Birmingham Chest Clinic

Peter Iles (M London 1971)

Birmingham Chest Clinic has played a major part in the treatment of chest diseases in Birmingham for more than 75 years. Its role has evolved with the changing demands on it as patterns of respiratory illness in the City have changed. Although the large majority of patients who are seen have chest problems, other specialities such as immunology and sexually transmitted disease (the Drake Unit) now make use of the facilities too.

The Chest Clinic building lies on the north side of Great Charles Street, next to the University College Birmingham, formerly the College of Catering and Food, and faces the extension to the Birmingham Museum and Art Gallery on the south side of the road. It was originally planned and built to house out patient tuberculosis medical services, the laboratories of the City Analyst and of the City Bacteriologist which before then had been on different sites.

The first tuberculosis clinic in Birmingham opened in 1911, ten years before an Act of Parliament was passed requiring all County Councils and Boroughs to provide treatment for people suffering from the disease. It was at 44 Broad Street in a building rented from the Water Department and shared with the City Analyst. The City Bacteriologist was at Lodge Road Hospital. In the late 1920s, the Water Department needed full use of their buildings again and wanted the TB Clinic and City Analyst to move, and Lodge Road Hospital required the City Bacteriologist to move too.

The City’s Public Health Committee decided that a new building to house these three services was required. The site was acquired in 1929 at a cost of £10.00 per square yard, totalling £8430.00. The building, of a stripped classical style faced in Portland stone over a steel framework was designed by the architects Frank J. Osborne and built by T. Elvins & Sons Limited. It backed on to an extension of the nearby Birmingham and Fazeley Canal which was filled in at the same time as the building works, but as a separate project.

The Georgian architectural style chosen by Osborne was one which he had always admired for its symmetry, simplicity and cleanness of line. The mellow stone and good proportions of the frontage gave a dignity and style which expressed its function as a civic building without ostentation or excessive expenditure at a time of severe economic recession. There is a sculptured panel over the doorway designed by Osborne and Boye, then head of sculpture at the Birmingham school of art, representing a figure of healing with a winged staff in one hand and snake in the other, an allusion to Asclepius the Greek god of healing.

The rear of the building was different with plain concrete rendering and closely spaced metal glazing bars which give it a prison-like air. In its early days the building stood proudly at the top of the hill at Great Charles Street, flanked by smaller buildings and so was a dominant feature but it has been long dwarfed by its redeveloped neighbours. The total cost of the building, fittings, furniture and equipment was £44,880.00, which including £21,670 for the City Analyst and Microbiology Departments. Building work was completed in 1932 and the official opening ceremony was performed by the Lord Mayor on September 29th 1932. He was presented with a silver tobacco box by the Chairman of the Public Health Committee as a souvenir to mark the occasion.

The ‘Anti-tuberculosis Centre’ as it was then called was a source of civic pride as shown in contemporary newspaper articles. It was the first building in Birmingham to have heating pipes imbedded in the walls and ceilings, and Birmingham Water Department had to be persuaded this would function properly. It seems that in its early days the heating did not appear to work well – the building seemed cold. Eventually the reason was traced. The main thermostat was in an office where the secretary, who felt the cold, had secreted an electric fire.

With the advent of the National Health Service in 1948, the building was rented from the City by the Ministry of Health on a 99 year lease for £2000 per annum plus charges for maintenance and insurance. It was subsequently taken over by the Area Health Authority in 1974, and following the multiple NHS re-organisations is now run by Heart of England NHS Foundation Trust, but still rented from the City Council.

From the late 1940s and early 1950s the clinic was staffed by consultant chest physicians who were also based at the 3 tuberculosis sanatoria at Yardley Green, West Heath and Romsley Hill Hospitals. SHMOs formed part of the team in the 1950s. The thoracic surgeons were based at Yardley Green and Little Bromwich Hospital, before it was established as East Birmingham Hospital and orthopaedic surgeons also attended for skeletal TB. Clinical assistants and associate specialists were then added to the staff in the 1960s and 1970s.

Lead consultants with responsibility for the Chest Clinic have been few and often had long tenures. Dr J. Geddes was in charge when the NHS started in 1948 and was responsible for the Birmingham TB services in 1951, followed by Dr V. Springett in 1955 who made major and highly useful organisational changes, then Dr H. Thomas from about 1976 and Dr J. Innes from 1982. Drs Springett and Innes justly earned a national and international reputation for their tuberculosis related research. They also advised and participated in national committees and working parties on the control, investigation and management of tuberculosis.

As the non-tuberculous component of chest medicine became a larger part of inpatient and outpatient work and also an integral part of acute hospital medicine, newer consultant appointments from mid to late 1970s were of general physicians with a special interest in respiratory disease (or infectious disease). The appointments were made to the acute general hospitals such as East Birmingham (later the Heartlands Hospital), Dudley Road (later City Hospital), Selly Oak and Solihull with sessional commitments at the Chest Clinic.

This pattern is now changing again as the acute hospital trusts are tending to regroup their staff onto their hospital site or in newly developing community clinics and the large majority of Chest Clinic consultants are currently based at the Heart of England Foundation Trust.

There was no chemotherapy for tuberculosis before the discovery of Streptomycin in 1944 and para-amino salicylate (PAS) in 1948 and their introduction in the late 1940s.

Unfortunately, mycobacteria have an innate capability to develop drug resistance when treated with only 1 or 2 drugs and this happened readily in these early years. Following its discovery in 1952, the introduction of Isoniazid as a third effective drug was a great help in curing patients and avoiding the development of antibiotic resistance.

The treatment, however, was a long drawn out matter, usually with these 3 drugs including Streptomycin, which had to be given by injection 3 times weekly for a period of 3 months, and then PAS with Isoniazid continuing for a further 15-18 months and sometimes for a total of 2 years. Bed rest, fresh air, better food, increased intake of milk, Vitamin D supplements and a more hygienic and less crowded environment were all the mainstays of inpatient treatment in the sanatoria which were in use from early in the Century until well into the 1960s and were important

adjuncts to the medication.

The need for 18-24 months treatment with some in- and mainly outpatient care and then subsequent prolonged follow up to detect relapses created a great workload for all outpatient services, especially at the Chest Clinic. The tuberculosis health visitors played a crucial role in the continued clinical supervision of the patient care and their

compliance with the prolonged treatment with its relatively unpleasant side effects. The health visitor team had to expand to cope with the load and reached 17 at its largest. Much of the visiting was done on foot or by bicycle.

Surgery, such as thoracoplasty, plombage – the insertion of materials such as Lucite balls (like ping pong balls) outside the parietal pleura to collapse an upper lobe and phrenic crush procedures were employed to restrict the movement of selected regions of the lung. Artificial pneumothoraces or artificial pneumoperitoneum were introduced as outpatient procedures to try to achieve similar results by less invasive means. Sometimes lung resection was required, despite a high operative risk and the anxieties of developing a tuberculous empyema. The success rate in terms of survival

and cure rose with the use of antituberculous drugs and it became clear that they were having the major beneficial effect on outcomes.

Pulmonary tuberculosis was the most common site for the disease, but lymph node, vertebral or other orthopaedic, abdominal and renal disease were common and also required prolonged treatment. Meningeal tuberculosis was often eventually fatal and miliary tuberculosis frequently so at this time.

The development of Rifampicin in the very late 1960s and its progressive use from about 1972 meant that treatment regimes became much more effective and lasted about 9 months rather than 2 years. With current quadruple therapy, 6 months treatment using 4 drugs for 2 months then Rifampicin and Isoniazid for 4 is effective in the majority of patients if they have fully sensitive organisms and take their treatment regularly.

The development and spread of Multi-drug resistant (MDR TB) is an increasing problem, although fortunately relatively rare in Birmingham and extremely drug resistant TB (XDR TB) which is becoming more common in parts of Africa and Eastern Europe, means that the development of new, effective anti-tuberculosis drugs is crucial.

Chest disease in children, including TB was managed at the chest clinic, with arrangements to keep their clinic sessions separate from those for adults. Inpatient care was provided at Yardley Green hospital or the other sanatoria when required.

Former patients remember Dr Dale, who was noted for his small stature, always playing Father Christmas. Other chest problems such as bronchiectasis and asthma and were managed at the Chest clinic too.

Dr Morrison-Smith realised in the 1960s that paediatric asthma was grossly under-recognised and under-treated. Working with Dr C. Gwynn, a GP from Stourbridge, he set up Birmingham’s main children’s asthma clinic and demonstrated that the prevalence was much higher than previously thought. Cromoglycate and then Beclomethasone inhalers, together with safer beta agonist inhalers became available in the later 1960s and early 1970s which allowed much better management of this condition.

He set up the “Give a Child Health” fund which was initially to help children with tuberculosis and subsequently with asthma. At a time when asthma treatment had limited benefits, “Give a Child Health” allowed children to be sent away to high altitude health clinics – initially in Davos in Switzerland and later to Font Romeau in the French Pyrenees. Groups of several Birmingham children would go together for periods of 6-12 months. A minority never got over the initial homesickness, adapted to the French food nor picked up the language, but for the majority who adapted, the results were very good. The house dust mite could not breed at the high, dry altitudes, the air was clean and non-polluted, there was a healthy diet with good food and the day was quite regimented with activities in education so that the treatment was usually taken more regularly than at home! The number of children requiring such a drastic step fell as the available medication and treatment regimes improved and the link with Font Romeau eventually finished in about 1986.

Dr Peter Weller, who was based at Dudley Road and the Childrens’ Hospitals took over the paediatric asthma clinic in 1980 and was later joined by Dr Low, based at Sandwell. The children’s clinic eventually ceased when the requirement that all clinic nurses had to have paediatric training came into force, since it was not possible to comply. A paediatric allergy clinic is now run by Dr S Hackett, with paediatric nurses from Heartlands hospital.

As the workload from tuberculosis fell, although now rising again, other conditions such as asthma, tobacco related diseases (COPD and lung cancer), and the interstitial lung diseases came to make up the greater part of the respiratory work. The recent and current clinicians have developed interests in these conditions over the last decades, partly from necessity but also from the clinical and intellectual challenge.

The arrival of Dr PS Burge in 1979 led to the development of the nationally renowned department of Occupational Lung Disease which has its outpatient base at the chest clinic and investigation/challenge facilities at Heartlands Hospital. His work led to a personal chair but his clinical interests include interstitial lung diseases and acute lung problems.

Prof Lane and Drs Huissoon and Krishna run adult allergy/ immunology clinics.

It would be invidious to try to list the achievements of the consultants who have served the Chest Clinic so well over the years. This is a summary of staff, which I hope is complete, based on decade of joining (Physicians).

1950s

Drs M. Hemming, H. Ross, V. Springett, H. Thomas, J. Morrison-Smith, R. Austin, D. Dale.

1960s

Drs P.K. Mukherjee, D. Forbes, Waddy.

1970s

Drs C. Skinner, D. Stableforth, P.S. Burge, J. Innes.

1980s

Drs P. Weller, P.B. Iles, R.A. Stockley, D. Honeybourne, A. Robertson.

1990s

Drs D.S. Kumararatne, O.A. Khair.

2000s

Drs A. Raghuram, M. Jaakkola, H. Kunst, S. Hackett (paed), Welch (paed), A. Mansoor.

Surgeons

Mr D’Abreu, Stephenson, McHale, Mathews, Miss Watson,

No clinical department can work well without dedicated and high calibre staff. The Chest Clinic has been no exception. It could never have functioned without a team of expert clinicians supported and helped by the tuberculosis visitors and clinic nurses, secretaries and clerks, radiographers, respiratory physiology technicians, reception and portering staff and the TB aftercare service. The Chest Clinic has engendered a remarkable loyalty and affection from its staff with many giving 20-30 years’ service and some working there for more than 40 years.

The current impetus in the NHS is to reduce the amount of work done in acute hospitals, especially outpatient activity, and transfer this to community based units. The Birmingham Chest Clinic, situated as it is in the city centre and some miles from the Heartlands Hospital, would be suitable, in theory at least, to become a community chest centre. The only limits to this come from its internal layout, which was well ahead of its time in 1932, but now has limitations compared with purpose built centres. It does have the advantage of a 99 years lease and a low rent.

The future ultimately depends on Department of Health policy and local expediency and planning initiatives from the PCTs. However, with the forthcoming financial stringency in the NHS, in the writer’s opinion, it will still be serving the Birmingham population for many years to come.

Acknowledgments

I am very grateful to current and past members of staff, especially Mrs M. Cowley, Miss J. Goodwin, Mrs J. Ansell, Dr P. Weller, Mrs M. Connelly for their help. ‘Birmingham Chest Clinic’ by Mrs Dinah Penman was invaluable for details of the planning,design and early history.