Pathology Department History
Conversations with Robert Heptinstall
Robert Heptinstall - Director of Pathology from 1969 to 1988.
October 28, 2007
| Hruban: | Today is October 28, 2007, I am Ralph Hruban and I am joined by Ed McCarthy and Dr. Robert Heptinstall for a Sunday afternoon. So Heppy what we thought we would do is start at the beginning and move forward chronologically. |
| Heptinstall: | Before we do that, let us decide what we are trying to accomplish. One of the few sensible things I learned in the Army was in the Officer's Field Handbook and it told you how to conduct an exercise, or a battle if you like. And the very first question asked (it is a question that is very seldom asked at Johns Hopkins committee meetings or of any other meetings you go to) was what are the aims and objects of the exercise. |
| Hruban: | What we are trying to do is to capture a time in Hopkins' history, and in particular the characters in Hopkins' history and since you've obviously been associated with Hopkins and the department for a long time and quite a character, we thought we would try to capture both and document both and what we hope to do is to... |
| Heptinstall: | But you see this rather conflicts with what you had on your email. On your email you wanted to know something about my history, my evolution. What has that got to do with this window framework. |
| Hruban: | Because you did not arrive out of the blue at Hopkins. I think clearly who have a wonderful history that frames who you are. So we will start at the beginning. And I think the main thing we can do is to feel free to edit it. If someone says something that they regret later, we'll just cut it out. Nothing is written in stone. So you were born in Cumberland, England? |
| Heptinstall: | I was born in England, yes; in Cumberland yes. |
| Hruban: | What year? |
| Heptinstall: | 1920. |
| Hruban: | So if you can start with that, who your parents were and all that and move forward. |
| Heptinstall: | I grew up in Cumberland. I had two very nice parents. I went to a local school. |
| Hruban: | Was your father a physician? |
| Heptinstall: | No, my father was in the bakery business. |
| Hruban: | And you had a sister? |
| Heptinstall: | I had a sister. A sister brighter than I was. She was a school teacher. The school I went to was a rather unique one - it was a coeducational school. Both day boys and boarders. I was a day boy naturally because I lived there. It was a very good school. |
| McCarthy: | Does it still exist? |
| Heptinstall: | No, it doesn't exist anymore. Its foundation was not a very large one and it went out of business about 15 years ago. |
| Hruban: | And then at one point you knew you wanted to go into medicine, you had an inkling for science, at what point was that? |
| Heptinstall: | When I was at school, I specialized in chemistry, physics, and mathematics. I wanted to do medicine and of course, when I applied for med school in 1938 the war clouds were looming so I applied to two schools where we heard that they were going to shorten the course if a war came along, Oxford, Cambridge had made no such provisions so I applied to London University and Edinburgh. I was accepted at London first so I naturally went there. |
| Hruban: | Why did you want a shorter course? |
| Heptinstall: | Because it was obvious the war was coming and I wished to graduate as quickly as possible. I wasn't going to be branded as a stay-at-home, would you? |
| Hruban: | And so that's the Charing Cross Hospital Medical School? |
| Heptinstall: | London University has many different medical schools: Guys, London, St. Thomas's, Bart's, St. Mary's, Charing Cross is about the smallest of the London hospitals. Its students did their preclinical work at King's College in London. |
| Hruban: | Do you remember any of your teachers - your professors from Charing Cross? |
| Heptinstall: | I remember the ones I want to remember, some of them particularly well. No doubt in the many teaching classes you and I have shared you've heard me mention a man named Gordon Holmes. Gordon Holmes was the world's premier clinical neurologist. As an aside, Hopkins tried to get Holmes back in the 1920's. His signature is in the department visitor's book. Probably it has disappeared now. I don't know. Holmes was invited to come here, but he was not at all flattering about Baltimore. |
| Hruban: | He's the one with the needle. |
| Heptinstall: | I told the students many tales of Gordon Holmes. He was an absolutely brilliant teacher, but we were all terrified of him. |
| Hruban: | Did you have a nephrologist professor? |
| Heptinstall: | There was no such thing as nephrology in those days. Nephrology didn't come along as a specialty until the 1950's. |
| Hruban: | What about in surgery? |
| Heptinstall: | I interned in Surgery. I interned under one of the best surgeons in London named Norman Lake. Lake was a wonderful man. He was not just a very good surgeon; he was a highly intelligent man who knew something about everything. He took part in a very popular program on B.B.C. radio during the war called The Brains Trust in which they would have four very bright people who would be asked questions on a variety of topics. Lake was a member of The Brains Trust and his knowledge was so extensive that he could hold his own with these very bright people. He was a wonderful surgeon too. |
| Hruban: | so you were in London during the bombing and in school? |
| Heptinstall: | I wasn't in London during the bombing of 1940-41. What happened at the beginning of the war when it finally came in September 1939, was that they decided to evacuate the medical students from the London medical schools and teaching hospitals. They kept a skeleton number who were in their final clinical years in London to do fire watching duties and work in the emergency room and in the half dozen wards that were kept open. But all the London teaching hospitals had what they called a sector which was the area draining the particular London hospital, and in each sector they had the sector hospital which was where most of the patients were sent. I didn't particularly enjoy the sector hospital. It was rather like a country club. It was on the verge of the Ashridge Golf Course which was one of the best courses in England. There was just a general laid back atmosphere there. |
| Hruban: | Even during the war? |
| Heptinstall: | Yes. They wanted students at Charing Cross in London to do fire watching duties and other things, and I went there after several months at Ashridge and saw a tremendous amount of material. We were allowed to do a great many things that medical students weren't usually allowed to do and I became very friendly with a surgeon from the Urology hospital around the corner, St. Peter's, and he let me help with many procedures. I got a very solid grounding in surgery and that's why I interned in surgery and always intended to be a surgeon. But to get back to your original question about the bombing of 1940-1941. At that time I was still at King's College where Charing Cross students went to do their pre-clinical work. So I was doing anatomy, physiology, pharmacology - that was all in Glasgow where we had been evacuated. I think they got rather fed up with us in Glasgow and in the summer of 1940 we went to Birmingham University in the Midlands. So I was in Birmingham the nights of the big air raids on Birmingham. But they didn't go on night after night. I think there were three or four big raids on Birmingham. I did experience air raids in London later in the war including the V-1 bombs in 1944. |
| Hruban: | Did you have a good pathology professor during that time? |
| Heptinstall: | Charlie Vines. Charlie was the author of one of the standard English textbooks. Charlie was a very good teacher but a very acid sort of fellow. Very sarcastic always taking the piss out of people. On the whole we were taught pathology well. |
| Hruban: | Then your motivation to go into surgery was essentially the hands on experience you received? |
| Heptinstall: | Yes, because of all the practical experience that I had had and I wanted to continue with that. And then when I was in the Army, I decided that I didn't really want to do surgery. |
| McCarthy: | How did you come to get into the Army? |
| Heptinstall: | I was drafted as were all physically fit people. |
| McCarthy: | During what year was that? |
| Heptinstall: | I went into the Army about the Spring of 1944. I graduated in about the middle of 1943 and we were allowed to do a six month internship and then when I finished that I was drafted into the Army. We learned how to salute and all that rubbish and about regulations and learned how to make latrines. And then we probably had the best teaching I've ever had in my life. The RAMC (Royal Army Medical Corps) put on an absolutely wonderful course in tropical medical which lasted two weeks. I had never had such good teaching and this was by officers from the RAMC. They had a wonderful collection of specimens because the RAMC had a long history of service overseas. All those famous people like Leishman and Ross were somehow connected with the Army and all their material and all their specimens were filtered back to London and we had all this wonderful teaching material. |
| Hruban: | So you must have known at that time that you were going to go to the Far East for your military service? |
| Heptinstall: | No, there was tropical medicine to be practiced in the Middle East, West and East Africa and numerous other places. But I was put on a boat after I'd done the course in tropical medicine and sent to India. |
| Hruban: | What did you do when you arrived in India? |
| McCarthy: | And what year was that? |
| Heptinstall: | Summer of 1944. First thing I did the first night I was in India was to eat eight eggs because eggs were very severely rationed in England. I had two boiled eggs, two scrambled eggs, two fried eggs and two poached eggs. |
| McCarthy: | Where in India? |
| Heptinstall: | I was first sent to a place near Poona, Center of British imperialism, where the Army was strongly represented. I was sent to a depot a few miles from Poona, but I wasn't there very long. I was put on a train and sent over to Calcutta and from Calcutta we went by boat and various conveyances into Burma. In Burma I went first of all to a field ambulance, a mobile hospital. And then after a time in the field ambulance there was a vacancy in one of the rifle battalions and I went as the battalion medical officer to an infantry unit. I stayed in Burma until approximately March of 1945, when as we shall see, my unit was sent back to India. |
| Hruban: | So the war was still going on at that time? |
| Heptinstall: | Of course it was. Why otherwise would we have been there? Yes the war was still going on. Then we came out of Burma. Before I went out to India, I had used every device I knew in how to avoid being sent to the Far East. I wanted to go to France because the second front was just being opened up at that time while we were doing our basic military training. So I applied for airborne troops, I applied for the Commandos, I told all sorts of terrible lies that I spoke fluent French and German which would be absolutely wasted in the Far East, but in spite of that, they sent me out there. Well, my unit pulled out of Burma and went back to India to a place near Madras in the south of India and we went there to rest and refit and then we were to go over to the coast to train in combined operations because the next item on the agenda after Burma was the invasion of Malaya. While we were there, I got a telegram one day telling me to report to headquarters Force 136 in Kandy in Ceylon. I had no idea what Force 136 was. So I went to see my C.O., charming man called Tony Read. He said, oh gosh, Heppy, you've really let yourself in for it. Those are the people who parachute into Japanese occupied territory. I know all that because my brother's in it. And he was. I met his brother and he was an equally charming fellow. This is where the Army wasn't so stupid, they had got my records. They had seen while in the U.K. that I had volunteered to jump out of airplanes. So I went to Ceylon and was sent to a training camp where we were taught how to survive in the jungle and other things from like using plastic explosives to unarmed combat, etc. Then I was sent up to a place called Jessore in India for parachute training and then came back to Ceylon to be allocated to a team to be dropped into enemy-held territory. I was in the Siamese section, but before I was put into a team, Harry Truman sensibly dropped the atomic bomb. At that stage all operations were cancelled and it was decided to drop doctors into the prisoner of war camps where conditions were dreadful. I parachuted into a camp in the Kra isthmus in Siam where I stayed for about two months or so until all the occupants had been evacuated. |
| Hruban: | The prisoners were British soldiers? |
| Heptinstall: | The prisoners were from many different countries; most of them were British. But the camp that I dropped into was a camp of Malay coolies who had been taken up to Siam to build yet another railway. The Japanese were obsessed with building railways, and this camp held about 3,000 Malays in various stages of breakdown. It was the most appalling sight. They had been terribly neglected and very cruelly treated. |
| Hruban: | What were the illnesses they faced? |
| Heptinstall: | Beriberi, malaria, dysentery and all forms of malnutrition. Those were the main things. I found that the situation was altogether too much for me to handle as I was the only medical officer. So I sent a signal back that I needed help. In response they parachuted in several young medical officers from an Indian Airborne unit and gradually we sorted things out. The Japanese had the medicine and the means to treat them all, but did nothing. The Japanese general in charge of the area, I got to know him very well because I had to deal with him on many issues. I remember very clearly he was called General Hamada. |
| Hruban: | Where was the flag pole incident? |
| Heptinstall: | The flagpole incident happened when I was in Siam in this awful camp. It was a storm in a teacup and best forgotten. After we had cleaned up the mess in the camp, with the survivors evacuated to Malaya, I was sent to Singapore where I went to see a charming man, I think his name was Colonel Thompson who was in charge of postings. He said "what would you like to do"? I replied "go where there is something interesting going on." He said there are some interesting things going on in the Dutch East Indies where the Indonesian rebellion against the Dutch had just begun. The British has been given the task of taking over the Dutch East Indies from the Japanese but encountered opposed landings. It was one of the few places in the Far East where the Japanese didn’t observe the terms of the surrender and many of their weapons got into Indonesian hands. At least that is what was believed at the time. Regardless, the British and Indians had a lot of casualties and there was a full-scale rebellion going on. I told Colonel Thompson I should like to go there and was sent there as a medical officer to an artillery unit. I was in Java for the best part of a year during which Dutch troops gradually replaced the British, and Indians, and were able to leave. After Java I went back to Singapore (September 1946) and was given a posting as medical officer to Changi Jail which was a huge prison that housed Japanese war criminals. My job was to supervise the Japanese doctors looking after their own awful people. I had an uneventful time there and left for England in January 1947 to be demobilized. |
| Hruban: | When you were in India at one point, you told me a story where you took some new troops out to teach them about the jungle and tell us about the rock that moved. |
| Heptinstall: | It was in the spring of 1945 at a camp near Madras. We had just got a batch of new young officers from England who had just come into the Army. It was decided that in preparation for going into Burma that they should get some experience of the jungle. There was a very nice smallish area of jungle close to where we were so the second in command of the unit, John Robinson, and I, went out to do a reconnaissance of this local jungle area to establish water holes so that the new officers could survive for a few days and fend for themselves. We soon found that there were a lot of snakes (cobras) around. We reached a place where our primitive map showed a water hole. We saw the water from a distance with a very dark slope adjacent to it. As we approached, this dark area started melting away and revealed a rocky slope bereft of any form of life. I don't know what these snakes were doing; resting I suppose but they disappeared by the time we got there. On the basis that we had not been attacked by any snakes, we decided to let the young men go ahead. All emerged quite healthy after several days and that was the story of the disappearing rock. |
| Hruban: | So you are now on the boat back to England in 1947? |
| Heptinstall: | January 1947. So I get back to England and it's the bitterest winter Britain had had in about 100 years. There was snow everywhere. My parents lived in the Lake District in Cumberland and I naturally I went to stay with them because this was home. I decided I was going to take a two-month vacation before I went to London to explore any postgraduate training. I had a wonderful time up in Cumberland. The Labor government was in power then; Churchill had been thrown out in 1945, and Labor were screwing up on the fuel supply. There was very little coal. You see, people in England heated their houses with coal in those days. We had a cottage on the coast about 20 miles away from where my parents lived. My father decided to close the house down and move to the cottage to conserve coal. Up to this time I had seen very little of my parents and I was with them in this little cottage for about six or seven weeks. We played dominos and cards every night. (There was no TV in those days and only radio to amuse us.) Father and I used to plow our way though the snow to the local pub to purchase our sustenance. And then I decided it was time that I went and started making some arrangements for my future. I went up to London to Charing Cross Hospital and I found that Charlie Vines, the Professor of Pathology, was now the Dean. I interviewed with Vines and I told him that I no longer wanted to continue with my original plans to do surgery, but that I'd like to take up pathology. I thought that this would please him. "Well, before I take you on in pathology," he said "you've got to do some more training in internal medicine and you've got to get your MRCP. That's the higher qualification that internists have in England. So I asked him why should I want to have an MRCP and go through all this training if I was going to be a pathologist? He told me that the pathologists of tomorrow would have to give advice to clinicians as to what tests should be done and what these tests mean. And in order for you to understand these matters you've got to have a thorough training in medicine. I thought to myself, what bloody nonsense. No mention of doing research or anything, all just routine clinical practice. So I told Charlie that I really was very sorry he couldn't take me, but I was unprepared to take training in internal medicine as he suggested. I realized I had now burnt my boats with my old medical school but fortunately I met a friend at a pub that night or the night after, a fellow called Ken Turk who told me that he had had a similar experience and how he had dealt with it. We had been students and interns together at Charing Cross. Ken had also decided to take up pathology and following a similar rebuff to mine went to see a man called Sir Philip Panton who was working for the government, Ministry of Health I think. Panton was interested in getting people into pathology, having been a distinguished pathologist himself. He had found a trainee position in pathology for Ken at The Royal Free Hospital, one of the London teaching hospitals. Ken gave me Panton's address and telephone number, and I called him the very next day. He agreed to see me at his office in Whitehall and I liked him immensely. He laughed at the story of Charlie Vines and said that was typical Charlie. He asked me one or two questions and then picked up the telephone. I had no idea who he was speaking to, but he kept asking me questions coming from the other end of the phone. Are you married? I said "no" and he relayed the information to the person. He said "do you have any money?" I said "yes, I have some money. I have a government grant in the princely sum of ₤650 a year" - which was quite a lot in those days (about $3,000 in American currency). He asked various other questions, talked to the voice at the other end and then put the phone down. He said "you have half an hour to get to St. Mary's Hospital in Paddington where Sir Alexander Fleming is waiting to interview you. So it was Fleming that he had been talking to on the phone. I went to St. Mary's and I interviewed with Flem and he took me on straight away. |
| Hruban: | Tell us what the interview was like? |
| Heptinstall: | It was very short. Flem was a man of very few words. He puffed on his cigarette - he smoked an enormous amount and I told him I wanted some training in bacteriology as it was called in those days and immunology. I told him I eventually wanted to do tissue pathology; in England it was called Morbid Anatomy. So he took me on and I started working in his department just doing routine things. We weren't doing any research. I stayed there six months and then I went across the road to the Morbid Anatomy Department. It was run by a charming man called Wilfred Newcomb. I trained with "The Newks" for over 2 years and really learned everything there was to learn about tissue pathology. I did a fantastic number of autopsies, surgical pathology, cytopathology and hematology. At the end of my training I got a junior staff appointment. There was no research of any consequence going on in the department, but I was very fortunate to have met the Professor of Medicine, George Pickering, and he asked me if I would like to do a project with him which I did. Incidentally he introduced me at a later time to experimental methods. He was interested in the treatment of hypertension and he had a lot of kidneys that had been removed from patients who were thought to have unilateral chronic pyelonephritis. At that time of course, effective antihypertensive drugs had not appeared. I did a couple of papers with Pickering, one of which was a very controversial one showing that malignant hypertension could be reversed if you could reduce the pressure below a certain critical level you could stop the nasty changes going on in the blood vessels and glomeruli. |
| Hruban: | Was that in humans or in animal models? |
| Heptinstall: | These were in human beings. We wrote a paper with a surgeon called Dickson Wright, who had done most of the surgery, entitled The Reversibility of Malignant Hypertension. It appeared in the Lancet at the end of the year in November 1952. Ann and I lived out in the country in a place called Beaconsfield which was about 25 miles out of London. I used to travel up to London by train every day. George Pickering lived at a place called Chalfont St. Peter or Chalfont St. Giles (I can't remember which of the two) which was only about three or four miles from Beaconsfield. I was out in the garden one Saturday morning, I think I was digging up the tubers of the dahlias to wrap them up in paper and store them until the spring next year. Suddenly my wife called out through the French windows, "Pickering is on the phone and he sounds very, very angry." So I got to the phone which was really crackling; you could feel the rage at the other end. What had happened was that our article had appeared on Friday the day before and was accompanied by an editorial centered on our paper. This editorial cut our paper up. I had already read it on the Friday evening and realized the explosion it would evoke. Pickering asked what was I doing? I said I was gardening. He replied, "put your gardening off and get over here." So I got in my car, drove to his house and there he was writing at his kitchen table. He was a most fluent writer and could have been the editor of The Times quite easily. He said, "some mischief making bastard has pulled us to pieces," or words to that effect, "but here is the reply." He asked me to read it and wanted to know whether he was right on certain technicalities. I read it and found it to be an absolutely masterly rebuttal of the editorial. We both knew that it was Clifford Wilson who had written this. |
| Hruban: | So it wasn't a signed editorial? |
| Heptinstall: | Oh no, Lancet editorials were always anonymous and for all I know they may still be. We knew it was Clifford Wilson because he ran the rival school of hypertension in London. He was at The London Hospital while Pickering was at St. Mary's. One of the criticisms in the editorial, if I remember correctly was a conflict between our findings in man and those in the rat. Pickering ended the letter by saying, "After all, when human conditions are being discussed the evidence from man is entitled to at least a little consideration" or words like that. This has often been quoted and sometimes attributed to me. I should like to make it abundantly clear that the author of this was George Pickering and not I. To follow with our chronology, in 1954 I applied for a Medical Research Council Fellowship to study in the United States. The Medical Research Council used to give six fellowships every year. Four of them were funded by the Rockefeller Foundation and two by the Eli Lilly Company in Indianapolis. The Eli Lilly ones were rather better - they paid you a few more hundred dollars a year and included a trip to Indianapolis. The amount was $3,900 for a year. I applied for one of the six fellowships and there was heavy competition for them. I had a very frightening interview. The committee was made up of the big men in British medicine and they were very intimidating. Anyhow, they decided to give me one of the fellowships and fortunately it was an Eli Lilly. |
| McCarthy: | What year did you arrive at Hopkins? |
| Heptinstall: | September of 1954. I came over on the Queen Mary and then by train from New York. I got a taxi at Baltimore station which brought me to the front door by the dome. I remember very clearly standing there in the bright sunshine. Ann and I had decided that she and the three children would stay at home for a couple of months and I would come over here first and save a bit of money. It obviously was going to be difficult supporting five of us on a small salary because you were not allowed to export a single penny from England because of the strict currency regulations. Rich very kindly arranged for me to live in the residency free of charge so we were able to save quite a bit of money. In those days the residents lived in what is now the administration building – Billings Building. That is where I picked up athlete's foot that I never got rid of. The bloody showers on the 3rd floor. My next door neighbor was Jerry Spear who was a resident in pathology. Jerry as you know was a wonderful violinist and he used to play his violin for me most evenings. It was wonderful. Ann and the children came over from England a couple of months later and we went to live in a rented furnished house. |
| Hruban: | What was your impression when you first arrived at Hopkins? |
| Heptinstall: | That it was bloody hot, especially for September. That everyone was kind and helpful to me. That Hopkins was a bustling place with many activities, and that pathology had a high standing. Rich was in Europe when I arrived but I made friends with a young man called Fred Germuth who was Associate Professor of Pathology and doing excellent research in the immunopathology of glomerular disease. I spent the whole of my fellowship working with Fred. I did of course do some studies on blocking antibody in the Arthus phenomenon with Rich, who taught me a great deal on how to approach a scientific problem. Apart from my research I taught the second year medical students and helped the housestaff as much as I could. |
| Hruban: | Were they competitive with what you had in England? The thought level was competitive with what you had in England? |
| Heptinstall: | I was tremendously impressed with Rich. He was of the same mental caliber as George Pickering. Rich had a wonderful mind and seemed to me to be the outstanding man at Hopkins. |
| Hruban: | Can you give an example of Rich? |
| Heptinstall: | In contrast to most present day heads of Pathology Departments, Rich had a thorough knowledge and understanding of human pathology. This, coupled with his imagination, amazing visual acuity and ability to devise ways for solving problems made him what he was. Who, but Rich, would have noticed that in certain patients with what in his day was called lipoid nephrosis showed a selective sclerosis of the juxta medullary glomeruli, an observation that laid the foundation for our recognition of the entity focal segmental glomerulosclerosis as well as opening up studies on the differences in the circulation between the superficial and deep glomeruli. Notice too, that these groundbreaking observations were made on autopsy material and required no external funding. He was also a master at experimental studies such as his work on tuberculosis, serum sickness, polyarteritis and glomerulonephritis. After several weeks, Ann and the three children joined me and we spent the rest of my fellowship in a small house in Parkville. As my year came up, Rich asked if I could stay on a little longer. Ann was absolutely terrified. She thought that he was trying to get me to stay here permanently. I don't think he was, I just think he wanted me to finish what I set out to do. So we stayed on until December instead of going home in September. We went home just before Christmas 1955. That was my first experience in Baltimore. Because I had an Eli Lilly fellowship, I was allowed to go at their expense to their home base in Indianapolis. Unfortunately, I could not afford to take Ann and the family on the trip. I had a very good time at Lilly and made some good contacts there. Oh, Something I didn't mention when we were talking about St. Mary's days. After Pickering asked me to do the work on the nephrectomies and hypertension. I told him that I wanted to learn something about experimental methods, but that there was little chance of doing anything in the pathology department. So he said that he had a young South African coming over to work with him for a year (a young man called Bronte-Stewart from Capetown) and that it might be a good thing if Bronte and I would work together on the project that he was proposing. The project was to test whether high blood pressure accentuated atherosclerosis in an experimental model. The model chosen was cholesterol-induced atherosclerosis in the rabbit. So Bronte arrived - charming young man - and after Pickering had shown us how to put silver clips on rabbits' renal arteries to produce hypertension, take blood pressure readings on rabbits, etc., we embarked on the project. We showed very conclusively that hypertension did accentuate atherosclerosis in the rabbit model. I recount this to show that I had some experience in working with experimental atherosclerosis. So when I went to Eli Lilly and found they were interested in atherosclerosis and had produced a new compound called sitosterol which interfered with the absorption of cholesterol. They arranged for a large amount of sitosterol to be sent to me when I got back to England. I did various studies on it. My visit to Lilly also gave me a jumping off point to visit other parts of the United States. George Pickering had very kindly given me several letters of introduction to distinguished Americans and I next went to Cleveland to visit Harry Goldblatt. I had a delightful day with Harry and he took me home to dinner and asked me to spend a longer time with him at some time in the future. I was unable to do that until 1959 when I was visiting the United States from England. I spent several weeks with him and had a wonderful time. I also met Irvine Page in Cleveland and John Gofman at Berkeley. I also visited Stanford when I was on the West Coast. I went to Chicago and met Bob Kark who was pioneering the percutaneous renal biopsy, and Conrad Pirani. Then I got back to Baltimore where we had a summer vacation in Ocean City before I resumed my work at Hopkins. We went back to England at the end of 1955 and started working again at St. Mary's in January 1956. |
| Hruban: | So at that time, what was your impression of the Untied States? |
| Heptinstall: | Very favorable on the whole, but with certain reservations. 1954-55 was the time when Joe McCarthy was conducting his awful vendetta against anyone whose politics were to the left. I wasn't impressed with that. I was rather shocked to the find that almost anyone could buy and own a gun. I saw other things that surprised me - that there wasn't a national health service and that many people were medically uninsured. Finally, and most importantly, black people didn't have the same rights as whites. On the whole, my impressions were favorable. |
| Hruban: | Any your impressions of the science? Were they better funded than in England? |
| Heptinstall: | Oh yes. In England in order to get research funds of any substance you had to be a big name or under the umbrella of one. It was difficult to get started and this must have discouraged many people from embarking on a research career. It is of interest that when I did my Fellowship Fred Germuth was the only person who had a research grant in the entire pathology department. Rich used to scorn research grants. He felt you must not become dependent on the federal government. He hated anything to do with the federal government. |
| McCarthy: | Did you know his daughter, Adrienne, at all? |
| Heptinstall: | I didn't know her. I knew Cynthia. Cynthia was his younger daughter. Adrienne had left home by the time I had got there, but I corresponded with Adrienne after I gave a talk on her father on the occasion of his 100th birthday. I had nice letters from her. |
| Hruban: | Had she reconciled with her father by that time? |
| Heptinstall: | I don't know. |
| Hruban: | In 1955 did you go to journal club? Rich's journal clubs were famous? |
| Heptinstall: | Yes. Rich's journal clubs used to be held at his house, if I remember correctly, every Tuesday evening and they were wonderful affairs. He would conduct the professional part, which took some two hours, and when that was over, Mrs. Rich used to serve soft drinks and the musical part would begin. Mrs. Rich was a terribly good pianist. Rich played the viola, Jerry Spear played the violin and there were one or two others who used to contribute. It was a wonderful evening, educational and entertaining. |
| Hruban: | Back in 1955 when Rich was Chair, did you have a sense of him as a leader? |
| Heptinstall: | He led by example, showing the way by his teaching, research and profound knowledge of pathology. To me, and to many others, he was the intellectual giant of his era in the entire Hopkins medical school. His basic philosophy was not to cram people with facts, but to get them to think. In this he succeeded brilliantly. Generations of Hopkins students still remember his influence on their careers. This is all the more so with those residents who trained in Rich's department. However, there is always a downside to fame and there were certain members in the department who regarded him as a god and never questioned any of his views. The exception to this was Fred Germuth who thereby gained Rich's respect. Fred was very bright and did pioneer work on the role of immune complexes in the production of glomerulonephritis. Fred was an associate professor when I worked with him and he had set his heart on succeeding Rich. In a better world it should have happened, but they decided to appoint Ivan Bennett, which in retrospect was a very good appointment because Ivan knew his way around the NIH and set the department on a modern footing. Fred left the department in 1958 but continued his research in a number of different places, although never achieving his full potential. So I went back to St. Mary's and continued my experimental work on kidney infections, atherosclerosis and hypertension. I used this wonderful drug of Eli Lilly, sitosterol, and found that I could almost completely prevent cholesterol-induced atherosclerosis in the rabbit. I stayed at St. Mary's for the next few years doing research, service work and teaching. I applied for several chairs of pathology. In England, as you know, you have to apply for chairs. You don't get invited to them. Unfortunately I did not get one. Fortunately I received various feelers from America including an invitation from Stanley Hartroft at Washington University in St. Louis, offering me a position as a Visiting Professor of Pathology. So I came over to interview with Stanley in 1959. I used the occasion of a symposium. I had been invited to a symposium on urinary tract infections in Detroit at the Henry Ford Hospital. I got a lot done on that trip. Before the trip I had been asked whether I would be interested in the foundation chair of pathology at the newly formed medical school of the University of Kentucky in Lexington. I went to the symposium in Detroit and used that as a jumping off ground for various other enterprises. I then went to Kentucky and was treated very well and liked all the newly appointed heads of department, but I knew nothing about the politics of American pathology and funding agencies and obviously, if you are going to take over as chairman of a new department you ought to know your way around. I began to think it best to work with Hartroft so that I could learn the ropes before going on to a chair in the United States. I then next went to Duke University where Wiley Forbus was retiring from their chair of pathology. I went to Duke and had very good interviews. I loved Duke but had the same reservations as I had at Kentucky. Duke was very sensible in seeing my shortcomings and sent me a letter to that affect. They very wisely appointed Dr. Tom Kinney (a wise and experienced old hand). He did a splendid job over the ensuing years and I got to know him well. I often thought in later years how nice it would have been to have gone to Duke, just as I thought how nice it would have been to have gone to McGill in Montreal where I was considered for the Strathcona chair of pathology in either 1957 of 1958. To continue with my trip I went to St. Louis to see Stanley Hartroft. I spent several days with him and agreed that I would accept his invitation and would join his faculty in July of 1960. The last event on my trip was to accept Harry Goldblatt's longstanding invitation to work with him for 6 to 8 weeks. He was then running the pathology department at the Sinai Hospital in Cleveland, but still running a productive research lab. We had a wonderful time together and he taught me countless experimental procedures and his general philosophy of hypertension. I literally lived with the pioneer of experimental hypertension and profited enormously. He was one of my scientific fathers and we became lifelong friends. |
| Hruban: | What kind of person was he? |
| Heptinstall: | Wonderful! Harry Goldblatt was every bit as bright as Rich, but a much more retiring sort of man. He was American but went to medical school at McGill in Montreal. Because he had been a medical student at McGill, he qualified for what was called a Beit fellowship. Beit was a partner of Cecil Rhodes (who endowed the Rhodes scholarships) in South Africa; he made a great deal of money in gold and diamonds. And like Rhodes, set up trusts to educate young people. Beit fellowships were open to people who had been to British Commonwealth Universities to go and study in England. So Harry, even though he was American, qualified for a Beit and went and spent two years at the Lister Institute in London, working on what was then called the anti- rachitic factor which later became known as Vitamin D. Harry did what he considered the most distinguished work of his career on this topic. His two years at the Lister being up, he went to work with Bayliss - a great physiologist working at University College in London for six months. So he then went to work with Bayliss who taught him techniques and tricks with dogs and different laboratory animals. When he finished with Bayliss, he went to spend a year with Erdheim who was the greatest pathologist in Vienna at that time. |
| McCarthy: | Did you ever meet him? |
| Heptinstall: | No. He was before my time - a whole generation. He told Harry that there wasn't much he could teach him in the time available, but at least he could teach him to speak and write German. To that end, Erdheim suggested that Harry write a monograph of all the work he had done on the anti-rachitic factor and rickets in general in German. It appeared in the Ergebnisse der Pathologie back in 1931. It is a classic work and Harry told me an amusing story about it. Apparently Harry was at a dinner and sitting next to Fuller Albright, the great sage of Boston. Albright said, "You know Goldblatt, I have just read a superb monograph written in German by a man with the same name as you on rickets and the anti-rachitic factor!" Harry just smiled and said, "It was I." How lucky I was to have met such men as Newcomb, Pickering, Joekes, Rich, Germuth and Goldblatt who did so much for my education. |
| Hruban: | Let's go back because we still haven't talked about your work with Marc Joekes. |
| Heptinstall: | By the time I got back to England in January 1956 and started working again at St. Mary's, Joe (as he was always called) had just done a handful of biopsies. He had got Ken Porter who was a little bit junior to me to look at these biopsies. Ken had gone shortly after to work at the Brigham in Boston. So Joe asked me if I would like to take over the pathology on this biopsy service, which I did. Joe and I continued our association until I left for the United States in 1960. He was a most charismatic man with a profound knowledge of the kidney and a wonderful sense of humor and fun. We got on together splendidly. |
| Hruban: | Where was the first kidney biopsy in humans? |
| Heptinstall: | It is not really known who did the first kidney biopsy. Using it in a systematic way it was either a man named Nils Alwall in Sweden or a pair, Pol Iverson and Klaus Brun in Copenhagen. The story goes that Alwall tried a few, but when one of his patients developed a nasty hemorrhage he abandoned them. Iverson and Brun did very large numbers and they usually get the credit for being the first to put the percutaneous needle biopsy on the map. Word of this technique gradually spread and two people at the VA Hospital in Washington, DC - one was an old Hopkins pathologist: John Howe. Alvin Parrish and John Howe did the first biopsies in the United States. They were soon overshadowed by a group from the University of Illinois headed by a South African named Bob Kark. Bob Kark was primarily a liver man. He had done a lot of liver biopsies and immediately saw the potential of the renal biopsy. In short order he got together a team made up of Bob Muehrcke who did the actual biopsies, Victor Pollack, a young South African who handled the clinical side, and Conrad Pirani from the pathology department who interpreted the biopsies. Between them they did an incredible amount of work and showed the enormous potential of the renal biopsy. This group really put the renal biopsy on the map. Kark sent Bob Muehrcke to spread the gospel to England; this was while I was over with Rich. Bob Muehrcke went to St. Mary's and gave a demonstration to Joe and taught him how to do a renal biopsy. So that was how Joe came into it and in short order became adept at doing biopsies. He and I did very large numbers. We wrote quite a lot of papers on various renal conditions. |
| Hruban: | I'm still curious about your impressions of Hopkins back in the 50's. What about people outside of the department - who did you meet? |
| Heptinstall: | I got to know a lot of people mainly in the Department of Medicine and Surgery. On a regular basis I used to go to Medical Grand Rounds and the meetings of the Hopkins Medical Society. I saw people like Lock Conley who was head of the Hematology Division for whom I developed a tremendous admiration. Ivan Bennett, head of Infectious Diseases, was a very impressive person. Mac Harvey, who was head of Medicine was very bright although somewhat retiring. He used to do the CPC's with Rich. There was an absolutely wonderful chief resident in medicine that year who impressed me a great deal - a man by the name of Lee Cluff. I used to go on the rounds he did with the Osler housestaff. Lee became the head of medicine at the University of Florida and I think he took over from Dave Rogers as head of the Johnson Foundation at a later time. Lee was a brilliant teacher and he really brought one up to date on internal medicine. There were also some good young people like Dudley Jackson and Henry Wagner. Others didn't really impress me as much. Although St. Mary's was much smaller on a proportional basis, Pickering's medical unit could match the Hopkins internists. The big difference was the number of conferences and opportunities for discussing and disseminating knowledge. Academic surgery was more advanced at Hopkins, but I did not have time enough to go to their conferences. |
| Hruban: | The path department must have been very small, right? |
| Heptinstall: | The pathology department was smallish, but it did a lot of work. In those days they used to do 850 to 900 autopsies a year. It didn't do as many surgicals as now and of course it did not do gyn pathology because Woodruff from the gyn department used to do it. There was a tremendous amount of teaching with this relatively small staff. People worked very hard and everyone including the housestaff was involved, but they loved teaching because Rich set the example. There were few senior people of whom Ella Oppenheimer stood out. She was the main bulwark of the department and gave years of service. City Hospital pathologists also taught of whom Abou Pollack was the most effective. The housestaff, with a few exceptions, were very good. The chief resident, who shall remain nameless, was a dummy, but Ed Andrews was excellent and eventually became President of the University of Vermont. Jim Shaka was excellent and became a great friend. Sumner Wood was already showing great promise in research, and Jerry Spear and Jack Yardley went on to have successful careers in pathology. There were plenty of conferences and the intellectual environment was good. On the whole it was a very happy and cohesive department. |
December 9, 2007
| Hruban: | It's December 9, 2007, I am Ralph Hruban and with me is Belur Bhagavan and Robert H. Heptinstall and this is segment 2 of interviewing Heppy. In the previous segment we came all the way up to when you came to the United States. The last time we finished it was 1959 and you just completed the two-month fellowship with Harry Goldblatt in Cleveland. |
| Heptinstall: | Yes, well I went back to England and prepared to come over here permanently in 1960. |
| Hruban: | And one thing I want you to reflect on is why you decided to move from England to the United States. |
| Heptinstall: | Two main reasons. First I was frustrated at not being able to get a chair in Pathology at home, and second, the opportunities for doing research were greater in America. In England the system is that you are not invited to a chair; you have to apply for it. Applications were advertised in the medical journals. I applied for a couple of chairs which I didn't get, and then decided I would go for one more. The chair at Newcastle became vacant and I applied for it. It had been occupied by John Duguid who had resurrected Rokitansky's theory that atherosclerosis was caused by organization of fibrin thrombi on the intima. Anyway, Duguid's chair came up and I applied for it as did other people and we all went up to Newcastle for our interviews. It turned out that they had been very foolish and had an even numbered search committee. According to the account I heard, when the final vote was taken after the interviews, a chap called Bernard Lennox, who was a senior pathologist at Hammersmith, and I got equal numbers of votes. So instead of doing the sensible thing of taking a coin out and flipping it, they decided to disband the committee and readvertise the job. This was the final straw so I decided to accept Stanley Hartcroft's invitation to go to St. Louis, which I did. Perhaps I was very conceited because I was still only in my thirties, but certainly very impatient. The second point about research opportunities was discussed earlier. We came to St. Louis, myself, Ann and five children, in the summer of 1960. I had a very pleasant and productive experience in St. Louis for two years. I was given the title of Visiting Professor and had full professorial status. I was introduced to the NIH and all the ramifications of getting research money in America, about which I knew nothing. This is where the committee at Duke had been so sensible. I learned a great deal about American pathology and got to know a lot of American pathologists as well as getting on with my work. I also met one of the finest pathologists I ever met. You probably know him - a chap called John Kissane. John worked in the next lab and he and I did quite a lot of work together and had a wonderful time. |
| Hruban: | What did you like about John? |
| Heptinstall: | What I liked about John is that he had a great sense of humor and was a very bright fellow. I think he was top of his year at Wash U. I admired his intellect. He was a wonderful pathologist for a young man particularly at a time when young people in pathology were being pushed into doing experimental work and doing nothing else. He did very good research work, too. He learned a great deal of his pathology from Margaret Smith who had trained at Hopkins with Ella Oppenheimer under MacCallum. As you know, John became one of the foremost pediatric pathologists in the country. |
| Bhagavan: | You kept in touch with him and he contributed some chapters? |
| Heptinstall: | Yes, in the first two editions of my book he wrote on the embryology of the kidney and developmental defects. The other thing I owe to John is teaching me baseball. He knew a fantastic amount about baseball and had been a very good player when younger. He was a catcher. John knew so much about the finer points of the game and taught me so much about the game that I knew much more about it than the average American did. I had been to my first major league game with Fred Germuth at 33rd Street when I was here in 1954-55, but barely understood what was going on. I went to see the Cardinals with John several times in St. Louis and only then did I begin to understand the game. Now to cut a long story short, after I had been there a year, Stanley Hartcroft decided to go back to Canada so he resigned his position. They appointed a man called Paul Lacey, primarily an investigator. I didn't like the prospect of not having Stanley there so I put out several feelers and Ivan Bennett asked me to come back to Hopkins in 1962. I owe a tremendous debt to Stanley, who not only invited me to America and introduced me to American pathology, but showed me the subtler points of running a first class department. From 1960 to 1962, his was without a doubt the best department of pathology in the United States. |
| Hruban: | What work did you do in St. Louis? |
| Heptinstall: | John and I did some micro-enzyme studies on various kidney conditions and on my own worked on kidney infections and experimental hypertension. For the first time in my life I was freed of service work and able to do full time research. I came back to Hopkins in the summer of 1962. What followed was probably the happiest period of my life because I had no routine duties. All I had to do was teach and build up a lab and get on with my research. I did this for four years. |
| Hruban: | Who was on the faculty when you arrived at Hopkins in 1962? |
| Heptinstall: | Rich had retired in 1958, and they did the unusual thing of appointing a non-pathologist in Ivan Bennett to the Baxley chair and to be in Pathologist-in-Chief to the hospital. Of course, many people thought that was a terrible thing to do and that was the reason why Fred Germuth left. Fred had hoped to get the chair and in many ways he deserved it because he was the brightest thing that had ever come along for years in the pathology department at Hopkins and was doing superb work. As I told you last time, I spent most of my 15 months, 1954-1955, working with Fred rather than Arnold Rich which was the original intent. I did some work with Rich of course, but he saw the merit of my working with Germuth and learning something about immunopathology |
| Bhagavan: | Was there anyone at Hopkins at that time interested in renal pathology? |
| Heptinstall: | In 1954-5 Rich was interested in renal pathology and so was Germuth. Their work was confined to experimental studies and autopsies, as the renal biopsy had not come into general use at that time. So there was no renal biopsy service as we have nowadays. It had come along by the time I returned in 1962 and Gerry Spear was doing the reading of the biopsies. Gerry was a resident when I was there in 1954, and by 1962 was a faculty member. |
| Hruban: | I am interested in the reaction when Ivan Bennett was appointed chair. |
| Heptinstall: | Fred reacted to this very, very badly. He resigned and became Chief of Pathology at Charlotte Memorial Hospital in North Carolina. However, they did give him facilities to continue doing research, but he was only doing it on one cylinder instead of eight. He stayed at Charlotte Memorial for several years before moving to another hospital in North Carolina and eventually getting the chair at St. Louis University where he continued his research. He seemed to be getting a bit restless by that time, and when St. Johns - Mercy Medical Center - asked for advice on their vacant headship of pathology he took the job himself. The holy sisters were terribly good to him and fitted out research labs for him so that he could continue his research. He did some splendid work and with a young assistant, called Rodriguez, wrote a wonderful book entitled, "Immunopathology of the Renal Glomerulus," which described correlations of his experimental and human renal biopsy observations. It was an absolute classic published in 1973. Tragically, he died shortly thereafter with much of his promise unfulfilled. He was one of the smartest young men I have ever met. I have many happy recollections of our friendship. |
| Hruban: | St. John's is in St. Louis? |
| Heptinstall: | Just outside St. Louis. The chap who took over as head of pathology there was Fred Kraus whom I knew as a promising pathologist at Wash U earlier. Very nice fellow and a fine pathologist. Now to revert to the reaction to Ivan's appointment. The most dramatic concerned a man called Stan Eversole who was I think an Associate Professor. I met him on my first trip to Johns Hopkins. Stan apparently picked up a bottle of stain and threw it against the wall where it left an indelible mark. It was kept there as a sort of memento for several years. Fred Germuth and Stan Eversole quit, but apart from those few disruptions, things settled down and Ivan did an absolutely excellent job. He was a bright, intelligent man who knew his way around funding agencies and his research was appropriate for a pathology department. He wasn't devoid of any knowledge of pathology; he had spent a year with Rich. He brought the department into the NIH age. Because Rich, you see, had a thing about accepting government money for doing research, and as I said earlier when I was there in 1954-55, there was only one research grant in the whole department and that was Fred Germuth's. Ivan got things moving in spite of a stormy introduction. Teaching went on as it did before, but he encouraged people to go for research grants and recruited people who could do research. On the whole, I think he did a splendid job. He was always very helpful to me. Rich, of course, was there. He used to come in most days, but made no attempt to interfere. I saw a lot of Rich after I got back in 1962 because he used to live just down the hill from me in Roland Park. Another good thing that Ivan did, realizing that he was no great expert on pathology, was to recruit one of the best human pathologists in the country, Walter Sheldon, who was not very happy at that time as head of pathology at Emory. Walter came to Hopkins and took over the residency training program and things like that. He was a great help to Ivan as he was a very, very great help to me later. Walter was an incredibly fine pathologist, one of the best I have known. He was also a very cultured man and I enjoyed his friendship for many years. |
| Hruban: | I think he was still in the department when I was there, but he had a stroke or something? |
| Heptinstall: | No, Walter got a nasty tumor, it was either a melanoma or retinoblastoma and had his eye removed. It was very sad and he died as a consequence. Ella Oppenheimer was still there of course as she had been since MacCallum's day. |
| Hruban: | Tell us about Ella. |
| Heptinstall: | She came from a Baltimore merchant family and had a most regal personality. Ella was a magnificent person. Ella, as you know, was a pediatric pathologist, but she was a very good adult pathologist too. She didn't do much experimental work, but was an absolutely first-class pathologist and a wonderful teacher. The students used to call her the dragon lady because she was very strict with them. Yardley was now on the faculty, as were Gerry Spear, Sumner Wood, and I think, John Boitnott. Gerry used to run the renal biopsy service (which was very small) and he used to do good experimental work on the kidney. Sumner Wood used to work on tumor metastases. He had an experimental model in the lop-eared rabbit and used to put little chambers in their huge ears so that he could take cinéfilms to record what was happening to the microvasculature. Yardley did electron microscopy and was developing an interest in the G-I tract. Several of the people I had known in 54-55 had gone. Shelley had come back from Memorial Hospital in New York where he was when I was there the earlier time. He ran surgical pathology with Bill Hartman. |
| Hruban: | What was Bill Shelley like? |
| Heptinstall: | He was a very good pathologist and had improved surgical pathology enormously. |
| Bhagavan: | But also associated with City Hospital at that time - Abbou Pollack. |
| Heptinstall: | I never went to Baltimore City Hospital on my first visit to Hopkins, but went there regularly after 1962. I used to go there once a week and work off some of the microscopy of their autopsies. Pollack was head of pathology and ran a very good department. He was another absolutely wonderful human pathologist and had worked at Mt. Sinai in New York with Paul Klemperer. He was on the definitive paper on systemic lupus that came out of Mt. Sinai with Klemperer, Pollack and Baehr as the authors. Klemperer was head of the department at Mt. Sinai and George Baehr was a clinician who did a great deal of work on the kidney - many different aspects. So you're right, I used to go around to BCH. As I said earlier, I had no service duties and I was rarely coming upon renal biopsies. Gerry Spear was doing a good job running the service, but they didn't do very many biopsies. In order to keep in touch, I arranged with George Schreiner who ran the renal unit at Georgetown University Hospital in Washington, DC to go down there every Friday afternoon or every second Friday afternoon to see their biopsies and take part in their very good conference. It was a very busy service. They had George, and a very good nephrologist called Jack Maher who later became head of nephrology at the Uniformed Medical University, but who died at a relatively early age. George had lots of fellows who all came in very useful later, because when we were building up the renal biopsy service at Hopkins at a later time they were in various jobs in Baltimore, on the Eastern shore, or down in Annapolis. They used to send us their biopsies for interpretation. Off the record, I think now, the pendulum has swung too far. I think they are doing too many renal biopsies. They are doing over 2000 a year - a tremendous number. That involves a great deal of work. It is keeping people like Mark Haas, Lorraine Racussen and Serena Bagnasco away from doing more basic research. They are bogged down with all this routine work. No doubt it brings in a great deal of money, but is very time consuming. In the early days when we didn't know much about the kidney you needed biopsies, but now we are very familiar with most conditions so you can have too many. I owe a great deal to George Schreiner who not only allowed me to work with his unit, but who gave me the entrée to American nephrology. We became great friends and spent many happy times together. |
| Bhagavan: | Was there electron microscopy at City Hospital at that time? |
| Heptinstall: | No I don't think City Hospital had an electron microscope for service work. It was something Bennett introduced to Hopkins. Yardley used to do all the electron microscopy in Bennett's early days. |
| Bhagavan: | Didn't David Brandes do some electron microscopy at City Hospital? |
| Heptinstall: | You're absolutely right. David Brandes had an electron microscope, but I believe it was purely for his research. David was another good man they had at BCH. And then they had Garcia who took over when Pollack died. |
| Hruban: | How did Pollack die? |
| Heptinstall: | He had pancreatic cancer that was found inoperable by Jack Handlesman. I remember the day Jack operated on him - so sad. So Bennett had some very good senior pathologists Ella and Walter. Abbou used to come to Hopkins quite often, especially to teach. |
| Hruban: | You were going to say something about Hartman. |
| Heptinstall: | Well, Hartman used to assist Shelley; they were the two in surgical pathology. Then Hartman left to go into private practice in California, didn't he? And later, much to everyone's surprise, he was appointed head of pathology at Vanderbilt. He had never worked in a lab in his life, but Bill was a very smart fellow, a nice man too. |
| Bhagavan: | At that time in the city my boss, Dr. Weinberg, who trained along with Dr. Pollack at Sinai Hospital, can you reflect on him? |
| Heptinstall: | I never knew Toby terribly well. When I was first here (1954-55), Sinai was on Monument Street, and then they moved out to their present location while I was back in England. I saw very little of Toby after he moved. But for many years Toby always used to take 2 or 3 of our summer students and it was very popular until we found out why they like going to Sinai. It appeared that Toby gave them a steak dinner every day, but that was just a small point. They got very good training out there. He was a very good pathologist. |
| Hruban: | Is your sense, between 1962-1966, was it one of great excitement in the research labs? |
| Heptinstall: | Oh yes, there was quite a good spirit because things were moving. The tragedy was that there was very little space. The promises that had been made to Bennett about new labs and increased space, incidentally the same promises that were later made to me, were never honored. Any spare space was turned into a lab and had to be fitted out on the cheap and Ivan had to use Sears Roebuck kitchenware. Benches weren't benches they were Sears Roebuck Formica kitchen tops. This breach of faith haunted me when I took over the department and deservedly revisited the Administration when they had to recruit my successor in 1986. |
| Bhagavan: | Can you also reflect on clinical pathology vs. anatomic pathology? |
| Heptinstall: | Clinical pathology in the 1960's was run mainly by the department of internal medicine; hematology and all pertaining to that came under its Hematology Division. I don't know which division of internal medicine clinical chemistry came under, but it was done by them. Bacteriology or microbiology that again was all done by the division of infectious disease in the department of Medicine. Ivan decided that the pathology department had to have a much greater stake in the clinical pathology and a committee was set up under, if I remember rightly, the aegis of the Hospital. I was on this committee, and we set out search the country for someone who could head up clinical pathology. It was all very vague because nothing had been discussed, as far as I remembered with internal medicine as to what was going to be taken over, but it was mainly going to be a hospital operation and Russ Nelson, the hospital President, did most of the running of this. The committee went around interviewing people. We decided on Rex Conn. And Conn came and was allowed to take over certain things, but not others. He was supported financially by the hospital, but he had a university faculty appointment. His faculty appointment was in the Department of Pathology. They were an independent hospital department of laboratory medicine and a subdepartment academically of the Pathology Department of the Medical School for teaching and research. |
| Bhagavan: | The pathology residency program did not include training in clinical pathology at that time? |
| Heptinstall: | That is so. Early on when I was here in 1954-55, the pathologists just got training in anatomic pathology. And even then they did not get a complete training in anatomic pathology because the department of gynecology would not give up the gynecologic pathology and that was a fight the whole time I was there. After Rex Conn came in the 1960's we began to offer residency training not only in anatomic pathology, but clinical pathology too. Rex soon recruited some very good people such as Bill Merz, Bob Baisden, Bob Rock and Dan Chan. Unfortunately, they were just worked to death with routine duties. They had very little time for doing research. A very sad story brought about by The Johns Hopkins Hospital taking the money for service work and doling it out parsimoniously to the faculty. It wasn't until Sanfilippo came that things improved since one of his conditions for coming was that he had to have control of the whole of clinical pathology and the money that it brought in. They were so desperate to attract somebody they let him have it. Bennett couldn't get a deal like that and neither could I. The Hospital kept all the proceeds in our day. The entire episode was disgraceful. |
| Bhagavan: | In the early 1960's as a prelude to this, the College of American Pathologists played a great role in terms of supporting clinical pathology and that the renumeration that was got from the laboratory should go to pathology. This was a political philosophy that was propounded by the American College of Pathologists which is really what got pathology departments to incorporate clinical pathology into their departments. Do you have a recollection of that? |
| Heptinstall: | No, I have no recollection of that. I was brought up to despise the American College of Pathology. There was a story of Ivan that he was asked to speak at an American College of Pathologists meeting and he went up to the blackboard and chalked up a dollar sign. He said, "I'm afraid this is all that I know about you." |
| Bhagavan: | You don't remember all the political nuances that went on? |
| Heptinstall: | No. I was never interested in the sordid money side of pathology and in retrospect should never have been a departmental chairman. |
| Hruban: | So was Gary Hill one of your fellows between 62 and 66? |
| Heptinstall: | Yes, he was my first fellow, and certainly the best. |
| Hruban: | Did John Hodson work with you at that time? |
| Heptinstall: | Hoddy was a radiologist and an old friend from my time in England. I worked with him on and off and collaborated with him from a distance over many years. We never worked at the same institute. Let's go back to 1966. Ivan suddenly announced that he was going to spend two years as the Assistant Director in President Lyndon Johnson's Office of Science and Technology. The director was a physicist, a man I think was called Horning. Ivan had spoken to Walter first about holding the fort, but Walter wasn't interested so he came to me and I agreed. I shouldn't have accepted it because that is what killed my research. I was never able to do research on 8 cylinders again. It was a very big department even though it did not have full control of clinical pathology. I very foolishly told him I would do it, but only for two years. I did it and I didn't enjoy it all that much. I was given help by various people, but was not treated well by the Medical School. For example, before I could attend a meeting of the Advisory Board, I had to receive an invitation to go. The Advisory Board was made up of all the heads of department, preclinical and clinical. I thought this was awful. I was made to feel that I was purely a fill-in. I did not take particularly kindly to the medical school over those years. I didn't really enjoy it. I enjoyed helping the younger people in the residency training program, helping faculty with their research, giving them advice on how to get research grants and things like that. I enjoyed the medical student teaching, naturally. All the politics I loathed. I used to regard it with horror having to go to the monthly meeting of the Advisory Board. The Medical Board of the hospital treated me better. I didn't receive a monthly invitation; I was just made a member of it and went as a matter of course. The hospital however did not treat us very well as I have said earlier. Then came 1968, and Ivan suddenly announced that he was not coming back. He was going as Dean to NYU - the Dean of the faculty of medicine at NYU. He was a very good choice. One of Ivan's great strengths was in administration. So then Hopkins decided to look for a permanent director. They set up a search committee chaired by Bob Cook from Pediatrics and appointed me permanently in 1969. I was Director until 1986 when I reached retirement age. However, I stayed on until 1988 because for two years they were scrambling to find a successor to me. The man who was chairman of the committee was Tom Pollard - a cell biologist. The people they were looking at were entirely research people. Many of these were good people, but none of them would take it because they felt the administrative duties were too heavy and that the research facilities were inadequate. |
| Hruban: | Who were some of the people? |
| Heptinstall: | One was Lance Liotta who was at NIH. Another was a virologist at NIH whose name escapes me (Howley?). The one I liked the best was Joe Davey (I think that was his name) from Washington University, St. Louis, but he was at the same time being considered for a job in the pharmaceutical industry. He would have been very good if he had taken it. Another they looked at was Mike Gimbrone, but he did not want to leave Boston. He was rooted in Boston and as it turned out it he eventually succeeded Ramzi Cotran at the Brigham. So four people turned down the job and then they ended up with a chap called John Morrow from Yale who hadn't really done very much pathology and his research was only peripherally related to pathology. He also turned it down (Thank Goodness!). They were in a bit of a panic as to what they should do. They asked me to stay on and I stayed on until 1988. They then started looking again for somebody and whittled it down to Sanfilippo from Duke and a very nice chap from Brigham - Madera, who eventually went to Emory. |
| Hruban: | He is now Dean at the University of Chicago. |
| Heptinstall: | He has now gone Deanwards and also Downwards. I misjudged him. The new head of the search committee was John Cameron. And Cameron was being considered for a job at NYU in New York at that time, so he was giving the Baxley chair scant attention because he wanted to get the NYU business over quickly. So they interviewed both Sanfilippo and Madera. They got Sanfilippo back for a second interview, but they didn't get Madera for a second interview because Madera had promised his family that he would take them on a trip somewhere so they did not reschedule him. It was a disgrace really. So the Baxley chair went to Sanfilippo almost by default. He got a very good deal. First, pathology was given much new research space after all the promises that had been made to Ivan and me. Second, they let Sanfilippo have clinical pathology which they had denied us, and the money it brought in. Also by that time the professional fees were coming in in larger amounts so the financial situation of anatomic pathology was getting better. These concessions and long overdue fulfillment of old promises substantially altered the department's financial situation and its research potential. It is really remarkable that we had done so well considering the difficulties and constraints we worked under. It is sad to reflect on the way these benefits came about because they were really forced on the hospital and medical school by their inability to find my successor. Although it's now a very rich department, I am not sure it is a better one. The teaching is not as effective as it was, but this is largely the result of the once discrete course being made part of a mish-mash. As an example, we used to get people interested in pathology when we had an autonomous course in pathology. There was one year, a halcyon year, when five or six of the graduating class came into pathology. They were I think Risa, Sharon, the two Sayers, Lowell Rogers, and I believe, Jimmy Eagan. The old course really kindled the student's interest in pathology. |
| Hruban: | Let's go back because we skipped a lot. So going back to 1966 the first edition of your book came out. Why did you decide to write a book? |
| Heptinstall: | I decided to write a book because there was a need for one. Number two, I enjoyed writing and had written on the kidney in various books. I wrote a fairly large kidney section for what was then the new British book on pathology. This was Payling, Wright and Symmers. Damn good book. I wrote the kidney section for that. I also used to write the kidney section for that very good British series called Recent Advances in Pathology. I did the kidney section in two editions of Recent Advances. I wrote a chapter on focal glomerulonephritis for an American book on the kidney by Strauss and Welt. I wrote for Douglas Black's textbook on the kidney. So I thought, OK, I might as well have a book of my own. It was about 1964 when I started writing it. I wrote in the evenings and weekends; I wrote in airports and railroad stations, all over the world. I was very lucky to have had a wonderful secretary. She's still at Hopkins and you both know her - that is Mary Lakin. She was very young at that time and she was my first secretary. Mary came to me in 1962. Incidentally I also acquired a very good technician at that time who had been Ramzi Cotran's technician at the Boston City Hospital when he was there. Harvard had a service at the Boston City Hospital. And that was Marilyn Miller. Marilyn, who was also superb, retired about 18 months ago. Back to the book. Mary was absolutely wonderful. She was able to take these little scraps of paper on which I had written things and restore order out of them. |
| Hruban: | So you would write it out by long hand? |
| Heptinstall: | Oh yes. I was never very good with a dictating machine. If I may make an observation, very few are! I always like to write them out in the sort of the English I hoped will appear in the final version so I wouldn't have to rewrite it. Mary did this job and we finished the book by the end of 1965 or early 1966. It took two years - a great deal of work. It was a big advance because it took into account the information gleaned from the renal biopsy. All the books up until that time were dependent on autopsy observations. The two main books on renal pathology were a book by Elexious T. Bell. Bell was a Professor of Pathology at the University of Minnesota. He was a very good pathologist, and wrote a good book but he was entirely dependent on autopsies. Another book, that was really more of an atlas but which achieved greatness in its day, was one written by Arthur Allen. Arthur Allen was at the AFIP and was primarily a skin pathologist, but he took an interest in the kidney and did a very good job. Arthur Allen was married to Sophie Spitz, a distinguished pathologist. The book that I wrote was able to take in the advances that had been made through the renal biopsy. The renal biopsy came into general usage in the mid 1950's so we had ten years of experience with renal biopsies by the time my book appeared in 1966. It was based on both autopsies and renal biopsies. It also contained a fair amount of experimental work. |
| Hruban: | So when you first came to Hopkins, Gerry Spear was doing the biopsies. How did you get the material? |
| Heptinstall: | Gerry showed me the interesting ones, and as I told you, I used to go down to Georgetown to see George Scheiner's cases. I also recieved a lot of consultations. Oh no, I used to see plenty of material. I also had a great friend in Kash Mostofi who was head of the renal side at the AFIP and Kash used to put a lot of material at my disposal. I used to go down to the AFIP quite often. That's where I saw all those cases of ethylene glycol poisoning and material only the AFIP would have. And Hopkins had wonderful autopsy material that had been kept for years. So I was able to write a really decent book and it became very popular. It sold very well when it first appeared and quickly went into a second printing. The first edition sold very much better than any of the subsequent editions. Number one it was new; second, it was the only really up to date book on the market. There was another book that came out near that time which really didn't do very well. It was edited by a friend of mine, Stretch Becker who got hold of all sorts of people to write for him. |
| Bhagavan: | That was more clinically oriented? |
| Heptinstall: | No, it was pathology. It didn't do very well because it came out about the same time as mine which rather overshadowed it. |
| Hruban: | One thing that puzzles me is that it's very useful for the diagnostician when it first came out and here you were mostly doing research? |
| Heptinstall: | Yes! But I wasn't a researcher locked away out of touch with clinical medicine. Another reason why it sold so well is that it was so cheap. It was only $28 when it came out. The present edition (6th) is about $360. For that first edition I had contributions from two friends. Ken Porter, who was an old colleague of mine at St. Mary's and wrote on Transplantation about which I knew nothing. John Kissane from Washington University at St. Louis did the development of the kidney and developmental defects. I wrote about 30 chapters and Ken and John wrote three. It went down very well. So that was the origin of the book. I brought out another edition about six or seven years later which increased in size to two volumes. Ken and John again wrote their chapters. I got Bob McCluskey to write a chapter on immunologic mechanisms in kidney diseases. Again I wrote the rest of the book. I did a 3rd edition that went up to three volumes. I think at that time I got a few more people in to help such as Gary Hill and Kim Solez, but I still work the bulk of it. The 4th edition was the last one in which I wrote most of the chapters. The prospect of a 5th edition was too much for me. I was having problems at home. Christopher had fallen sick by that time and I could not give the time to writing. I decided the best thing to do was to ask several younger people to take over the book because it was beyond the scope of one person. I very much wanted Gary Hill to be one of the new authors, but Gary was tied up in his big row with Sanfilippo at that time and he couldn't accept. I got Jean Olson, Fred Silva, Charlie Jennette and Mel Schwartz. These four did a very good job. They did a 5th edition and the 6th edition came out several months ago. It is now called Heptinstall's Pathology of the Kidney. It doesn't mean a damn thing; I don't make a penny out of it. I didn't make much out of the original four editions. That was one of the disappointing things. I reckon that it educated half a child a year from the royalties. There is no money in specialized books. |
| Hruban: | Can you go through renal pathology at Hopkins? |
| Heptinstall: | Renal biopsy as I told you had not really come into widespread usage when I was here the first time. When I came back the second time in 1962, Gordon Walker had started the biopsy service, he being the clinician and Gerry Spear the interpreter. Jack Yardley did the electron microscopy. It was never a very energetic service. I don't think Gordon, who was a splendid clinician, was wholly convinced the renal biopsy was such a good thing. He wasn't anti-biopsies, but was never a great enthusiast like my friends Mark Joekes or George Schreiner so I really can't tell you very much. Gerry ran the pathology and then when Gerry left to go to California I gave it to Kim Solez. Then Solez went to Canada and I gave it to Jean Olson to do. And Jean Olson was doing it when I left. So I can't tell you much more. Nephrology in my time at Hopkins was not one of its strongest suits. |
| Hruban: | What about your relationship with Gary Hill? It obviously goes back many years. |
| Heptinstall: | Gary worked in my lab when he was a medical student and continued his work on pyelonephritis and hypertension when he came on the house staff. He did superb work, showing great originality and thought and wrote several important papers. He was one of my chief residents. The two best chief residents I ever had the whole time I was there were both residents in the same year - they were co-residents together. One was Gary the other was David Page who later joined the faculty at Vanderbilt. They were superb. Gary then went off to do his military service. He went down to Walter Reed. I was hoping he would come back. Meanwhile, I had put Solez in Gary's position of seniority and Gary didn't like it (not many people did) and Gary wouldn't come back. He went to Penn which was a great disappointment to me because I regarded Gary rather like a son. Everything now is reconciled, but there was a little bit of ill feeling. Gary felt I had given Solez too much responsibility and power. In retrospect he was quite right and I now realize this was one of the biggest mistakes of my life. Happily, I was able at a later time to attract Gary back to take the headship of pathology at BCH where he ran a very good department until his contretemps with Sanfilippo. |
| Hruban: | So he was the chair at Bayview and you were the chair at Hopkins for many years? |
| Heptinstall: | The director of the department at Hopkins was mainly responsible for choosing the head of pathology at Baltimore City Hospital. Let me just add that when Sanfilippo took over he had a row with Gary which led to the latter's leaving and taking a research position in Paris. There he did the most superb work and established himself as one of the leaders in nephropathology. |
| Bhagavan: | And the VA Hospital also? |
| Heptinstall: | No, we never had anything to do with the VA during my tenure. |
| Hruban: | Can you comment on your relationship with the various Deans and head of the hospital? |
| Heptinstall: | Relationships were tolerable because they knew I was a decent person and that they could usually get me to go along with what they wanted to do. I didn't particularly worry about most things except for breaches of faith and they were guilty of many. I just hated the bloody administrative side of my job. I should never have taken it. I had been brought up very frugally in England and was therefore not very demanding. I told you the story, probably many times, that when I was working with Fleming in 1947 I wanted a bit of apparatus once. It was a very small sum involved. Fleming wouldn't give it to me. He said, "No, you've got to make your own; we make our own apparatus here." And we did. I learned to make and calibrate pipettes out of glass and all sorts of things. I could make a burette and glass pipettes. He then said, "What you've got to realize Heptinstall is that we have an equation in this department which is that brains times equipment is a constant." So you see I was brought up very frugally and could get by on very little. In retrospect I wasn't treated very kindly by either the school or hospital from a financial point of view and that is really what counted. Nor was I treated very well in getting additional space. So far as money for salaries was concerned it is a matter of record that my salary was in the lowest 15% of pathology department of chairman in the United States. Even then part of it came from my research grants. Other faculty salaries were also low. |
| Hruban: | Was the promise as far as space? |
| Heptinstall: | When I took over in 1969 I was promised new space and labs. None was provided and it wasn't until their feet were put to the fire when they couldn't find anyone to replace me that they honored their promises. Johns Hopkins in my time was a prime example of infidelity and parsimony. |
| Hruban: | Reflecting on your days at Hopkins which faculty stood out in your mind? |
| Heptinstall: | We had both good and bad faculty. The research people were by and large disappointing, although some, like Don Price, did well. I was very impressed by those doing service work and teaching. |
| Hruban: | What was your relationship with Eggleston? |
| Heptinstall: | Always very cordial; Joe was splendid. When Shelley left to go to Charlotte Memorial (Hartman had already left), I had to get somebody to run surgical pathology. I appointed two of Shelley's trainees, Joe Eggelston and Darryl Carter. And on the whole it worked out fairly well. They were both absolutely excellent surgical pathologists. You couldn't find a better pair of surgical pathologists anywhere. This arrangement worked well for a few years until Darryl left to go to Yale. Joe then took over sole control and was magnificent. And then Joe got this bloody cancer of the bronchus. He smoked like a chimney unlike Jack Frost who ran Cytopathology and also developed a similar cancer about this time. Poor Jack had spent years working on the early detection of lung cancer. He had never smoked a cigarette in his life. |
| Hruban: | How did Joe tell you he had cancer? |
| Heptinstall: | I don't know. I just remember going to his house in Stoneleigh one evening when I heard of it. It was a very sad evening. He bore his burden with great dignity and courage. He carried on with a full load of service work and teaching for a considerable time, but eventually died. I was devastated when Joe died because I had a developed a great affection for him and relied heavily on his wise counsel. I was honored to be asked to read one of the lessons at his funeral and to speak at his Memorial Service. There should be a transcript of my speech at the latter somewhere. Try Mabel to see if she can locate it. While I was running the department I still managed to do a certain amount of research. I had an R01 that I first got in my time in St. Louis in 1960. I took it with me to Hopkins. It gradually got bigger and bigger and was still intact when I stepped down in 1988. Then in about the 1970's I put in for another R01 to study the monoclonal theory of atherosclerosis and I got that funded. And that again was intact until the time I retired. So although I couldn't do much of it myself, I was still able to make a good many contributions with other people acting as my surrogates. I was able to keep one R01 for 18 years and the other one for about half that time. The atherosclerosis work I handed over to Tom Person who had contributed mightily and the other I handed over to Jean Olson. |
| Hruban: | What of your research findings are you most proud of? |
| Heptinstall: | I'm proud of some of them, but if I had not been burdened by administration, I could have done much more. Gary and I were way ahead of the crowd in hypertensive glomerular & vascular injury when he had to go into the Army, and as I have said, he never came back to me. The paper that I always remember is one I wrote years ago when I was at St. Mary's. I had done a lot of work on the effects of hypertension on experimentally induced atherosclerosis. I had a vast amount of material and eventually I got it all together. I wrote a paper which showed very clearly that in an experimental model plotting the height of the blood pressure against the amount of atherosclerosis showed an absolutely straight line but no correlation with the level of serum cholesterol once you exceeded a nominal level. I never completely believed the cholesterol story. I believe in it in part. I believe in it for the people who are the heterozygotes/for familial hypercholesterolemia, people who are running cholesterol levels in the high hundreds. They undoubtedly are at risk. But putting people on drugs when they have serum levels just over 200 seems to me rather excessive. I sent this article off to Circulation Research. The editor of Circulation Research at that time was a man called Carl Wiggers who was a physiologist from Western Reserve. The statistics were terribly simple. Even I could understand them. Just to make sure, I got a young man called Peter Armitage to check the statistics. Peter was working with Bradford Hill whose book you probably used on statistics. This man was a protégé of Bradford Hill and later became the head of the statistics department at the London School of Hygiene and Tropical Medicine. I got a letter back from Carl Wiggers, Dear Dr. Heptinstall, Thank you for sending this paper. We are unable to accept it for Circulation Research. There are two main reasons. Number one, your findings conflict too much with contemporary thought. I thought to myself, what is the point of doing research? Isn't it to show that contemporary thought may be wrong? Secondly, he said his statistician claimed that the statistics were inappropriate. They were done by one of the leading statisticians in the world! What did I do? I tore up the bloody letter and have cursed myself ever since because I should have framed it as a badge of honor. |
| Hruban: | Where did it get published? |
| Heptinstall: | It got published in some other journal. |
| Hruban: | One thing we didn't cover last time is the CIBA conference. |
| Heptinstall: | It was either 1961 or 1962. CIBA, as you know, put on symposia. The man I had worked with in England doing biopsies, Marc Joekes, had persuaded Gordon Wolstenholm, who organized these things for CIBA to put on a symposium on the renal biopsy. And it was held either in 1961 or 1962. They got Arnold Rich to act as chairman and a very good chairman he was too. The participants were the people who were the coming stars and the established stars in the kidney field. We had an excellent symposium. Joe (Joekes) and I had written a paper in the Quarterly Journal of Medicine in 1958 showing that there was such a pathologic entity as focal glomerulonephritis. This is a form of glomerulonephritis in which only some, but not all the glomeruli are affected. A man who used to work with Pollack at Sinai in New York, George Baehr, had described this entity in patients with subacute bacterial endocarditits as had Löhlein in Germany. That used to be the classic and only example of focal glomerulonephritis. Joe and I, in the renal biopsy service at St. Mary's, came across about 14 or 15 cases of focal glomerulonephritis outside subacute bacterial endocarditis, which we published in the Quarterly Journal of Medicine. And then by the time the CIBA symposium came round, we had seen many additional cases and felt we were on very solid ground to make our presentation at the symposium. Others at the symposium included Bob Jennings, who at the time was at Northwestern, and later became chairman of pathology at Duke. He and David Baldwin gave their findings on post-streptococcal glomerulonephritis. You remember the Naval Station in Chicago; they had a big outbreak of streptococcal infectiori and many of them got glomerulonephritis. Dave and Bob did biopsies on these people and wrote a wonderful paper which appeared in The JCI, an absolute classic. They presented their work at the symposium. Bob Kark who was also in Chicago was there with Conrad Pirani representing the University of Illinois. They presented on lupus and microchemical techniques. Various English people, French and various Scandinavian people also made contributions. It was an astounding success and really put the renal biopsy on the map. |
| Hruban: | How was your work on focal glomerulonephritis received? |
| Heptinstall: | Joe and I presented our first paper on focal glomerulonephritis in 1957 or 1958, at that wonderful club in London called the Renal Association. The Renal Association used to meet once a month, oddly enough at CIBA house. The Renal Association was the best bargain you could get anywhere. I think the annual subscription was a guinea - that was a pound and a shilling. For that we used to have 6 or 8 meetings a year. A meeting started out with a tea party about 4 o'clock. At 4:30 we would go down into the lecture room and papers would be presented. At 6:30 we adjourned and drank sherry for about half hour or three-quarters of an hour. The meeting where we presented our cases of focal glomerulonephritis was a doubly traumatic event for me. The first thing that happened was that Joe presented the clinical findings and then I got up and gave the pathology. The chairman of the session was an irascible man called McCance. McCance had a chair of experimental medicine at Cambridge. A very bright and nononsense man. McCance warned me I was exceeding my time, but I very foolishly went on because I hadn't quite finished. He then came over, grabbed hold of me, and threw me off the platform. That incident is recalled in the book produced to celebrate the 50th Anniversary of the Renal Association. That was point one. The next thing that happened was that the paper was thrown open to discussion. A man called Clifford Wilson was first on his feet. Clifford Wilson was the professor of medicine at the London Hospital. He was the man who did all that wonderful work on hypertension in the rat with Frank Byron. Clifford Wilson somehow felt that our paper cut across the Ellis classification of Bright's Disease of which he was one of the authors. The three authors were Ellis, Wilson, Evans. He tore into us. It was a most unpleasant experience. We had this distinguished Professor of Medicine chopping us into pieces and making out that we were talking nonsense. Other people in the audience came to our rescue, but the whole episode was most unpleasant. When we gave the expanded paper, the paper with more cases, several years later at the CIBA symposium, Joe gave the clinical side and I gave the pathology. I didn't exceed my time because I didn't want my old mentor, Arnold Rich, to emulate McCance and throw me off the platform. To our horror the first person on his feet for the discussion was Clifford Wilson. Joe and I looked at each other and groaned. Remarkably, Clifford Wilson had completely changed his mind on the matter and went on to say that he thought that one of the greatest contributions the renal biopsy had made was the unfolding of the entity of focal glomerulonephritis. So we heaved a sigh of relief and sat back contented. |
| Bhagavan: | Doesn't Hopkins also have the distinction of having described focal and segmental glomerulosclerosis? |
| Heptinstall: | What Belur is talking about is a paper that Arnold Rich wrote in the 1950's to which I have already referred. He showed that certain children with the nephrotic syndrome developed segmental sclerosis of the juxta medullary glomeruli which was focal and segmented. At a later time a large renal biopsy study showed that this was the early stage of an entity that came to be called focal segmented glomerulosclerosis. It was yet another example of Rich's remarkable powers of observation and perspicacity. Note however that this has nothing to do with focal glomerulonephritis. |
January 20, 2008
| Hruban: | Today's date is January 20, 2008, I am here with Robert Heptinstall and Belur Bhagavan and my name is Ralph Hruban. What we want to do is to go back, actually. What we are interested in is the broader picture from you about your thoughts about medicine in England when you first started and any interesting characters you met at that time rather than specific details chronologically. |
| Bhagavan: | What promoted you to go into medical in general, biology in general, and pathology in particular. |
| Heptinstall: | I can't really answer that. I was always interested in science. I should have liked first of all to be a physicist, but my mathematics wasn't good enough for that. So I suppose by default I went into medicine. |
| Bhagavan: | Where there any role models for you in the family or among your friends? |
| Heptinstall: | No. |
| Hruban: | What about teachers? |
| Heptinstall: | Oh yes, I had very good science teachers. That's why I wanted to go into physics. I never did biology in school. Biology wasn't taught in all English schools. I think it is now. It was mainly chemistry and physics. I was interested in physics. I had a very, very good physics master, Oliver Matthews, who stimulated me a great deal, but nobody prompted me to go into medicine. |
| Bhagavan: | There was no one in the family in the field of medicine? |
| Heptinstall: | No. I was the first one. |
| Hruban: | When you were starting in medicine in England, what was the state of medicine like? What were your recollections? |
| Heptinstall: | I had no sooner started my medical course, when the war started so everything was thrown into chaos. London was considered unsafe. All the teaching hospitals reduced the number of patients and evacuated most to what they called sector hospitals. The preclinical departments scattered all over the country. I was doing preclinical work at King's College and spent my first year in medicine at Glasgow University. We had our own teachers from King's and worked independently. |
| Hruban: | Separate courses? |
| Heptinstall: | Oh yes. Glasgow University continued with its own medical courses. We from Kings had our own. And then France fell in the summer of 1940 and I don't know what happened to the arrangement between Kings and Glasgow, but we suddenly found ourselves at Birmingham University. I did the last part of my preclinical work at Birmingham University. When we finished our preclinical years, we moved on to clinical work. We left Birmingham and worked partly in London at Charing Cross and partly at the sector hospital in Hertfordshire - on the edge of the Ashridge Golf Course which was a great distraction for many students. At a previous interview I spoke of my student days and will say no more. |
| Bhagavan: | Did you know you would go into pathology when you were in medical school. |
| Heptinstall: | I was much more interested in surgery. I did well in surgery. I suppose I was stimulated to do that by a surgeon I knew before the war. So when I had won the second and third year (clinical years) surgery prizes, I got the prime house surgeon job, called intern in the United States. Interestingly enough, my great friend all through medical school, Kenneth Turk, had won most of the medicine prizes and he got the prime medicine job. So Turk and I were on the house staff for 6 months and then we were drafted into the Army. This would be about fall of 1943 through the spring of 1944. I mention these facts because Ken and I both ended up in pathology. |
| Hruban: | What did you do as an intern? |
| Heptinstall: | As I told you earlier, Charing Cross - which is just off the Strand near Trafalgar Square - kept the outpatient department plus the casualty or emergency department fully open, but we only operated about 6 or 7 wards - each with about 30 beds in them. I had two surgical wards to look after; one male and one female, about 30 patients each. These were all civilians, there were no military people. Military cases went to the sector hospitals, in our case, Ashridge. |
| Hruban: | As an intern you would work under a faculty member? |
| Heptinstall: | I worked under the senior surgeon of the hospital; a man called Norman Lake (one of the best general surgeons in England) and under an Irishman called Fitzsimons. It was a most rewarding and enjoyable 6 months. |
| Hruban: | Those are very different careers that of a pathologist and that of a surgeon. |
| Heptinstall: | When I was a student my main interests were surgery and neurology. I spent a great deal of time hanging around with the surgeons and I also got very interested in neurology. I spent as much time as I could at the main neurology hospital in London, The National Hospital in Queen's Square. I used to go up there twice a week to attend their wonderful clinical demonstrations. I was stimulated by a man called Gordon Holmes who was probably the leading clinical neurologist in the world. As well as being on the staff at Charing Cross, Holmes was also at Queen's Square so I came in contact with him quite often. To continue: while I was away in the Army I had second thoughts about continuing in surgery. Then I thought what should I do if I don't do surgery, should I do neurology? Although I had been bored by pathology as a student, I saw in it an opportunity to view the whole of medicine and also to do some investigative work. I therefore decided to take this tack and the route by which I got into pathology has already been described. |
| Bhagavan: | Pathology was not recognized as a specialty in the United States until about late 30s or early 40s, if I remember. |
| Heptinstall: | Pathology certainly was in England. It was divided up into three main groups. There was morbid anatomy that you call anatomic pathology, there was chemical pathology - they were the people who did all the chemical tests. There was a third group, bacteriology or microbiology (parasitology came under that group) whatever you want to call it. In addition, hematology was spread out among the three. In that respect the British were way ahead of the Americans. Chemical pathology, microbiology and hematology in America, certainly at academic centers like Hopkins, were done by the department of internal medicine. There was, I think, at Hopkins a medical school department of microbiology but they did no service work. |
| Hruban: | But you only did morbid anatomy in training? |
| Heptinstall: | No, as I told you I started out with Fleming and did routine microbiology for 6 months. Then I did morbid anatomy. I never had any formal training in chemical pathology. Chemical pathology was picked up in my research, doing my own chemistry. I probably hold the world's record for the number of serum cholesterols done by hand. Hematology tests were spread out among the three groups at St. Mary's and I was exposed to most of them. So I had a good all-round training and got my boards in both anatomic and clinical pathology when I came here permanently. |
| Hruban: | At what point did surgical pathology become recognized as a subspecialty? |
| Heptinstall: | There was no such subspecialty when I was in Britain. I can't speak for today. You probably know better than I when it developed in the United States. It was certainly in existence when I was first here in 1954. |
| Hruban: | Bloodgood, even the surgeon did surgical pathology. |
| Bhagavan: | Particularly surgeons did the surgical pathology here. And only after that it was like that in Europe. All the dermatology pathology literature was written by dermatologists. Dermatology pathology was not recognized as a subspecialty. |
| Heptinstall: | At St. Mary's we did the pathology for dermatology. In fact, we did all pathology. It had always been a very good department and for most of my time there was led by a charming fellow called Newcomb. He was a superb anatomic pathologist and among the best tumor pathologists in Britain. |
| Bhagavan: | Tell us a little bit about your recollections of the famous British personalities in morbid anatomy. |
| Heptinstall: | I really never knew many of them. Who did I know in morbid anatomy? I got know Harold Sheehan very well. He described Sheehan's syndrome. Sheehan was a great authority on concealed accidental hemorrhage of pregnancy (abruptio placentae) which gives rise to renal cortical necrosis. This led to his work on cortical necrosis of the kidney where we had common interests. Incidentally, I came across some old correspondence with him only a short time ago. |
| Hruban: | What was Sheehan like? |
| Heptinstall: | I liked Sheehan and I got on very well with him. We were both from the same county. He was also from Cumberland. He had the chair of pathology at Liverpool. |
| Hruban: | Do you know that gentleman who wrote the book on the borderline between pathology and embryology? |
| Heptinstall: | Rupert Willis. I didn't know him well. I met him at meetings. I always enjoyed talking to him. |
| Bhagavan: | What was he like? His books were the Bible that I studied as a student. |
| Heptinstall: | His book, Pathology of Tumors was a classic. Willis was an Australian who built up a lot of experience mainly from autopsies, not so much from surgical pathology. He was invited over to England to take the chair at Leeds. He succeeded Matthew Stewart who I also knew. I knew Matt because he was the editor of J Path Bact. In his retirement he came to live in Stoke Poges fairly close to where I lived. Incidentally, Stoke Poges was where Grey wrote his famous Elegy. Whenever I had an article, instead of submitting by mail, I would call him on the phone and drive it over to his house. He would either reject it on the spot or would say it needs this, or it needs a little more polishing here or a little more adding here. He did this in about 20 minutes and then asked me to stay for tea. Anyway, Willis succeeded him. Willis had to retire after a few years because he became jaundiced. He was opened up and he was found to have a hard lesion in the head of his pancreas. I don't know if he had a biopsy or not, but he was told that he had a cancer of the head of the pancreas. So he resigned and went to live in southwestern England - Cornwall. He lived for many years. Sic transit Gloria mundi! |
| Bhagavan: | Was he a very opinionated person? |
| Heptinstall: | I didn't know him well enough to know if he was opinionated. |
| Bhagavan: | There were lots of errors in his book. |
| Heptinstall: | Oh yes. He wasn't well thought of by many, but did a good job of writing and the other book you mentioned was also excellent. |
| Bhagavan: | Did you know Boyd? |
| Heptinstall: | Funny thing. In the correspondence I was throwing away recently there was a letter from Bill Boyd. |
| Bhagavan: | Tell us something about Boyd. |
| Heptinstall: | I never knew Boyd well as he lived and worked in Canada. I met him once and the rest of the time I corresponded with him. The letter just mentioned was in his own handwriting, asking if he could use some of the pictures from my first edition in one or other of his books. The letter was dated 1966. I replied that of course he could use as many as he wanted because I was brought up on his book. Who else was there? Dorothy Russell. She was a great neuropathologist - a very fearsome woman. I met her occasionally at meetings. Then, Dible was head of pathology at Hammersmith. He had a book Dible & Davey which you may have used. His second in command was a man called Victor Harrison who I think succeeded Dible when he retired. Harrison used to be editor of the Recent Advances in Pathology series. He asked me to write in two consecutive editions. Vic was the man I consulted when I was in training, or later, if I had a kidney section that nobody at St. Mary's could help me with, and that was often the case. On these occasions I would go to Hammersmith to Victor Harrison or another very good pathologist called Isidore Doniach. "Doe" was a wonderful pathologist and a fine man. "Doe" later got Dorothy Russell's chair at the London Hospital. I remember the first time I ever saw eosinophilic, PAS-positive material in the interstitium of the kidney. I remember how scathing Vic was when I took the slides to consult him. He said, "God, Heptinstall, I thought you were one of the upcoming pathologists, but I know differently now. This is what we call the 'piss lesion.'" That was vintage Harrison. What we were seeing was extravasated urine. Hammersmith had the strongest pathology department in Britain at that time and in addition to those mentioned had Tony Pearse of histochemistry fame, Bernard Lennox, and shortly after, Ken Weinbren, a great authority on the liver. |
| Bhagavan: | What about Greene? |
| Heptinstall: | Greene was dead and buried long before my time. The only thing I know about Greene is that he wrote a book, Greene's Manual of Pathology. It was a very dull book and my old professor of pathology, Charlie Vines, edited later editions of Greene. You probably read Greene edited by Charlie Vines. |
| Hruban: | Can you describe the meetings you attended? What were they like? |
| Heptinstall: | I shall confine myself to the meetings of the British Path Society as the renal meetings are described elsewhere. To me as a young impressionable man they were wonderful meetings. They didn't last as long as the American meetings. The Path Society meetings used to last a couple of days and had no social distractions. The society used to meet twice a year - one meeting in London, one in one of the provincial cities. So far as I recollect, it consisted entirely of people presenting papers and with no posters or anything like that. There was one absolute rule of the path society and that was you were not allowed to read your paper. You had to get up on the podium without any props and deliver your 10 minute paper and then answer questions in a 5 minute discussion. All of this without any notes. If you used them, you would either be thrown off the platform or never again be allowed to present another paper at the society's meetings. |
| Hruban: | I guess they didn't have lantern slides then? |
| Heptinstall: | Oh yes we used big lantern slides. I am not all that ancient! And of course you don't need notes when you lecture if you have slides. The slides keep you on track. The reason for the rule of the path society was it was assumed that if you had worked on the paper for 6 months you probably knew more about it than anybody in the audience and heaven help you if you couldn't remember what you were going to say in a 10 minute talk. I tried to instill this idea into people at Hopkins. There is nothing worse than going to a meeting and seeing someone giving a talk and never taking his eyes off his notes. You could put up a slide of Marilyn Monroe and he'd never know because his eyes were glued on his notes. |
| Hruban: | There must have been a drive to leave England and come to the States? Were you unhappy with the quality? |
| Heptinstall: | We have been through all of this before and it would be frivolous to repeat it. |
| Bhagavan: | You mentioned the name of Dorothy Russell. Were there a lot of women in medicine in your time, or were there gender issues in pathology? |
| Heptinstall: | Very few women. Not just in pathology, but throughout medicine. In fact, pathology probably did better than any other discipline in England because you had people like Dorothy Russell, who was very distinguished, and Joan Ross who was also a wonderful morbid anatomist. She had a little book called Postmortem Appearances. There were various other women doing research all over the place. Dorothy Russell had the chair at The London Hospital. I don't know what Joan Ross' position was, but it was a fairly senior one. I suppose there were so few women in senior positions in London because most of the teaching hospitals were male only. There were only two women's teaching hospitals in London - the Royal Free and the West London. All the rest except K.C.H. and U.C.H. which had a smattering of women, were men only so they were not going to appoint women on their staffs. That partially explains it. They're all mixed now. There were of course some distinguished women biologists such as Honour Fell, a zoologist, who was Director of the Strangeways Research Lab in Cambridge for many years, and biochemists and biophysicists such as Dorothy Hodgkins (Nobel Laureate) and Rosalind Franklin. |
| Hruban: | When you came to Hopkins, you must have heard some Hopkins history. Do you recall any stories of MacCallum or people before your time? |
| Heptinstall: | I can't remember any specific stories. MacCallum apparently was a wonderful pathologist and was in the first class of medical students to graduate from Hopkins. It was during a summer vacation that he studied a form of malaria that affects birds. He proposed the idea that the various flagellate forms that he saw under the microscope in blood smears from affected birds were the sexual, reproductive parts of the cycle. And Ross, the great British expert on tropical medicine who won the Nobel Prize for his work on malaria, said he had never been so embarrassed and ashamed in his life when it took a medical student on his vacation to put forth an idea that had eluded him. MacCallum was a very smart fellow and ran a very good department that included such greats as Winternitz, Whipple and Rich. |
| Hruban: | We were interested in your relationship with people like Ramzi Cotran? |
| Heptinstall: | I got to know a lot of people over the years such as at national pathology and nephrology meetings at study section meetings of the NIH, and international meetings and symposia on subjects of common interest, and we saw a lot of each other at those meetings. Several of us had a common interest in the kidney so naturally we often met each other - Ramzi, Bob McCluskey, Ben Spargo, Bob Jennings who went to Duke, Jack Churg, Jay Bernstein and many others. The kidney people tended to stick together. |
| Hruban: | What do you remember about Ramzi? |
| Heptinstall: | Ramzi was a wonderful man and one of my dearest friends. He had a superb mind and was one of the brightest people I have known. Ramzi graduated from the American University in Beirut before coming to this country. I first met him when he became interested in the kidney. I think he had spent a year or more at Memorial Hospital in New York. That is where Bob Prendergast who worked in Wilmer met him. Then Ramzi went to Boston where I first met him. We were both interested in kidney infections. We used to meet at various kidney meetings as well as pathology meetings. Ramzi and I traveled the world together and had a wonderful time. He was a most agreeable companion and most amusing fellow. He was an absolute terror to hotel keepers. If he didn't get a decent room, he would complain like nobody's business. When we checked into a hotel, he would always come to see my room, and if mine was better than his, he'd insist on a better one. Bob McCluskey was an equally good friend. He started out at New York University and ended up as head of the department at Massachusetts General Hospital. Mac did superb research on immunologic mechanisms in the kidney and never got the recognition he deserved. He was a great authority on Shakespeare, an excellent pianist and was possessed of a wonderful dry sense of humor. He and Ramzi were my best friends in pathology of that generation. |
| Hruban: | How about some of the other leaders in pathology in the states while you were chair? |
| Heptinstall: | I knew many of them. |
| Hruban: | Who did you admire? |
| Heptinstall: | Of the older generation, the people I admired most were Arnold Rich and Harry Goldblatt. Two people I couldn't imagine anyone surpassing. Of the later and my own generation I was very fond of Joel Brunson. Joel had the chair at the University of Mississippi and was at the University of Minnesota before that. I liked Ellis Benson, who was probably the best clinical pathologist in the country, and was at Minnesota. I didn't like Castleman. I thought he was an arrogant man - so conceited. I once went on an NIH site visit to the Mass General and saw how Castleman did his surgical pathology teaching. He used to sit on a raised platform with his microscope and had his housestaff looking up at him as he gave, in a very pontifical way, his diagnosis of the slide in question. In spite of this stricture he was a very fine human pathologist who made many contributions and trained scores of young men. His style was not mine. |
| Bhagavan: | But that's the way pathology was practiced in those days; people pontificated and have spoken and that was it. |
| Heptinstall: | He was very like the old German Geheimrat. In Germany you never questioned the head of the department. I remember Helmut Rennke telling me his experience of that. He was a pathologist at the Brigham. Helmut, as part of his training, went over to Germany for a time. They were all sitting around a table and the head of the department was laying down the law as to what they were looking at under the microscope. Helmut disagreed with one of the diagnoses and said so. He remembers getting a huge kick on his shins under the table from his next door neighbor who told him never to question the Geheimrat. Rich and Goldblatt were never like that and always welcomed fresh and original opinions. |
| Bhagavan: | Did you know the chairman at Cincinnati? |
| Heptinstall: | Ed Gall. I liked Ed. He was a very amusing man and a very good pathologist. Tom Kinney was a great organizer; he was at Duke. Jack Carter was at Western Reserve. He was a great jazz musician and was alleged to have played in Glenn Miller's band. Averil Liebow was #2 at Yale; he ran the department for Harry Green who was chairman. Harry Green was always in his lab. Harry was another wonderful character and I was very fond of him. I always tried to sit next to him at the dinner held at the APB meeting. He was always good company. Liebow later took the chair at the University of California at San Diego. He was the premier pulmonary pathologist in the United States. |
| Bhagavan: | Liebow reminded me very much of Toby Weinberg. The way he taught, the way he held the big knife in the autopsy room - he was a classic pathologist. What about the chairman at the University of Maryland - Trump and the very famous person before Trump who went to Colorado. |
| Heptinstall: | I didn't know Trump well and I can't think who it was who went to Colorado. Was it Harlan Firminger? |
| Hruban: | What was the relationship like between Hopkins and Maryland? |
| Heptinstall: | Very little relationship. |
| Hruban: | Why was that? |
| Heptinstall: | I don't know. There was little contact with Maryland right across the board. Trump was a good electron microscopist, but apart from our association on the Medical Examiner's Board I saw little of him. Similarly, Philadelphia was very close, but I never knew anyone in Philadelphia except a very nice man, Peter Nowell, who discovered the Philadelphia chromosome. |
| Hruban: | That was the associate with Janet Rowley at University of Chicago? Maybe she discovered the gene? |
| Heptinstall: | I don't know. It was called the Philadelphia chromosome because Peter and Hungerford discovered it in Philadelphia. Talking of Chicago, I knew Bob Wissler. Nice man. And a very agreeable ex-University of Chicago man I knew was Earl Benditt who had the chair in Seattle. Earl was also terribly smart, probably one of the smartest men I knew in pathology. The wide range of things that he studied was amazing. But he wasn't much interested in routine pathology and was invariably in his lab. |
| Hruban: | That's one thing I wanted to ask you about is the balance between clinical and research and teaching, and your thoughts on that. |
| Heptinstall: | It is very difficult, you see. You'd like to give people much more time for doing research, but where is your money coming from? When I ran the department, we used to get our money from three sources. I used to have a budget with the hospital and that paid for people doing the service work. Then I had a budget from the medical school that paid for teaching, but after that you had to scrape around at the NIH, and the National Science Foundation and other sources for research grants. It was a most unsatisfactory situation. And then of course as the budgets started tightening up at the NIH and grants became more and more difficult to get. We had the MacCallum bequest to support research but the medical school made us use more and more of that to support salaries. There was no such thing as professional fees in those days nor did we get any of the money from clinical pathology. All of that has changed and I am sure things are easier now. The first lot of people they interviewed when they came to replace me wouldn't take the job because it was so busy and the department was so badly funded and housed. The hospital and medical school, particularly the medical school, had shown such bad faith in not providing new research labs or even space that they all shied away. Then it became apparent to the medical school that they had got to do something. So they started building the labs in the Rutland Street building and they got Yardley to carry on while that was being done. And then of course, the next thing that came up was the running of the clinical pathology labs and the distribution of their considerable income. Sanfilippo must have been a tough negotiator to have got almost everything he wanted. He was able to take over the labs run by the Department of Medicine. He had a lot of money coming in from professional fees in surgical pathology by this time. He got the new research labs that Bennett and I had been crying out for over the years as well. He was clearly a very good businessman and deserves credit. |
| Hruban: | What about promotion? The sense I had about promotion from Hopkins that in the years past it was impossible for someone doing clinical work to get promoted. |
| Heptinstall: | Not impossible, but very difficult. |
| Hruban: | Why was that? |
| Heptinstall: | They did not want to have too many full professors around. They rather looked down on the system at Homewood where there were large numbers of full professors. |
| Hruban: | Whose they? |
| Heptinstall: | The people who were running the medical school and the people who were heads of departments who made up the Advisory Board. You should have been at the Advisory Board meetings when people with mainly clinical skills were being discussed for promotion. When I came here permanently in 1962, I think Lock Conley was the only full professor in Medicine besides Mac Harvey, the Director. You'll have to check that. Walter Sheldon certainly was the only full professor in pathology apart from Bennett, the Director. I had to drop a rank when I came. I had been a full professor at Washington University. |
| Hruban: | Were there specific things you had to avoid in trying to get someone clinically promoted? |
| Heptinstall: | You had to emphasize their teaching skills and the effect their clinical prowess had on the students. They'd always say what are his scholarly activities? They had no bloody idea what scholarly meant. In retrospect it was laughable but so typical of academia. |
| Hruban: | What research do you feel was your proudest accomplishments? |
| Heptinstall: | Apart from laboratory studies that we discussed earlier, I liked some of the human studies I did. A particular one I did was on old fashioned renal biopsies taken at the same time as lumbar sympathectomy. Until the last 50 or 60 years there was no satisfactory treatment for severe hypertension. The surgeons were called in and they used to strip out the dorso-lumbar sympathetic chain. They sometimes took out 1-3/4 adrenals and did all sorts of things to get the blood pressure down. At St. Mary's we had a surgeon who used to do all George Pickering's sympathectomies, a chap called Dickson Wright. And Dickson Wright was bright enough to take a wedge biopsy of the kidney in every case he did. I inherited these specimens while a young man. I did not have a very large series - 50, 60, 70 compared to that of Castleman and Smithwick in Boston which numbered some 500. They wrote a paper - very extensively quoted correlating the height of the blood pressure and renal vascular changes. I wrote a paper addressing certain specific aspects in the British Heart Journal. It cleared up various important points that I can't go into but it was probably one of the best papers I ever wrote. The paper with Joekes on focal glomerulonephritis was also very satisfying. On the experimental side, the papers showing that hypertension accelerated atherosclerosis were very satisfying and that in which we showed that blood pressure was more important than the serum cholesterol has already been recounted. And then at Hopkins we got on to mechanisms of vascular injury in hypertension. In some work with Gary Hill we showed that vascular necrosis did not take place in constricted segments as previously thought but rather that necrosis took part in the dilated segments. You must realize that in the rat with severe hypertension the small arteries show an alternating pattern of constriction and relative dilatation resembling a string of sausages. This was first shown in the cerebral circulation by Frank Byron. Later on I got Steve Wilson to do some resin casts of hypertensive rat kidneys as well as direct observations on the mesenteric arteries, which confirmed that the string of sausage phenomenon was generalized. Gary and I postulated that the dilated segments could not withstand the distending force and underwent necrosis. I did quite a lot of work on the juxaglomerular apparatus and hypertension. I also worked on experimental kidney infections and their relation to hypertension. After a good many years away from atherosclerosis I took up Earl Benditt's idea on the monoclonal theory of atherosclerosis. I got Tom Pearson to run that show and we had some good papers. And then when the hyperperfusion-hyperfiltration theory came along I did a series of experiments with Jean Olson on that topic. But my research, Ralph, was severely curtailed by taking on that directorship. I could only go down to the lab one or two days a week and as time went by even less. I should never have become chairman or director as they prefer it at Hopkins. |
| Hruban: | When you were Chair, how did you spend your week? Let's take a typical week as a Chair? How did you divide your time? |
| Heptinstall: | I never got in terribly early; I got in around 9 o'clock. I usually used to go through my correspondence and make appropriate replies. Then I did various things according to what duties I had. I used to do the gross conference one day a week. I used to go to most of the other conferences in the department. I did a lot of teaching. I did much more teaching than the senior people do nowadays. I had my own group from 1962 to 1988. In the actual course, I used to give up to ten lectures depending on the year. I used to give all the lectures on the kidney, hypertension, atherosclerosis, and the introductory lecture. The rest of the day I used to get down to the lab when I could which wasn't very often. In addition, I went to committee meetings, listened to people's gripes, etc. When I got home I used to write. I used to write until about 1-2 in the morning mainly on the book. What I should like to say very feelingly is that I am most disappointed in the way teaching has been relegated in importance over the past decade. This is reflected in the fact that whereas when I was running the show, we used to attract 2 or 3 of the Hopkins graduating class into our pathology training program each year. How many have come in since the turn of the century? Probably 3 or 4 in total. Disgraceful. Mainly because the heads of the department have shown no interest in teaching. But also because there is no longer a discrete course in pathology. The second thing that distresses me is the demise of the autopsy. This is a generalized phenomenon, but nonetheless a very sad thing. How can you train pathologists unless they can see a large number of autopsies? And where would we be in research without it? I was just thinking the other day; a friend of mine from England called me, and we were talking about cancer of the prostate. And I said do you recall the first person to draw attention to the enormous prevalence of cancer of the prostate in older men? It was Arnold Rich. So I gave him Rich's reference. Rich showed that if you examined routine autopsies and examined the prostate, you would find cancer in a very high proportion of older people. Arnold Rich did this in 1935. This could not have been done without the autopsy. Many of the other conditions that he and others described were derived from autopsies. At one time they did 900 autopsies a year at Hopkins. That was probably too many. In my time, we were doing about 650. But now, the autopsy rate is about 10 percent. Scandalous! |
| Bhagavan: | At Sinai we used to do 480 autopsies a year. |
| Heptinstall: | I suppose clinicians feel they don't need autopsies because of CAT scans and things like that. No doubt malpractice lawsuits enter into it. |
| Hruban: | There are two questions - if you have any broad thoughts or broad advice in reflecting back on your career. |
| Heptinstall: | Never become a departmental chairman unless it's in absolute desperation. If you are offered a chair, you think, God this is a great honor. Vanity will tempt you, but unless the department is small it will destroy your research. It's going to screw it up unless you abdicate some of your other obligations. Many do this and hand over the service work to someone else, or dodge their teaching obligations. A lot depends on your present job. If you are happy with the chap you are working under, stay with him. But if you take on a departmental chairmanship, you are likely to become so immersed in administration, particularly now, that it will destroy your research. This assumes of course that research is your main interest, as it should be. |
| Hruban: | For me, that is the irony, you left England in many ways pursuing a chair in the United States. |
| Heptinstall: | That is not so. I didn't come to the United States specifically to get a chair. I came to the United States because #1 I was pissed off with the way things were happening to me in England, and #2 that the opportunities for doing research were very much greater over here. And that's what I wanted to do. The best years of my life were the two years at Washington University and the four years from 1962-1966 when I came back to Hopkins from St. Louis until the time I very foolishly told Bennett I would run the department while he was away. I fully expected him to come back and allow me to get back to the lab. It never happened. Those people who interviewed in 1986 when I stood down, they were wise young men. |
| Bhagavan: | Who were the candidates, do you remember? |
| Heptinstall: | We have been through this earlier. |
| Hruban: | Tell me about your recollection of Arnold Rich and your relationship with him because he seems an extraordinary character in the department. |
| Heptinstall: | We have already covered this. To repeat, he was a most extraordinary man and had a remarkable brain. I think, in my time at Hopkins the two people I reckon who had the finest minds were Arnold Rich and Vernon Mountcastle. |
| Bhagavan: | I'm curious to know if you had any impressions or thoughts of anti-Semitic feelings at Hopkins in general or in the department. |
| Heptinstall: | No, the only possible anti-Semitic action was the inordinate length of time it took to appoint Rich, although there may have been other reasons. It was certainly very difficult to get a housestaff job in the better American programs if you were Jewish. I remember one evening at an IAP meeting I was having dinner with Manny Farber, who had the Chair at Pittsburgh and Toronto, with Nate Kaufman, who had the Chair at Kingston in Canada, and another Jewish professor whose name eludes me. I hadn't realized how difficult it was for a Jew to get a good housestaff appointment in this country in their lifetime. I was quite shocked. |
| Bhagavan: | And this was in the 50's. |
| Heptinstall: | Yes, this must have been in the 40's and 50's. It is all changed now and the wheel has turned full circle. |
| Hruban: | What was Arnold Rich's personality like? |
| Heptinstall: | Very thoughtful. Very critical. Terribly amusing, a wonderful sense of humor. I liked him enormously and got on with him well. |
| Hruban: | Do you have any specific anecdotes? |
| Heptinstall: | I can't think of any at the moment. Yes, I liked Rich. I got to know Rich very well. I used to live quite close to him. He lived just down the hill from me. During the last year of his life Mrs. Rich used to call me occasionally in the evening to say would I come down I'm having a bit of trouble with Arnold. After we had got him settled down she would open a bottle of wine and we would spend a wonderful evening all together. |