Research

Gisssane quoted a Chinese proverb.

“If you plan for one year, plant corn, if you plan for 20 years, plant timber, if you plan for 100 years, plant men”

Gissane recognised from the outset the importance of establishing research in the hospital and he was to plant men.

Research studies were a feature of the Accident Hospital from the earliest days

Over 1000 research papers were published by staff at the Accident Hospital

MRC Unit

• Established 1942 under direction of Prof AA Miles (later Sir Ashley) and Dr R E Williams (later Sir Robert Williams)
  • Miles appointed as Director
  • Williams appointed as Pathologist
  • Dr B Cooper appointed as anaesthetist
  • REO Williams left, position taken by John Squire 
  • 1946 Elizabeth Topley joined
• Unit created by converting an unused operating theatre and two wards
• 1950 MRC producing a wealth of papers
• Accident research taken on by Gissane – John Bull supported by the Automobile Association
  • Established the Road Injuries Research Group 
  • Collaborated with the University of Birmingham under the leadership of Dr G M Mackay (Murray Mackay)
• John Squire and Betty Topley introduced controlled trials and the importance of assessing the results accurately. 
• The published the results of a landmark trial of 169 finger pulp infections reporting the outcomes of various antibiotics combined with a minimal rather then the usual radical incision. Systematic penicillin with a minimal surgical approach provided the best results
• John Squire subsequently became Professor of Experimental Pathology in Birmingham
• 1970 there were over 30 staff in full employment working for the MRC

Research at BAH

• More than a thousand research papers and books published from the Birmingham Accident Hospital.  An amazing outcome from a small non-teaching hospital.

Aspects of Research Infrastructure follow:

1. Wound Infection 

• Infection has been a major problem amongst the wounded evacuated from Dunkirk
• In 1942 the Medical Research Council recognised the potential for studying large numbers of fresh injuries treated under standard conditions at the Accident Hospital.  This coincided with Birmingham’s need to discover how best to prevent and treat infection of the numerous injuries by the semi-skilled (workforce) labour force engaged in 24-hour production of armaments
• MRC provided two very able Microbiologists:
  • Ashley Miles
  • Robert Williams
• Miles & Williams set up the Wound Infection Unit
• One of their terms of reference to investigate the new agent penicillin and its use in wounds
• Studies of factory surgeons and at the hospital confirmed the importance of wound infection 
• Usually incurred at the time of wound dressing
• These were common Staphylococcus or more seriously Streptococcus
• Both Staph and Strep markedly delayed the healing process, increased time lost from work
• Improved dressing procedures were devised and tested – a modified no-touch technique was found to greatly reduce the infection rate.  A controlled study showed that for Staphylococcal infection reduced from 100% to 18% and for Streptococcal infection from 14% to less than 1%
• Reorganisation of the dressing station at the hospital was along the lines developed by Miles and Williams 
• Mrs (later Lady) Florey came to help with the research of penicillin using the early calcium penicillin which was applied locally.  A controlled trial of infected hand wounds demonstrated its value.  Penicillin cases returned to work, on average, 4 weeks earlier than controls.

Burns Research Group

• Set up in 1944
• As MRC funding ceased in 1989 the Burns Research Group was reformed as a charity
• 1982 saw 13 publications in peer review journals
• 1990 the Burns Research Group have the following staff:
• Renumerated staff:
  • Dr JC Lawrence – Research Director
  • Mr H Lilley
  • Mrs A Kidson
  • Mrs B Pullen
  • Mrs J Grant
• Associate workers
  • Dr J Bull
  • Dr S Barr
  • Mrs C Cason
  • Dr E Topley
• Postgraduate students
  • Dr J Soothill
  • Mrs A Blight
• The department averaged 13-20 publications annually as well as national and international presentations.
• Gissane opened hospital to all comers – all types of trauma patients
• There were many cases of burns – not popular at other hospitals or on trauma wards
• Gissane asked the MRC to help.  They produced the right man to organise the Burns Research Group in Leonard Colebrook
• Colebrook had worked in wound infection in the first world war and had already recognised the value of skin grafts for burns
• Colebrook had worked in Glasgow where he had developed ideas on the management of burns cases and now welcomed the opportunity to putting these ideas into practice at BAH
• With Robert Bowdillon, also from MRC they designed the plenum ventilated dressing station so that all inpatient dressings undertaken in clean air
• BAH responsible for design, development, testing, and clinical assessment
• Colebrook laboratory situated adjacent to Burns Unit making easy access for surveillance
• Unusual bacteriological infections were investigated, and appropriate measures taken
• Burns Unit records showed the high incidence of clothes catching fire, particularly in children.  These accounted for 3/4 of predicted deaths
• Colebrook with his wife led a national campaign of accident prevention in relation to the use of fireguards and fabrics
• First the clinical problem, then the technical evidence and finally a British Standard 
• It was once said “that Colebrook will never be thanked by those with most reason – the children who will not be listed in hospitals or Coroners reports”

Report by J. C. Lawrence 1989

• 1942/44 to 1989
• A wound infection Group led by the late Professor Ashely Miles and Professor Robert Williams produced definitive reports on how casualty wound infection and dressing stations should be organised – this basic work appears to have been largely ignored when a large part of the outpatient department here was recently re-designed by McDonald’s.
• The Burns Unit and the Burns Research Unit were formed in 1944 by the late Leonard Colebrook – pioneer work recognised world-wide which established the basic principles of burn care that ate as valid today as when first compiled over 40 years ago.
• The Industrial Medicine Unit was formed by the late Professor John Squire in 1946; Colebrook retired in 1948 and the two units merged to form the Industrial Medicine and Burns Research Unit, directed by Professor John Squire. When he moved to Birmingham University in 1952 Dr John Bull became Director and the unit was renamed The Industrial Injuries and Burns Unit.
• From this time the epidemiological studies of burns initiated by Colebrook were expanded and the results used to support the campaign for improved standards and legislation in the field of burn safety – fireguards and flammable nightdresses being particularly important examples.
• Statistical analyses of burns mortality were made, one use of such data is to discover whether modifications of treatment have resulted in genuine improvement.  An excellent example was reported in 1971 which showed that the introduction of topical antibacterial prophylaxis using silver compounds in 1964 was associated with a significant decrease in burns mortality.
• The enormous progress in infection control during the last thirty years is the result of the energetic diligence of Professor Edward Lowbury (who retired in 1979; all this work was, and remains, recognised world-wide.
• Other important studies: Dr Elizabeth Topley (who left in 1962 to work in Gambia) and Dr John Davis (who moved to Glasgow in 1980) concerning blood volume measurements in burns and other trauma together with the related work of Dr Colin Ricketts (who retired in 1981) on blood volume expanders especially dextran.
• Mr Tony Groves and Dr Chris Lawrence made detailed studies on tangential excision – an operative procedure for deep dermal burns introduced by Mr Douglas Jackson (consultant surgeon to the burns unit until he retired in 1978)
• Dr Rod Jones (who moved to the University in 1982 and to Liverpool in 1985) developed the basis of an anti-pseudomonas vaccine. 
• Several important books were published, the most recent being “Treatment of Burns” by Mr Jack Cason (consultant surgeon to the Burns Unit until his death in 1983). There was a wealth of other work and apologies are offered if offence has been inadvertently committed by act of omission (writes J. C. Lawrence, 1989)

Industrial Medicine

• Dr John Squire appointed 1946
• Set up MRC Unit of Industrial Medicine
• Squire and John Bull both had experience of military “operational research” so were ideal to apply the same methods to peacetime problems
• Research thrived post war, after the challenges and frustration of war
• BAH had a thriving and enthusiastic unit
• John Squire on joining said:

“Most important of all, we need the right spirited atmosphere of association with a keen and enquiring clinical staff off a well run hospital.  We are happy to feel this exists already in Birmingham Accident Hospital” 

• John Squire invited staff to present and rare research opportunities
• Jack Duncan – presented 40 cases of divided flexor tendons and 60 of mallet finger followed by anatomical analysis of different treatments

Early Research Projects

• Betty Topley and Stuart Harrison
• Controlled trials 189 finger pulp infections
  • Antibiotics and various surgical treatments
• Systemic antibiotics with minimal surgical intervention produced the best results 
• Nigel Cruikshank with Stuart Harrison showed antibiotics and minimal surgery could produce good results in supportive tenosynovitis 

Progress

• When Colebrook retired the two units were combined with John Squire as Director and Douglas Jackson in clinical charge of burns patients
• John Bull, working with Dr Irwin at the London School of Hygiene was to publish “Mortality Probability Tables” for burns patients
• Bull became famous for his work on “probit analysis”

Blood Loss and Replacement 

• Betty Topley joined Ruscoe Clarke
• Exploring role of hypovolaemia in shock
• Pioneering work to measure external losses and labelling methods for blood volume estimates
• Able to forecast the likely blood loss from injuries of different types and demonstrate clinically the prevention of shock – often referred to as the “illness of trauma” when adequate transfusion was given
• 24 hour pioneering blood bank set up, organised in the hospital with initial NHS staff
  • MRC volunteer staffing
• This was an excellent example of recently application of clinical research findings. This work was ground breaking.

Pathology Research 

• Simon Sevitt – a pathologist with extensive wartime experience 
• Post-mortem, meticulous through information excellent teaching value 
• Appreciated by all attendees
• Nationally recognised expert having documented the sequence of post traumatic thrombus leading to pulmonary embolism
  • As a consequence, prophylactic anticoagulant regime was introduced 
• Sevitt who studied kidney damage following hypovolaemia
  • Sevitt called it “low nephron nephrosis”

Clinical Trials of Antibiotics

• Edward Lowbury joined research team continuing Colebrook’s interests
• Clinical trials became the norm
• The roles of virtually all methods of prevention and treatment of infection were researched
• Lowbury as well as being a distinguished bacteriologist was an accomplished poet

Road Injuries Research Group 

• Road Injuries Research Group set up by Dr John bull and Professor William Gissane at the suggestion of Dr Donald Stewart, the chief medical officer at the Austin Motor Company and a member of the governing body of the AA
• Funding from the Automobile Association (pump priming)
• Much of the data collecting was undertaken by Miss Barbara Roberts who was appointed full time secretary and whose post for the first 10 years was paid for by the AA and subsequently the MRC
• Barbara’s first task in post was to collate all the fatal accidents in and around the city of Birmingham in 1960 This amounted to 149 people who died on the city’s streets and another 34 fatalities brought into Birmingham who came under the city coroners jurisdiction
• In 1961 the Road injuries research group published its first annual report with strong recommendations in relation to safety features on cars and lorries. Their recommendations included the importance of the car’s exterior being smooth, without projections where possible. This would lessen the severity of injuries by direct impact car/pedestrian and car/cyclist collisions. The report also recommended that bumpers should be wide and deep, without overrides, and covered with energy absorbing material to lessen the severity of direct impacts. Number plates should be flush fitting… in addition the report recommended doors should be hollow and filled with energy absorbing plastic for the safer packaging of car occupants against the common head to side collisions at road junctions
•  The group also demonstrated the need for protective devices, helmets, seatbelts
• BAH records of cases were invaluable to produce the clinical evidence to draw political change
• Collaboration work with the Government Road Research Organisation helped drive further changes
• Close links with established with Birmingham University and Professor Murray Mackay’s Unit

Other Works

• John Bull, Sue Baker (Beltar) on trauma scoring
• John Hicks – fracture fixation
• Colin Ricketts – Dextran
• Chris Lawrence – biological requirements of dressings
• Stella Baar – red cell changes
• Peter Bewes – 3rd world trauma
• Ann Blight – skin cultured grafts

Specialist condition of the Accident Hospital that permitted and supported research:

• Large throughput of similar cases providing material for clinical services, clinical trial, and epidemiological studies
• Full time staff found on treatment of the injured giving care through to rehabilitation, with the same team being in charge of care throughout
• Systematic typical care records
• Integrated research and routine laboratories on site 
• Thorough on-site autopsies 
• An active medical society for sharing ideas 
• A management keen to apply research findings to improve the quality of care
• A full-time research unit of wide rather than narrow interests’ role to respond to clinically indicated need to help others and provide a base for affected workers
• As specified by John Squire – “the right spirited atmosphere of association with a keen and engaging clinical staff of a well-run hospital”

Summary

• The special conditions at the Birmingham Accident Hospital permitted and encouraged clinical research.
• A large through-put of similar cases provided material for clinical series, clinical trials, and epidemiological studies.
• Full-time clinical staff, focussed on the care of the injured, giving service from admission with the same team in charge throughout.  Important features included:
  • Systematic typed case records
  • Integrated research and routine laboratories on site
  • Thorough autopsies done on site
  • An active medical society for sharing of ideas
  • Management keen to apply research findings to improve the quality of care
  • A full-time research unit, of wide interests, able to respond to clinically indicated needs, to help others with their projects and provide a base for attached workers.
  • These features were all generated in a century old building with no associated frills.