Royal College of Surgeons of Edinburgh Quincentenary

SPECIAL REPORT FRIDAY 4 NOVEMBER 2005

The Royal College of Surgeons of Edinburgh Quincentenary

INTRODUCTION

Meeting the challenges to stay relevant John Smith

Health Department and with NHS Education Scotland continues to President, Royal College of improve to our mutual benefit.

Surgeons of Edinburgh Training and assessment are important factors in NHS workforce planning an d service delivery, but it is not the college’s responsibility to manage these latter two items.

However, working in partnership with Ministers and others on these issues makes sound common sense. Our training programmes can then be adapted and made appropriate to what is reOR 500 years, the core business quired for the care of patients in of the Royal College of Sur- the future.

Times are certainly changing and geons of Edinburgh has been the education, training and assess- a new body with statutory authorment of surgeons to ensure the ity for the control of postgraduate highest possible standards of training in the UK – the Postgraduate Medical Education patient care.

Over the years, it has been neces- and Training Board (PMETB) – came sary for the college to be adaptable into authority on 30 September, and flexible in its approach to cope 2005. The college has very clear with advances in medical and sur- ideas about how it can work with gical technology, to meet chang- this Board and, indeed, other bodies responsible for posting patient expectagraduate training. As a tions and to meet the “ I n s t i t ut i o n s college we have been inappropriate service denovative in many differmands made by gov- that last 500 ent areas, for example, ernments. years can simulator and basic surThe reputation of the only do so gical skills training. college has spread with a vision Institutions that last worldwide and its 500 years can only do so badge continues to be of the future. with a vision of the fuseen as a true mark of exThat vision ture. That vision must cellence whether that refers to our Diplomas must change” change with changing times and today’s vision of Membership and Fellowship or to publications, or pol- is clear. We are in no doubt that the icy documents. At the present time, college will continue to play a leadthere are more than 17,000 Mem- ing role in training, assessment bers and Fellows in good standing and lifelong education of surof whom approximately 48 per geons and dental surgeons. This cent work overseas in 92 countries remit may broaden to encompass throughout the world. Within the other professions allied to surgery UK, at the last count, there were and medicine.

We are developing modern nearly 8,000 Members and Fellows working in England and Wales, of new facilities to meet the changes whom more than 50 per cent are af- and challenges. Our new Sympofiliated only with the Royal College sium Hall, the emerging Quincenof Surgeons of Edinburgh. We can tenary Building (for education therefore claim legitimately to be a and training) and a hotel to Scottish, a British and an inter- accommodate examiners, candidates and visitors alike, will pronational organisation.

Because of our base in Edin- vide us with state of the art faciliburgh, our relationships with the ties. We will be uniquely qualified Scottish Executive are important, to stay relevant for the foreseeable and our collaboration with the future.

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II Royal College of Surgeons of Edinburgh Quincentenary

A 500-YEAR C

HILDREN trying their hand at laparoscopy. Surgeons climbing mountains, wine tasting, and implicated in mass murder. Also, what would you expect to find under the floorboards of a well-to-do Edinburgh residence? The handiwork of a 17th century surgeon, in a state of some decay, that’s what. Yes, jolly old staid Royal College of Surgeons of Edinburgh. Nothing much happening there then. Five centuries of dedication to the craft, and not much else.

Nothing could really be further from the truth.

As part of the quincentenary celebrations, ninety-odd schools are taking part in a cross-Scotland competition. It’s not “I’m a Patient, Get Me Out of the Operating Theatre!” It’s even more fun – and educational too. And from the pages of Surgeons’ News – which also features an imaginative Surgeons’ Wives section (illustrated) – come tales of rock climbing, wining and dining.

So visit the Royal College of Surgeons of Edinburgh. Here is a remarkable story

As it marks its fifth century of epochdefining existence, Edinburgh’s Royal College of Surgeons continues to offer not just a fascinating and distinguished past but also an accessible present and a future full of promise to be told, some of it frivolous, much of it fun, all of it fascinating and crucially important in the course of medical history and the advancement of mankind.

The college, as embodied by its Members and Fellows, has been involved in almost every surgical breakthrough since its inception – from chloroform to kidney transplants. Those who have already visited have discovered the leadFRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

been at a higher ebb. It continues to promote and maintain the highest standards of surgical practice, through its keen interest in education, training and assessment.

All over the world it is acknowledged as one of the oldest surgical corporations in the world, held in the highest esteem, and Fellowship is a coveted prize for surgeons worldwide. Lister, Syme, Bell and Woodruff are all names familiar to surgeons. Just a few from the selection in Surgeons’ Lives – a compendium of a mere 200 biographies, drawn from the near 20,000 who have been added to the roll over the centuries.

Though sometimes appearing daunting – and no wonder behind Playfair’s imposing façade – the college has at heart always been welcoming and modest.

I

FOUNDATION BRIGHT FUTURE Surgeons Hall and the Royal College of Surgeons are renowned throughout the world. Left, a 17th century medical book donated to the College Museum Pictures: Royal College of Surgeons, Kenny Smith

ing role the college has played through the last five centuries, and how it is prepared to play an equally vibrant part in the future.

Those who have not stepped in, off Edinburgh’s Nicolson Street, are yet to experience the treasure that lies behind the Ionian pillars of the new building, a mere 173 years old, and still serving its original purpose. In here, the library, the

archive, the rooms and lecture theatres, and the unique collections of the college, are all laid open to the public at large, every day, for the enlightenment of all.

The college is a worldwide organisation, with a conspicuous commonwealth stretching across half of the countries on Earth. The reputation and the integrity of the college have never

THE SCOTSMAN FRIDAY 4 NOVEMBER 2005

t has taken a modicum of each to have remained intact and relevant over five centuries. The feat is almost unique. Enduring the evolutions and revolutions of those times takes something that is more than influential, more than resilient – it would take something that is part of the fabric of the nation, like the land itself.

The college predates the union of parliaments. It predates the union of the crowns. Only three Scottish educational establishments have existed for longer.

As a solid part of our heritage, and a living part of our culture, the Royal College of Surgeons stands like Arthur’s Seat. Immovable forever, yet accessible forever too.

At first visit, like the first climb of Edinburgh’s mountainous landmark, there may be trepidation. More so, if that first visit is to follow in the footsteps of Joseph Lister or James Syme, Norman Dott or Michael Woodruff, and sit the Fellowship exams. Less so, if that visit is to the astonishing museums and galleries within, which offer a fascinating insight to the world that we all share, and the mortal coil we all inhabit. What lies within the college is not something apart from us; it is very much within us all.

Its welcomes young and old, man and woman, for the business of medicine, or for the pleasure of learning.

In this quincentenary year, the college is celebrating with an exciting programme of conferences, exhibitions and events for Fellows, Members and the general public. Whatever the reason for the visit, that is reason enough to be invited in. In this and in many respects, it is like Scotland herself.

And of that desiccated find beneath the floors of an Edinburgh residence? A priceless manuscript from the 17th century, found by chance and donated by the householder.

The Royal College of Surgeons of Edinburgh is not only a venerable institution; it is one of the foundation stones upon which the nation of Scotland has been built.

Royal College of Surgeons of Edinburgh Quincentenary

CONTENTS PAGE IV

History 1505-1847 Surgery was noisy before the discovery of chloroform PAGE VI

History 1848-2005 The college and its craft have changed at an astonishing rate PAGE VIII

Women Surgeons The RCSEd has had more than its fair share of female trailblazers PAGE X

Art The development of surgery owes much to the painters of pain PAGE XI

Publications The story of the college and its characters is a real page-turner PAGE XII

Property The buildings of the RCSEd have been getting facelifts PAGE XIV

A week in the life It’s easier to be under the knife than to be the one holding it PAGE XVI

Training Making sure the next generation has the tools for the job PAGE XVIII

Future of the RCSEd After 500 years, the college continues to adapt to thrive PAGE XX

Future of Surgery Operating manual goes out the window in brave new world PAGE XXII

Exhibitions The RCSEd’s skeletons in the cupboard go on show Deputy Editor: Stuart Farquhar, 0131-620 8879 Production: Jackie Cameron, Simon Childs, Andrew Mackenzie, Michelle Owenson Design: Andrew Rainey Words: Simon Walton

Royal College of Surgeons of Edinburgh Quincentenary III

HISTORY 1505-1847

BC: BEFORE COLLEGE The Edwin Smith papyrus – the oldest known surgical text Picture: The Metropolitan Museum of Art

Ancient medical practices uncovered by sands of time AN ANCIENT Egyptian mandible, dated to approximately 2750 BC, was found with two perforations just below the root of the first molar, indicating the draining of an abscessed tooth.

Uncomfortable even today, the suffering of the patients of those times must have been acute to even consider such treatment. Yet this kind of surgical practice has been part of human life for thousands of years.

The Edwin Smith papyrus, currently on show at the Metropolitan Museum of Art in New York, is the oldest known surgical text, dating from around 1600 BC (although it contains information dating back to 3000 BC).

It is an ancient Egyptian textbook on surgery, describing the examination, diagnosis, treatment, and prognosis of numerous ailments. Not quite Gray’s Anatomy, but evidence that even in the darkest of times, surgeons strove to shed light on their craft.

Wrapped up in superstition and supposition for millennia, early figures, such as

the Indian surgeon Susrutha (about 400 BC), taught and practised based on experience and deduction, without the help of a clinical or anatomical understanding of the human body. Modern western medical tradition probably owes much less to these figures than to the Greek philosopher physicians like Galen and the much better-known Hippocrates, popularly called the father of medicine, who, rejecting superstitions, held the belief that illness had a physical and rational explanation.

Evidence of the earliest known surgical procedure, trepanation, or the drilling of a hole into the skull, was found in human remains near Kiev, dated to between 7300–6220 BC. Although surgeons are now seen as specialised physicians, the profession of surgeon differs from that of physician historically. The oft-quoted Hippocratic Oath actually warns physicians against the practice of surgery, which was best left to the barbers.

THE SEARCH James Young Simpson’s 1847 discovery of chloroform eased patient anguish, but the foregoing years were long, and very loud

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OR A patient, the sweet bliss of a modern surgical operation, no matter how frightful the trepidation, is as nothing to the horrors faced by the poor souls who went under the knife five centuries ago. How the air must have rung with their anguish.

Into this brutal world, in 1505, the barbers and surgeons of Edinburgh were formally incorporated as a craft guild. A document, called the Seal of Cause, laid out a charter of privileges and obligations handed down by the Town Council of Edinburgh on 1 July. The most important parts of the Seal are still relevant today: “... that no manner of person occupy or practise any points of our said craft of surgery... unless he be worthy and expert

in all points belonging to the said craft, diligently and expertly examined and admitted by the Maisters of the said craft and that he know Anatomy and the nature and complexion of every member of the human body... for every man ocht to know the nature and substance of everything that he works or else he is negligent.”

The seal was ratified on 13 October, 1506 by a Royal Charter granted

by King James IV of Scotland, a man of many diverse accomplishments, who was particularly fascinated by medical science.

One of the most important landmarks in the early history of the Incorporation is the exemption granted to them by Mary Queen of Scots, which formally relieved members from the obligation to bear

arms in defence of the realm but obliged them to treat sick and wounded soldiers in the Queen’s armies – in the first formal statement anywhere of the non-combatant role of the army doctor.

Gilbert Primrose, who was elected Deacon of the Incorporation on three separate occasions, and is listed as number one on the Roll of Members and Fellows, was appointed Surgeon to King James VI of Scotland. When the King succeeded to the English throne, in 1603, Primrose went south with him and became Chief Surgeon to the Royal Household in London.

In 1647, the Incorporation acquired a permanent meeting place for the first time by renting three tenement rooms, and by the end of the 17th century, an increasing number of Edinburgh surgeons had acquired a formal academic training in medicine, and certain physicians had begun also to practise surgery.

The most notable of these was Archibald Pitcairne, who became Professor of Medicine in the University of Leiden where amongst his stu-

Timeline: 1 July: City of Edinburgh grants charter of incorporation upon its surgeons and barbers

Incorporation of Edinburgh Surgeons and Barbers granted royal charter by James IV

1505

1506

Mary, Queen of Scots grants exemption to armed service for Incorporation

1513 Battle of Flodden kills James IV and much of Scottish nobility

IV Royal College of Surgeons of Edinburgh Quincentenary

1567

Two apothecaries (medicine makers) enter the Incorporation

First formal examination structure for College

1647

1576

1603

1645

First bible printed in Scotland

Union of the Crowns of Scotland and England

Last outbreak of plague in Scotland

William and Mary Patent confirms Incorporation's privileges

Old Surgeons' Hall opens in Edinburgh

1695

1697

Darien Scheme, Scotland's colonial adventure begins

Separation of Edinburgh surgeons and barbers

1715

1722

Jacobite Rising

FRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

KING JAMES IV 14 88–1513 RENAISSANCE MAN HE REIGNED over a cultural renaissance, but the military misadventure of James IV into the battlefield of Flodden cost him his life in the greatest disaster to befall a Scottish army. However, the intellectually-gifted monarch had seen fit in 1506, seven years earlier, to ratify the city council’s one-year old Seal of Cause, granting Incorporation to the barbers and surgeons of Edinburgh.

The king would have been an eminent candidate for membership of the new Incorporation. Among his many talents, he practised the surgical techniques of the time, such as blood-letting, bonesetting and dentistry. Had he not been of regal lineage, he would have been a riveting intellectual. As it was, James IV spoke seven languages, including the native tongues of his allies, his enemies, and many of his subjects.

His nobility was his undoing. He stood by his alliance with France against England, and, on the fateful field, stood firm uallowing his troops be outmanoeuvred before hostilities began.

FOR COMFORT dents were many Scots. He returned to Edinburgh in 1693 and joined the Incorporation in 1701. A Royal Patent reaffirmed their privileges in 1695, and hastened the building of what is now known as “Old Surgeons’ Hall”, completed in 1697.

The Faculty of Medicine in the University of Edinburgh was established in 1726 and no one did more to achieve this than John Monro, who was Deacon of the Incorporation of Surgeons from 1712 to 1713.

Surgery, however, suffered from the effects of a lingering academic prejudice against what was seen as a manual craft rather than an intellectual discipline. The Incorporation agitated strongly for the establishment of chairs in surgery at Edinburgh University, though this long process took more than 100 years to fulfil.

By the beginning of the 19th century, the Old Surgeons’ Hall had become inadequate for the college which needed more space for the large collection of anatomical and surgical specimens which had been presented to it by Dr John Barclay. A site for this was acquired by the

Hanoverian dominated Incorporation makes the Duke of Cumberland an honorary Freeman

What’s in a name?

SURGEONS are distinguished from physicians by being referred to as “Mister”, not “Doctor”, which stems from the time when surgeons were both barber and surgeon, and had no formal qualification, unlike the university-educated physicians.

The colleges improved the status of the surgeon, and the conferring of Fellowship remains a great honour.

Today, surgeons with Membership or Fellowship of one of the Royal Colleges may call themselves Mister, or a female equivalent. Physicians are always addressed as Doctor.

purchase of the Riding School in Nicolson Street.

William Henry Playfair, the foremost Scottish architect of that era, was commissioned to design a building containing a meeting hall, Museum, Lecture Room and Library.

The original plans are preserved in the college archives and the handsome furniture, designed by him for the college building, is still in use to this day.

College diploma examination introduced – initially at behest of War Office

Royal charter granted by George III. The Incorporation becomes RCSEd

1776

1778

1746

1767

Major Jacobite Uprising, ends in Battle of Culloden.

Field surgeons are praised for their impartiality in treating the wounded

James Craig submits plans for Edinburgh’s American New Town independence declared

THE SCOTSMAN FRIDAY 4 NOVEMBER 2005

While the college was ever developing, and the anatomical understanding of the human body had moved on greatly in 300 years, there were still obstacles which kept surgery languishing in its traumatic roots. Even then, the patients’ screams were the most familiar sound of the operating room.

Medicinal herbs like henbane, alongside alcohol and mesmerism remained the only means of calming the terrified subject.

Yet, while contemporary surgeons were honing their rapid skills on the battlefields of Europe, there was, born in the midst of the Napoleonic Wars, a man who was to make modern surgery possible.

Shortly afterwards, while Europe was still recovering from the wounds of 12 years at war, were born the men who made modern surgery survivable. Between them, James Young Simpson’s discovery of the properties of chloroform, and Joseph Lister’s understanding of the nature of infection were to drive not just the college, but the entire craft of surgery into a new age.

Charles Bell paintings prove valuable aid to surgery

SOLID INSTITUTE The Old Surgeons’ Hall was completed in 1697

JOHN RATTRAY 1707-71 TO THE FORE A FELLOW of the college, Rattray produced the first rules of golf in 1744.

Despite being a prominent figure in the Hanoverian-dominated Incorporation, Rattray’s Jacobite sympathies led him to the Stuart cause, and by 1745, he had risen to be personal physician to the Prince himself.

Upon defeat, he surrendered himself, with the possibility of family persecution aiding his decision. But for the intersession of Duncan Forbes, then Lord President of the Court of Session, and a golfing partner of Rattray, he would have suffered the gallows.

A second death sentence was commuted at the instigation of Lord Milton, the Lord Justice Clerk, and a patient of Rattray in less divided times.

“Herbs like henbane – and alcohol – were the only means of calming the terrified subject”

Advances in military surgical organisation saves many lives

Present day Surgeons’ Hall, designed by William Playfair, opens

1809

1815

1817

Napoleonic Wars: British evacuation from Corunna

Napoleon defeated at Trafalgar

The Trial of William Scotsman is Burke for 16 launched Edinburgh murders

1828

1832

James Simpson discovers the anaesthetic properties of chloroform

1843

1847

The Disruption – the Free Church of Scotland forms

Royal College of Surgeons of Edinburgh Quincentenary V

HISTORY 1848-2005

PASSING THE TEST OF TIME Thanks to the occasional evolutionary leap, the RCSEd has developed in tandem with the science of medicine and the craft of surgery

D

ESPITE a new Charter, granted

by King George III in 1778, it took until a further Charter had been granted, by Queen Victoria in 1851, for the college to complete its severance from the town council and change its title to “The Royal College of Surgeons of Edinburgh”.

By then, a massive change had taken place, and the craft was moving into today’s enlightenment. Before the advent of anaesthesia, surgery was a traumatically painful procedure and surgeons were encouraged to be as swift as possible to minimise patient suffering.

This also meant that operations were largely restricted to amputations and external growth removals. In addition, the need for strict hygiene during procedures was little understood, which often resulted in life-threatening post-operative infections in patients.

Beginning in the 1840s, surgery began to change dramatically with the discovery of effective and practical anaesthetic chemicals such as ether and chloroform.

Intricate operations in the internal regions of the body became possible, and the discovery of muscle relaxants such as curare also facilitated

the development of abdominal surgery.

However, the move to longer operations increased the risk of dangerous complications since the prolonged exposure of surgical wounds to the open air heightened the chance of infections.

It was only in the late 19th century, following the insights into microbiology from scientists like Louis Pasteur, that the need for strict cleanliness and sterile settings emerged. None was more important in this area than Joseph Lister, possibly the most famous Fellow of all time. The principles that he introduced shaped the modern surgical method more than anything else.

The contributions of Lister and James Young Simpson, who discovered chloroform anaesthesia, were immense, taking the field of surgery far beyond the terrifying realm it inhabited, and paving the way for the new science.

Still, it took the adoption of new techniques by the supremely popular monarch Queen Victoria to win over a sceptical profession and a doubting public. If it was all right for Victoria to give birth, to Prince Leopold, under anaesthesia and in hygienic conditions, then it was fine for the masses.

In July 1905, the college cel-

ebrated the fourth centenary of its incorporation and the most important occasion was the conferment of the Honorary Fellowship upon 36 of the world’s most distinguished surgeons. These included, of course, the now ennobled Lord Lister, by then acknowledged as no less than “The Father of Modern Surgery”. He remains the only Fellow of the college ever to be awarded its Honorary title as well.

The 20th century delivered a wealth of characters and brilliant surgeons for the college. JCB Grant is a name familiar to all anatomy students, for his simple diagrams of the body’s inner workings; Gertrude Herzfeld was the first female Fellow to take her seat, and surgeon at the Sick Children’s Hospital in Edinburgh; or Norman Dott, the neurosurgeon and engineering designer who became the first Fellow to be granted the freedom of Edinburgh since Lister and Simpson, more than a century previously.

But there is no doubt that the biggest character of the century, and, in the eyes of billions across the world, the most famous of all Fellows was the Canadian son of a Presbyterian minister, Scottish only through ancestry. Norman Bethune, cut down by septicaemia at the early age of 49, had packed into a half century the sort of life that Indiana Jones would have found hard to keep up with.

Quite apart from his prodigious skill, Bethune was a humanist of great conviction. Allied with his Communist persuasions, he served with the Republicans in the Spanish Civil War, and was personally summoned to meet Mao Tse-tung, after he had pledged his allegiance to

the cause of repelling the Japanese invasion. For his service there he is commemorated with a statue in the Cemetery of Martyrs, a museum, and a hospital in his name. His exploits are also part of the national curriculum.

Matched by the emergence of so

Timeline: New Royal Charter breaks College link with Edinburgh City Council

College maintains basic training status but change is on the horizon

Lister publishes antisepsis paper

School of Medicine of the Royal Colleges founded

1867

1895

184 8

1851

1858

First railway to England opens

Great Exhibition

The Medical Act passed and GMC formed

VI Royal College of Surgeons of Edinburgh Quincentenary

College’s 400th Death of anniversary Joseph, Lord Lister

1901

1905

Marconi makes first transatlantic radio transmission

Royal Titanic sinks commission on Poor Law results in old age pension

1912

With the help of the college, Polish School of Medicine instituted in exile at Edinburgh University

First female to pass Fellowship exam – Alice Hunter

1914 Outbreak of First World War

1920

1928

1939

1941

Alexander Outbreak of Fleming Second discovers World War penicillin

1945 War ends in allied victory

FRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

“If it was all right for Victoria to give birth under anaesthesia, it was fine for the masses”

HANDY MAN An Xray of the hand of Joseph Lister, the most famous college Fellow of all time.

many great names, the pace of development in all the medical sciences has increased rapidly in the last century and, since the end of World War Two, the relentless refining of techniques and new discoveries has quickened to breakneck speed. Improved communications have

spread the reputation and influence of the college.

The Annual Clinical Meeting of Fellows has developed into an important scientific occasion, in which distinguished surgeons from all over the world participate. The first annual col-

lege meeting outwith Edinburgh was held in 1960. That has now been augmented with an international meeting programme, after a 1976 invitation from senior Egyptian Fellows resulted in the first full-scale college meeting to be held outwith the British Isles, in Cairo and Alexandria.

And in keeping with the precedent of royal renewal, as Dr Helen Dingwall noted in her book A Famous and Flourishing Society: The History of the Royal College of Surgeons of Edinburgh: “Her Majesty Queen Elizabeth II was graciously pleased in 1979 to grant the college its sixth Royal Charter.”

During the first two centuries of its existence, the surgeons admitted to membership those apprentices who had been trained for six years by master surgeons and who had given satisfactory service. A statutory fee had to be paid and the aspiring surgeon was required to produce his “ticket” as a Burgess of the City of Edinburgh, but the most important condition of entry was the passing of an examination.

For a period of 33 years in the late 19th century, the requirement for admission by examination was dropped in favour of election only. It was not until 1884 that the Fellowship Examination was reintroduced. From its inception – and this proved to be the making of the modern college – the examination flourished and the recruitment of candidates increased steadily, particularly from overseas. Soon many Fellows were to be found in senior surgical posts in Australia, Canada, New Zealand, South Africa, India, and in all other parts of what was then the British Empire.

During the 20th century, the examinations have been adapted to changes in science. The college has always been prompt to recognise the need for such change. Now, with the most recent introduction of central government standardisation of the examination regime, it has again adapted with aplomb.

Though incredibly changed over the five centuries of its existence, there are fundamental aspects of the college that would still be recognisable to Gilbert Primrose and James IV. It seems that to the skills of precision and speed, must also be added the skill of endurance.

Who is to say that, in 2505, the college will not be celebrating its millennium?

Primary Fellowship examination introduced to satisfy requirements of the new NHS

School of Medicine of the Royal Colleges closes

Prince Phillip made patron.

Dental Council founded

UK’s first kidney transplant performed in Edinburgh

First hip replacement takes place in the UK

Lister Institute of Training opens.

Christian Barnard conducts the first heart transplant, in South Africa

194 8

1949

1954

1960

1962

1965

NHS formed, placing greater responsibly for post graduate training on the college THE SCOTSMAN FRIDAY 4 NOVEMBER 2005

1961 Yuri Gagarin is the first man in space

JOSEPH, LORD LISTER 1827–1912 PEERLESS FELLOW NO-ONE would begrudge Lord Joseph Lister his baronetcy, or his fine house on Edinburgh’s Charlotte Square. He more than earned his good fortune with the body of work he bequeathed to mankind. His revelations about the nature of infection made much of modern surgery and medical procedure possible, and changed the way we all live.

He achieved more honours than any other British surgeon, and was the first doctor to be made a Baron. Despite being the pre-eminent medical mind of his time, he was described by contemporaries as a gentle and kindly man, quite modest and unassuming, with concern for the welfare of others and a disarming smile.

In a famous picture of him, and the six other residents at Edinburgh’s Royal Infirmary, the image is autographed by all seven men. Each has a flamboyant script, with the name proudly emblazoned upon the plate. Only one is modest and restricted to a single word: “Lister”.

SIR MICHAEL WOODRUFF 1911-2001 TRUE SURVIVOR IT WAS perhaps his experience as a survivor of a Japanese prisoner of war camp in the Second World War that moulded the thinking of this amiable Australian. In an atmosphere of despair, he found the will to survive and, in so doing, inspired so many others.

In a post-war career in surgery, he took that resolve into the uncharted waters of transplant surgery, saving the life, in 1960, of Lewis Young, a man from Leith, by transplanting a donated kidney from his twin brother Martin.

Forty-five years later, the number of transplant patients given hope, where once there was only despair, many times outnumber those who were in despair in the jungles of South East Asia. Woodruff was a guide to them all.

First female First laser eye surgery member of the College Council – Caroline Doig

Museum of the History of Surgery opens

Robot used in heart surgery in Belgium

RCSEd is 500 years old

1969

1984

1987

1992

1999

2005

Neil Armstrong walks on moon

Indian Prime Minister, Indira Gandhi, is assassinated

Piper Alpha and Lockerbie disasters

1997

Dolly Scottish parliament the re-established sheep cloned

Royal College of Surgeons of Edinburgh Quincentenary VII

WOMEN SURGEONS

FIRST LADIES Women may be underrepresented in the surgical profession, but role models exist for a new generation of female recruits

SCREENING ROOM College Council Member Christine Evans came to the fore on the television series Under the Knife, in which she performed operations and discussed the ups and downs of her profession.

Picture: Trevor Owens/ Channel 4

T

HE television series Under the Knife brought College Council Member Christine Evans to public acclaim. Five million viewers heard her explain that the biggest problem about women surgeons is that they tend to show their feelings and that she cried with her patients. She is not alone. More than a few of her male counterparts are in touch with their feelings too, and more than a few secretly harbour a wish that they could express themselves as openly. It’s just as manly to be emotional in the 21st century, and 21st century surgery is a career striving for equality.

Women and men, in equal measure, have the opportunity to aspire to be the hand that sees. The challenge facing the profession is to overturn the outdated historical image of a male-dominated society, where women have been an exception, and replace it with a future perception of an association where gender is not an issue, and men and women stand side by side in the advancement of the craft.

It would be easy to pay token homage to the small number of women who have taken the decision to follow the surgical career path. There are outstanding examples whose contributions readily lend themselves to that approach. These include Gertrude Herzfeld, the first woman to take her seat as a fellow of the Royal College of Surgeons of Edinburgh; the College Council’s first female Member Caroline Doig; and the household name of Elsie Inglis, for whom the cause of women in society was made most apparent by her endeavours in medicine.

However, as surgeons of either gender will point out to students and patients alike, the easy route is not always the best route. It would be simple to celebrate the fact that more women than ever are operating in British surgery, but it would be wrong to overlook the fact that while more than half of all students entering medical schools in the UK are

female, barely 6 per cent of consultant surgeons are women – among the smallest representations of all the medical disciplines. There is a challenge and an opportunity there, for women to play a vastly increasing role in the future of surgery, and the future therefore of the RCSEd. Efforts are being made to engage with the female representation in the profession. Women in Surgical Training, WIST, is a national organisation working to promote surgery as a career for women and to enable women who have chosen a career in surgery to realise their professional goals. Set up over a decade ago, by the college’s English counterpart and the Ministry of Health in response to significant under-representation of women in the profession, WIST maintains a community of members and provides them with a range of information, advice and support.

Tangibly, that means encouraging women in medical training, and at advanced career stages, to come together to share experiences and solutions to the perennial problem of juggling a career in surgery with a semblence of life balance. Among the most innovative measures, there are organised workshops at school level, aimed at inviting students to consider the career options open to them in surgery.

Today, the 17,000 membership of the RCSEd reflects the national representa-

VIII Royal College of Surgeons of Edinburgh Quincentenary

FEMINISTS UNDER FIRE Elsie Inglis was one of the first female pioneers in surgery, here pictured in the French field hospital she ran during the First World War Picture: Edinburgh City Libraries

“Surgery is as much a skill as a science.

There is no short cut to becoming a surgeon”

tion of women in surgery. While less than 700 are female, all women Fellows and Members have been admitted within the last century of the college’s history, and almost all of them are Fellows and Members today. Even so, while female representation continues to grow, the overall number of women surgeons remains low. It is a problem of considerable concern, but it is not a problem unaddressed.

Previously known simply as flexible or part-time training, the NHS Less than full-time (LTFT) training initiative has a wider remit than simply attracting women to surgical disciplines. Nevertheless, the scheme does offer a practical avenue for many students, and is now an integral part of Postgraduate Medical Training in Scotland.

The problem remains though that surgery is as much a practical skill as a medical science. There is no short cut to becoming a practising surgeon. While the training period remains relatively lengthy, even with the current reforms, it might not be practical to extend that over a protracted, part-time, career.

However, the RCSEd supports the stated NHS Scotland ambition to create family friendly policies and to ensure all staff are able to contribute their full potential to the service.

Until the 20th century, women played a very small part in the college’s history.

Given the longevity of the college, and

the prevailing social attitudes to women throughout more than four centuries of that history, this is perhaps unsurprising. It was as late as 1920 that the first female Fellow, Alice Headwards, was admitted. However, in social context, at the time of her admission women had not yet had the opportunity to exercise their right to vote in a general election.

Caroline Doig became the first female Member of the College Council in 1984.

WIST was established in 1991, the same year that Mother Teresa was awarded an Honorary Fellowship in recognition of her untiring work in the hospitals of Calcutta. Since then, WIST has grown to a membership of nearly 2,000 women and, through a network of regional representatives, aims to assist in doubling the number of women consultants over the next ten years.

Attracting the best people, regardless of gender, is one of the major issues facing the profession today. If surgery continues to be a male-dominated profession, the surgeons of the future will have to come from a declining number of male medical school graduates. Making surgery a more attractive career option for women involves difficult issues, including where the line is drawn between patient care and acceptable disruption to family life, and how the profession can be structured to cater for the needs of work-life balance, when the nature of patient care has the scales tipped so far in one direction.

These are difficult choices but, fundamentally, surgery is all about difficult choices. Such is the importance of the issue, if the present imbalance of the sexes can be successfully addressed, then it may be more than Christine Evans who has a tear of joy in her eye.

FRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

CAROLINE DOIG b. 1938 A JOLLY GOOD FELLOW GIVEN a toy stethoscope as a present at the age of five, playing doctor for Caroline Doig was an early ambition.

A Fellow of the college since 1967, the retired Consultant Paediatric Surgeon became the first woman to be elected to the ruling body of the college, in 1984.

Originally from Forfar, Miss Doig started surgical training

in Dundee. Her paediatric surgical training, starting in Glasgow, was finished at London’s Great Ormond Street Hospital for Sick Children, and she went on to become a lecturer in paediatric surgery at Manchester University in 1975.

Among the most respected surgeons in the country, she served as President of the Medical Women’s Federation, the largest body of women doctors in the UK, and became the first woman Chairman of a major General Medical Council committee.

GERTRUDE HERZFELD 1890–1981 LIFE OF FIRSTS BORN in London of Austrian descent, Gertrude Herzfeld pioneered the cause of women in medicine. She became president of the Women’s Medical Federation, but is

THE SCOTSMAN FRIDAY 4 NOVEMBER 2005

best remembered as the first woman to become an honorary Fellow at RCSEd. Graduating from Edinburgh in 1914, she served in the Royal Army Medical Corps throughout the First World War. On returning, she went into paediatric surgery where, as the first woman surgeon in

Scotland, she practised at the Royal Hospital of Sick Children, alongside neurosurgery pioneer Norman Dott. That her colleague’s work should earn him the distinction of Freeman of Edinburgh troubled her not – she always lived up to her reputation “large in heart and mind”.

Royal College of Surgeons of Edinburgh Quincentenary IX

ART

Surgeons captured in paint THOUGH portraiture within the walls of Surgeons’ Hall displays the work of almost every prominent Scottish artist through the ages, it is the Belgian Sir John Baptiste Medina, the last Scottish Knight before the Act of Union, who is probably the best represented.

Under the patronage of the Earl of Leven, the painter was persuaded to move his studio from London to Edinburgh where he gained a commission to paint thirty Fellows of the College.

Though he died in 1710, just three years after receiving his knighthood, the series was completed by his apprentice, William Aikman.

John Kay’s 18th century caricatures offer a more irreverent insight into the times. In his career as an engraver, Kay produced more than 900 representations of Edinburgh and Scottish society figures – many of them from the ranks of the college. Within the library reading rooms hangs an interesting composite painting (pictured on pages 4 and 5), based on an engraving

by Paul Sandby of the original Surgeons’ Hall, built in 1697.

The characters in the foreground, however, all surgeons, have been copied from John Kay’s portraits.

The Dalkeith-born barber plied his art while running a highly successful business catering for the tonsorial requirements of Edinburgh society – rather like a Charlie Miller of his day.

Artistic touch JOINING in the celebrations of the quincentenary, the Scottish National Portrait Gallery, on Queen Street in Edinburgh, has a retrospective of Scottish men and women who have played a pioneering role in the history of medicine. The Healing Touch runs until Sunday, 27 November.

BODY OF ARTWORK The RCSEd boasts a remarkable collection of visual history within its elegant gallery

WAR PAINT Charles Bell’s depiction of a tetanus sufferer, above, is his most famous, although he also painted other pictures of victims of the Battle of Waterloo, left Picture: Sean Bell

T

HERE is more than the art of medicine within the walls of the Royal College of Surgeons of Edinburgh. The National Portrait Gallery does not have a monopoly on the cameos of Scotland.

The gallery at the college has a comprehensive collection of faces from the five centuries of the institution, including some of the most famous men and women of medicine and of Scotland.

Of medical significance, and artistic acclaim, the works of Sir Charles Bell are among the most prized possessions in the collections of the college. In context, his work was invaluable. At a time when printed matter was less widespread than today, and photo imaging had yet to be invented, he produced a body of work that provided an incomparable educational resource. Many examples remain on permanent display today, ranging from his portraits and landscapes to a series of oil paintings made in the weeks after the evacuation from Corunna, when British forces suffered at the hands of Napoleon.

Bell had a talented contemporary in the early 19th century. In this age before photographic reproduction, sketches and engravings were the primary pictorial tool available to the surgeon, eager to learn from the experience of his peers.

An aptitude for both made John Lizars therefore a valuable ally in the advancement of surgery. Together with his brother, William Home Lizars, who was established as Edinburgh’s leading engraver, they published his standard

X Royal College of Surgeons of Edinburgh Quincentenary

reference book, A System of Anatomical Plates, in the early 1820s. Brother William was also to produce the first ten subjects of John James Audubon’s celebrated ornithological compendium, Birds of America.

Lizars’ particular gift, however, was his teaching ability. Add that to his authoritative drawings, and it is easy to see why he was soon attracting attendances of 150 and more to his lectures at

“In this age, sketches were the pictorial tool for to the surgeon”

the extramural school of anatomy. Examples of his work are still on display at the college, but perhaps his greatest talent was foresight. In 1859, in his Practical Observations on the Uses and Abuses of Tobacco, he made the link between tobacco smoking and cancer of the mouth and tongue, and he concluded: “Injury to the constitution of the young may not appear immediately, but cannot fail to become a national calamity.”

SIR CHARLES BELL (1774–1842) SURGEON AND ARTIST RENOWNED for his artistic works, which are on a par with the best of his day, Bell was foremost a surgeon and a teacher.

His seminal, ground-breaking research into the nervous system brought him international recognition and a knighthood. Several conditions described by him carry his name, most notably Bell’s Palsy, a condition of facial paralysis.

Bell’s art works did much to educate and enlighten his fellow surgeons. Of these, the most famous is that of the hideously convulsed body of a soldier, suffering the horrific effects of tetanus infection to a wound.

The picture is in no way gory, however. The agonisingly arched body and the grim expression of the man depicts his undoubted suffering well enough.

Though of great significance, Bell did not confine himself artistically to medical works.

His whimsical study of a cruel jailer taunting prisoners confined at the Heart of Midlothian in Edinburgh is an often-reproduced image of the brutality of the 1800s, while his landscapes often depict scenes throughout Scotland, England and Italy.

FRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

PUBLICATIONS

HISTORY WRITTEN IN BLOOD New publications give a fascinating analysis of the characters and events that make up the college’s history

W

ITH Edinburgh achieving the UNESCO City of Literature accolade, it’s only appropriate that the Royal College of Surgeons of Edinburgh should celebrate its own achievement in attaining quincentenary status with a raft of publications, each offering a fascinating new view of the college, past, present and future.

It is a central device in the coat of arms of the college, but The Hand that Sees is also the title of an anthology of poems, written especially for the quincentenary. Twenty-one Scottish poets, inspired by visits to the college, have contributed work to the booklet, conveniently sized to provide a literary equivalent of minimal access therapy, when slipped without trauma into a back or breast pocket. The anthology is edited by the capital’s poet laureate Stewart Conn. Crime writer Ian Rankin, whose own famous character Rebus has fictionally stalked the corridors of Surgeons’ Hall, said that these verses make “a vivid and moving collection from a gathering of fine poets who really do see ‘the skull beneath the skin’ … and a lot more besides.”

More historical, yet equally fascinating, is the much weightier Surgeons’ Lives. Iain Macintyre and Iain MacLaren, both long standing and senior figures within the college, have undertaken the mammoth task of compiling from the entire Membership an anthology of just 200 of the most fascinating figures down the centuries. Their combined effort is a singularly riveting read.

Capital choices ANYONE who says surgeons should get out more should read Surgeons’ Edinburgh.

Planned for updates twice yearly, this 16page magazine offers a different take on the capital’s restaurants, hotels and bars.

The surgeons’ eclectic choice of attractions is available free of charge at quincentenary conferences and events.

Surgeons’ Lives weaves together the personal and professional achievements of Fellows of the college, from its inception to the present day. It is impossible to pick out a name – Lister, Liston, Woodruff, Dott – without becoming engrossed in the wealth of context, and the realisation that every Fellow of the college portrayed here has a story to tell that’s relevant in some way to many other aspects of Scottish society.

Interesting stories are nothing new to the college. Many have been written within the walls of Surgeons’ Hall or have been inspired there. Literary connections are commonplace, and the company kept by Joseph Bell illustrates this. Robert Louis Stevenson numbered him among his close friends, and even wrote to Arthur Conan Doyle, a pupil of Bell, to voice his opinion that Doyle had indeed based his most famous character

on the surgeon. The letter is still in the archive at the college and it will be on show at next year’s special exhibition.

For the publications department of the college, which is involved in a wide range of academic and more accessible texts, Surgeons’ Lives is one of the more high profile contributions to the quincentenary celebrations, while The Surgeon and the quarterly topical lifestyle magazine Surgeons’ News are the staple

TAKEN AS READ Many stories have been written or inspired within the walls of Surgeons’ Hall. And literary connections abound Picture: Nathaniel Benefield

JOSEPH BELL 1837–1911 LIFE IMITATES ART HAS our impression of Sherlock Holmes been modified by our impression of Joe Bell, or is it the other way around?

Clearly there’s no separating the man from the myth, since Bell’s university pupil Arthur Conan Doyle freely admitted that the fourth generation of the Bell surgical dynasty had been the blueprint for fiction’s most famous detective.

THE SCOTSMAN FRIDAY 4 NOVEMBER 2005

Bell’s supremely shrewd powers of observation, diagnostic acumen and manner of demonstration brought him particular fame. In addition to his outstanding ability as a teacher, which brought him great professional popularity, he developed an interest in two areas that further added to his almost spiritual powers of observation – namely calligraphy, and the lesser known science of dialectology, or the placing of a person’s origins by their accent and vocabulary.

As a medical man at heart, Bell was at first nonplussed by the attention drawn by his close association with the fictional persona of Sherlock Holmes.

However, in later life, he revelled in it, and even took to wearing an Inverness cape and deer-stalker hat, reputedly in recognition of his fictional doppelganger. That’s as far as emulating the resident of 221b Baker Street went. To the possible relief of pupils, Fellows and friends, he never did take up the violin.

of the department. The online publication of both magazines makes access even easier, and readable by anyone.

By far the weightiest read, as befits a volume covering five centuries, is the superbly comprehensive A Famous and Flourishing Society, The History of the Royal College of Surgeons of Edinburgh from 1505-2005, by Dr Helen Dingwall, senior lecturer in history at Stirling University. The book charts the evolution of the college through five centuries, and assesses the medical, political, social and technological influences which shaped it, as well as celebrating its achievements. To undertake the task is to be applauded. For coming to terms with the college history, to put that in context, and to deliver an engrossing read that is also a scholarly work of reference, an academic script and a comfortable read deserves a standing ovation.

The college shop within Surgeons’ Hall, and open 9am to 5pm, Monday to Friday, stocks all the RCSEd publications, including these souvenir editions, and a range of related gifts and mementoes, or visit the website at www.rcsed.ac.uk

Royal College of Surgeons of Edinburgh Quincentenary XI

PROPERTY

HISTORIC GEM SET TO SHINE Plans to adapt and open up the buildings around the Surgeon’s Hall will create a lasting national treasure

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ITH a portfolio of property in central Edinburgh, the Royal College of Surgeons has a fantastic asset for the future. Centred on Surgeons’ Hall, this historic site is earmarked for improvement and protection.

The central building of Old Surgeons’ Hall, begun late in the 17th century and finished early in the 18th, still exists within the nearby university grounds.

Not since its replacement has such a flurry of construction activity been seen around the college. Here, in an echo of the past, plans begun in one century will be completed in the next. With the exception of the famous pillars, new building works surround the present hall.

The development will provide new facilities and upgrade existing buildings, creating training, education and assessment facilities alongside the William Playfair-designed Surgeons’ Hall. The redeveloped campus will provide ample facilities to meet the growing needs of college and public alike.

Reconstructive surgery Perhaps the most exciting of the projects is the plan to open this magnificent building and its historical collections as an educational centre accessible to the public. The Surgeons’ Hall Trust has been set up to oversee the preservation and conservation of the heritage collections and historic buildings. It’s a mammoth task. The medical collections alone are the largest of their kind in Scotland. While encouraging participation and access, the trust has to bear in mind the need to protect and conserve the buildings and the heritage values of

COLLECTORS’ PIECE The Pathology Museum at Surgeons Hall is more accessible to the public after its facelift

XII Royal College of Surgeons of Edinburgh Quincentenary

the site for the college and the people of Scotland to enjoy in the future.

With increased access to its unique treasures, the RCSEd will be even better placed to celebrate its achievements while showcasing modern healthcare.

Central to the plans for the building is a desire to involve and enthuse young people about all issues relating to health and the medical professions. As a corporate venue, Surgeons’ Hall is predicted to grow in popularity. The revenue from its use will help to underwrite its maintenance, and preserve its use for future generations.

FRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

“The redeveloped campus will provide ample facilities to meet the needs of college and public alike”

Quincentenary Hall THE new skills training and assessment centre is currently under construction on a site immediately north of Surgeons’ Hall. The building will provide a unique facility on three floors to satisfy a wide

Ten Hill Place Hotel WITH stunning views over Arthur’s Seat, the hotel will be an attraction in its own right, replacing the existing collection of adapted postgraduate residences.

Work has started on converting the old

Symposium Hall WORK has been completed on a farreaching modernisation of the College’s Symposium Hall. The new facility provides a 157-seat auditorium with modern audio-visual and audience particiTHE SCOTSMAN FRIDAY 4 NOVEMBER 2005

variety of requirements associated with education and examination.

There is a wide choice of meeting offices and classrooms planned, together with a main hall covering one entire floor. Completion is anticipated in the Summer of 2006.

tenement apartments and an adjacent vacant site into a modern, high-quality modest-cost hotel. The accommodation will attract college visitors, those using the symposium hall and other visitors to Edinburgh. This project is scheduled for completion in September 2006.

pation equipment. The new facility offers tiered seating in an impressive new theatre.

Completion of this project has given a new lease of life to the building and has already seen service during the quincentenary celebrations.

Royal College of Surgeons of Edinburgh Quincentenary XIII

A WEEK IN THE LIFE

Edinburgh’s pass mark to India FROM Kathmandu to the canals of Birmingham. The reputation of the Royal College of Surgeons of Edinburgh persuaded Rajamiyer Venkateswaran that the journey was worth undertaking.

As a medical student in Madras, Venkat never imagined that his career would take him on a journey from the Nepalese capital to the canals of the West Midlands.

“I suppose that once I’d made up my mind to become a surgeon, I was already moving in the direction of Edinburgh. The whole training regime in India and Nepal is based on the British model, and that is very much influenced by the college.”

The deal may well have been sealed by the RCSEd presence in Kathmandu, making it possible for postgraduates to sit the first part of the basic Fellowship exam without travelling overseas. In 1997, already six years into his medical training, Venkat passed that first hurdle.

“It’s a worldwide organisation,” says Venkat. “But for full Fellowship, you have to come to the United Kingdom.”

In July of that year, he came to Edinburgh for the prospect of entering the college for the first time as an examinee. “Of course it’s an impressive place, even frightening, as you step through the doors, knowing that the greatest surgeons on earth have done the same.

“But then I thought, if they have led this way, I can follow.”

Venkat continues: “I was really impressed with the way the whole thing was conducted. There were four written papers, each of about three hours in duration, and an oral examination before a panel of Fellows of the College. Even then, this is only the beginning. You have to pass these papers before you can complete the examination process.”

Notification comes by sealed envelope. A small one contains a note of failure, but Venkat found a large envelope delivered to his Edinburgh B&B, requiring him to report to the college at seven in the morning for a trip to Dundee’s Ninewells Hospital in, as he puts it, “The College limo!”

“The exam began with a 45 minute interview, taking the his-

CANAL DREAMS Heart surgeon Rajamiyer Venkateswaran moved from Madras to the Midlands via RCSEd

tory from your patient. Then you do three or four short cases, giving a demonstration of your understanding.

“I believe the more short cases you are asked to do, the better you are performing. I felt a little sense of achievement as I was asked to do each of four examinations.”

By the same afternoon, the results are announced to the candidates. “The feeling of passing I can’t explain. I left home in July and by October I had a surgical qualification.”

Now, after a number of positions in England, Venkat is settled with his family south of Manchester, while working in Birmingham, where he is a practising and published surgeon, and studying towards a part three examination and full qualification as a consultant. Venkat plays an active part in the college, where he is a member of the Trainees Speciality Advisory Board.

“I am a heart surgeon and I wanted to come to Britain. Edinburgh was simply the best place to take my exam. The college is world famous and its intention to expand means I’ll be going back there to sit a part three exam in 2007.

“Of course, the training regime has changed now, and it should be a shorter journey for new candidates, but I still say that experience counts for a great deal and, in Edinburgh, I benefited from great experience.”

XIV Royal College of Surgeons of Edinburgh Quincentenary

FACING UP TO A week in the life of a Scottish surgeon is a hectic whirl of activity. Simon Walton shadows an RCSEd Fellow out west

T

HE operating theatre of a West of Scotland hospital is not where you want to be on a Saturday night, not if your specialities include facial injuries. That’s not a view shared by Royal College of Surgeons Fellow Roger Currie, on duty from a rota of twelve specialists in the region.

“It’s just what you do, it’s not something to make a song and dance about,” says Currie, who is very sanguine about the busiest night of the week.

Though based at Crosshouse Hospital in Kilmarnock, Currie’s weekend on-call duties can take him anywhere from Ayrshire to Argyll. And it’s from somewhere outlying that his biggest job of the day arrives. A cyclist has fallen from his bike, impaling his cheek on a broken fence post.

By midday the errant cyclist is being prepared for four hours of procedures, including an angiogram – a vascular x-

ray to determine if all the debris of the fence post has been located and removed, and nothing has entered the bloodstream. He won’t be going home just yet, and will have a while to think about the consequences of drinking and riding his bike, all on the same morning.

Scrub up though, because before the day ends, or rather reverts to “on call” at around eight in the evening, there are three patients scheduled for procedures to relieve facial infections, all brought about by neglected oral hygiene.

As a specialist in oral and maxillofacial surgery, Currie’s day began with another couple of broken jaws. “We’ve got a fairly high incidence of interpersonal violence,” remarks Currie. “You’re not going to treat the root cause at this stage and you have to look at these things with an open mind and believe what the patient tells you.”

FRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

SLICE OF LIFE Roger Currie, also pictured above, looks on as David Koppel, left, a consultant in craniofacial surgery, operates on a patient Picture: Colin Templeton

SURGERY Next, it’s to patients in various stages of recovery. “We all work as a team. So for my colleague who operates on Fridays, I take a look at his patients who are in day one or day two of recovery, and I make sure I see those who are immediately post op, and possibly in intensive care, because they require a significant amount of work.”

Monday’s ward round at Crosshouse involves an early start, to allow for a three-hour clinic beginning at half past nine. Over the course of the morning he gives each patient the same respect and courteous attention. Skill in dealing with patients who are awake is every bit as important as the skills displayed during the weekend’s operations.

In this day of clinics, the afternoon is

spent working closely with a colleague dermatologist and six patients being assessed with skin cancers. A sensitive task also to complete the day – pre-op ward rounds. “These are the people I’m seeing next so, even though this is an on-call night, I want to finish up with a look in.”

I

t’s a fairly light operating schedule for Tuesday, because the morning has been given over to a teaching session.

“I’m working with some of the nursing staff on the principles of facial fractures, we’ll be putting plates on plastic mandibles and the like,” says Currie, as he quite gleefully looks forward to an opportunity to share skills and experience.

Though he, or any of his surgical

“As an oral surgery specialist, Currie’s day began with another couple of broken jaws”

colleagues, probably wouldn’t need the Seal of Cause to compel them, Currie takes teaching opportunities very seriously, delivering the same attention to detail as he does in the afternoon operating session. A post-op ward round on Tuesday evening can be open-ended, but with luck, he’s on his way by 6.15.

It’s the first Wednesday of the month, so ward round and on-call duties are mixed with the Day Surgery Unit – procedures under local anaesthetic that, to the chagrin of Currie are known as “lumps and bumps”. The team’s skill and practice make the extraordinary appear routine. “My majors from last night are still in,” notes the busy surgeon. “But they’re in good hands and everything is fine.”

With confidence in his colleagues and support staff, Currie heads for Ayr and a weekly clinic with around thirty patients to see today. Though time is limited in this clinic, he works methodically through a carefully prepared list of appointments. It’s most apparent here that the surgeon relies on efficient support throughout the working day.

After checking in at Crosshouse, it is home but on call, and a 50 per cent chance of call-out. “I can give advice over the phone, but sometimes it’s simply best to go there and help out. It all depends on which patients are in the hospital. Of course, if there’s something like a traffic accident, there’s no question about it.”

There’s an extra clinic at Crosshouse on Thursday afternoon, arranged in an effort to reduce waiting times. Patients report in from as far south as Stranraer, and as far north as Largs. Fresh from a

morning ward round and an opportunity to catch up on administration, Currie launches into the appointment book with customary enthusiasm. “Patients do get exasperated by late running, especially if it’s for something that can be done in five minutes, but it’s difficult to explain that I’ve just had to tell someone that they have a melanoma, and that took a while longer than expected.”

Today’s clinic runs efficiently, and the Stranraer patient is in plenty of time for her train – which runs late. Currie rounds off the day with a ward visit and is out of the hospital by five. For the first time this week he leaves and arrives home in broad daylight.

Currie has a ward round to begin on Friday, but he’s soon in the operating theatre, assisting a colleague with a complicated facial procedure that takes care of the morning. This seems to be the day where planning for the week ahead is done. “From lunchtime, about one o’clock, I’ll do my pre-op clinic, where I’ll see the patients I’m working on the next day. That can run to about three-thirty.

This week I have a lot of kids – with impacted teeth and the like – not many broken jaws!”

Currie says he sees all strands of society in the consulting room. He could be forgiven for taking it easy after such a demanding week’s workload, but he’s still got one more call to make before the week is officially over. Even a surgeon has to do something with his spare time.

“Took out a private set of wisdom teeth at seven and was home by eight-thirty.

I’m not on call tonight.”

ESSENTIAL READING EVERY MONDAY Getting to the heart of medical issues with the latest news, views and analysis.

MEDICAL MATTERS THE SCOTSMAN FRIDAY 4 NOVEMBER 2005

Have your say by emailing us on medicine@scotsman.com Royal College of Surgeons of Edinburgh Quincentenary XV

TRAINING

A VISION OF THE FUTURE Good preparation for patient care IMPROVING patient care is at the until now, had to be made at a very heart of the Modernising Medical early stage.

Careers initiative which aims to Foundation programmes will achieve such improvements be followed by progressive or “runthrough a major reform of post- through” specialty and general graduate medical education, de- practice training programmes livering doctors attuned to the re- leading to a Certificate of Complequirements of the service and the tion of Training (CCT) and entry to needs of the patient. It aims to the Specialist or General Practice meet these goals through the cre- Register of the General Medical ation of efficient, high-quality, in- Council. MMC will not be impledependently assured training pro- mented overnight, but parts of the grammes. scheme are already live.

The perceived need is for a flexiSince the end of September, the ble workforce of doctors, compe- job of establishing and monitoring tent at dealing with the postgraduate medical acutely ill patient and “MMC is education, including effective at communisurgery, has fallen to the intended to cating with patients Postgraduate Medical and colleagues alike. ensure that Education and Training MMC is intended to the expertise Board, an independent meet the needs of pastatutory body responof our doctors tients and ensure that sible for overseeing and is realised to the talents and experpromoting the developtise of our doctors are best effect” ment of postgraduate realised to best effect. medical education and The scheme aims to bring about training for all specialties across improvements to career pathways the UK. It takes over from the Speat every stage of a doctor’s career. cialist Training Authority of the The introduction in August of Medical Royal Colleges, including two year foundation programmes the RCSEd, and the Joint Commitfor all medical graduates marked tee on Postgraduate Training for the first scheme. In time, the MMC General Practice. initiatives will require doctors to In an age of audit and accountdemonstrate their abilities and ability, PMETB reflects the desire of competence against set standards the government to offer a transbut, more importantly for the pro- parent and independent measure fession, they will offer doctors the of standards in specialist fields. Its chance to gain insight into possi- board of 24 members, mainly from ble career options or to build a medical backgrounds but includwider appreciation of medicine ing eight lay colleagues, is before embarking on specialist accountable to Parliament but acts training – particularly relevant to independently of government as surgery, where decisions have, the UK competent authority.

XVI Royal College of Surgeons of Edinburgh Quincentenary

Qualifying for a career in surgery is never going to be easy, but changes now being brought in will help to make the process much clearer

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HERE is a good reason why surgeons encounter only complications, not problems. It isn’t a question of semantics, a careful choosing of words to comfort the patient, but more a statement of the ethos of surgery.

Overcoming complication is a part of the skill, and something to be expected and dealt with on a routine basis. This is a philosophy that’s inherent in the surgeon’s training, and it is possibly the only fundamental left untouched by the radical changes currently sweeping through the craft.

Training of course is not in crisis.

There has never been any doubt about the ability and expertise of the thousands of surgeons qualifying through the four colleges in the United Kingdom and Ireland. However, as Professor David Rowley, director of education at the RCSEd observes, there has, until now, been an element of self-regulation that has relied upon the integrity of the colleges. “In the past there has always been devolution of control of surgical outputs to the college. The college used to be poacher and gamekeeper. Univer-

sities have done that for a very long time too, but within the university establishment there is a very clear set of external checks and balances. The colleges have not until now had an obligation for the same level of external scrutiny.”

The catalyst for change has been the government in Westminster, where responsibility for medical training resides. The embodiment of that external pressure is the Postgraduate Medical Examination and Training Board, a mouthful made easier to swallow by its already adopted acronym “PMETB”. The body does not however have, as yet, an administration behind it, so the duty of examination and qualification will remain with the RCSEd and its sister colleges in the foreseeable future.

Providing a single standard of qualification seems a logical step forward, and one to be welcomed. “The government made it very clear that it wanted change,” says Professor Rowley.

“We’ve got to live in the world we live in, and realise that the PMETB is providing a missing element. For an organisation as influential and important as the RCSEd to have remained at the forefront

KEY IN THE DOOR The RCSEd encourages school leavers to try their hand at keyhole surgery Picture: Danny Lawson

SIR HENRY LITTLEJOHN (1826–1914) PUBLIC HEALTH DEFENDER THE 19th-century population of Edinburgh and Scotland owed much to Henry Littlejohn, the first medical officer of health for the city.

His pioneering 1865 work, A Report on the Sanitary Condition of the City of Edinburgh, showed the correlation between mortality and living conditions. Adoption of the report by the city paved the way for widespread reform, including slum clearance, that was to be repeated elsewhere

throughout Britain. Most importantly though, he instigated the system of compulsory notification of infectious diseases, a move which helped counter the scourge of cholera, typhus and smallpox.

In Littlejohn’s varied and distinguished career, it is possible to overlook his surgical skills, even though there is ample evidence to support his justifiable reputation. He was however, in great demand as a

forensic scientist and as an expert witness, often called to give evidence in high-profile trials. Doubtless, his ability as a teacher made him known to society at large and, even though his contemporaries included some of the best medical educators of all time, his work was still held in high esteem.

That esteem was recognised in his election to the college presidency in 1875, where he served with distinction.

FRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

GUIDING HAND Professor David Rowley, right, director of education at the RCSEd, is keen for the college to establish a school of surgery in Scotland

of society for five hundred years has required a will to change and adapt. We’re in the process of another crossroads of change. It is not the first time that the college has faced up to change, and we’ve nothing of which to be frightened.”

T

he institution of the PMETB is part of a wider ranging government review entitled Modernising Medical Careers.

Legislation such as the European Working Time Directive, and a government drive to increase the numbers of doctors available, means that for the freshly qualified doctor considering a career speciality in surgery, the path should now be clearer, even if the dedication required remains the same.

The RCSEd has embraced the new direction for surgical training, and provides a wealth of experience and advice. An annual open day for young doctors and medical students is backed by a catalogue of lectures, talks and publications, including the highly informative booklet “Becoming a Surgeon”,

which outlines the changes in the training regime.

Though the changes to training are radical, it’s unlikely that there will be wholesale changes within the RCSEd. The changes should, at least, be less disruptive as the college, in keeping with its shrewd attitude to change, has already begun a process of adoption.

“Within the college you won’t see a great deal of change as a direct result,” says Professor Rowley. “We’ve already taken the opportunity to review our internal governance. This pressure to change has made the RCSEd ready for the 21st century and beyond.”

While RCSEd Council members are reading this celebration of the quincentenary, Professor Rowley is preparing to present a speech outlining his visions for the future of the college, and its training role. Making use of the expertise of the college, and in tangible terms utilising the new skills training and assessment centre, currently under construction adjacent to historic Surgeons’ Hall, and the recently

THE SCOTSMAN FRIDAY 4 NOVEMBER 2005

modernised Symposium Hall, he will propose the establishment of a new educational facility. “I would be keen to see the college establish a school of surgery in Scotland.”

Professor Rowley goes further to say that in a flexible college for the future, there is a need for greater engagement with all medical professions, from students to senior consultants, seeking to train in the whole skills base required in modern medical practice. He sees the business disciplines of management and leadership playing an important role in the work of the college, and the life of the modern surgeon.

“This is the oldest college of surgeons in the world, and Scotland has a fantastic reputation and tradition in education,” he says. “We need to build on that very potent badge, and reinvent the school of surgery in a modern context, inclusive of doctors, podiatrists, nurses and technicians. Make this a modern college of surgery, not just of surgeons. That is our role for the 21st century.”

JAMES SYME 1799-1870 TEACHER AND INVENTOR JAMES Syme probably made just one mistake in his illustrious life, but it was a mistake which benefited many thousands through his continued work in surgery.

Syme was also a talented chemist. His great mistake was in not realising the potential of his discovery – a method of waterproofing silk through a process he had pioneered.

Unfortunately for Syme, he failed to register a patent, and Glasgow chemist Charles McIntosh went on to become a household name.

It is primarily as a

teacher, not an inventor, that Syme is best remembered. His methods were both innovative and informative, and laid the foundations for modern medical training.

Of his contemporaries, Syme was not always on the best of terms. He grew apart from his mentor, Robert Liston, to such an extent that he set up his own surgical hospital nearby the college. The rivalry never abated, especially as, in later years, Syme became president of the RCSEd. His influence succeeded in persuading Joseph Lister, who transformed surgical hygiene, to stay in Edinburgh.

Rather it was his daughter Agnes, who married Lister into the family.

Royal College of Surgeons of Edinburgh Quincentenary XVII

FUTURE OF THE RCSed

OPERATIONAL SECRETS Adaptability lies behind the college’s successful navigation of 500 years, but it knows it cannot afford to rest on its laurels

without an administration, so it has required the royal colleges to continue in their role, but under unified standards set by the body.

Foster accepts this as the way forward and believes it is no bad thing. “Colleges had to update education and exam standards. The most radical changes are that, as a collective, all four surgical colleges have to make intercollegiate decisions on examinations. As a result of legislation, we have separated training from exams, making assessment more merit-based.

“We are now also permitted to review experience as a qualifying factor. This has opened the way for overseas doctors in significant numbers. In the first ten days of October, since the regime became live, around 500 overseas doctors applied to PMETB and are now waiting for assessment. That assessment load is being taken on by the colleges and will be a continuing part of our involvement for some time to come.”

Legislation at home affects the college in its international relations. A huge international programme and developments everywhere have consequences. Foster describes the relationship as many levers interacting. “Some surgeons come to us for the specialist training they can’t get at home, or so they can work here and realise salaries unobtainable at home. Sometimes there are refugees. Whatever is happening in the world is reflected in the work we do. There have to be job opportunities here in the UK to make overseas surgeons want to come. While there is a perceived shortage in the UK, that will continue to be the case. Our undergraduate training programme will produce more doctors, but it will take time and there will always be a demand.”

W

ITH such a weight of history on its shoulders, the Royal College of Surgeons of Edinburgh has a heavy load to carry into the future. It was only five years ago that the then president, Arnold Maran, felt confident enough to state that the college had grown in stature commensurate with its illustrious past. “We have made the transition from a club to a major organisation, not without some difficulties, but successfully and, more importantly, without changing our essential character.”

Most outside observers would have come to that same conclusion hundreds of years earlier. Modesty has played no small part in the college’s longevity.

Faced with change, it might be said that the college stands, as does the craft of surgery, at a crossroads, facing new directions and a new role in society. The situation is not unprecedented. The college has seen disciplines come and go, and medical science transformed.

Monarchies and parliaments have been and gone. Revolutions – political, social, industrial – have all provided stormy waters through which the college has sailed safely. The question is not whether the RCSEd is good for another 500 years, but what will the coming years add to its history, and what part will it play?

With a distinctly international presence, the college is more entwined in world affairs than ever. While its international reputation and influence grow, its independence and individuality at home are courted by government, seeking to harmonise standards set by the college and its sister organisations.

The college voice continues to grow.

There are now 17,000 Fellows, more than at any time in its history. In fact, there are more Fellows alive today than in the entire roll of those deceased. The number of Fellows outwith Scotland continues to outgrow the home-based by a ratio of ten to one, testament to an enduring and enhanced reputation.

S Worldwide, the membership is charged with fulfilling the college’s prime purpose – maintaining and promoting the highest standards of surgical practice and training. Today however, the college is increasingly concerned with the provision of surgical education and training. And it is with the professions and the administration that the college has most to address.

Chief executive Jim Foster sets the college’s directional change in context thus: “Prior to the NHS, when all medical

XVIII Royal College of Surgeons of Edinburgh Quincentenary

IN THEATRE A Palestinian girl is operated upon by trainees in Gaza City.

The RCSEd is more entwined with world affairs than ever.

Picture: Getty Images

delivery was private, the royal colleges were the standard-setters in training and in licensing. In 1948 the delivery was nationalised but the training vehicle was not. The colleges became partners with the NHS but with no real contract between them. Yet it worked, and some would say it still works.”

The system has recently changed, requiring a new relationship between the college and the NHS. The new standards body, the Postgraduate Medical Education and Training Board (PMETB), is

urgery is not the most egalitarian profession. While 60 per cent of the intake into medical schools is female, only 6 per cent of surgeons are female.

The college is working to address that, and Foster admits surgery must become more female-friendly, and that the current lifestyle may not be good for men either. “Today’s surgery requires sacrifices, and yet the modern trainee is often seeking a certain lifestyle. Some are not prepared to put in 90 hours a week – indeed they’re not allowed to under working time legislation. Yet others crave the opportunity to learn, no matter what the personal sacrifice. The workload has shifted, at least temporarily, on to the shoulders of senior staff.

“This is very much a topic of debate.

For example, how does a hospital cope at

FRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

night under this legislation? To a large extent, hospitals have been used to having doctors on call 24 hours a day. You cannot cut down to a 56-hour week without significant sacrifices.”

While continuing to set a lead on such issues, the college is also addressing its future stability. With a shift of emphasis towards participation in training, the college is revisiting its original seal of cause and emphasising its teaching role. In the immediate future, developments designed to enhance commercial stability will also help define that role.

Key to delivering any new training is, of course, the membership. The tangible assets, though, are in a state of development. The key project is the construction of a skills training and assessment centre on a site next to historic Surgeons’ Hall. Together with the mod-

ernised Symposium Hall, this forms the new seat of learning within the college.

The college also wants to develop training techniques outside the hospital environment. Developing technology, virtual reality and other techniques may allow more efficient ways of learning, including, perhaps, the use of cadavers. As the college’s educational role continues to grow, so too, it is anticipated, will the overseas presence, offering more trainees the opportunity to gain qualifications suitable for continuing their study and career in Britain.

Even as options grow, increasing numbers turn to the RCSEd to affirm their professional standing. In her book, A Famous and Flourishing Society, historian and senior lecturer at Stirling University Dr Helen Dingwall recognises the continued intertwining of the surgi-

THE SCOTSMAN FRIDAY 4 NOVEMBER 2005

LEADING LIGHT The modernised Symposium Hall, along with a new skills and training lab, will guide the college into the future

“Individuals continue to be impressed by the gravitas of a long history.

Fellowship has meaning”

cal craft and practitioner with every aspect of society, yet still they retain their core values, unchanged by half a millennia. “Surgeons, as other medical practitioners, are subject to national registration, national standards, national politics and a national health service.

They have far greater opportunities to cure patients than they had half a millennium ago; they have access to all sorts of technology, diagnostic and paramedical support services; they operate in purpose-built buildings and they still demonstrate the caring ethos. They share, in modern terms, the original aims of the incorporation.”

Mr Foster agrees, saying that the RCSEd still has much to offer the medical profession and the public. He says that much of the wealth of knowledge and talent available through the college

goes unrecognised by the public. “I want to see the college much more accessible, to everyone. It is a hidden treasure with an extraordinary history.”

As to whether there is a future for institutions such as the college at the beginning of the 21st century, the answer is undoubtedly yes. While many of the college’s original functions have become largely irrelevant, it is only through fortitude that so much has been achieved. As Dr Dingwall argues in her book, institutions with long histories continue to attract candidates and members, but she sounds a note of caution. “However much it may be denied, many individuals continue to be impressed by the gravitas of a long history.

To be Fellow of an institution whose earlier members included Syme, Lister and many other famous names still has meaning,” Dr Dingwall writes.

“Tradition is not everything, and no institution should sit back on the laurels of its long history, but it is still a considerable advantage. Adherents to institutions nowadays, though, expect rather more in return for their loyalty, and prestige alone is not sufficient to guarantee allegiance and support.”

Royal College of Surgeons of Edinburgh Quincentenary XIX

FUTURE OF SURGERY

VIDEO SET TO FAST FORWARD C

HANGES in administering examination and qualifications represent reorganisation for surgical practice and training on a nationwide scale, but at the cutting edge of technological advancement, there are also fundamental issues on the horizon between here and health.

Jim Foster, the chief executive of the Royal College of Surgeons of Edinburgh has been involved in preparation, with other medical colleges in the UK, for the introduction of the new Postgraduate Medical Education and Training Board (PMETB) standards regime. He sees the introduction as an opportunity for the good, which will help the profession meet the exciting challenges of the future. “If you spoke to ten surgeons you would get ten opinions on the future direction of surgery, but there are a number of factors we can take as read,” says Foster.

“With the advancement of science and knowledge, specialities are bound to increase. The diversity and effectiveness of treatments has continued to grow throughout medical history, and they will continue to move on apace, as will public demand for a greater and greater degree of healthcare.

“Most surgeons would say that foremost they are doctors specialising in surgery, but that speciality is becoming more and more focused and closely defined, which could have some quite radical effects on the way we tackle healthcare in the future.”

Almost everything has changed since the inception of the Incorporation of Barbers and Surgeons. To a steady hand,

Technological advances allied to a changing landscape of training and specialisation should see patients reap the benefits in the long term literacy was once the only additional skill required. Now, computer literacy is also an indispensable proficiency, as surgery moves further and further into technological realms.

Computer-controlled robots are no longer the stuff of science fiction. Ever more delicate operations are carried out by surgeons operating mechanical instruments with precision down to tenths of a millimetre. The reassurance for, say, spinal injury patients is that the surgeon’s meticulous care can now be replicated without human contact – in the way that a camera, framed for the perfect picture, can reproduce a steadier shot when tripod mounted than can ever be achieved hand held. Similarly, a robotic laser-scalpel, directed by a trained surgeon can venture into ever more delicate areas with greatly increased accuracy.

Inevitably, training has become an ever lengthening process. Including the undergraduate years, it can be fifteen years or more before an individual reaches consultant status. The recently introduced Modernising Medical Careers (MMC) reforms have set out to rationalise and streamline medical training, but a craft skill such as surgery, where technology is advancing so

rapidly, requires practical experience to reach skilled competence. It is hard to see how this can be reduced.

College Fellow and member of the Special Advisory Board for Education and Training, Rajamiyer Venkateswaran, who came to Britain in the late 1990s to complete his qualifications at the college, and has since become a cardiothoracic surgery specialist, Registrar, and researcher, believes he benefited from the extra experience the previous regime allowed him.

“In my field I found it was a really difficult job. The amount of exposure we got was really good, but the time I spent in surgery as a postgraduate trainee just isn’t allowed any more. The European Working Time Directive makes that illegal. Far from reducing the length of time spent training, I think there may be a case for increasing the number of years spent training, to reach the necessary level of competence.”

Venkat adds that due regard must also be given to the needs of the patient, and that they are at odds with a culture that requires medical staff to “clock off” regularly. He says that’s particularly the case in the surgical fields. “In my speciality you can’t say I come at nine and I go at five. If I operate today I believe I should

REMOTE CONTROL In 2001, surgeons in New York operated on a patient in Strasbourg by manipulating scalpel-wielding robotic arms Picture: Reuters

Competition is tough in the school of life GIVE children sharp knives to start them on the career path.

That’s not quite the intention of this fun initiative from the college. Persuading young people to consider a medical career is always a good idea, but this could be the making of the new generation of super surgeons, or the exposure of a failed class of demon barbers.

Higher studies children from up and down Scotland have been taking part in a

XX Royal College of Surgeons of Edinburgh Quincentenary

competition to find the most dextrous and clinically efficient classes in the country.

Tests have included peering through laparoscopic cameras and equipment to perform keyhole surgery techniques; getting plastered putting a cast on a broken arm – simulated of course – and dissecting specimens and suturing up wounds of all shapes and sizes (again simulated).

The results have quite literaly had participants and surgeons alike in stitches.

Nearly 100 teams from schools across Scotland, each consisting of two pupils representing an S4, S5 or S6 class, have been battling it out in the competition for the past two months.

Each task completed is scored and the best team from each heat progresses to the next round and the finals early next year.

see through the patient’s recovery for the first six to 12 hours – this is the crucial recovery time and I want to be on hand for any complications. It should be that if you’re the operating surgeon and there’s a patient care issue, you are the surgeon and you will be called.”

These concerns have been voiced elsewhere, and the wider MMC reform takes account of them, if not offering an immediate solution. As Jim Foster explains, the long lead times are such that, whatever modifications are made to streamline the training pipeline, it will be a number of years before these become manifest in the provision of service.

Moreover, a lot can happen to social and patient demographics in a period of 15 years, and so tomorrow’s generation of surgeons may have to have flexible or transferable skills to remain effective during their working life. Technological and social change can have a significant bearing on the future medical requirements of the population – and on the wisdom of speciality choices.

“Take the example of cardio-thoracic surgery,” says Foster. “The advances in cardiology over recent years have significantly reduced the requirement for

FRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

The key to rapid recovery

interventional surgery. On the other hand there are areas of treatment that are growing – such as joint replacement and brittle bone traumas in an aging population.”

These requirements have already been met head-on in regional independent treatment centres in England. In future, it may be unrealistic for the public to expect the full range of specialist services to be available in all hospitals. It could become necessary to introduce a greater centralisation of services.

F

rom technology to patient transfer, the issues raised are at the forefront of debate in the college. There’s no desire to shorten basic medical training, but there is a suggestion that training to 80 per cent of current specialist levels will still provide competence to cover 80 per cent of cases. “Some would call this dumbing down,” says Foster, “But it’s not sensible to train all surgeons to do all things within a speciality when some of that training will never be used.”

Specialities of the future might include telesurgery, where surgeons not only advise local teams by sophisticated video links, but also employ the ad-

vances in robotics to perform their work entirely remotely from the patient. In a pioneering operation in 2001, surgeons in New York successfully removed a gall bladder from a patient in Strasbourg, using video technology and telecommunications to manipulate scalpelwielding robotic arms.

Better materials too are enabling savings in aftercare and reduced recovery times. The oft-heralded advances in nanotechnology, the application of sub-microscopic techniques and materials, have already led to surgical gowns that are better able to resist contamination and infection, and pins for fracture repair that are coated to reduce rejection by the body.

While welcoming such advances, Foster suggests that to help bring more surgeons to the operating table more quickly, specialisation could begin at an earlier stage. “Another more radical approach may be to challenge the five year undergraduate period. Many undergraduates have focussed on a career in surgery before they have even left school – so why not modify the programme at the outset to provide a background suited to surgery? It does lead back to

THE SCOTSMAN FRIDAY 4 NOVEMBER 2005

the conceptual question of: ‘Is a surgeon a doctor who specialises in surgery – or a surgeon who is medically qualified?’

“There is also the question of how far non-medically qualified people in professions allied to medicine can be trained to undertake interventional procedures. That is an issue that’s been addressed abroad – particularly in the US where non-medical surgical practitioners, eg podiatrists, have trained and undertaken surgical intervention” The British model may also be to have more surgical practitioners – carrying out procedures that lend themselves to a narrower field of training – such as endoscopy or carpal tunnel release. Here, advances in miniaturisation and manipulation make possible less invasive exploratory procedures.

Despite the current shortage of surgical facilities and teams, the complications in the health professions are not insoluble. The RCSEd is cooperating with reform and encouraging interested individuals through its doors.

With technological advancement, and cultural change in the medical profession, the horizon between here and health is destined to get ever closer.

MINIMAL Access Therapies is a collective term for the techniques those of us confined under the covers in a hospital bed tend to refer to as “keyhole surgery”.

Those techniques though are the reason so many of us can leave hospital much sooner than if we’d been treated traditionally, and it’s a Fellow of the College we have to thank for that.

The first man in Britain to peer through that opening and unlock the potential for a less invasive way to deal with an endless variety of conditions was Alfred Cuschieri.

Over a period of thirty years, he developed the infant technique of “laparoscopic surgery” from the difficult early days of looking down a telescope to the wide-ranging field of expertise that it is today. When asked what skills would need to be acquired, he said it would be necessary “to operate from images using long instruments that are like chopsticks, without looking at your hands”.

Such has been the success of his work that, in 1992, the Royal College of Surgeons of Edinburgh collaborated with its counterpart in Glasgow to set up the Minimal Access Therapies Training Unit for Scotland under his chairmanship.

For the patient under the care of a skilled operator – even one who isn’t watching his hands – keyhole techniques significantly reduce trauma, and speed up recovery. These are obvious benefits for the patient, but they also mean that better use can be made of all the medical resources, from operating theatre and consultant’s time, to beds and waiting lists. For the technically minded Cuschieri, the sky is the limit. 3D imaging, super thin “chopsticks” and remote supervision are all coming onstream thanks to his pioneering work.

For the future, Cuschieri foresees what he calls “disease-related treatment groups”, breaking down the barriers between disciplines with the help of technology. Whether that very modern notion of demarcation may mean more medical staff performing more tasks remains to be seen. There’s certainly still going to be a place for the minimal access specialist.

As anyone who has ever struggled in an Oriental restaurant would agree, looking through the keyhole is one thing, doing anything meaningful with a set of chopsticks can be entirely another matter.

Royal College of Surgeons of Edinburgh Quincentenary XXI

EXHIBITIONS

The director of heritage at the Royal College Dawn Kemp guides Simon Walton around a fascinating if sometimes spine-tinglingly gruesome collection of museum exhibits

T

HE children squeal with delight. The adults look on, outwardly with intrigue, inwardly with a shiver of discomfort. A visit to the Dental Medicine Room at the Museum of History of Medicine within the Royal College of Surgeons of Edinburgh is not for the faint of heart – even though nothing here is outside a glass case, and the vice-like devices, mounted around realistically raw gums, have not pulled a tooth in the best part of a hundred years. Still, they look as if they could, and that’s all it takes to bring the display to life. That and a little suitably stimulated imagination.

“This is somewhere for the public, young and old, to relate to the profession,” says Dawn Kemp, the director of heritage at the college. She talks with great enthusiasm, as she conducts a tour of the museum facilities, a series of rooms and galleries, housing the fantastic treasure trove of exhibits and specimens, collections and cornucopia from five centuries of the surgical craft.

With work on the college campus well underway, and the Surgeons’ Hall Trust on the verge of coming into being, Kemp is anticipating a great influx of new visitors to the museums and galleries, and most of all to the Pathology Museum, a great colonnade running the length of Playfair’s outstanding building.

This fascinating and right up-to-date attraction is actually the oldest museum in Scotland still used to house and display its original collection. The permanent exhibits range through medical, anatomical and pathological material, dating from Roman times to the present day – and it’s about to get even better.

Peering out from behind the diffusing window screens, the new skills training and examination centre – the Quincentenary Hall – is taking shape not twenty yards to the north of the building. Its completion will be the catalyst that opens up the space of Surgeons’

SKELETONS IN THE CABINET There’s something for everyone on display at the museum – from the gruesome to the more historically edifying

Hall so that, on a daily basis, it can fulfil its educational role in a new way.

Kemp says that engaging visitors in the reality of surgery as a part of everyone’s life is the most important goal of the redevelopment. “It’s not all about getting straight A results. By coming here young people can learn that surgery means manual dexterity and dedication too. It’s also about something that isn’t voyeuristic, even if the specimens seem astounding at first. It’s about a fascination for the human body, how it works, how it’s put together. It’s the same sort of fascination that drove the early surgeons to explore.

Tackling a problem at source THINK carefully the next time you consider a rash tackle. The video display in the new permanent exhibition, Sport, Surgery and Well Being, could take the legs from under you.

Knee surgery to allow recovery from a sporting injury is the subject of a graphic video display in this new exhibition on Sports Surgery.

XXII Royal College of Surgeons of Edinburgh Quincentenary

The Royal College of Surgeons of Edinburgh was the first college in Europe to set up a specialist Faculty in Sports and Exercise Medicine. The exhibition explores the development of sports and exercise medicine and the wider medical and social issues raised through the changes in recreational sport in recent times.

THE BARE “There’s an ancient Greek maxim that says ‘first know thyself’. We have to learn how our own bodies work through observing others. We will never be able to look into our own bodies in the same way. That, in essence, is what the museums here are all about. If 90 per cent of how we conceptualise is by observation, then where better to come to learn about how your own body works than to a place where the workings of the body are displayed and explained.”

It is in these halls that Charles Bell’s clinical paintings hang, the works that shed light on the nervous system, as well as the horrors of battlefield wounds and the morbid legacy of infection, drawn from those newly returned from the war on the Iberian Peninsula.

Another exhibition with a war-like theme, running until June 2006, tells the fascinating story of Edinburgh’s Elsie Inglis, a doctor and tireless campaigner for women’s rights. Her offer of military service as a surgeon to the British Army

in 1914 was met with a derisory and flippant response, not uncharacteristic of the times – “My good lady, go home and sit still.” Inglis did anything but.

The exhibition, The Scottish Women’s Hospitals 1914-1919, tells how, in defiance, Inglis formed hospital units, staffed entirely by women, at ten places along the European fronts. Over one thousand women joined up in her quest to relieve the suffering of the wounded in the bloody conflict. A unique collection of personal artefacts, diaries, letters, photographs and paintings reveal the horror of war from this unique perspective, and reveal the tragic outcome of this woman’s crusade.

Kemp is rightly proud of the collections. The exhibitions and displays are certainly designed to encourage more visitors through the doors. With the museums already recognised as a major tourist attraction, Kemp would like to see more local people make use of them, especially young people. She says that

FRIDAY 4 NOVEMBER 2005 THE SCOTSMAN

“We have to learn how our own bodies work through observing others”

BONES OF IT once a young person is in the frame of mind to think seriously about health issues, they are receptive to the issues that affect them in later life. “If you see a blackened lung as a twelve-year-old, that’s an image that stays with you, and shapes the way you think about your life.

It’s another way of developing education. If you see that image here as an adult, you have a chance to reflect on your own situation in a way that you generally can’t do in other situations.

Coming here is an opportunity to come to terms with disease and infirmity, things that you might not like to face when they’re personal to you.

“These are all positive things, which might make you think more about current health issues, such as organ donation.”

In establishing these great resources in 1832, the college overran its budget, and was about 40 per cent overspent when Surgeons’ Hall opened in 1832.

Though some collections had been be-

queathed – Dr John Barclay’s fascinating Comparative Anatomy Collection for example – others were purchased at great expense. The Fellows put the college finances on the line in order to secure these resources for the future. If that mortgage needed vindication, then a letter from a visiting school, 173 years later, from those same pupils who squirmed uncomfortably in the Dentistry Rooms, is evidence enough.

“I’m writing, on behalf of the pupils who took part, to thank you for giving us a very interesting and encouraging tour of the college museum,” says their head teacher. “The tour has been a constant topic of conversation within my Higher class for the past couple of weeks and I think news of the tour has filtered down to other classes who now also ask me about it. The tour certainly made a big impression within the school. For many of the students it was the first time they had considered human biology as something other than abstract dia-

THE SCOTSMAN FRIDAY 4 NOVEMBER 2005

grams in books. I hope we can come again, maybe next year.”

Kemp has that letter, and many like it, kept safely with a visitor book for the museums. Making the college, and the work of surgeons, relevant to everyday life is her goal, from schoolchildren to retired people, and everyone in between. “We’re starting a pilot scheme next year where surgeons will make a video in their special field – to introduce their area of surgery and to broach it in such a way that’s approachable and understandable to the general public.”

By making the college and surgery more relevant to everyday life, Kemp says the mission is to encourage more people to become more enquiring. “The collection of pathological specimens represents great personal suffering. The misery of individuals from the past whose pain and distress helped future generations understand more about death and disease is something not to be forgotten.”

Lecture series

DURING the quincentenary year, the college is participating in the Edinburgh Lectures series, the prestigious public talks promoted by Edinburgh City Council, the Scottish Executive and a number of other leading educational and cultural organisations.

The RCSEd events are in the new Symposium Hall. Professor Arnold Maran, past president of the college, gave the October lecture to a packed house on his speciality, the human voice. There’s still time to attend the other lectures, if you speak up for tickets quickly.

On 25 November, there may be some availability left for a talk by Dr Ian Jackson, adoptive father of “the Boy David” (pictured above). He will be discussing his work as a leading plastic surgeon. In the New Year, Professor David Rowley, director of education at the college, discusses the human cost of war in the January lecture Landmines, Bombs and Bullets. Before that, college Fellow Sir Alfred Cuschieri will include his pioneering work in keyhole surgery as part of his lecture on 19 December at the Royal Society of Edinburgh in George Street.

Details are available online at www.edinburghlectures.org or telephone 0131-529 4441.

Elementary case PLANNING ahead always worked for the super sleuth of 221b Baker Street, so he should really find it elementary to uncover the subject matter of next June’s special exhibition, entitled Conan Doyle and Joseph Bell, the “Real Sherlock Holmes”.

Of course, as any Inverness-caped crusader against crime will readily explain, Conan Doyle was a medical student, inspired to base his character on the persona of Joseph Bell, the writer’s own medical teacher and later president of the Royal College of Surgeons of Edinburgh.

Bell’s own extraordinary powers of observation and deduction were the obvious inspiration for Doyle’s worldfamous character.

Bell, however, had a few secrets of his own and all will be revealed next June.

Only Professor Moriarty could possibly disapprove.

Royal College of Surgeons of Edinburgh Quincentenary XXIII

Open noon – 4pm

Nov: 1, 2, 3, 7, 9, 10, 11, 14, 15, 21, 22, 30 Dec: 1, 2, 7, 8, 9, 12, 13, 14, 15, 16, 19, 20, 21, 22, 28, 29 Jan: 4, 5, 6, 9, 10, 17, 18, 19, 20, 23, 24, 25, 26, 27, 30, 31 Please note: the History of Surgery Museum is open every weekday.