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Howard Burchell—Personal Reminiscences

      Bill Roberts has performed a great service by publishing >100 oral history interviews of cardiologists and cardiovascular surgeons. His interview of Howard Burchell recorded a dozen years ago provides rich insight into his life and career. We are pleased to have this opportunity to share our personal perspectives on this remarkable centenarian.
      To put things in time perspective, Howard was born in 1907:
      • Five years after Einthoven published the first electrocardiogram
      • Four years after the Wright brothers' first flight at Kitty Hawk, North Carolina
      • Two years after fellow Canadian William Osler left Johns Hopkins for Oxford
      • One year after the San Francisco earthquake
      I first met Howard at a meeting of the American Osler Society 3 decades ago. A few months later, I wrote to him asking for reprints of his articles on the history of cardiology. My letter began, “Dear Dr. Burchell, We share many interests. I have met you, but you have no real reason to remember me.” Howard's response will not surprise anyone who knew him: “I do indeed remember meeting you . . . . Hope the enclosed [reprints] may be of some interest.” That was the beginning of a friendship that grew closer over the years.
      When we met, Howard had recently retired as chief of cardiology at the University of Minnesota and I was finishing my cardiology training at Johns Hopkins. I was unaware of the vital role he had played in introducing modern cardiology into the Mayo Clinic after World War II. My excuse is that I had not yet begun studying the history of cardiology and my age, or lack of it. When Howard coordinated the first catheterization at Mayo in December 1946, I was 2 months old. When he was a key member of the team that launched Mayo's open-heart surgery program in March 1955, I was in the third grade. When Howard and I spoke or corresponded during the 1980s and 1990s, he never boasted about his contributions. In fact, he never mentioned them. It was only after I joined the Mayo Clinic in 2000 and began researching and writing a history of cardiology at the clinic that I began to appreciate Howard's enormous contributions.
      It is fitting that we met through the American Osler Society because Howard was more like William Osler than almost anyone of his generation. They never met, of course, but they were kindred spirits. As was Osler, Howard was born in a Canadian village. They studied pathology and physiology after receiving their medical degrees. Importantly, they shared an interest in cardiovascular disease and the history of medicine. Although Osler was a first-generation internist, more than 1/3 of his publications in pathology and clinical medicine dealt with the cardiovascular system. They both edited prestigious journals. Howard Burchell edited Circulation. Osler edited the Quarterly Journal of Medicine, which was launched in 1907, the year Howard was born.
      Howard Burchell was a quiet, modest man with intellectual curiosity that knew no bounds—his mind was always working. He stimulated 3 generations of medical students, trainees, and colleagues to read, contemplate, speculate, and draw conclusions. Not absolute conclusions, however. There were always other things to know and other ways to look at things. He filled the margins of drafts of chapters of my history of Mayo cardiology with comments and questions. Three years ago, he wrote in a cover letter, “My scribbles on the manuscript are at places we could have discussions.” That was Howard—as inquisitive as ever and 98 years old.
      So much could be said about this remarkable man. I was fortunate to know Howard and to learn so much from him.
      To go on rounds with Dr. B—for many of us he was always Dr. B and never Howard—was a treat and a lesson far beyond cardiology. He showed us that a cardiologist could be a primary care physician in the broadest and finest holistic sense—not, of course, with the Eastern flavor of herbs and tea and manipulations.
      Often on rounds, Dr. B would show us that the Emperor had no clothes. For example, when the chief resident claimed to have heard a murmur and the students and residents testified they, too, had heard it, Dr. B, who knew the case well, might listen carefully to the heart and then ask for clinical details. As often as not, he might then grasp the patient's hand and, with a wry but never-condescending smile, assure the patient and the multitude that “this heart has no murmur.”
      Dr. B loved physiology, loved what could be measured, but he was likely to be critical when things became metaphysical. I vividly recall a discussion about psychoanalysis and our realization that neither of us had referred a patient to “the couch.” We wondered whether we had missed something with them, or whether it was that we did not sufficiently value psychoanalysis.
      A visit to Dr. B's studio at home revealed a monastic enclave of books and artifacts, including an image of his beloved foxglove on prominent display, a photograph of digitalis from the garden of his long-term Dutch friend Frits Meijler. His fascination with cardiac sounds was revealed by a collection of well-worn stethoscopes hung on a coat rack, some antique and brittle with age. Two were constructed by him, one with a bell and 7 tubes to 7 pairs of earpieces. When in use at the bedside, it gave the appearance of an octopus emanating from the patient's chest. He admitted it did not work all that well for group auscultation, because the sounds were muffled, presumably by a windkessel phenomenon. He always hoped that an electronic wizard might come up with a better instrument for group learning, one without resort to a loudspeaker.
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      Figure 1A 1964 photograph by F. Meijler, when inspecting the construction of the new water defenses along the coast of The Netherlands, together with Dirk Durrer, Rudolf van Dam, and Fritz Meijler.
      The other stethoscope of his making had 2 bells, one for each ear, such that, when carefully placed about the chest, the heart sounds would roll by stereophonically. When asked what one could learn with this contraption, he quoted the title of a Festschrift for his friend, Oslerian Harold N. Segall: “It is good to know.”
      In that same manuscript, he had contributed a paper, “Left Bundle Branch Block—An Elementary Catechism,” in which his dedicatory comment reflected what I consider the essence of Howard Burchell's professional life: “I had aspired to blend aspects of history, investigation, logical analysis, and care of the patient.”
      When I once returned from a meeting of the American Osler Society that Dr. B could not attend, he requested a detailed report. One speaker had bemoaned the fact that today's scientific publications were devoid of poetry: even a stellar journal such as Circulation had hardly a word that spoke to the heart. On hearing this, Dr. B promptly took down a couple of volumes of that journal, published under his editorship, and with some satisfaction pointed out several poetic quotes and humane reflections printed in the spaces between the articles.
      The entourage of Dr. B's hospital rounds often got a treat at the close of the bedside encounter with the final patient. He might gently straighten out the patient's blanket or fluff up the pillow, and then lean in with a last, quiet question: “Anything else I could do for you, Mr. Smith?”
      Howard Burchell was one of a kind. He would immediately have corrected me by saying: “Everyone is one of a kind.” Of course, he was right. But now that he has left us, with the largest possible “footprint” on all his pupils (a whale could not surpass it, and believe me, whales leave footprints!), I stick to my claim. Howard was the “one-est” of one of a kind.
      I say “pupil” because I never met anyone I could see as Howard's peer. He was a teacher in almost a biblical sense. For example, my first and master teacher, Dirk Durrer, once nominated by Howard for a Nobel Prize, never published without consulting him.
      So, here we are, a few colleagues, “the last of the Mohicans,” geriatric orphans in a desolate intellectual desert, thirsting for his wisdom.
      I first met Howard Burchell in the spring of 1958, when he visited Dirk Durrer at University Hospital in Amsterdam, the year after Durrer had become professor of cardiology and clinical physiology. I was, in fact, Durrer's first research fellow, having as a student developed a Langendorff preparation for the isolated rat heart, which was to be installed in Durrer's new laboratory. In the final preparations, I had replaced the fragile glass tubes used for heating the perfusion fluid by durable polyvinyl chloride (PVC) tubing.
      Howard visited on the first day of our experiment using the renovated setup—and the experiment was a disaster! Within minutes of starting the perfusion, the nicely contracting isolated heart ceased beating. We had no clue as to why. It was almost 1 year before we discovered that polyvinyl chloride was highly toxic.
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      Figure 2A 1966 photograph by Ancel Keys of Howard at the Taj Mahal, on tour during the World Congress of Cardiology in New Delhi, India.
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      Figure 3A typical portrait from his St. Paul home in 2000.
      Our visitor left the laboratory as disappointed as I, but said to me in parting: “Never mind Dr. Meijler; failures are the first steps to success.”
      Ever since that fateful day, Dr. Burchell has been a coach to my career, mending my conclusions, stimulating me to dig further, guiding my scientific thinking, teaching me cardiology, and improving my English. What had I done to deserve this support and friendship that lasted half a century? I had supposed he had a weak spot for me because of my suffering in Holland during the war, but later I realized that I was not his only privileged pupil. All his pupils were so privileged. However, our relationship had a particular personal touch because Margaret and Howard knew and loved our children. As a boy, our son, Theo Dirk, tried to teach Margaret to speak Dutch during their many visits.
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      Figure 4A relaxed portrait in retirement by Frits Meijler in 2002, Howard at 95.
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      Figure 5A more formal portrait by Ron Vlietstra with Howard, aged 99, at the Walker Apartments in Minneapolis, Minnesota, in 2006.
      In 50 years of friendship, we exchanged hundreds of letters. Going over them brings tears today. There is no better way to characterize Howard B. Burchell than to let his own words do it. For that I share here a small but salient selection of his remarks:
      I suppose I take my commitments too seriously.
      Probably “honesty is the best policy” most of the time, or all the time, but candidness may not be.
      I liked your provocative style; we disagree, I think, on the conceptual aspects.
      How can you call atrial fibrillation “The grandfather of cardiac arrhythmias?” Does celibacy protect against atrial fibrillation?
      Do you know a medium through which I could talk to Dr. Engelmann or Dr. Wenckebach?
      I suppose one could calculate the Rhine total flow if one had a good estimate of the amount of the indicator injected at Basel, and the time concentration curve anywhere downstream.
      If I posted this letter tomorrow, it would cost me 4¢ more.
      Howard was always pursuing the truth, but truth “like beauty, is in the eye of the beholder.” Who taught me that?
      I loved the man.
      He never said so, but I am pretty sure Howard Burchell decided to draft me into his editorial office at Circulation in the late 1960s because I had referred to the classic “Uncertainty Principle” when introducing a Festschrift honoring Ernst Simonson. In any case, Howard also had recognized early the burgeoning research we were involved in in cardiovascular disease epidemiology, just as he had supported other innovations in the field: cardiac catheterization and coronary surgery and electrophysiology. In his leadership of cardiology at the Mayo Clinic and then at the University of Minnesota, he seemed immediately aware of the place and the potential of a new concept or technique.
      Scholarship, worn lightly and quietly, was Howard Burchell's professional identity. No one spent more time than he in the Mayo Clinic and Diehl medical libraries, and no one carried scholarship more effectively into scientific review and criticism. No editor gave more effort to improving the science and supporting the authors of the material submitted to the journal, such that most were deeply grateful for his handling of their articles, even when he was compelled to reject them for publication. His thoroughgoing, personable letters were always kind, fair, and useful. The formulaic and disinterested letters of rejection often seen in recent times are in stark and painful contrast to Howard's thoughtful responses.
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      Figure 6A 1967 photograph by H. Blackburn, with cardiologist Vittorio Puddu and physiologist Ancel Keys in Minnelea, Pioppi, Italy for the International Society of Cardiology.
      His associate editors on Circulation witnessed firsthand Howard's effectiveness. We watched him complete at least 3 articles a day and saw the energy, skill, and devotion required to review scientific work rigorously and fairly. On each review, he strengthened the investigator and elevated the science with his studied, specific criticism. Also, he imparted to all around him the sense that scientific criticism is among the higher intellectual functions and nobler professional obligations. He was the master editor.
      Howard's correspondence ranged far beyond journal business. He sent handwritten, pithy letters, often enlivened by line drawings and appended documents, to colleagues and friends of all ages around the world. His intelligent critiques were consistent and insistent in carrying an argument a step beyond, provoking expanded thought and debate, genuinely curious, on point, and stimulating.
      “Do you think it might rather have been this way?” He would ask the question rather than declare the affirmation. However, his most acidulous criticism might be “The idea is good but the language a bit overdrawn, don't you think?”
      He sought out good epidemiologic studies for the journal but was most comfortable with clinical trials that offered practical meaning to the practitioner. Trying to learn more epidemiology while always questioning its validity and meaning, he would challenge one to react, as to a particular editorial: “Would it get a blue ribbon in a contest wherein 100 epidemiologists submitted essays on the topic?”
      One might go round and round with Howard in disputation over words. For example, he despised the word “paradigm,” but could not suggest a better alternative. He once mused that my use in a book of a colleague's motto, “If it isn't fun, it isn't epidemiology,” referring to the intellectual delights of a career in the field, would surely be considered by some of his associates as “unserious, even tomfool frivolity” that we were up to.
      It was always thus with Howard. Parry and thrust!—and, I'm sorry Howard, but I have to say I considered our lively repartee to be—fun!
      Howard early recognized a canker in today's cozy involvement of investigators with “the medical-industrial complex.” He once asked: “Is the old adage applicable, ‘he who pays the piper, calls the tune?'” He saw clearly the chilling effect of commerce in medicine: “The data may be impeccably analyzed but the conclusions can be so phrased that, when quoted, the clinical value might be overemphasized.” Always understated, but always to the point.
      Howard's final, long, loving, and protective support of his wife Margaret through her last years of illness is a lesson for all in kindness and devotion through the bad times, in joyful acknowledgement of the balmy times. He showed us in his work—and in his life—that we must not only care, but also care enough.

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