays, and I think these two things have greatly increased, and should do, the public confidence in the way transplantation goes.
Throughout this time, with all these various strands of work, from the earliest research, one thread which is common is the friendships you've made, isn't it, and which have persisted over the time, both from these earlier friendships and ones with people like myself. It's been, I think, one of the good things that we've been able to have in Britain and you perhaps have been a paradigm of this continuity through constant personal contact and knowledge of each other, their work, what you are trying to do; and I think that may be something which is less spoken and developed than to know about and feel. I think that's led also to some recognition to you from a number of bodies. You are an Honorary Member of the Renal Association, Honorary Member of the British Transplantation Society, and their Archivist (I don't think one necessarily depended on the other); also Honorary Member of the European Dialysis and Transplant Association and the Nursing Association, one of the few physicians, I think, who have been honored by the Nursing Association. You are also a Commander of the British Empire (CBE) which is an honor well recognized as a senior one from the Queen in Britain, but would not be so well known and needs to be properly explained, I think, to people abroad.
So you've really gone through a very long period of time and it shouldn't be forgotten that within that time you have had a growing and developing family. How many grandchildren do you have now?
MM: I've got five now and another on the way.
NM: So the family line is growing all the time. I know you take great pride in what they do.
So I think we should all be grateful to you for having given us so much time to tell us about your life. Thank you.
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