Rolfe Birch

1944 – 22nd May 2023

Obituary by Michael Stewart

There must be a beginning of any good matter, but the continuing to the end, until it be thoroughly finished yields the true glory.

(Drake to Walsingham)

Rolfe Birch was one of the most remarkable surgeons and clinical scientists of his generation who determined the modern principles of surgical treatment of Brachial Plexus and complex peripheral nerve injury, and by whose outstanding leadership in a unique specialty established two world class Peripheral Nerve Injury Units, one Civilian and one Military.

Rolfe Birch (‘RB’) was born in London; his father was a toolmaker at De Havilland, his mother was an elementary school teacher. He was educated at Haberdasher Aske’s Hampstead, Cambridge University and St George’s Hospital. After five years in Accident and General Surgery, he joined the Southwest London Orthopaedic Training Scheme. He developed an interest in nerves in his years at Cambridge studying for the Natural Sciences Tripos; his interest in nerve repair was supported by the Consultants of the Training scheme who recognised his flair and, unusually for the time, sponsored six months of microsurgical training and laboratory research.

In 1979, he was appointed Consultant Orthopaedic Surgeon to St Mary’s Hospital, Paddington and to the Royal National Orthopaedic Hospital, Stanmore. At St Mary’s, he replaced Mr J Crawford Adams and joined Mr George Bonney, a pioneer of surgery on the Brachial Plexus. Mr Michael Laurence, Emeritus Consultant Orthopaedic Surgeon, Guy’s Hospital recalled of his appointment, "Medical progress requires some contradiction of received wisdom, lateral thinking, and devoted curiosity. The study of the peripheral nervous system calls for a degree of obstinate persistence, often in the face of disappointment. Professor Rolfe Birch had those rare characteristics. Serendipity played a part. Few departments could accommodate two such maverick minds as those of Bonney and Birch."

In 1991, the Unit at St Mary’s moved to the Peripheral Nerve Injury Unit at Stanmore where RB concentrated on the study of Brachial Plexus Injuries. He established an outstanding multidisciplinary team in research based on clinical and investigative assessment, with Neurophysiologists and Neurologists and workers in similar disciplines at the National Hospital for Nervous Diseases Queen Square, and the Hammersmith Hospital.

The main thrust of research related to regeneration between the central and peripheral nervous systems, pain, prognosis in obstetric brachial plexus lesion, and the results of surgical interventions. He strongly advocated a new policy of urgent surgical exploration in the case of blunt trauma where clinical evidence pointed to major disruption of the brachial plexus, then to improve the prognosis by nerve repair, nerve transfer or other means. In challenging the policy of the time, which was to wait for spontaneous recovery to occur, his case was greatly strengthened by two established and essential facts: The first was ‘the biological imperative’, the proof that the central pool of neurones died after separation from the axon at a proximal level; and the next related to changes distally, to the increasing technical difficulty in definition of nerve stumps in scar, and the deterioration within those stumps and target organs with time’. He reasoned that in the presence of clinical evidence of root avulsion, the severity of the plexus lesion was extensive, the chance for spontaneous recovery was low, and therefore, the presence of avulsion justified urgent exploration. He also challenged the concept of Complex Regional Pain Syndrome: he established that surgical reinnervation of the limb relieved pain, and which, alone, justified urgent action even in those cases where the nerve lesion injury was severe, and previously considered beyond cure. He stated with characteristic conviction that repair of the closed brachial plexus traction lesion came close behind reattachment of the amputated hand, or
repair of a great artery and a trunk nerve in the combined plexus lesion.

In presenting the Inaugural David Kline Lecture, he said with some introspection, "One of the great joys of this work, for it is also a burden, is to work with these young men and women. Many of them live on the edge, they are risk takers, they take chances, which is perhaps one reason I get on with them so well."

Throughout his career, he believed in two fundamentals: firstly, unfaltering commitment to the patient’s well-being; and duty, specifically to teach and train young surgeons. He also expected the best from you, not by way of imposition, but rather an invitation to strive to do whatever you were doing, as well as you could. He would quote Marcus Aurelius - "It is your duty, the long strait road of duty."

In teaching, his analytical style, and oratory richly laced with reference to the classics, challenged and dazzled his audiences. His anecdotes and imaginative examples of how one might elicit clinical signs in the examination of the peripheral nervous system were legendary: pity the poor trainee, untrained in the art of Fencing, who when examining for long thoracic nerve palsy could not demonstrate to a patient how to ‘lunge’ with an epee. There was something of D’Artagnan in RB, in his generosity, resourcefulness and zest for life.

As the expert in his field, he was asked to teach up, down, and across the country and cut a dash in his deer stalker hat and long tweed coat. Jimmy Hutchison, Professor Emeritus Chair of Orthopaedic Surgery University of Aberdeen recalled, "No matter how busy he was, he made the effort because he knew the importance of sound clinical teaching; he made it all look so straightforward and simple common sense, but therein lay his great skill. The regional units he helped to establish nationwide kept in close contact with him, and he continued to visit them regularly to provide senior opinion and to assist at urgent operations. Always supportive, never critical, and always ready to share the burden in those cases, which do not proceed as intended, he was both mentor and inspiration to a generation of younger surgeons, many of whom went on make substantial contributions in different branches of Surgery and Medicine."

For over 30 years, he served with great distinction as Honorary Consultant Advisor in the management of Brachial Plexus and Peripheral Nerve Injury to the Defence Medical Services. In 2003, he was appointed Consultant in Charge, War Nerve Injuries Clinic, Defence Rehabilitation Unit, Headley Court. To the role, he brought his unique experience, and found his destined place. He quickly established a world class team, which assured accurate and early diagnosis, and continuing treatment of injured servicemen and women many of whom had suffered catastrophic limb injuries.

Colonel John Etherington, former Director Defence Rehabilitation, Headley Court, recalls, "He would predict with accuracy the likely recovery of each nerve, how it would affect their function, and how they would recover. This helped the rehabilitation team immensely. He would focus on the positive, at the beginning of the soldier’s pathway, when brutal honesty could be crushing."

Mr Rod Dunn, Consultant Plastic and Reconstructive Surgeon who undertook major reparative surgery on many of the severely wounded limbs, recalls, ‘Because of the extraordinary advances made by the DMS over the period, patients were surviving dreadful injuries that would have been fatal even in the recent past. His empathy, affinity, and respect for these young service men and women, giving them time and individual attention, conveyed an inestimable sense of being valued and cared for, of hope of recovery, and a meaningful future."

This collaboration at Headley Court represented a high point in British Surgery and Science; and from it flowed the current concepts of management of Nerve Injuries sustained in war. RB forged close links with the primary treating physicians at Selly Oak Hospital in Birmingham; and with graciousness, charm, and diplomacy, he overcame many of the inevitable political difficulties involved with such a task.

His academic scholarship is highlighted in the definitive textbook entitled ‘Surgical Disorders of the Peripheral Nerves,’ which he wrote in 1998, in conjunction with Mr Bonney. In 2011, he completed his magnum opus, 3 years in the writing, a revised and re-edited second edition. Both editions bear the mark of his personality - his meticulous analytical style, clarity of thought, powers of organisation, and humility and generosity in recognition of the work of many colleagues and friends. His research and published work altered the attitude of clinicians worldwide. David Kline, Emeritus Chair and Boyd Professor of Neurosurgery, Louisiana State University Hospital, said, "We know that when Rolfe publishes something, his contributions are based on clear observations and hard work and that they will make us think about, or rethink our approaches to a Nerve problem."

His contributions to the understanding and management of Brachial plexus and peripheral nerve injuries were recognised in this country with Honorary appointments Consultant to the Hospital for Sick Children Great Ormond Street in London, Consultant to the National Hospital for Nervous Diseases Queens Square, London, Consultant to Raigmore Hospital in Inverness, Visiting Professor in Academic Neurology at Imperial College, London, and a Personal Chair in the Department of
Orthopaedic Neurology at the University College Hospital, in London. He was also visiting Professor to Hua Shan Hospital in Shanghai, and to the Mayo Clinic in the United States.

He delivered numerous prestigious and eponymous lectures: The Robert Jones Lecture titled ‘The Transition Zone’ presented to the British Orthopaedic Association in 2000, and the James IV lecture ‘Lesions of the Supraclavicular Brachial Plexus: Power and Pain’ presented to the Royal College of Surgeons of Edinburgh in 2009 were later published privately. Both represent singular works of scientific literature.

He was dismayed by the political developments that he saw as destroying the National Health Service to which he devoted his professional life. He described the introduction of Modernising Medical Careers in 2005 as, ‘meddlesome government legislation, the motive for which was malicious destruction of professional autonomy, initiative, and vigorous involvement in teaching and training. Responsibility was taken away, the relationship between Master and Apprentice broken.’

In leisure time, he climbed, walked, and fell ran at every opportunity. In retirement, he gave his energies to working wood, reading, writing, sea swimming off Harwich, and creating a fragment of English woodland in his garden at Stanmore - ‘bare root trees, so cut low, all flourishing, where before were horrid laurel and evergreen.’

In the last two years, RB bore his illness with stoical courage and dignity. He died on 22nd May 2023. He is survived by his dear partner Margaret Taggart with whom he also worked at St Mary’s in her capacity as Sister in Charge of the Orthopaedic Department, and at Stanmore, where she was Coordinator of the Peripheral Nerve Injury Unit. He was divorced and leaves a son and daughter from that marriage.

Surgeon, Scientist, Leader, Teacher, Author, Mentor. It is given to few in Medicine to be more than one of these. Rolfe Birch was an exception. His range was truly remarkable, and in every one of his vocations, he excelled. He was one of Nature’s gentlemen, always kind and considerate, loyal, and trustworthy.