key: cord-0957541-lnbqkimv
authors: Emery, Roger
title: What I’ve learned….
date: 2021-03-19
journal: JSES Int
DOI: 10.1016/j.jseint.2021.01.005
sha: 056a920fc5cad3d1d47e97c3ca873f8c147b3d63
doc_id: 957541
cord_uid: lnbqkimv

nan

What shapes a professional career and service to our patients? The requirement for acquisition of multiple skills and knowledge by study and experience are unquestionably the foundation of one's career and the pursuit of the craft of surgery. The invitation to write this article, at the time of a pandemic, has made me aware of other aspects and observations. The opportunity and privilege of a good education whether it be at college, medical school, or during one's internship and subsequent training programs is undoubtedly formative. For me, this was the journey through medical school and surgical internships at St Thomas's Hospital in London, an ancient and revered institution dating back to before the 13th century, a general surgical program at the Middlesex Hospital in central London and orthopedic training programs both at the Westminster Hospital in London and Addenbrooke's Hospital in Cambridge.

Surgical trainees traditionally acquired their skills by an apprenticeship system and their knowledge by self-education. Textbooks were supplemented by a limited number of rather parochial general orthopedic journals. The number of subscriptions was limited even in the best-endowed institutions. This inevitably leads to "schools of surgery" even within the confines of a city or a region. Diligent trainees with a desire for a more global outlook turned to 'Year Books" to access the most important contributions to our discipline, notably published by Mosby and, more recently, Elsevier. One such UK publication was edited by Alan Graham Apley who had been my teacher as an undergraduate and during the passage through postgraduate examinations. I vividly recall opening his first volume of "Recent Advances in Orthopaedics" published by J.A. Churchill in London and Williams and Wilkins in Baltimore written in 1969 and encountering a chapter on "The reattachment of severed extremities" by J.S. Horn. 1 This remarkable article on microsurgery for traumatic amputations advocated that the success was largely owing to the political system in mainland China and, to my surprise, "largely stemming from the teachings of Mao Ts e Tung." For Joshua Samuel Horn (1914 Horn ( -1975 , the practice of surgery was inextricably linked to politics: Born in London to poor Jewish parents, he won a scholarship to University College Hospital, where he had a brilliant career and collected various undergraduate medals and prizes. 2 After qualification in 1936, he became a lecturer in anatomy at Cambridge, then returned to University College Hospital and took the FRCS when he was only 23 years of age. 3 In 1954, the most fascinating part of his career began. In that year, a committed communist and disciple of Chairman Mao, he returned to China to help build a socialist state spending 15 years practicing as an accident surgeon both in Shanghai and in the countryside. He attended to sufferers from the precommunist regime, recording treating a youth whose penis had been chopped off by a landlord because his father could not afford to pay and a Tibetan serf whose hamstrings had been slashed by a nobleman as punishment for running away. He helped to pioneer the reattachment of severed limbs, and as an adviser to the Ministry of Health, he founded an accident hospital in Peking and planned modern burns units. His activities took him far and wide through People's China, learning at firsthand the medical and social changes which had followed liberation during the Cultural Revolution. He wrote about his experiences in a fascinating book, Away with all pests: an English surgeon on People's China (1971). 4 He intended to write more on the changing Chinese medical and social scene, and, in 1974, revisited Peking for this purpose. He collapsed in his hotel room from a heart attack, and as he was too ill to move, his room was converted into an intensive care unit for the days before his transfer to hospitaldan indication of the esteem in which he was held. He died in Peking aged 61 years. 5 It is often said that learning truly develops in independent practice. The concept of influence by the community in which one was practicing did not occur until my first consultant post in the United Kingdom. I had been a spinal and pediatric fellow at the University of Hong Kong where I had been exposed to the treatment of postpoliomyelitis syndrome and ankylosing spondylitis. Although I attempted to integrate, even trying to learn Cantonese, the language and perception of being an outsider or gweilo made this difficult. My first permanent appointment was to the Central Middlesex Hospital, this hospital had previously been known as the Willesden Workhouse and was established as an infirmary for sick paupers in 1903. It is located in the Borough of Brent, one of the poorest and most diverse parts of London, currently exemplified by having the highest coronavirus disease 2019 mortality rate in the UK (210.9 per 100,000dOffice of National Statistics). The hospital had a very distinct tradition with four controversial giants of postwar UK medicine; Horace Joules , Sir Francis Avery-Jones (1910-1998), Richard Asher (1912-69) , and finally my own medical director Martin McNicol (1931 McNicol ( -2012 . Horace Joules, a chest physician was interested in the adverse effects of air pollution on health and, with Sir Richard Doll, the evidence linking cigarette smoking to lung cancer. He was largely responsible for the Clean Air Bill and subsequent law in 1956 which eradicated "Smog" in London and thousands of avoidable deaths. He wrote in 1953, "The air we breathe is as important as the water we drink. It must be uninfected and unpolluted." 6 Tuberculosis was a major problem in the postwar period, and Joules lobbied extensively to improve clinical services and was instrumental in opening 2 new hospital wards for these patients. This was at a time when many general hospitals refused admission to patients with tuberculosis (TB) owing to the perceived risk to staff. Joules instituted meticulous procedures of care that minimized the risk of infection, such that levels of TB were no higher in staff at the Central Middlesex than in other hospitals that refused to admit patients with TB and lower than the London teaching hospitals.

Joules was also a founding member of the Socialist Medical Association in 1930 and supporter of the Spanish Medical Aid Committee formed in 1936 to assist the Republicans in the struggle against fascism. He played an important role in the postwar peace movement, calling for doctors to work for peace and disarmament.

Sir Francis Avery Jones, a gastroenterologist and pioneer of gastroscopy, changed the management, results, and mortality of gastric bleeding due to peptic ulceration by persuading his surgical colleagues to operate on patients directly from his wards, leaving their postoperative care to him; something that was only just beginning to be managed scientifically with detailed attention to biochemical control.

Richard Asher, an endocrinologist, is best known for the description of Munchausen syndrome in 1951 and the controversy that followed: A serious psychiatric disorder of self-harm was named after a largely fictionalized literary German Baron. 6 "Here is described a common syndrome which most doctors have seen, but about which little has been written. Like the famous Baron von Munchausen, the persons affected have always traveled widely; and their stories, like those attributed to him, are both dramatic and untruthful. Accordingly, the syndrome is respectfully dedicated to the Baron, and named after him."

It was considered that the use of the anglicized spelling "Munchausen" showed poor form; that the name linked the disease with the real-life Munchhausen, who did not have it; and that the name's connection to works of humor and fantasy and to the essentially ridiculous character of the fictional Baron Munchausen, was disrespectful to patients suffering from the disorder.

Possibly of more interest was his plea for us to be led by evidence-based medicine and he emphasized the need "to be increasingly critical of our own and other people's thinking" in an article entitled Straight and Crooked Thinking in Medicine. 7 Other provocative publications included "The dangers of going to bed," "The dog in the night-time," "The Seven Sins of medicine," and "Why are medical journals so dull?" Asher took his own life in 1969.

Finally, Martin Wilkinson McNicol, a consultant respiratory physician, who a fostered multidisciplinary team working and managing the surge in the incidence of tuberculosis in the early 1970s among Asian people, many of whom had been expelled recently from Idi Amin's Uganda. At the epidemic's peak, doctors saw as many as 360 cases a year. He was ahead of his time in managing the outbreak with chemoprophylaxis for newly arrived immigrants and the Bacillus CalmetteeGu erin vaccination at birth for all children born in Brent. Most people with active disease were managed as outpatients with excellent results, and by the 1980s, the incidence of the disease fell, although was still seen regularly in my own orthopaedic clinic. In retirement, he worked on reform of the healthcare systems in Russia for 4 years. 8 The orthopedic department was solely manned for 16 years by Josiah Grant Bonnin , an Australian who had had trained between 1936 and 1938 at Freiburg University and in Vienna under Lorenz B€ ohler. He is best known for his surgical technique of transposition of the tip of the coracoid popularized while being the President of the Orthopedic Section of the Royal Society of Medicine in 1972. His influence was surprising and can be accounted for the polarity and almost tribal nature in the management of recurrent anterior dislocation of the shoulder in the United Kingdom: Blundell Bankart's legacy at the Middlesex Hospital had been virtually eradicated by the 1970s. 9 The promotion by Sir Henry Osmond-Clarke of the Putti-Platt procedure together with the adoption of Rowley Bristow's operation south of the Thames created confusion among trainees wishing to embark on the subspecialization of shoulder surgery and many adopted Bonnin's procedure. 10 By 1993, I had the opportunity to move into a more central location but was still able to retain links with the multiethnic community of North West London. The orthopedic center of activity was at St Charles Hospital: It also had an interesting history and origins as the Marylebone workhouse and by 1918 the St Marylebone Union Infirmary having 744 beds for the "sick poor," many of whom had tuberculosis and other chronic lung conditions. Florence Nightingale established a training school for nurses at the Infirmary, one of the first in a poor law establishment. It features prominently during the 1918 Spanish flu epidemic. In October 1918, as a second wave spread across Britain, its wards were inundated with pneumonia cases. As per his classic description of the infirmary's medical superintendent, Dr Basil Hood, the hospital "literally reeled." Hood's harrowing frontline account is as follows 11 :

"All training, and indeed every sort of trimming, went by the board," Hood recalled in his notebook 30 years later. "The staff fought like Trojans to feed the patients, scramble as best they could through the most elementary nursing and keep the delirious in bed!"

"Each day the difficulties became more pronounced as the patients increased and the nurses decreased, going down like ninepins themselves," Hood wrote. "Sad to relate some of these gallant girls lost their lives in this never-to-be-forgotten scourge and as I write I can see some of them now literally fighting to save their friends then going down and dying themselves."

Hood made the nurses wear lint masks and advised them "not to interpose their faces too near the blast of those coughing." But when it came to tending to a fellow nurse, many refused to wear the masks for fear of distressing their colleague.

Revisiting his notes in retirement, Hood called the epidemic "the worst and most distressing occurrence of my professional life." In all, the hospital had admitted 850 patients with influenza. In an era before vaccines and antibiotics, nearly half had developed pneumonia, many because of secondary bacterial infections, and 197 had died. By the time the pandemic ended in April 1919, 250,000 Britons had perished. Writing shortly after the establishment of the National Health Service in 1948, Hood worried that despite the arrival of vaccines and new drugs such as penicillin, the hospital system would struggle to cope with a virus as destructive as Spanish flu. "Our helplessness now," Hood wrote, "would be nearly as great."

My academic base was St Mary's Hospital, affiliated to Imperial College, London. It also enjoyed the diversity of population characterized by Irish, central European, Afro-Caribbean patients and, more recently, people displaced from the Middle East. Its proximity to Paddington station and the train links to Wales gave a distinctive flavor, not only with respect to prowess at rugby but also its influence on its graduates. It transpired that St Mary's Hospital had been the cradle of shoulder surgery in the United Kingdom. In 1937, three noteworthy events occurred. A moral tale of practising medicine in the Welsh valleys and Central London was written by A J Cronin called The Citadel. Cronin was a local general practitioner working within a stone's throw of Paddington. A film followed in 1939 starring Robert Donat, Rex Harrison, and Ralph Richardson receiving four Oscar nominations including best film and best actor. Many of my outstanding trainees received a copy of The Citadel or Codman's The Shoulder on completion of training; depending on their needs! In the same year, Valentine H. Ellis , the orthopedic surgeon to the hospital, published jointly Recent Advances in Orthopaedic Surgery in which he demonstrated his interest in disorders of the shoulder and admiration for Amory Codman, writing in the preface 12 :

"The chapter on painful shoulders is considerably more detailed than some others, as we feel that this obscure subject is been greatly illuminated by Codman's recent book.

We have not hesitated to draw on the works of others as extensively as we consider necessary we hope it will be found that suitable acknowledgment has been made in the text in all cases."

Mary's was a small friendly hospital and medical school, and it is almost certain Ellis would have been aware of one of his students graduating in the same year, Alexander William Lipmann Kessel, a South African of German and Lithuanian parentage.

Kessel returned to St Mary's after the Second World War to the position of Valentine Ellis' senior registrar at the age of 42 years, having been decorated with the Military Cross and awarded Member of the Order of the British Empire. Kessel's wartime story is well known, but it is interesting to consider the scenario of receiving a trainee who had been surgeon in command of No. 1 Parachute Surgical Team at the battle of Arnhem in 1944, operated on prisoners of war in a hospital under occupation of the SS, assisted the escape of his patients to the Dutch resistance, escaped from prisoner of war camp at Apeldoorn, lived underground behind enemy lines, escaped to freedom by canoeing across the Waal river and probably worst of all, leading the surgical team to Belsen Concentration camp in June 1945.

Valentine Ellis pursued his interest in the shoulder, publishing articles on rotator cuff injuries until shortly before his premature death in 1951, and Lipmann Kessel acknowledged his influence in the preface to Clinical Disorders of the shoulder. 13 "Lippy," as he was widely known, practiced with an "informed but questioning approach" and made a major contribution to our subspecialty. 14 He left the Communist Party in 1956 after the Soviet invasion of Hungary but "held firmly to Marxist principles." 15 The timeline of my career has seen the transition of a low-volume subspecialty to major contributor to reconstructive surgery. The outcomes of our procedures are well documented; whether it be from pooled data, albeit often provided by opinion leaders and enthusiasts, or the many shoulder registries now available. However, the evaluation of our patient's journey and particularly the effect of adverse complications on their lives is sparse. This severely limits our ability to provide risk benefit ratios and, in many situations, essential informed consent to our patients undergoing treatment.

On reflection, I firmly believe that one's ethos of care and clinical decision-making, whether or not it favors a conservative approach, is characterized by the community in which we choose to work and the patients we serve.

Funding: No funding was disclosed by the author. Conflicts of interest: The author, his immediate families, and any research foundations with which he is affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

The reattachment of severed extremities

Plarr's Lives of the Fellows, Royal College of Surgeons

Away with all pests: an English surgeon in people's China 1954 to 1969

Surgeons in Companion to medicine in the Twentieth Century Edited by

Munchausen's syndrome

Straight and Crooked Thinking in Medicine

The Middlesex Hospital Orthopaedic Department

Coracoid Transposition for anterior dislocation of the shoulder -A 20 year follow up

Wellcome Library, The Wellcome Collection GC/21

Recent Advances in Orthopaedic Surgery

Clinical Disorders of The Shoulder

Plarr's Lives of the Fellows, Royal College of Surgeons

Red Star -The remarkable story of Lippy Kessel, The Heritage Portal