Heart specialist who survived TB and the cold shoulder to found the cardiology service at Papworth Hospital
Wednesday 13 September 2006
Hugh Alexander Fleming, cardiologist: born Glasgow 22 October 1923; Director of Cardiology, Papworth Hospital, Cambridge 1957-88; Fellow, Darwin College, Cambridge 1969-90 (Emeritus); married 1950 Elisabeth Galway (died 1983; two daughters), 1984 Julia Cusden; died Cambridge 5 August 2006.
Papworth Hospital in Cambridge, a world centre of excellence for heart disease, owes its cardiology expertise to a New Zealander, Hugh Fleming. In 1959, when he started at Papworth, he was the first cardiologist to be appointed in East Anglia. For seven years he worked single-handed; a second cardiologist was appointed in 1966 and it was not until 1977 that they were joined by a third colleague. There are now 41, and the centre is Britain's most famous.
The cardiology registrars that Fleming trained are now consultants throughout the world. He was a gifted, hard-working and caring teacher, and did original research that enabled the diagnosis of sarcoid heart disease, which hitherto was only recognised post-mortem. He did it all having overcome tuberculosis and, in the early days, considerable discouragement.
Papworth Hospital had been founded in 1917 as an enlightened and pioneering tuberculosis hospital and colony. A surgical unit was added in 1935 so that lung operations could be performed. The hospital was taken over by the National Health Service in 1948. The settlement had model cottages for patients and their families, and as some were expected to stay for long periods and were reasonably well, it had industries, including cabinet-making and coach-building.
TB sanatoriums were being closed in the 1950s, as streptomycin had proved equally effective as a treatment given at home as in sanatoriums. The hospital expanded to incorporate cardiology and heart surgery, then both in their infancy, and the settlement became a rehabilitation centre and village for the disabled, which it still is.
Fleming, who was a distant relative of the discoverer of penicillin, had been born in Glasgow, in 1923, but his parents - his father was a dried-fruit importer - emigrated to New Zealand when he was a baby. Hugh was educated at the Presbyterian New Plymouth High School in North Island, and won a scholarship to Otago University in Dunedin, South Island, in 1941, qualifying in 1946. He worked in the holidays - both to support himself and because everyone was expected to contribute to the war effort - in the docks, a cheese factory, a dairy farm, a tungsten mine, on a hydro-electric construction site, a timber yard and a meat-processing factory. He felt this later gave him a better understanding of his patients' lives.
During his student years, Fleming caught tuberculosis, but it was initially "silent" - his diagnostic test was positive but he remained well. He had plenty of exposure to it: during his clinical years he saw many TB patients, and few steps were taken to minimise the infection risk. When he first qualified he worked as a locum GP; one assignment was in a TB-ridden Maori community.
In 1947, when he was newly qualified, a routine X-ray showed active TB. This was to give him trouble for years, and it would be another decade before streptomycin, the first effective treatment. Fleming was awarded a scholarship and travelling fellowship to study and train in Britain but was too ill to undertake the long boat journey for several years. In those days, aspiring hospital consultants in Australia and New Zealand had to get their "BTB" - Been to Britain (similarly ambitious British hospital doctors had to go to America).
In between stays as a patient in various hospitals and sanatoria, Fleming did his post-qualification house jobs at Dunedin General Hospital. The dean, Sir Charles Hercus, who had given a lecture series on the Papworth Settlement, said that a clinical career was out of the question for Fleming and started him off on some research on kidney function in hypertensive rats and rabbits. He did a year of this, a year as pathology registrar, and a year as medical registrar.
Then, Fleming persuaded a young surgeon newly returned from England to remove the tuberculous lesion in his lung. It was almost certainly the first time that the operation had been performed in New Zealand, and it was a success - in 1952 Fleming travelled to Britain.
In London he worked under Guy Scadding and Paul Wood, two of the founders of British cardiology, and with a young cardiothoracic surgeon, Ben Milstein. It was common for doctors and nurses who had had TB to look after patients with the disease, which, like cancer, carried a social stigma. Lung diseases were common, and one of Fleming's first memories of London was pea-soup fog and yellow sputum in the streets.
Cardiology was in its early stages at the Brompton and was barely tolerated: Fleming had to do cardiac catheterisation at 8am in the X-ray department, before the department opened for normal business at 9am, and often the films were sabotaged by the radiographer. He recalled that the consultants wore morning suits, many were prima donnas, and most arrived at the hospital in Rolls-Royces driven by their chauffeur to be met on the steps by a fawning matron and their juniors. Fleming often assisted Lord Brock in the operating theatre, silently and stoically tolerating the great man's verbal abuse. Towards the end of this time Ben Milstein was appointed as heart surgeon at Papworth, and Fleming often travelled, unpaid and in his own time, to Cambridge, to perform and teach cardiac catheterisation.
At Sully Hospital, Glamorgan, he performed cardiac catheterisation on a wooden kitchen table. During three years in Wales, a travelling scholarship enabled him to spend four weeks in Scandinavia, visiting cardiac centres. He was often taken home for meals by the consultants he visited, something that had never happened in Britain.
In 1957 he moved to Sydney as director of the Hallstrom Institute of Cardiology, at the suggestion of Paul Woods, founding father of British cardiology. Fleming disliked the atmosphere and organisational structure that prevailed, and the mostly disastrous open-heart surgery that was performed there. A year later he got a phone call from England: would he be interested in applying for a new position setting up cardiology at Papworth? He borrowed the fare, came over for the interview, jetlagged after 18 hours of flying, and was appointed. Milstein eased him into the evolving needs and culture of Papworth.
The chairman of the Addenbrooke's medical council told Fleming, "I understand there is no need for a cardiologist in East Anglia, but I expect you will find something to do." The Regius Professor of Medicine, Joe Mitchell, broke down in tears, said he didn't know why Fleming had come there, that Cambridge was an awful place which had treated him abysmally.
Fleming built up the department from scratch, providing diagnostic services for the heart surgeons, working single-handed for many years, training generations of heart specialists, and earning their love and loyalty. It was a slow start. GPs in the region sent him patients - he saw 800 new patients in his first year and more thereafter - but Cambridge physicians cold- shouldered him and he had no beds for admitting patients. They were, however, happy for him to look after their in-patients when they took a day off to go shooting together.
He had to fight to get accommodation for a weekly clinic at Addenbrooke's. His department suffered from the lack of co-operation between the regional hospital board and that of the Cambridge hospitals and from the internecine feuds of the Cambridge consultants. Fleming travelled all over East Anglia in his Baby Austin, seeing patients in a dozen small towns. Most were reluctant to be admitted to Papworth and had to be reassured that they had neither TB nor cancer, both of which were considered shameful. The hospital in Norwich, which had cardiac ambitions of its own, refused for some years to refer patients to him, and sent them to London instead.
Fleming was ahead of his time in many of the things he did: when a child had to be admitted, he would put them in a two-bedded room with one of their parents, long before this was established practice. He made a practice of labelling patients' medicines, which was considered taboo in those days. He abolished the undignified practice of making patients undress before a consultation, even though this often made the consultation last considerably longer, especially with the elderly. In the 1960s he introduced the pacemaking service.
He supported the surgical and, especially, transplant service. He ran postgraduate courses for hospital doctors, which resulted in referrals from outside the area, including north London. He overcame the nursing shortage by running post-qualification courses for nurses. He sidestepped committees because, he said, "they started at 2pm and went on through the afternoon at a leisurely pace". In 1961 he was offered the chair of cardiology in Sydney and turned it down.
His professional isolation among the Cambridge physicians came to a dramatic end when one of them was ill and needed his services. He gradually became cardiologist to 100 doctors with heart disease in the region. In the early days, the evidence connecting smoking with heart disease was unknown and many doctors and their patients were heavy smokers.
Fleming did some private work. There was a certain amount of hostility to private in-patients at Papworth, who got the same food as NHS patients but on china plates, and were served last so that their food arrived cold. All patients, whether NHS or private, were put in the same cramped, shabby rooms, which were so small that a patient needing resuscitation had to be dragged into the corridor. He did private consultations at home. This being Cambridge, many patients arrived on bicycles and Fleming was probably the only consultant cardiologist in the UK with a patients' bicycle rack outside his house.
He examined the novelist E.M. Forster in his college along with the help of the great man's GP. Undressing the great man took some time as he was wearing a woollen dressing gown over a three-piece suit and many layers of underwear. Finally, they discovered Forster wore layers of pink flannel wrapped round his stomach.
Many of the Fenland patients had rustic standards of cleanliness - they would wash their face to visit the doctor but did not expect to have to remove their shoes, and "often their feet were beyond description".
Fleming published about 70 research papers, mainly on infectious endocarditis and sarcoid heart disease, and an account of the early years, Papworth Cardiac Unit 1957-1967 (1996). He retired completely in 1988, aged 65 - "You can't be a part-time cardiologist in the NHS."
He took up tennis (despite hip, lung and cataract problems) and furniture restoration, and attempted tapestry and violin-making. He was a committed Christian and helped in his local Cambridge churches, St Michael's and Great St Mary's.
Hugh Fleming was the quintessential New Zealander, warm, resolute, independent and socially aware. He endowed an organ scholarship at Otago and a bridge over the river at Darwin College, Cambridge, and supported many aid funds, wildlife charities, Macmillan Cancer Relief and the Alzheimer's Society. He was elected a Fellow of Darwin in 1969 and an Emeritus Fellow in 1990, and was an inspiration to their postgraduate students.
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