Richard Hewlett - Full Transcript

hewlettAssociate Professor, Departments of Anatomical & Forensic Pathology, Faculty of Health Sciences, University of Stellenbosch, and National Health Laboratory Service, South Africa

Interview location: His home, Cape Town, South Africa.
Interview date:
14th January 2008.

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SECTION 1

SA:  Richard, will you describe for me how you came to do pathology?

RH:  Well, I always wanted to do medicine.  Or something in wildlife…My father was the warden of the Serengeti National Park, and he said, “There is no future in wildlife for whites."  And there wasn't; and so I did medicine.  I was educated in Nairobi; I came down to UCT (University of Cape Town) and there, quite early on, I became interested in neurology.  I wanted to do neurosurgery initially and I took a demonstratorship in the anatomy department whilst preparing for the surgical fellowship exams. Then the post of junior lecturer came up and I was able to work for a  PhD on the brain of the rock hyrax - the dassie.  And then, because of friends in neurology, I became interested in the pathology of the nervous system. 

There was no heritage of neuropathologyI'm afraid from then on most of it has been very difficult, because in this country there was no heritage of neuropathology.  People that you've met in Britain, including friends of mine, are neuropathologists, but to try to do neuropath here led to endless difficulties.

After completing my PhD, I moved to the department of Anatomical Pathology with the expressed intention of doing neuropathology. Quite soon my relationship with the head of the department became acrimonious and one day he called me into his office and said “I have decided you are unfit ever to become a pathologist”.  And I was fired.  In fact I am one of the very few people to have been fired from that department – possibly the only one. 

Betty Brownell in 1975When  all that happened  I had this house and three small children and no job – because once you were fired in those days they blocked you from working anywhere else at the Medical School.  One of the senior consultants, Dr Len Kahn called me into his office and told me not to give up, insisting that I write to people he knew in America - “and I want to see the letters” he said!  In fact I was offered a post at Duke University, to do neuropathology.  But my father went into a terrible decline saying I must do neuropathology in Britain otherwise we would never see each other again.  He said, "How about doing neuropathology in Bath?"  You can imagine!  So, I looked up Bath and of course there was not much going on there.  But I found Betty Brownell’s name listed on the staff of Bristol University as Consultant Neuropathologist . So I wrote to her and she offered me a registrar post in the recently established Clinical Neuroscience Unit at Frenchay Hospital. 

So I went over to Britain and I trained there and that was an excellent job.  Betty Brownell was an outstanding woman, absolutely outstanding but very temperamental, unfortunately.  But she's one of the few people I've met who would do anything to further her registrar’s career in neuropathology.  The exact opposite to here in South Africa -- or anywhere else, for that matter.

SA:  What d'you think was the problem here?

They didn't want 'super-specialists'RH:  They didn't want 'super-specialists'.  They said "Everybody is a general pathologist.  If you're interested in the liver you can do a bit of liver pathology, or you can do a bit of pathology of the gut, or a bit of the brain."  Those people – the South African College hierarchy - had no idea of the heritage of neuropathology, which has become a part of neurology from Freud's time really.

“The heritage of neuropathology”

SA:  Yes, tell me a little bit about how it became a speciality.

RH:  Well in the late nineteenth century, the people most interested in the structure of the brain besides anatomists, included the surgeons and psychiatrists and it was the psychiatrists who began the routine examination of the brains of individuals displaying behavioural disturbances. That's how Alzheimer made his diagnosis.  He was involved with a patient who had a very bizarre psychiatric illness, and when she died he took her brain out, stained samples from it, and found the changes that now bear his name – the most common dementing illness, Alzheimer's disease.

SA:  And so before that, what did people know about the anatomy of the brain, and what could go wrong?

RH:  Oh they knew a lot about the anatomy of the brain, but it wasn't until the 1880s and 1890s, along with a whole burgeoning of neuroscience, that people began doing experimental neurophysiology, studying the electrical activity of the brain.  That was done in Britain by people such as Charles Sherrington and Victor Horsley -- and famous people in Europe as well.  The structure and the function of the brain gradually came to be perceived as integral to one another, and that led physicians to specialise in the nervous system in one way or another. 

Neurology was the first specialty.  And then general surgeons started to confine themselves to the nervous system if they were interested in it.  But it wasn't until some very famous surgeons in North America settled for the nervous system -- Harvey Cushing probably is the most famous of these -- in the 1920s, that neurosurgery became established as a discipline. 

But in Britain nothing much happened in neurosurgery until World War II, I think, when it became apparent that these injuries to the brain were a special category and required special treatment.  By the '50s neurosurgery was pretty well established in Britain.  I don't know when they had their own qualifying exam. 

Neuropathology had always been done by general pathologistsBut neuropathology had always been done by general pathologists  The first people to show special interest in the brain were usually pathologists who were attached to lunatic asylums, and who had access to the brains of patients who were neurologically abnormal. 

It was quite interesting for me to be in Bristol in the '70s, because that was when there was a movement in Britain to establish neuropathology as its own discipline, and Betty Brownell was one of the leaders -- she and Marion Smith, at the National Hospital for Nervous Diseases.  Being women they had quite a lot of difficulty persuading the Royal College of Pathologists, the RCPath, to establish a separate training and examination in neuropathology.  I trained in Britain from 1974-1977, and there was no qualifying exam.  The only qualifying exam in the world then was in America, where you could specialise in general pathology, forensic pathology, haematopathology, and neuropathology.  Typically American, always way ahead of everybody else; and they still are, I think.  And so having trained, my only option in the UK was to do the general path exam. 

I wasn't in the least bit interested in the gut, or the prostate or any of those thingsBut I didn't want to be a general pathologist. I wasn't  in the least bit interested in the gut, or the prostate or any of those things.  So with Betty Brownell's help I actually got accepted to write the American Board exam.  That was a spectacular bit of string-pulling, because normally, you could only write the Boards if you had trained in the US.  But they knew her, you see.  She had made a name for herself.

SA:  And had she done the exam herself?

RH:  No.  In fact she didn't have any degree in pathology.  She had trained at Oxford where Dr Joe Pennybacker, a famous American neurosurgeon, was the Chief.  And there were two general pathologists at Oxford, David Oppenheimer and Trevor Hughes, who had succeeded in confining themselves to neuropathology by establishing a reputation for themselves through writing and providing clinicians with a diagnostic service, and she trained with them by absorption.  As she told me herself, she just went and made herself terribly useful – especially to the neurosurgeons, but also by doing a huge amount of donkey-work for the pathologists.

SA:  Did she have a medical training?

RH:  Yes, she was a medic, and in those days she somehow got a job working for these people.  David Oppenheimer was already quite a famous neuropathologist in Oxford -- very erudite, difficult man -- and she trained with him or rather, worked for him and this American neurosurgeon.  That's why she had a good background in surgical neuropathology, which is what the clinicians wanted.

Then what happened was the Regional Neurological Centre was established at Frenchay Hospital in the late 1960s, with a full-time neurological and neurosurgical staff.  They also had a neuroradiology unit, which, quite unusually for its time, was part of the neurosurgical department, and in 1973, they got the second CT scanner in Britain.  There was one at the National Hospital [for Nervous Diseases], and the next one went to Frenchay Hospital, so they were quite ahead of their time.  And one of the neurosurgeons who had known Betty in Oxford -- Huw Griffith, who had also trained with Joe Pennybacker -- got in his car, went up to Oxford and fetched her down to Bristol to show her the set-up and to persuade her to be their neuropathologist. 

So that was how she became a consultant neuropathologist – still with no formal qualification.  She set up the department, which was also attached to the Neurosurgery Unit and quite separate from general pathology, with its own staff, and she became well-known in the UK and abroad through her contributions to meetings and the literature.  She herself told me that if she had been in a general pathology department, she wouldn’t have got anywhere.
 
SA:  And what was she like? What did you feel about her as the person who trained you?

RH:  Oh she was an extraordinary woman.  Extraordinary.  Very knowledgeable in neuropath and, interestingly, in ornithology, but otherwise very restricted in her outlook.  For example, I'm very interested in music and all sorts of things.  She thought these were trivial diversions.  There was one famous Bristol pathologist who was a very good musician, but also a very eccentric man – he was Oliver Cromwell Lloyd, descended from Oliver Cromwell, with a huge house to go with it.  Betty didn't like him, and she didn't like me playing music with him. 

Furthering neuropath was simply her life's workFurthering neuropath was simply her life's work.  She was not married and we discovered later she had had a long-time affair with a well-known Oxford pathologist, whose wife had died, but it was extremely discreet.  In fact, when she retired she married him. She retired, married him got cancer and died, all in the space of a couple of years.  Isn't that extraordinary?

I became aware of the very best of North American neurology and neuropathologySo Betty Brownell got me to America, where I stayed with another friend of hers, Bill Schoene, who was the neuropathologist at the Brigham, and I did the exams there. It was through Bill that I got to meet the East Coast gurus in neurology and neuropath at Harvard and the ‘Mass General’ and they have influenced me ever since -- just their approach and their manner and their vast knowledge.  And the care which they took with cases, and the quality of their writing -- marvellous.  They were very careful about everything – the history and the slides, documenting everything.  And the beautiful descriptive language!  Because of those East Coast neurologists – Ray Adams, Miller Fisher and Pearson Richardson particularly -- I  became aware of the very best of North American neurology and neuropathology.

And then I came back here to South Africa, against everybody's advice, because … well, my family was here.

SECTION 2

An African childhood

SA:  Yes, let's go back to your earlier years…You say your father worked in Serengeti – what's the history of your family in Tanzania and Kenya?  Did you grow up in Serengeti?

Kenya safari 1931, left  to right, Ray Hewlett, Denys Finch-Hatton, Prince of WalesRH:  I was born in Tanzania.  My mother's parents emigrated to German East Africa at the end of World War I, to help run the country.  The Brits imported these people;  there were all these openings, you know. The Germans were displaced and the Brits moved in – farming, commerce, and of course the administration.  My mother's family were Scottish, from Lanarkshire, and they came to Moshi, at the foot of Kilimanjaro - my mother and her brothers and her grandparents, the entire family.  My grandfather was a timber merchant, and he took over the Kilimanjaro sawmill.  They had a beautiful house in Moshi with a stream running through the garden, which I can never forget.

My father came to Kenya after World War I.  He had joined the Indian Army in 1922 and had fought in the second Afghan War.  He was returning to Britain when his ship had to pull into Mombasa for repairs, and he travelled up to Nairobi and never returned.  He often told me that when he woke up in Nairobi, he knew that was it.  So he resigned his commission; he telegraphed and said he was not coming back.

[Richard shows me a wonderful photo of his father next to an old car on a dirt road in the middle of Africa.]

He became one of the so-called 'White Hunters' – I don't like the term -- and he took people on safari.  Though it was normal at the time, for me now it's almost unbearable to think of the animals that were killed -- including by him.  He was one of the crack shots in East Africa and a friend of Denys Finch-Hatton, who was immortalised by Karen Blixon in her book Out of Africa.  My father and Finch-Hatton had gone into partnership when Finch-Hatton was killed.  My father was meant to have been flying with Finch-Hatton when his aircraft stalled on take-off.   He was killed in 1931, I think, and when that happened my father left Kenya and went to Tanzania – to Tanganyika – and he joined the Game Department there.  That’s where he met my mother. 

SA:  Your father and Finch-Hatton had been partners in what?

RH:  ‘White hunting’, so called.  They took the Prince of Wales on a famous East African safari.  [He shows me some wonderful old photos framed on his study wall.]  That's my father and that's Finch-Hatton and that's the Prince of Wales.  And of course, when that ended, he moved to Tanganyika, gave up hunting and joined the Game Department: he became a conservationist.

SA:  So how long did you spend in Serengeti?

Where my heart isRH:  We were there for five years.  He was the first warden.  Before that he had been in the Game Department in the Eastern and Northern provinces of Tanganyika.   But the longest period was in the Eastern Province, which is really where my heart is.  And then he was facing retirement when they offered him the job as the first warden of the Serengeti Park, which had just been gazetted.  He was also one of the founders of the Selous Reserve. 

SA:  So are your earliest memories of wonderful wild Africa?


RH:  Oh yes, that was my whole life.  I've got some pictures of my mother and father driving through Serengeti in the rain in 1935, with my infant sister who had just been born.  Oh yes, those were great days…

SA:  And you wanted to go into that world, did you?


RH:  Yes, yes, I wanted to go into wildlife, but my father just said, "Forget it." And I didn't ignore his advice – I was quite interested in medicine.  I was educated at the most famous school in Kenya, the Prince of Wales School in Nairobi, and then I had the opportunity of coming to UCT and there I became, as I told you, interested in neurology.

A change of environment

SA:  What was UCT like in those days?  I mean, having come from wonderful wild places in the bush, how did you like it?  Was it a stimulating place to be?

This was like being on the moonRH:  Well I didn't like it, because I didn't like South Africa.  Everything was fenced in; it was run by a very dour crowd of people.  I had to wear a tie, which I'd never done before.  You couldn't go to the flicks on Sunday in those days in this Calvinist society... And miles of fencing, and this empty landscape!  I was born and bred in the bushveld.  This was like being on the moon for me. 

But I immediately fell in love with the university -- the buildings, and the history… I'm still very interested in colonial Cape Town and its buildings and Rhodes's heritage; very interested.  I love the old buildings.  That's actually one of the reasons I loved Cape Town so much that I came back here, against all advice.  Betty Brownell was very upset because she offered me a post in the department in Bristol.  Later on she offered the whole department to my colleague, Stuart Rutherfoord, who went over and trained, and he also came back here.

SA:  You decided to come back here rather than going back to East Africa which is where you'd grown up?

There was nothing there to go back to, nothingRH:  Oh, I couldn't have gone back there.  When I qualified I applied to do my housemanship in Nairobi, and I got a letter saying they were only employing nationals – meaning blacks, of course.  My parents had separated.  My father came down here to stay with my sister, and my mother stayed up in East Africa, on the property that we had there, on the seafront north of Dar es Salaam.  But there was nothing there to go back to, nothing.

Life under apartheid

SA:  The National Party had been in power for some time by the time you came to UCT.  What were your feelings about the politics of South Africa?

RH:  It was horrible!  Specially for the coloured people -- there weren't a lot of blacks in the Cape then, but the demeaning treatment of the coloured people… I reckon the biggest mistake that the Afrikaners made in this country was alienating the coloureds; and they knew it in the end.  The coloured people spoke their language, went to their church; some of them had resulted from mixed marriages.  Oh it was terrible.

SA:  How did it affect the university itself?


It was like a bad dreamRH:  There was a quota system... That's another reason why I fell out with the university.  There was a quota system imposed by the Nationalists: there could only be so many brown faces, the rest must be white.  The coloured medical students had to live elsewhere; they couldn't see white patients, they had to function in the 'brown' end of the hospital.  It was like a bad dream actually.  And yet the place was so beautiful, and the whites ran it in a way it will never be run again.  Everything was planned and orderly.

SA:  So despite the politics, the way it was run was good?

The hospital service – it was absolutely excellentRH:  Oh yes.  Especially the hospital service – it was absolutely excellent.   Groote Schuur Hospital was marvellous - spotless, spick and span, and everybody toed the line.  But after we got democracy, it went into a dark age, I tell you, with theft and racism... A dark age.


SA:  So what made you come back, was it just Africa in your blood?


RH:  Yes, my family was here.  My father and sister were here; my mother was in East Africa. I had already bought this house.  And I couldn’t get used to Britain – I didn't like the climate, and I didn't like the over-population – that was very troublesome to me all along.  You know, to go into the remotest part of Scotland and to see 20 hikers appear out of nowhere… I couldn’t get used to that.

SECTION 3

SA:  When you came back here, what was the difference in pathology compared with what you had been seeing in Britain?

RH:  There was one big difference – infections of the nervous system, tuberculosis, which is very common here and has become, I suppose, my main interest.  In the work that I did with Stuart Rutherfoord, tuberculosis of the brain is what we're best known for.

But what happened was very interesting.  I couldn't go back to the University of Cape Town, so I got a job with a German professor who was head of pathology at Stellenbosch University Medical School, which was located at the new Tygerberg Teaching Hospital.  He knew what neuropathology was; he had no difficulty with it at all, so he let me do neuropathology there as I had already done the American exam. 

I had to start all over again, and it was toughAnd then in 1982, Betty Brownell wrote to me and my colleague Stuart Rutherfoord, and she said, "Look here, you chaps…"  (When she said, "Look here you chaps…" you knew that was trouble!)  She explained that she'd got this exam going with great difficulty, and because we had trained with her, we must go and write it.  This was some undertaking!  What was I? Getting on for 40, with four children, and to be told to go overseas and write an exam – and to prepare for it.  I had to start all over again, and it was tough.  It was a tough exam.

SA: Why did you have to take it again?  Just for her?


RH:  Yes.  But also because in those days the American exams weren't recognised in this country, whilst the British exams were.  You could do the fellowship in surgery and the membership in medicine, and that's what people did -- they all trained overseas.  The college here still recognised British degrees in pathology, medicine, surgery, so it was quite important for me. 

Every attempt I made to have neuropathology recognised here was blocked at the topThe people that kicked me out of UCT ran pathology in this country, and every attempt I made to have neuropathology recognised here was blocked at the top by these same people!  They just said they didn’t want any super-specialists -- and they specially didn't want any neuropathologists.  They said it was a branch of pathology that any general pathologist could do, and they stuck to that. They didn't want to employ someone in the department who wouldn't look at lungs and everything else, someone who just looked at the brain.  They do now, of course, if there's anyone who wants to do the job.  But there isn't anyone now.

SA:  Really?  So how many neuropathologists are there around here?

RH:  One.  Me.  And of course no one could train at UCT because it's still the policy.  There's a heritage there from the man who fired me, Professor Dirk Uys. And there's a consultant there called Bowen who's been a long time friend of mine. When the head of department says, "Shouldn't we get a neuropathologist?" Bowen always says, "No, we don't need a neuropathologist."

SA:  So you're the only neuropathologist in Cape Town?

RH:  In Africa, I believe.  There's hardly any pathology in Africa outside of South Africa.

SA:  So do the general pathologists see neuropathology cases?


RH:  Yes, they have to do some surgical neuropathology because the neurosurgeons keep taking bits out of the brain -- almost always tumours.

SA:  But how bad is it, the fact that there aren't specialists?  How important do you think it was to specialise?

RH:  It's very important.  They're missing out… They have no means of knowing these structural changes in the brain because they haven't been trained in them.

SA:  So what are the biggest things that are getting missed?


Even very basic reactions in the brain, like stroke, are not properly understoodRH:  I’m not sure if ‘missed’ is the right word, because many general pathologists are competent at CNS neoplasia, but there’s a generally inadequate standard of basic neuropathology, particularly brain-cutting – the macroscopic examination.   But even very basic reactions in the brain, like stroke, are not properly understood by the general pathologist…

Brain imaging opens new horizons

The neuropathologist is actually very well placed to interpret the imagesBut I was going to tell you something that changed everything for me – that's brain imaging.  When I got to Tygerberg [Stellenbosch Medical School] I had a friend in the neurology department and he used to invite me to the imaging meetings.  Of course the brain images are the same as the gross anatomy of the brain: if you look at the brain in slices, the images are identical, so the neuropathologist is actually very well placed to interpret the images.  That really was the sea change in my whole lifeThe professor of Radiology at Tygerberg, an elderly Afrikaner called Andre Beyers, perceived this and he said to me one day, "This brain imaging, it’s just macroscopic brain pathology."  He said, "You must come to my department, as the neuropathologist in the neuroimaging department."  Just then my colleague Stuart Rutherfoord wrote to me saying he wanted to come back to South Africa -- he'd trained with Betty too, and he couldn't go to UCT, of course.  So I moved out of my job as a full-time consultant in the Pathology Department at Tygerberg and he moved into it, and I moved to neuroimaging.  That really was the sea change in my whole life.

SA:  And how happy were you with imaging as opposed to having the brain in your hands and cutting?

The people that are interested in imaging don't understand the pathologyRH:  Oh it's absolutely marvellous.  It's as good as neuropathology.  You can't separate the two. You can't do without the imaging; it's essential.  I still do both. The result of all that was a book on pathology and imaging that Stuart Rutherfoord and I wrote together and published in Britain.  Unfortunately no one reads it, because the people that are interested in imaging don't understand the pathology.  You see, the whole book is devoted to a mix of imaging and pathology.  There are CT and MR pictures of the brain and of the tissue samples that come out of the brain.  In fact there are more images of the brain than there are of Histologythe study of cells and tissues, usually carried out with the aid of a microscope.

Anyway, I've been in that ever since.

SA:  But I've spoken to pathologists who say that imaging is fantastic, but that there's nothing better than seeing the tissues direct.

They sometimes make terrible mistakesRH:  Oh no, you can't say that.  No.  Because you are given a little bit of brain like that [indicates a tiny bit with finger and thumb] – you have no means of knowing where it's come from.  With the images, you can see exactly where it's come from and even what its morphologic characteristics are.  But pathologists don't go and look at the pictures – and that's why they sometimes make terrible mistakes.  Ridiculous mistakes.

SA:  Like what for instance?

RH:  Oh, they may identify a lesion as a particular tumour when it can’t possibly be that because the location is completely wrong.

SA:  Okay, you were saying that TB is your main interest…?

TB of the brain became my main interestRH:  Yes, TB of the brain became my main interest, and of course the images that go with it.  We wrote the first detailed account of imaging and pathology of tuberculosis of the brain, which I think is more or less accepted now.  Because we were familiar with the histology, we were able to interpret some of the changes on the images. And because we looked at the images, we could work out the changes in structure that occurred over time in the brain, which you can't otherwise. That's the big difference -- the pathologist gets the brain or a piece of it just once. The imager can examine the brain repeatedly and see how a structural abnormality is changing over time, which is crucial to understanding the disease process.


SA:  So who's doing the imaging at the moment, and who's doing the interpretation of the images?

RH:  The neuroradiologists do the imaging, and they don't do any pathology so they have no idea of Histologythe study of cells and tissues, usually carried out with the aid of a microscope. – that is, microscopic morphology.  And the pathologists do the pathology and they have no idea what the images mean. 

Hands-on training in radiology

SA:  So how did it happen for you? Who first suggested it to you?

Overnight I became a radiologist!RH:  Well it was this elderly, conventionally-trained Professor of Radiology at Stellenbosch Medical School, Andre Beyers, who told me that I must come and work in his department.  And he just engineered it.  I often tell the radiologists that I became a radiologist between December 31st and January 1st 1987.  Overnight I became a radiologist! And some of them did not like that, you know!  But then, some of them accepted me and have been wonderful friends and colleagues ever since.

SA:  So he called you in to look at the images, and what did you feel when you saw them?


We were able to correlate the images and the pathology RH:  Well, I didn't have a formal training, so it was ‘hands on’.  But I could see what the pictures meant, and I could see the changes in the brain over time, and I could see diseases of the brain where the pathologist never gets the tissues -- a patient dies and you never get the hold of the brain.  So you have to work out in your mind from samples you've seen from another case, to the lesions that you see on the images -- you have to extrapolate.  Which is what we did with tuberculosis, because we get some of the brains of people who die from tuberculosis, but a lot of them don't die. Most of them don't die.  So we had to put things together there.  On a number of occasions we did actually get the images before the patient died, so we were able to correlate the images and the pathology.

The value of a database

Now I spend most of my time running a database.  That's really my life… The end of my life is spent running what's now called the Stuart Rutherfoord Database, designed and built by a radiologist called Stephan van der Westhuizen.  It’s a correlative web-based database where any specialist -- the neurosurgeons in Cape Town or anywhere  -- can log on.  They have to have credentials and be registered to log on because it's a restricted site, but then they can see a case anywhere.  I can report -- I do report -- tissues that are sent to me and I usually have the images with them, and I am able to put them together on the database. 

For example, we did a case for a paediatric neurologist in Pretoria who had seen a child with an undiagnosed seizure-condition who'd died.  She organised for us to be sent the brain, all the way from Namibia, as a matter of fact, and we put the whole case together on the database, which she could see in Pretoria.  She thought it was marvellous.

SA:  What had the kid died of?


RH:  It was a rare inherited metabolic disease and it looks as though the brother is also going to die.

SA:  What could you see on the imaging and then on the actual tissue?


RH:  You couldn't see anything on the imaging, and you couldn't see anything on the brain either except that the cells were disappearing.  So it has to be a disease where early on in life there's a gene defect, usually a deficiency of a particular protein that means the cells are electrically abnormal and just die.  It has to be that.  The actual biochemistry of the condition in those two boys' case hasn't been worked out, but there are parallel cases that must be the same thing.  The parents are in Windhoek and the last I heard, because of the work we did on the one child who died, they are very concerned to try and work out what it is. 

The brain was withering awayDuring the child’s illness the images showed only that the brain was withering away, nothing else.  And if we hadn't had the images and the history, we'd just have seen a small brain in which some cells were missing.  You have to put everything together – the history, the pictures.  You have to see it over time.  It started off looking normal, but when the child died his brain looked like a patient with Alzheimer's disease.  We only got the withered brain, but the child was already sick with a normal-appearing brain, you see.

SA:  So without the imaging you couldn't have known what was happening as it progressed, before the child died?

RH:  Exactly.

SA:  Who had started doing the imaging?  Do a lot of people do this now?

RH:  Oh yes, that's how it all starts.  It all starts with imaging.

SA:  And the radiologists didn't say, "There's something wrong with this brain"?

Everything in neurology and neurosurgery starts with imagesRH:  They just said that the brain is shrinking, they didn't know why.  Everything in neurology and neurosurgery starts with images.  The pathology is just a tiny bit of it now.  And because the images have become so informative there's a lot less pathology coming out.  That's a serious problem.  The imaging diagnosis has become so elaborate and so detailed and reliable…

SA:  But if radiology is good enough, why does it matter that the role of pathology is diminishing?

RH:  Well, in many diseases, like neoplasia, dementia, infections, it's still essential.  You see a mass, but you've no idea what it is.  You have to have the Histologythe study of cells and tissues, usually carried out with the aid of a microscope. there.  So it's still essential in brain neoplasia.  In some vascular diseases of the brain you can see the brain's getting short-circuited in terms of its blood supply, but you can't see what's wrong with the blood vessels unless you cut them up and stain them, examine them under the microscope.

SA:  So the two things are complementary and have to go together?

RH:  Yes.  In fact, David Stephens and myself, in Bristol all those years back, we described the first cases of a rare vascular disease that has now been fully worked out.  Now we're seeing the diagnosis being made on the images, but you still need the pathology.  The images are of vascular disease of the brain in a certain context, but unless you take the brain out and examine the blood vessels, you can't prove the diagnosis.  It’s the same with the degenerative diseases like Alzheimer's, you can't prove it unless you have the tissue under the microscope.  There's no marker for it.

SA:  So what you're trying to sell is the idea that the two things are brilliant together, and they really need to go together?

RH:  They are inseparable.

SECTION 4

SA:  So are new young pathologists being taught imaging as well?

RH:  No.  Another very interesting thing happened.  Because of my interest in imaging and pathology I have been asked to give a number of talks at radiology meetings, and there came out to South Africa an American neuroradiologist called Anne Osborn.  She's one of the world’s foremost radiologists really, and she came out here and she saw this correlative aspect of imaging and pathology straightaway. 

She had always been interested in pathology, and all her books, for which she's famous, include pathology – some of it our pathology.  She's been the one who has most supported the notion of the integrated neuropathology and neuroimaging of neurologic disease.  She's well known because her books on neuroradiology became the world's best sellers, unquestionably. She invited me over to America to her department to give lectures in neuropathology 

In the last three years, with her husband’s support, the company she started has produced a series of books.  Quite interesting how it happened – she and some of her colleagues decided the publishers were getting too much money for their books and they could produce them themselves electronically.  So they set up a company, theAmirsys Corporation, with their own money and these books are now world bestsellers in neuroradiology. 

Now they're doing the imaging of everything: the brain, the spine, the skull base, children's diseases.  This whole Amirsys corporation is worth millions today.  I agreed to make all of the neuropath from our archive available for those books, which is what I'm doing at the moment.  She's using the material because we know where it's come from -- we're possibly the only department that has correlated the tissue samples with the images, and we've been doing it for 30 years.

Financial restraints

SA:  Why has nobody picked you up on this?  That's what I find so strange, because you're such a passionate advocate of it, I can't understand why it hasn't caught on.

It's the issue of money reallyRH:  Well, it's the issue of money really, and how much work people do.  Another thing you need to know is that the pathology departments of all the teaching hospitals throughout South Africa were taken over under a single umbrella called the National Health Laboratory Service, the NHLS.  So whereas UCT and Tygerberg had their own seperate path departments... Well, they’ve still got their university path departments because they train people, but everybody actually works for the NHLS.  So when that happened, I said to the people at UCT, "We all work for the NHLS. I'll do the neuropath for you."  The answer was, "No. We don't need you to do the neuropath."

SA:  But at Tygerberg you still have your head; there's lots of work to do?


RH:  Yes, I still work for the path department.  I've resigned from the neuroradiology department really because there isn't time.  And because they still consult me in neuroimaging and I can get all the pictures I want, I don't have to be a member of that department.

SA:  Okay, so you can still do your pathology, and if you need the bigger picture, and you need time sequences…

RH:  Oh, I need the images every day.  And now, because of the advances in electronics and digital imaging and broadband I can study the images in my office. Originally I had to copy films, carry them back and forth, and then carry CDs back and forth.  I also work part-time still for a firm of radiologists, and I have one of these broadband cables into my office.  They do the radiology for five hospitals and if they want a report on a case, I can do it.

SA:  And you get neuropathology cases sent to you from all over the country, all over Africa, do you?

RH:  Yes, because I work also part-time for a big private pathology practice called PathCare.  It might be the biggest in the country, and they've expanded into other African countries.  They've got a branch in Nairobi now, and one in Windhoek, and I do most of their neuropath.

Kathy Taylor is a UCT-trained pathologist, and she does a lot of the neuropath for PathCare in Cape Town. She doesn't hesitate to send me anything, everything.   But pathologists are funny people, and radiologists too… I don't know what it is.  Territorial?  Hoarding?  Or maybe it's: "If I send this case away it means I can't do it myself."  I send all sorts of things away!  Because of this database, if I have the slightest doubt, I send things away. 

James Ironside can look at a case in Edinburgh, and Danie du Plessis can look at it in Manchester, and Pat Kirby, who trained with us, can log on in Iowa.  I often send them cases.  If I have the slightest doubt, I send them a picture and I say, "Please look at this picture", and they just log on and there is the whole case.  I don't have any difficulty consulting.

SA:  So Kathy Taylor, you say she does the neuropath, but she's not specialist trained?


RH:  She's an experienced general histopathologist, but mainly surgical, neoplasia especially.  But for example, the only epilepsy centre in the Western Cape – I think it might be the only one in the country -- is at Constantiaberg Hospital, and they excise parts of brain that have been identified as being responsible for the seizures.  This is so-called epilepsy surgery, and because it’s a private hospital, all the brain samples go to PathCare and to me. 

There's a particular operation for seizures which is called temporal lobectomy.  Now that's a very specialised area in neuropathology, and it's entirely because of Kathy Taylor that I now know more about this area of neuropathology than anybody else in the region, because I get all those cases – and I get the pictures as well.  I just have to ask Andy du Toit, who's the neuroradiologist at Constantiaberg, and along comes a CD.

SA:  What do you actually see when someone has seizures?


RH:  It depends on what bit of brain they take out.  You have to identify the bit of brain that is related to temporal lobe epilepsy.  But there are all sorts of other types of seizures that don’t start in the temporal lobe, and these are usually due to neoplasms, or cysts, or parts of brain that have been physically traumatised… A hundred and one things.  And I get the tissues from all those cases, so I've been very fortunate.  And it's because of my contacts in neuroimaging really, and talking and teaching neuroimaging.  At Tygerberg Hospital I am still involved in the combined neuroimaging/neuropathology meetings.

SECTION 5

Personal perspective on life

SA:  So going back to the beginning, you said you were not interested in other areas of pathology – what was so special about the brain?

It's the key to everythingRH:  It's the same with everybody who loves the brain, you know, it's its mystery.  It's the key to everything – to what we are and how we think.  And of course it's ramifications into religion and philosophy and history are just endless.
 
SA:  And what has your exploration of the brain meant to you philosophically?  Knowing so much about what goes on inside our heads, how has that influenced your feelings about who we are?  What has it taught you?

A very amazing systemRH:  Well, it isn't what it has taught me so much as what it has persuaded me of.  That there isn't anything up there [pointing upwards]; that it's all a system that has evolved.  A very amazing system.  Electrical, and chemical, controlled by the genes. 

SA:  But has it solved for you any of the mystery of who we are?


The solution ... will be in geneticsRH:  It has pointed me to where the solution is, which will be in genetics.  It'll be a mixture of what's called 'neural circuits' and genes.  As you know, there are these computer circuits that are actually starting to make decisions that are outside merely programming.  People can apparently design chess programmes that can make decisions that are different from simply the programme itself -- that's getting pretty close to it, I should think. 

we inherit a way of thinkingIt must be in the circuitry.  It must be a combination of the circuitry, and the facility for storage, and the facility for imposing on the receptor events recorded from the past to influence how they are interpreted now.  I imagine that's how it will all work out. Plus what you inherit from what we have been over centuries.  There's no doubt that we inherit a way of thinking -- in the genes; the ‘memes’.  I remember when I went to Britain I was so affected by buildings and scenes that I had never seen before that just 'belonged' to me, you know? 

SA:  What, you felt a familiarity with things you'd never seen before?

RH:  Oh yes, oh yes.  It was an extraordinary sensation.  Extraordinary.

SA:  But shrinking us to the workings of a system – doesn't that diminish us?

We are on the route to destroying everythingRH:  No, I don't think so.  It's such an amazing system.  But it does trouble me that this system is going to destroy everything.  In my old age now I'm convinced that we are on the route to destroying everything.  That's the other side of the coin for me -- I think this system, this operating system, is just going to consume everything.

I've actually been depressed since I returned from Tanzania, which is three years ago.  I went on a pilgrimage to travel all the roads of my childhood. 

SA:  And what did you find?  What were the changes that most distressed you?

Whole rivers drying up, because they've been destroyedRH: The destruction of everything.  The rivers – whole rivers drying up, because they've been destroyed… One river, which is a tidal river just north of Dar, which the Germans built the first bridge over – if you look into the water, it isn't water.  God knows what it is; it's sewage I think, or oil.  It's a mixture of oil and organic material.  And in my childhood it was a beautiful river.  It's terrifying.  I didn't know it would be so terrible.  And I wake up every night…what can I say?

SA:  Just fretting about it?

RH:  Mm.

SECTION 6

SA:  Okay, going back to the pathology, one of the things I'm fascinated by is HIV – there's a lot of brain involvement, isn’t there?  What have you seen?

They don't want to do HIV autopsiesRH:  At Tygerberg we don't see it.  It's very interesting, we do not see the pathology of HIV!  We see the pictures every day of the week.  At UCT they're seeing some cases of HIV, but there's the issue of the risks to the pathologist from HIV, so the registrars don't like doing these cases, and at Tygerberg the consultants wouldn't do them either.  They don't want to do HIV autopsies.  So this is the extraordinary thing -- although we're at the epicentre of the HIV epidemic, we don't see the pathology!  The patients are scanned, the diagnosis is made serologically [from the blood], you can see what's happening in the brain – we can see all the changes, but we don't know what they are.  Patients go home and die somewhere else. 

We see a hundred and one different things on the images, but we don't know what they areWe see a hundred and one different things on the images, but we don't know what they are, and I say to the neurologists, "Why d'you go on scanning these patients?  It's costing a lot of money. If you're not going to give us the brain, we never will know what this is that you are looking at." Well, in fact they do identify some of the changes, such as ischemia, demyelination, and even some infections – especially infections such at TB.  But not the structural changes directly due to HIV – for those you have to have Histologythe study of cells and tissues, usually carried out with the aid of a microscope..

SA:  But that's terrible! Have you had very few brains of HIV-positive patients?

RH:  Very few. We've had just one or two, and they're infections mainly.  But the things we want to know are not the infections.  These are patients with HIV with changes in the brain that are not the sort of changes you see in infection.  It's death of cells in some way -- probably a process switched on by the virus. Very interesting.  And we badly need to get to know the basic pathology of these events.

You have to have permission for everythingAnd what's happened now in South Africa is an effect of Britain and its ethics.  Now, you have to have permission for everything – even to do an HIV test, which is absurd.  The doctor doesn’t have to have permission to identify the patient as having syphilis, but with HIV, which is a million times more important, you have to have permission!  Can you believe it?  So now all these patients, who were never asked before, are asked, "Please can we take some blood?  Can we look at this?  Can we do a postmortem?" 

And when it comes to postmortem, patients’ relatives almost always say no.  The law in this country is still that if the doctors want a postmortem on a patient who dies in a teaching hospital, they can have one.  But because of the ethics now being applied, they say, "It is the law, but we don't apply it any more."  And that's what's happened to HIV.

SA:  So you have the same kind of ethical restrictions in this country as you do in Britain and the US?

They are terrible restrictions, very harmful to pathologyRH:  Yes.  And they are terrible restrictions, very harmful to pathology.  In fact the Alder Hay neurosis is going to be the end of anatomical pathology -- and I’m not alone in thinking this.

And there's another thing that's happened: it's the cost. I won't go on about it any more, but take the NHLS which works on billing. Because it's taken over the academic departments it has to pay lip service to academic pathology, which it does to a certain extent.  But it bills the hospital for every bit of tissue looked at.  Billing is definitely going to be the end of neuropathA general pathologist who works in a teaching hospital can do 80 cases in a day if the samples are appendixes, prostatic chips, uterine tubes, skin biopsies.  But a neuropathologist can do one or two cases in a day, and send out one or two bills.  And all the administrators want to know is how much work I'm doing and how much billing is going through neuropath.  So I can foresee that billing is definitely going to be the end of neuropath.

SA:  You really think it's desperate – in this whole region?

RH:  I think it is desperate – in Africa.  You see, the NHLS took over surgical pathology and microbiology.  It never wanted to take over autopsy pathology, because it costs the service money which cannot be recouped.  And the Province doesn't want to pay for an autopsy either.  They just say – specially if they are black or Moslem -- "Why are you billing us for someone who is dead?  What good is that?"  So autopsy pathology, the same as in Britain, has absolutely plummeted into the ground.  It is very terrible.

SA:  You mentioned a friend up in Zambia, is he a general pathologist?


RH:  Yes, he's training here, and I think he's pretty good too and he knows what pathology means, but he once said to me, "You know, where I come from no one is interested in pathology."

A continuing fascination with the brain

SA:  In your career, how much contact have you had with patients, or are you very much a backroom person?

RH:  I had a certain amount of contact with patients over diseases of muscle, which I'm not involved in any more -- we always used to take the muscle biopsy ourselves.  But I wasn't really involved with patients much in pathology.  But in imaging -- I did about two-thirds imaging, one-third pathology at one stage -- there people ask you straightaway, "What does the scan show?"

SA:  So when you worked in the imaging department you began to see patients?

RH:  Yes, and I didn't mind it.  As I said, I was going to do neurosurgery originally, but I just got to be more and more intrigued by the appearance of the brain under the microscope. It was when I was doing my PhD in anatomy, working on the microscopic anatomy of the dassie's brain that I became much more fascinated by it.  It's hard to say what the fascination is. 

I still am intriguedI often remark to my friends at the medical school that it's a mystery how, every day, something crops up that is fascinating.  Why does it remain fascinating after all these years?  A complete mystery.  Neuropath and neurology have never ceased to fascinate me to this very day.  I still am intrigued.

SA:  But has what you've learnt, and what you've seen under the microscope, made you fearful about how badly the brain can go wrong, or are you at ease with illness?

RH:  No, I'm at ease with it because the way things operate with such reliability is absolutely amazing. I am convinced that the system generally works better than it doesn't work, if you know what I mean.

SA:  And what about death?

'The oncosphere' ... The 'bio end-game'RH:  Well it's something I think a lot about– what I call the 'bio end-game'.  I'll turn 70 this year, and I've already entered another area for which I've invented the term 'the oncosphere', which is the area of higher than average cancer prevalence.  And 'bio end-game', that's also my invention.  So the oncosphere is where statistically you stand a greater chance of a mutation killing you -- cancer of the gut, of the brain… The 'bio end-game' is the phase of your life where you know you can't last much longer than another ten years, statistically.  It might be longer.  So it's the phase of your life where you have about a decade left, with luck.

Look at Stuart Rutherfoord, my colleague.  An athlete, squash champion, non-smoker.  He had a cough and one day we said, "What's the cough about?"  So he went and had his chest X-rayed, and he had a huge lung cancer and he died six months later.  Isn't that extraordinary, eh?  Non-smoker and athlete; 61 years old.

SECTION 7

Memorable cases

SA:  Tell me, in your time working in neuropathology, what have been the most memorable cases?

RH:  So many memorable cases.  They happen every day, cases that are very extraordinary.  You can divide them into two sets. There are those where what you find is quite unexpected – you think it's one thing and it turns out to be something completely different.  Then there are those cases where nobody knows what is happening to the patient and you do get the answer.  I have had a couple of amazing cases where the answer has come from the pathology. 

One was a woman, an accountant from Port Elizabeth who had had headaches and become irritable over quite a short period of time.  Then she decided to take a holiday with her sister, and she came down to Cape Town and got much worse, and that's when she was referred to our unit for a brain scan. The changes in her brain didn't look like anything I had ever seen before.  It had multiple patchy or focal changes all over, but not like cancer of the brain; not like an infection; not like multiple sclerosis.  Actually I had been working on a condition, a variety of LymphomaCancer originating in lymphoid tissue, a key component of the body’s immune system.  Cancers of lymphocytes (lymphomas) and other white cells in the blood (leukaemia) together account for about 6.5% of all cancers. where the tumour cells stay inside the blood vessels, intravascular lymphoma. 

The sneakiest condition to diagnoseThat's the sneakiest condition to diagnose, because you can't find tumour in the patient’s tissues.  The cancer cells are circulating, and in the brain these cells block small vessels.  And that's what had happened to her.  We eventually suggested intravascular lymphoma to them at UCT, where they didn't know what was wrong with this patient, and that turned out to be right.  She died in Groote Schuur, we got the brain, and there were the vessels plugged with lymphoma cells.  One of the youngsters wrote it up as a case in the pathology journal.

And then there was the case of Dr Liebenberg.  I don't know if you've been along the Wild Coast road, but there's a famous and beautiful bridge over the Storms River.  He built that.  He was an international bridge builder, an Afrikaner from Stellenbosch University.  He became unwell and they scanned his brain and saw what they thought was a tumour.  They decided to take a biopsy, and it turned out to be a condition called cerebral amyloid angiopathy, which is a degenerative disease confined to the brain vessels, where this amyloid protein is deposited.

I got sent the biopsy from PathCare because the people there couldn't definitely identify any abnormality – but it was obvious to me because I'd seen the condition before.  So I made a diagnosis of ‘amyloidosis with a mass’, which is a very unusual diagnosis, and I got a message back that the doctor in charge wanted the specimen to be re-examined "by some competent person".  [We both laugh]

SA:  What a cheek!  Have you had quite a lot of that sort of thing?


RH:  Well, having one’s diagnosis checked by someone else happens quite a lot in imaging.  Specially with Jewish patients, because they've all got medical relatives.  They say, "Can you send the disk to my uncle who's the chief neurologist in the Bronx."  I say, "That's fine by me, we'll send it off."  And I do; I don't mind at all.

What makes a good neuropathologist?

SA:  How often have you been wrong?

It's so easy to be wrongRH:  Often.  It's so easy to be wrong.  Specially on the images.  It's not so much being wrong with the pathology, because I've been properly trained, but I have made some mistakes with the images.  Sometimes I've had to tell the folk at the meeting that the only person who wasn't right was me. They love that!  I always own up.  If you're not going to admit to not getting things right it's hopeless. 

SA:  So what do you think are the skills that you have brought to this profession, apart from your intellectual curiosity – what makes you a good neuropathologist?

RH:  I don't know that I am such a good neuropathologist, though experienced certainly… It's interest, I think, just being intensely interested.  Prepared to look at everything, and especially to think about the collateral – the clinical picture.  It's no good being in a hurry, or being tired.  You've got to look at everything carefully, very carefully.  And also, always being prepared to talk to the clinicians.

A life outside the lab

SA:  You say Betty Brownell was very critical of anything that distracted you from pathology, so what is all that over there? You've got music on a stand there; you've got an instrument on the desk…

RH:  Well, yes, that's led to trouble at various times. [We laugh]

SA:  What do you do?  Are you a player?


RH:  Yes, I did play until I got this episode of arthritis that has wrecked my life actually.  It happened on my birthday, September 8th, overnight.  And now I can hardly play.  It's completely changed my life.  I can't even work the mouse properly.  What with this and the state of the planet and all that… I tell you Sue!

SA:  Oh dear!  So what were you playing?

RH:  The viola. I have started to play it a bit, but I can't play for long.  Over there in that cupboard, that's chamber music, said to be one of the best collections in Cape Town.  That was my big interest, the passion of my life, playing chamber music, especially string quartets and quintets. 

SA:  Did you ever think of doing music professionally?

RH:  Yes, I did, but only briefly.  My father said, "Good God! Let's not even talk about that.” Though, oddly enough, he always helped me in acquiring a better instrument when one came along.

SA:  Were you close to your father?


RH:  Yes, eventually very close.  Specially after my parents separated, and I spent more time with him.  I was about 15, and then I lived with him basically.

SA:  Was that a traumatic period?

RH:  Oh yes, it was terrible, because I loved both my parents.  And my home at Ngorongoro… At the time it seemed – it was – the end of my world, this beautiful home and my parents.  It was very difficult… But despite many shared interests, they were intellectually incompatible, that's all.

SA:  And what about other things – you're obviously a great reader?

RH:  Yes, yes, you can see everything's in a mess because I keep running out of book space.… History and biography, and English literature.  The trouble is I'm a bibliophile – I don't like paperbacks.  Right now I'm trying to get the Bronte sisters in a really nice edition. 

SECTION 8

A prion lab for South Africa

SA:  Richard, going back to the pathology – when James Ironside [Scottish neuropathologist expert in Creutzfelt-Jakob disease] visited recently, what was he doing?

RH:  Well, I have always been interested in the pathology of Creutzfelt-Jakob disease, almost certainly because of my days in Bristol with Betty Brownell, and for years I was the only pathologist in the country who collected these cases.  I once travelled to a remote farming town to take someone's brain out who'd been diagnosed by our neurologists and then sent home to die – which, by the way, is quite normal practice. 

Every case of suspected CJD that we got just sat in a bucket of formalin In fact, I have done a number of long trips to take people's brains out. Sporadic CJD isn't common here, we get about two cases a year in the Western Cape.  And what happened was that I went up to Port Elizabeth to take the brain out of a young chap who was thought to have got his infection from a dural graft, and when I wanted to put the tissue through the lab, the technologist wouldn't handle it.  He just said, "I'm not handling that; you can catch that disease, can't you?"  They wouldn't do it at UCT either.  And so every case of suspected CJD that we got just sat in a bucket of formalin.

Fortunately the two professors of anatomical pathology at Tygerberg are really helpful people and genuine friends of neuropathology, and one of them, Johan Schneider, said, "Well, we'll start a prion lab," and he got the money together.  Then I wrote to James Ironside, and he agreed to be the contact in Europe for the CJD lab here, which is the only one in Africa.  So we built the lab and he came out to Cape Town to preside over the official opening.  Amazingly enough, the week James Ironside got here we had a case – in a 46-year-old; unusually young.

SA:  Why did Professor Schneider reckon it was worth having such a lab when it's such a low incidence?

RH:  Well, we had run into an impasse which could only be resolved by conforming to European standards, and also because he is genuinely proud of the neuropath tradition in his department, and wants to Tygerberg anatomical pathology to be a referral centre for the discipline.  In fact, he wants us to be an African continental centre of neuropath expertise – so completely different from the attitude at UCT, alas.
 
SA:  And what are you discovering?

RH:  Well we're discovering various things.  Mostly that the diagnosis of CJD, both technically and morphologically, is really tricky – which of course is well-recognised in Europe and the US.  We had maddening failures in proving the diagnosis partly because the appearance of the brain varies, and there are these different neurologic forms of the disease.  It took a long time to convince the NHLS about why we wanted a very expensive immunocytologic procedure for a rare condition, and then when we got some AntibodyA protein produced by the body's immune system that recognises and attacks foreign substances. it didn't work! 

Then we got some antibody from Edinburgh and it immediately worked, so we're re-discovering all sorts of things now, not least in just running a dedicated lab...  These technical difficulties, like just getting the stains to work.  And you have to cut dozens of sections, because you find parts of the brain aren't affected at all, you can't see anything wrong, and then in another part, there are the characteristic changes.

SA:  And is James Ironside saying that's what they find also?

We don't have experts like that, we're just spuddlingRH:  Oh yes! I was wailing about these problems to the Edinburgh expert Dr Linda McArdle, and she said they’d had similar problems, to the extent that they’d had to revert to processing and staining the tissues by hand! The new autotec machine – like ours -- just wouldn’t work. Well, we  don't have experts like that, we're just spuddling.  And if you spuddle, you’re bound to have all these difficulties.  But it's terribly interesting.  A pity I soon won't be able to go on with this.

New discoveries in TB

SA:  You were saying earlier that you were particularly interested in TB of the brain – what fascinated you about that?

RH:  Well we had learnt from the images... the MR imaging machine identifies water and protein by means of a 'signal'.  When there's a lot of water the signal goes bright, and when there's blood the signal goes black, and so on. And we noticed that these brain tuberculomas were typically pitch black on the water-weighted images, and no one knew why.  And we re-discovered all sorts of things…some of the terminology going back for years had been misused by generations of pathologists.  We don't know why the signal goes the way it does, but we are certain that these tuberculous masses vary between different individuals, and we've learnt subsequently that the one that gives the black signal actually always gets better on treatment, and the one that's bright doesn't. 

SA:  What does it look like down the microscope – different or not different?

RH:  Oh yes! They look different in certain respects, but you wouldn't be able to explain why the signal is so different on the scan.  That's been a very interesting thing.

SA:  And where have you got to on that?


HIV, that's changed everythingRH:  Well we identified these black tuberculous masses as displaying a form of necrosis – tissue death – known as gummatous, which is like what used to be seen in syphilis in the old days.  In these cases of cerebral tuberculoma the individual is actually ‘walling off’ the disease and controlling it.  So patients who have those black masses – that is, black on the MR images -- appear to have a good immune system, whereas those patients with MR white or T2 bright masses (who are usually children, by the way) don’t respond well to anti-TB medication. But then the next thing we discovered, of course, is that there are lots of masses that are in between – specially in HIV, that's changed everything. 

SA:  But you said you weren't seeing many of the brains of people who'd died with HIV.  So have you seen some who died obviously of TB who then turned out to be HIV-positive?

Tuberculomas don't look the way they ought to lookRH:   Yes, and the tuberculomas don't look the way they ought to look.  It must be because of the compromised immune system; it can only be that.  You sometimes can't really identify them as tuberculomas, in the sense of the classical microscopic morphology -- though of course these patients have almost always been on anti-TB treatment, which is another complicating factor.
 
SA:  So has HIV just muddied the water, or are you beginning to be able to tease it out?

They'll have to reinvent pathologyRH:  Yes, it has muddied the waters.  And I doubt if it will ever be sorted out, because it has changed the immune system… They'll have to reinvent pathology.  Actually, when I say it'll never be sorted, it will be sorted out, of course it will.  But with molecular genetics, not by anatomic pathologists looking down the microscope.

SA:  So when you know that somebody has died of TB and you know they're HIV-positive, what you're seeing down the microscope is a real mystery?

RH:  It may be a complete mystery, yes.  Sometimes it looks like TB, but sometimes you don't know what it is and you can't prove anything either.

End of an era?

SA:  What do you do with those cases?  Do you file them away for when molecular pathology will be able to answer the questions?

RH:  Well there are some people -- clinicians like Professor Peter Donald, the paediatrician and guru of TB in South Africa -- who are intensely interested in the pathology of TB, but they are not pathologists, and it’s the pathologists who, generally speaking, are not interested in TB.  But occasionally there’s a surprise, and we have a colleague in the UK, Professor Alistair Lammie of Cardiff University, who is an enthusiastic revivalist. In fact, he writes extensively on the subject and has used some of our material. 

We've got a valuable, maybe even unique, archive of blocks.  Stuart Rutherfoord and I kept specimens from when we started here.  We've had three rooms full of brains going back 30 years, but we're throwing them out bit by bit, because they’re taking up too much room and the university wants to charge us storage.  But we keep the blocks, and we have a wonderful picture archive, and the pictures are what interest so many clinicians

SA:  What does it do to you having to throw out your collection of brains?


RH:  Well, the way I see it now in old age, Sue, is that everything comes and goes.  Here in Africa there's just never going to be the expertise or money to use the material.  And in Africa, what is the pathology archive compared to the survival of some of these animals and woodland and rivers?  It's nothing! I'd much rather money was spent on keeping the rivers running.  Really.  If people from overseas, who have the technology but not the material, want to use the archive, that would be the best that could be hoped for.

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But I really believe this era of anatomical pathology is over.  It started with Virchow and those people, and it's gone on for nearly two hundred years and it's now over; that's the only way to see it, because techniques are changing.  It’s no good looking at these HIV brains with ‘things’ in them. What you needs is molecular genetics to tell you what the things are. That's the way it has to go.  This is steam age stuff that I'm doing.

There’s often a point where actually looking down the microscope will tell you in  a minute what it is.  But there are not many things like that.  I’m happy to have been able to work, very happy...It’s a miracle that I’ve been able to do this blend of pathology and imaging.  But no one else will do it, because it isn't catered for anywhere.

SA:  But while you've been doing it it's been a worthwhile endeavour?


RH:  Oh marvellous, marvellous, yes. 

SA:  But you're philosophical about the fact that it will die off with you?


RH:  Yes.  Nobody buys that book [that we wrote]; nobody ever bought it, because it's [about] the interface, [and the bulk of folk are on one side or the other side, and they go their own ways].  When you work at the interface, you're talking two languages.  People in medicine would have to say, "Look this business of cross-over, it's a good thing."  But there's no provision for it anywhere, except in America.

SA:  So could you have had a different career if you'd worked in a place that was more interested in neuropath?  Do you think you could have been a pioneer of this cross-over in Britain?

RH:  No.  It's clear that it isn't working in Britain.  It took a very extraordinary once-off man like Professor Andre Beyers to be able to foresee the correlative basis of neuroimaging and neuropathology – and more than that: to actually do something about it. The teaching hospital neuroradiologists don't do that.  They don't invite non-radiologists, other than physicists, to come and work in their departments.

Low moments and high moments

SA:  Okay, so is there anything else you'd like to tell me about your life in pathology – high moments, low moments, for instance?

What do you do all day?RH:  Well, the low moments were getting fired from UCT, and then the long struggle to try to overcome the resistance from general pathology to recognise neuropathology as a discipline in its own right.   Years ago, one of the professors in Anatomical pathology, a very nice man, said to me, "Tell me, what do you do all day?" And he meant it!  He couldn't imagine what I was doing all day, and many still feel they cannot justify a specialty with such a low turnover of reports, compared with what the rest of their staff are doing.  The neuropathologist’s performance just doesn’t look good.  

So at Tygerberg Hospital and Stellenbosch University Medical School, the situation is pretty-well unique.  Heads of Department who tell you they like having you around! But even they can’t do much about the lack of interest that younger pathologists have toward neuropathology, and that’s where the future lies. Then of course, there’s the “Africa Factor”, which is so discouraging to so many doctors, especially pathologists. I can think of eight South African neuropathologists who are working overseas and who will never return here.

SA:  So it sounds like you've always been pretty isolated?


RH:  Yes. I have a copy of the document Betty Brownell wrote when she was setting up neuropath in Britain, and her words were: "Where neuropathology is part of general pathology, it does not thrive."  Full stop.  That was a document to the Royal College of Pathologists. That is why they had to have their own departments – because they couldn't make any headway otherwise. 

People always said, "How much work are you doing?  How much money are you spending?  What are you doing all day?"  The people who appreciate the neuropathologists are the surgeons and the neurologists.  And in recent times, some radiologists have been wonderful supporters of neuropathology, particularly the people in the Schnetler practice [a group of radiologists] in Cape Town, and of course Anne Osborn, in the USA.

SA:  When you were fired from UCT, had you been aware it was coming?

RH:  Well it was building up, and it had to do with Prof Dirk Uys’s vision of when I would mutate into a neuropathologist. This included an undefined period devoted to general pathology, with time spent doing general postmortems and looking at prostatic chips.  I had had a couple of rows with him over these very issues, but one day he called me into his office and he said, "I have decided…" -- these are his exact words -- "I have decided you are unfit ever to become a pathologist, and I'm terminating your contract."

SA:  How long had you been there?

RH:  I had already done a year in anatomical pathology and then I went to anatomy to prepare for neurosurgery.  But then I decided I wanted to go back to pathology to do neuropathology; he agreed to take me, and I went back for another year.  So I'd done two years.  Then he agreed that I would be the neuropathologist, but I could never find out from him how I was to be trained, you see.  He just said he'd decide when.   In America and Britain you have to cut so many brains, and do so many reports, and nerve biopsies and so on.  But there was no plan here in South Africa, and that's what caused all the rows.  The situation was hopeless. 

SA:  How long did you muddle on like that, with no plan?

RH:  I got fired in my second year in the UCT path department.  I already had a PhD in anatomy, and I was older than the others -- a good deal older, and more fractious.  Having worked on my own and done research and teaching, I didn't take easily to becoming a registrar.  It was certainly largely my own fault but what is so extraordinary is that getting fired resulted directly in my moving to Britain, getting a proper training, and qualifying in the specialty – all of which I could never have done here in South Africa.
In Britain one ... feels ... welcome as a neuropathologist I suppose the high moment was when Stuart and I passed the College exams in London.  And feeling part of the system, you understand?  In Britain one just feels that one is welcome as a neuropathologist, whereas here one is not welcome.  One is unwelcome.  When we took the exam, Stuart Rutherfoord said, "We actually have to go to Glasgow..."  The practical was in Glasgow in winter, and he said, "Look here, we are going to drink the best wine before, during and after this exam."  And we did!  When we arrived at the hotel the first thing we did was to go out and buy wine to have with our supper.

Stuart had trained originally at Bristol too, and because of Prof Beyers’ influence we were able to organise for him to move into my post, in neuropathology, at Tygerberg whilst I moved into a consultant post in radiology.  We had a very long and very successful relationship, culminating in the book on surgical neuropathology and imaging.

In fact when Stuart died it was as if half my brain had died too.  We used to argue all day long about things.  He loved neuropath.  He was a general pathologist who fell in love with neuropath.  We used to cut brains together, but I did the radiology part and he did the path part, you see.  Actually I wrote that book, because he couldn't write, but he knew what was needed, and he also knew what sounded right, journalistically. He used to say, “What you have written is incomprehensible – you must change it so’s ordinary people can follow you!”  That was the biggest sweat of my whole life,  watching the orange glow of the sun when it shone down the passage at sunset, day after day.  But even now, I still think the text is pretty well-written!
 
SA:  Were you very close to Rutherfoord?

RH:  Well, yes, I liked him very much of course, but I specially admired his qualities of unaffectedness and uncompromising honesty. How he hated hypocrisy!  Our personal lives were completely separate.  He lived the other end of town, he played squash and he liked drinking gin and tonic at night.  But when we got together at work, it was just a consistently harmonious relationship. We never had a cross word you know, all those years.…

Stuart wasn't interested in any of the other things I like.  He didn’t listen to serious music.  He was very well read in science, very interested in genetics.  Dawkins was his hero, The Selfish Gene.  He used to tease Norma – I'm married to a devout, obsessive Roman Catholic – and he'd say, "Norma, they're going to identify the God gene any minute!"  And you'd see Norma tottering away! [We laugh]

But he always succeeded in saying it in such a way that it never offended her. It was the same with the students – he would tell them if they were talking nonsense, but he never talked down to them. He used to say, “One day these people will be our colleagues”.  He was undoubtedly one of the most popular and successful teachers at Stellenbosch Medical School. 

SA:  Okay, one last question -- what is your identity?  If someone were to ask: "Who are you?"  What would you say?

The real me is somewhere up there in East AfricaRH:  Who am I?  It's something to do with Africa, is what I am.  Pathology has been a wonderful intellectual life, but the real me is somewhere up there in East Africa.

SA:  That's where your heart and your soul is, is it?


RH:  Oh I'm afraid so.

ENDS

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