An Open and Shut Case

The following sections are included:

• Dedication
• About the Author
• Foreword
• Acknowledgements
• Contents

Firstly, let me share my earlier background and how I was steered into a medical career.

I was enlisted as an Aircraftsman second class to be trained as a radar operator. At this time, it was not possible for National Servicemen to be trained as pilots and hold a commission in the Royal Air Force. This was because of a surplus of air crew left over from the war and still serving. My school contemporaries who had been in the Army Cadet Force were commissioned as second lieutenants, most annoying!

I had to wait until September 1949 to start at Barts Medical College, London. To give a full flavour of what it was like to be a medical student in post-war London is worth examining in detail. Each year consisted of about 60–70 students and about 50% were female. Of the men, 20% were ex-service persons who were taking the opportunity of a University placement having already achieved a sufficient educational standard. The remainder were students fresh from school as were most of the women.

I arrived there at the beginning of July 1955 having been picked up by my new chief Mr O’Connell in Finchley Road early one morning. He, living in London and driving to St Albans every day, kindly offered me a lift. It was intimidating having a close discussion with my first chief at 7.30 am for three quarters of an hour! On arrival at the hospital he deposited me at the hospital residence. I was shown to a large very pleasant and comfortable room on the first floor of this old Victorian building. The room overlooked the front lawn which was partially laid out as a tennis court. There was a wash basin in the room and a communal bathroom along the corridor. I changed and put on a clean long white coat, grabbed my stethoscope, pen and notebook and tried to look like a doctor. I descended to the ground floor and was directed to the Neurosurgical Unit in Ward FC which was a considerable distance from the residency along several of the long bare corridors found in the old type of mental hospital. A number of mental patients were drifting along the corridors in various stages of dress and weirdness. Some smiled, some glared and one tried to grab my stethoscope from my pocket — rather different behaviour than that in the corridors at Barts! But something one rapidly became used to.

It was now time to move on if I was to seriously consider a career in surgery.

I returned to the Green Firm as Junior Registrar in October 1958 to Consultants Mr A. W. Badenoch and Mr I. P. Todd. I attended Mr Todd’s operating list on a Tuesday, this time dealing mainly in colonic and rectal surgery. Mr Todd was an excellent and meticulous surgeon and I learnt much in surgical technique from him, but unfortunately the type of procedures he undertook were too complex for me to do at this stage and I could do little more than assist, although I now advanced to doing hernias, appendices, excisions of small cutaneous, lesions and at least two simple mastectomies. At last, I was on my surgical way using a scalpel on my own and the relatively minor procedures gave little cause for personal anxiety. Rounds and outpatient clinics filled up the remaining days. Duty days provided more scope for individual activity with the odd appendix, lacerations and fractures to treat again with plaster of Paris splinting. I had to call Mr Todd in for one bleeding gastric ulcer which required a partial gastrectomy, at this point beyond my capabilities.

My appointment was due to finish shortly and I now urgently needed a Middle Grade Registrar appointment to gain more badly needed experience in general surgery. I applied for several jobs. I was turned down at St Thomas’s and the Middlesex Hospitals but managed to get a post at The Royal Postgraduate Medical School in Hammersmith Hospital in West London (Fig. 7.1). It is interesting to note in retrospect the various London hospitals which turned me down over the years!

Time was again catching up on me and the usual anxiety that it was necessary to look for a further appointment arrived. As I had finally decided upon the neurosurgical pathway, I was preparing applications for a neurosurgical registrarship anywhere I could get in.

Suddenly luck tricked in again. Barts had for several years been in an exchange programme at Senior Registrar level with the University of Denver, USA under the auspices of Professor Ben Eisemann [Fig. 9.1]. I was asked if I would like to be the next exchange candidate and have a year’s contract with no clinical responsibility to pursue a research project. I grabbed the chance and then began to realise the social implications that heading for the USA plus wife and family entailed. Ann agreed and I said ‘yes’. We were not in any way affluent but finances eased a little as I was offered a Fulbright scholarship by the USA government to pay all travel and a few other expenses.

On return to Barts, I was rapidly back to the previous busy life. I continued to write up my thesis in the evenings in our bedroom with our youngest child crying at full blast in a cot next to my little desk! We were now established in this small house in Epsom which we had just managed to afford and I commuted each day to Barts by train. The thesis was finally finished in 1965. I was granted the degree ‘Master of Surgery, London University’ MS in 1966.

I took up my new appointments as a Consultant Urologist in the autumn of 1968 after a complete training programme that had started 18 years previously and having spent 12 years of this period in surgical training. About average for this time, but rather a contrast to the present day training programmes!

The following sections are included:

• Medical Student
• Neurosurgical House Surgeon
• Junior Surgical Houseman General Surgery
• Junior Surgical Registrar
• Middle Grade Registrar
• Senior Registrar
• Finally the Consultant Appointment

Another year at Barts, all the time gaining more experience and more confidence. I tried to get a prototype of the kidney cooler set up in Barts but for various reasons it was impossible. Now that I was fully committed to a Urological career I rapidly had to face up to a number of unexpected problems. Mr Badenoch had pointed out when I started in 1968 that he would be retiring in about 18 months and that I would soon have to take over the organisation of ‘Urology’ at Barts. No definitive department existed at that time as Mr Badenoch had been appointed to the staff as a General Surgeon although he had practised exclusively in Urology.

At about this time due to our Postgraduate publications, I began communicating with other surgeons in Europe who were also developing renal surgical techniques in various ways and established a close liaison with them. It seemed that it would be ideal to convene a small meeting of these Colleagues to discuss our efforts and I wrote to about 25 different persons to see if they would like me to arrange this. In discussion it was suggested that Copenhagen might be a satisfactory venue and we all met there together in 1978. This was one of the most stimulating gatherings I had ever experienced. Over a 48-hour period, we related our personal experiences with this type of conservative renal surgery. Other principal speakers were William Boyce from the USA, Gil Vernet from Spain, Auvert from France, Marberger from Austria, Alken and Eisenberger from Germany, Petterson from Sweden, Rocca Rossetti from Italy, Zing from Switzerland and Gelin from Denmark and a number of other contributors. John Ward, our Barts Senior Registrar of the time, was instrumental in developing many of the arrangements for this and subsequent meetings.

At the beginning of the 1970s, my private practice continued to enlarge and after about five years Mr Badenoch finally retired and I took over full occupancy of the rooms at the London Clinic with my own secretary. Mr Badenoch had also kindly recommended me as his successor on the staff of King Edward VII Hospital for Officers in Beaumont Street and also for the post of Civilian Consultant Urologist to the Royal Air Force which was confirmed. This latter gave me a feeling of considerable satisfaction and a slight step up from my previous incarnation in the Royal Air Force Medical Service, but now with an honorary rank of Air Commodore!

At this stage, I was asked by my nephrological colleagues at St Paul’s, Drs Joekes and Harrison to undertake the vascular surgery needed by patients requiring repetitive haemodialysis. This consisted of developing small arteriovenous fistulous connections in the wrist or forearm of the patient that would provide intravascular access to the circulation for repetitive chronic dialysis in a similar fashion to the plastic shunts that had been used in Hammersmith Hospital some years previously. I was very happy to take this on having had my previous vascular training and it was a rest from urological operating.

All was going quite nicely until the summer of 1976 when one Sunday morning on leaving church with the family I was suddenly seized with abdominal pains. Our GP was called who gave me one dose of analgesics which did little to ease the pain and then gave a second injection which rendered me unconscious and I lost interest in the whole procedure! My wife rushed around and organised for me to be transferred to Barts where I was seen by my old chief Ian Todd, who performed an immediate laparotomy which showed I was suffering from acute pancreatitis a fairly lethal condition. This was caused by a gall stone which had moved into and obstructed my bile duct and caused a reflux of the bile into my pancreas inducing it to rupture. I was closed up and over the course of two weeks I gradually recovered despite a dehiscence or breakdown of my wound which required a return to the theatre to be re-sutured. Interestingly, I diagnosed my own wound breakdown at about 5.00 am but it took until about 11.00 am before I could persuade the nursing staff that there was a problem! Incidentally, the first meal that I was offered after a week on intravenous (IV) fluids was Irish stew! So even in Barts in 1976 the system of nursing was showing evidence of strain as the Salmon nursing structure was beginning to kick in. As an interested patient, I noticed quite a number of incidents which would never have occurred in the 1950s. Very often, the ward was left in charge of staff nurse with no evidence of a Sister or Deputy. There were certainly no complete and regular rounds as in the old days. Frequently, my IV drip would run through and I had to turn it off myself and inform the nursing staff. I was nursed in the open ward with the patient in the next bed obviously becoming intestinally obstructed which took over 48 hours to be recognised and remedied. It was very difficult not to interfere!

As we became more affluent, we decided to move from our house in Esher which was small for the expanding activities of three teenage daughters, particularly as the open fields that we looked out on to were about to undergo development into a new housing estate which was another incentive.

It was in the autumn of 1979 that my colleague in Radiology at St Paul’s, Dr Michael Kellett [Fig. 19.1], had been refining a method of relieving the problem of outflow obstruction in kidneys that had been produced by various diseases. The technique involved making a direct long needle puncture percutaneously into the dilated and obstructed collecting system within the kidney under purely radiological control and then over a guide wire inserting a fine drainage tube. Quite a difficult manoeuvre as the kidney normally lies about 3.0 cm from the skin and surface. The relevant target area in the renal collecting system was sometimes as little as 5–10 mm in size. I had watched this operation developing with considerable interest.

At St Paul’s Hospital, we had a close liaison with the nearby Middlesex Teaching Hospital and one day a discussion took place between Radiologist Mike Kellett and Dr Bill Lees a Radiologist at the Middlesex concerning a patient who had recently presented there. She was an unfit ill old lady in her 80s suffering from an inflamed gall bladder full of pus which was caused by a gall stone obstructing her bile duct. Dr Lees under ultrasound guidance had managed to needle the gall bladder under a local anaesthetic and drain the pus filled system. He was then faced with the problem of dealing with the obstructing stone as the patient was unfit for a general anaesthetic and the stone was too large to be removed from further down the bile duct by retrograde flexible cholecystolithotomy and basketry.

The following section is included:

• Back to Urology!

The Unit was rapidly designed complete with a full radiological facility which Michael Kellett volunteered to establish. In the basement of this clinic, we could treat any type of renal stone by the most appropriate modern methods. There were an X-Ray room, an anaesthetic room, a recovery area, etc. All one could wish for. It was wonderful to at last work in a fully equipped facility unlike the often primitive situation at St Paul’s.

The 10-year period following the establishment of the Academic Unit was probably the most satisfying and professionally pleasant of my whole life.

In 1985, I was approached by the British Council with a view to organising a symposium on the subject of endoscopic surgery across all disciplines in view of our experience in this area at the Institute of Urology. This would also entail the production of a volume of the papers presented for the British Medical Bulletin.

In 1988, I thought it would be an interesting exercise to get a number of these people together to hear what we could learn from an exchange of views. I wrote round to a number of surgeons, radiologists and instrument manufacturers worldwide to ask if they might be interested in such a meeting. I had a good response and we suggested a modest gathering on neutral territory at the Royal Institution in Albermarle Street in London as a convenient and appropriate ground to get together. It did not seem advisable to hold a meeting at a purely surgical or radiological venue. This thought coupled with a reasonable quoted price seemed to suit but unfortunately the lecture theatre on offer could only hold 100 seats so we had to turn away quite a few interested enquiries.

Meanwhile, day to day life had to continue as usual and in 1986 the bad news came that the Kuwait Health Office had decided to combine all its activities at the London Bridge Hospital near Guy’s Hospital on the South side of the river. The lithotripter would have to move and would I carry on with the day to day running of the stone unit? This was geographically very difficult as all my other activities were based North of the River. I said this was an impossible task and I could not move around in such a difficult area once or twice a day and that I would have to give up the running of the Unit. This was a huge blow as we now had such ideal facilities well organised in Welbeck Street.

The Minimally Invasive Therapy Society was up and running well. The Journal was coming out bimonthly, NHS practice was continuing satisfactorily and the Institute of Urology was still doing its best to give Postgraduate Urological education to some grades of Urologists in the UK and occasionally from abroad.

At the time that the St Peter’s Group Hospitals and the Institute of Urology were closed or transferred to the Middlesex Hospital which completely stopped any of my further research developments, I was left frustrated with two significant problems

I have previously mentioned my interest in prostatic maceration which we had attempted many years previously at Barts. At the Shaftesbury Hospital, I mentioned this to Malcolm Coptcoat when the subject of robotics in surgery was being discussed. We talked the problem over and I explained to him that I had always felt that transurethral resection of the prostate was a purely mechanical procedure analogous to an industrial milling machine that removed the unwanted pieces of material from solid pieces of metal or wood. Such mechanical devices I had seen in action during my visits to the various instrument manufacturers. If this was the case then it might be feasible to build a machine that would do a similar job for more accurate prostatic resection [Figs. 29.1 and 29.2].

When I retired from the National Health Service in 1992, I continued with my private practice in Devonshire Place for two to three years and operated at the London Clinic and King Edward VII Hospital. I finally retired and I must here acknowledge with profound gratitude the tremendous help and back up that I received from many loyal secretaries. I have mentioned most in the narrative but I cannot fail to acknowledge the immense debt of gratitude I owe to my last loyal, honest and ever helpful PA Anneka Kelly, now Wright, who over a period of 20 years supported me unendingly and who has been dragged out of retirement to type this manuscript, she being the only person who can decode my appalling writing. My final operation at the London Clinic took place in 1998 [Fig. 30.1].

Another small experimental programme was unwisely started by myself at the point of retirement in 1992 when my Accountant asked me how I was going to spend my time.

I hope by now I have answered the primary questions?.

Over a 40-year period many associated changes occurred in medical practice apart from the developments in operative surgery described above and it is obviously impossible for one observer to itemise and comment on the multiplicity of various events that took place in this period. I can only report on a few of the changes that I personally experienced.

The Health Service, a large, worthy and initially an altruistic organisation, has been politically protected by many governments over a 50-year period.

The following sections are included:

• Appendix 1
• Appendix 2
• Appendix 3