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Career Olle Larsson was born 1927 in Stenbrohult, Småland. He obtained his basic medical training in Lund in the south part of Sweden. He served in The Department of Medicine in Umeå 1959-70, first as Junior Resident, eventually as Senior Lecturer. Later, he served as Senior Lecturer in Linköping (1970-72). He then held corresponding positions in Perth (1973-75), West Australia, in Kuweit, in Port Moresby, Papua New Guinea, in Saudiarabia. However, from 1977 he worked mainly in Sweden, a minor time period in Varberg, the main period in Växjö as consultant and chief of the Department of Intenal Medicine. At 73, he is still a coveted locum tenens, when hospitals and primary health care centers are short of qualified physicians. |
On how I got there
My first contact with the hospital in Umeå was a picture on the first page of the local paper ’Västerbottenskuriren’, which I bought a morning in November 1959 at the Vännäs railway station. I was on my way to begin a position as a junior resident at the Department of Internal Medicine. Those days it was considered proper, if you descended from South Sweden, to ’do’ a few years far up in the North, thus creating the basic steps in your future career. It was dark, cold and windy and small aggressive dots of snow pestered the face. The picture in the paper showed a large bull elk walking in front of the white hospital building. Neither people nor cars were in sight.
I saw the picture as a harsh northern greeting of wellcome without any words. This can turn out to be a few strange and interesting years, I thought. In fact, they grew to more than ten years before I left in 1970.
What now follows are a few very personal reminiscences from my stay at the medical clinic.
On the Department of Internal Medicine.
A Medical High School had been established the same year (1959), and the second cohort of twenty medical students had just started their term in Internal Medicine at the same time as the first professor Nils Törnblom took up his position. Before that Ingmar Bergström had been acting professor.
Below the professor there were three Senior Physicians at the Department: Ingmar Bergström was a versed Doctor with an impressive general knowledge of all aspects of Internal Medicine – its theory, its practice and how to teach it. His speciality was Hematology. He was responsible for the care of patients in two ward units. The two other Senior Physicians were Sverker Johansson with special interests in Neurology and Axel Tornberg, who was responsible for the Nephrology unit. Each of the five medical wards of the Department housed 30 beds who were clerked by one – or on lucky seasons – two junior residents, aided by the students.
Axel Tornberg had arrived to Umeå from the hemodialysis unit at the University Hospital of Lund and had brought with him the ’Alwall Kidney’. Nils Alwall was the pioneer of the treatment with artificial kidneys in Sweden, and Lund was the only place in the country where this treatment facility was available until Axel Tornberg was able to build up a second center in Umeå.
During these early years the artificial kidney could be said to be the flagship of the Department. I was lucky to serve the first years of my stay in Umeå at the Nephrology Unit in company with the other resident Jern Hamberg, a devote vegetarian, who later with great success built up the Alfta Health Resort.
Measured with a modern standard the Medical Staff at the Department was pathetically small: one Professor/Head of the Departmen, 3 Senior Physicians, 6 – 8 Residents. They had all responsibilties in patient care, sessions at the open clinics, they had to take part in the teaching of students and obligations to be On Call for 24 hours one time a week or more. There were no compensations for the last mentioned activity, neither as days off or as remuneration in cash. (My own optimistic trial to reduce the tax by claiming expences for soling of shoes and consumption of chocolate bars during nightly hours was met with a cold hand by the Tax Revenue People).
You had also the obligation to educate yourself if you intended to stay put at the Clinic. Residents came and went. Among those who stayed were Hans Melin, Alf Myrstener, Sigvard Avander and later on Karl-Anders Jakobsson, Erik Hägg, Ivar Ringqvist, Rune Andersson, Börje Ek, Kurt Nyström, Folke Lithner and Jan Holm.
The Senior Physicians moved on, too: Ingmar Bergström went to Östersund, Axel Tornberg returned south to Trelleborg and Sverker Johansson moved over to the new Department of Neurology and later on to Lycksele. He was replaced by Hans Melin, whom I in turn replaced, when he left for Härnösand. Maj Lewander-Lindgren was appointed after Ingmar Bergström, and in the wake after Axel Tornberg, I was in charge of the Nephrology Unit until Bengt Lindqvist came from Lund.
During these years all doctors were expected to have a knowledge of all the basic content of Internal Medicine and to be able to tackle the initial treatment of its diseases, syndroms and vague symptoms. Nils Törnblom had a keen ability to find and open the hidden gaps of falting knowledge. Neither sloppy neurological examinatinations nor missed cardiac murmurs could be spirited away and no thumb was big enough to hide data, hard to explain, in the laboratory reports.
Bone marrow examinations had to be done not only by the biochemistry people but also by the doctor responsible for the patient, the physiology-departments sometimes rather theoretical interpretations of the ECG-curves had to be translated into relevant clinical terms. The isolated communities in North Sweden had for long been greenhouses for inherited rare diseases. A genuine family history was a must.
The growth of subspecialization came slowly. Börje Ek was sent to Stockholm to engulf Gastroenterology and the same happened to Karl-Anders Jakobsson to grasp Cardiology. I myself went to SBL to learn more about immunology.
The demands on the students were also harsh. They had to know by soul the signs, symptoms and findings of the patients they were assigned to without peeking in the Record.
The distances between communities and hospitals in North Sweden could create problems. The GP in Tärna could in the early evening report that he is sending a patient with a cardiac event. The patient arrived in the morning, hopefully alive. Things improved when the Lycksele Hospital was opened.
It should be mentioned that also during the sixties patients had to be placed in supply rooms and passages. It was easier to pass into the gates of hospitals than to leave. The idea of ’clinically done for’ was not invented and the ’needle-eyes’ of Old Peoples Home and of Home for Chronically ill were indeed very narrow.
On The Artificial Kidney.
The artificial kidney which Nils Alwall invented comprised of two huge cylinders of steel. Between these should a hose of cellophane be winded. During the manoevre the hose had an ingrown tendency to break. The hose and the two cylinders was carefully immersed in a large wash-tub with saline. A pump was connected with rubber tubes and specially made ’catheters’ of glass were inserted into one vein and one artery at the wrist of the patient.
’The kidney’ was filled with heparinized blood. The insertion of the catheters of glass were made by the resident. It was important to catch the blood vessels as distant as possible on the wrist, since they had to be cut. Every treatment session ment a few centimeters loss of artery, since it was not possible to create functioning shunts with the material available at that time. While the resident operated upon the patient, Axel Tornberg prepared the dialysis fluid according to the patient’s need. Like a regiment cook preparing the Thursday pea soup he mixed various salts in lukewarm water in an enormous cistern, standing on a ladder. Pre-fabricated fluids were not available.
Each patient could only be offered at most sex or eight treatments. After that no arteries were available. The idea was to prolong the period between the treatment sessions as much as possible and pray that the body’s own kidneys might improve. We tried to delay the arrival of the uremic angel of death by providing the patient with a minimum of fluid and a tasteless feed of pure fat and sugar without any proteins and salt.
Whenever there was the slightest hope that the kidney problem was reversible, the dialysis treatment was tried. Too often this hope was a chimera, but the successes made the work meaningful.
After a few years new materials became available, the ’Kolff Artificial Kidney’ made the procedure easier, semi-permanent shunts could be established, and the method of peritoneal dialysis was introduced and the road made open for the modern management of patient with chronic kidney diseases.
Again I want to remind that in those early years the nephrology unit at Umeå was the second in Sweden where this form of treatment could be offered. Patients came not only from the northern half of the country but also from Norway and Finland.
On the professor.
Between a professor and his subordinates could the distance seem frightening at the middle of the last century. The revolutionary spirit within the students was hardly more than an embryo. A saying, often cited, was ’a professor does not ackomodate to see a student, so step back’. It was a tough task for a professor-to-be to grasp one of the few chairs in Medicine available those days.
Nils Törnblom made his ward rounds in all the five medical units according to a strict routine. For every unit he had a pocket-size card, where every room had its letter and every bed had its number. Thus each patient was given one line on the card. For the resident (or the student) it was imperative to deliver his report on the patient’s condition, planned and performed investigations and possible diagnosis in such a way that the essence could be written on one line. ’Cases’ of special interest got a small arrow in the margin.
The system was also a tool to control the capacity of the subordinates. Did they have a good grasp of the patient, were the planned investigations rational, what conclusions could be done? Drivel, unpreparedness and lack of knowlegde were forced deep down the throat of the delincuent by the gaze of the professor before he went to next bed. The unfortunates started to look for other options and those who passed the test were given other problems to solve on the road leading to research.
The arrows in the marging of the cards also enabled the professor to get a quick overview of all the patients in the Wards and find the problem cases to be solved or the interesting ones, who could serve as illustrations during The Large Cathedral Lectures of the week. In fact, the theme of these lectures was often governed by what type of case history that was available. If the professor requested a case record for closer study the day before a lecture the moment of truth dawned for that particular student (and resident) who was in charged of the patient.
Of course we all sometimes felt a small revolutionary devil inside us and found a secret pleasure in swopping around the patients beds before The Great Professorial Ward Round Of The Week, thus creating chaos on the professor’s card. Sometimes this was also a vain way to try to hide badly clerced patients. ’What are you trying to hide now’, the professor complained looking on his unreadable card, ’stop playing balls with the patients’ but there was often a twinkle of humour in his eyes. He knew his people well.
Although these Great Ward Rounds in some could create palpitations and clammy hands we were many who looked forward to them as moments of intellectual pleasure when thoughts were sharpened, ideas tested and knowledge judged and given.
On the research.
It was an ordinary county Hospital which suddenly became Umeå Medical High School (and later on University Hospital). In the beginning there were neither facilities nor traditions to perform any sophisticated research. It goes without saying that research had to grow from clinical observations.
In Uppsala Nils Törnblom had demonstrated a keen knowledge of experimental research not least in his work on calcium and phosphorus and their interrrelations with the parathyroid glands. He had also been able to isolate the glomeruli of the kidney from patients with diabetes and as a pioneer show that immunoglobulins were trapped in the glomeruli during the developement of the diabetic nephropathy.
Törnblom´s hypothesis was early that immunological processes might be of importance in the pathogenesis of the vascular complications of diabetes in conjunction with hormonal aberrations not only of insulin but also of growth hormone and steroids from the adrenal glands. It had been documented earlier that diabetic patients whose hypophyses were destroyed by disease experienced a remarkable improvement of their retinopathy. Heroic surgical removal of the hypophysis in diabetic patients had been tried as a remedy.
Nils Törnblom tried another way. He tried a chemical ’ablation’ of the adrenal cortex in a small group of diabetic patients. He continued these studies in Umeå.
Nils törnblom had also made the clinical observation that many patients with diabetes developed localized skin changes especially on the shins. He gave Hans Melin the task to study these changes systematically and in 1964 Hans Melin could defend the first dissertation from the Medical Department on ’atrophic circumscribed skin lesions’ not only in diabetics but also in patients who later on were classified as subjects with ’impaired glucose tolerance (1).
Melins work attracted attention internationally, and was followed up by reports on ’PP-lesions’ in diabetes – ’Pretibial Patches’ – and their connection with other diabetic manifestations. The study of various diabetic lesions on the feet and leg (erythema, oedema, bone resorption, nail changes) was later on pursued by Folke Lithner.
The hypothesis that immunological processes might play their part in the pathogenesis of diabetes was handed over to me and later on to Erik Hägg and Pontus Wiklund to tackle. I have in fresh memory how Nils Törnblom during a Ward Round handed me a small slip of paper.
’Here’, he said, ’read this, and we’ll see later on if you are capable of doing something’.
Three titles were written on the paper: one was a Textbook in Bacteriology and Immunology, the other a book from the first symposium on ’Immunopathology’ and the third a book on ’Fluorescent Antibody Technique’, a technique only a few years old.
My leisure time was saved for the weeks to come and when the time was ripe we had the first of many searching talks. The primary question was: why and when are immunoglobulins trapped in the renal glomeruli. For practical and ethical reasons it was out of the question to perform kidney biopsy on a large group of ’healthy’ diabetic patients and normal controls.
However, lesions in the small blood vessels were general in the body according to a series of reports and thus also in the skin. Nils Törnblom sent me to Professor Astrid Fagraeus at the State Health Laboratories to make me familiar with the fluorescent antibody technique and in 1967 I could defend the second dissertation from the Department (2).
In the thickened walls of the small blood vessels in the skin serum proteins were increasingly trapped and more so the longer the diabetic duration, but at the same time there seemed to be an increased leakage of albumin. A clinical manifestation of this is the microalbuminuria of diabetes.
At the same time Pontus Wiklund reported on an increased adhesion of immunoglobulin to diabetic white blood cells, and Erik Hägg could later on defend his studies of the effect of thymectomy on the renal lesions in experimental diabetes.
During his Grand Rounds Nils Törnblom noted, that in too many patients the amount of blood albumin was low. Why? Börje Ek was given the task to study the possible occurrence of malabsorbtion in the catchment area. This too resulted in a thesis (3) and the creation of a Gastro-enterological Unit at the Department.
In his Out-patient Clinic Nils Törnblom met a patient with peripheral oedema, neuropathy and diarrhoea, and his clinical instinct led him to suspect amyloidosis of a type, which at that time only had been reported in Portugal. He pestered the Eye Clinic to perform extra thorough examinations and they could confirm that the patient had lesions characteristic to the disease. Thus started the long row of the studies of the hereditary amyloidosis in Northern Sweden, initially by the thesis of Rune Andersson (4).
Final comments.
I came to Umeå planning a short stay of 2-3 years but remained there for 11 years. These, I feel, are the most important in my professional developement. A Medical High School became a University. The slowly developing Academic environment with its fertile exchange of opinions and its demand to look for connections and eventual new truths and the company of friends, young and developing as I myself, created my way to follow my profession and meet my patients.
Nils Törnblom tought me to ask questions and not to sweep the seemingly unexplainable under a carpet. The tiny question mark can sometimes hide the big answer.
During his work as a professor during these years I saw Nils Törnblom as a critical seeker after truth, an implacable cleaner of loose flesh and vague speculations and a fatherly support when everything seemed to falter. He was a man with a good sense of humour, maybe sometimes hidden, as the saying goes, under a harsh and gruff surface and above all he was a great mentor and a dauntless friend.
My picture is mine so as we all make our pictures in our memories, positive and negative, of those who cross our way
References
Andersson R. Familial amyloidosis with polyneuropathy. A clinical study based on patients living in Northern Sweden. Acta Med Scand 1976, Suppl 590.
Published January 17, 2001