Progress of surgery seen by a good medical teacher
February 8, 2017, 8:42 am
This launch of Volume 1 of the reprint of the book, "Essentials of Surgery" by R. L. Spittel, FRCS. Eng. first published in 1932 when he was a Surgeon at the General Hospital, Colombo, (now The National Hospital of Sri Lanka) and Lecturer in Clinical Surgery, Ceylon Medical College, (now The Medical Faculty, University of Colombo), together with annotations by experts is timely and welcome. It gives the reader an opportunity to appreciate the tremendous strides this discipline, and medicine as a whole, has taken since.
The book was written in the pre-antibiotic era, when viruses and genetics were unknown, when anaesthesia was in its infancy and when the only imaging investigation available at that time was X-rays. His objective was to present a concise alternative to larger textbooks, so that, as stated in his preface, "if fundamental principles are thoroughly grasped by the student, their application in diagnosis and treatment becomes a habit of the mind, then the subject of surgery becomes both interesting and simple". The book achieves this and more, displaying at the same time the author’s attributes of a true scientist, a good doctor and surgeon, whose practice was based on these foundations together with his skills as a good medical teacher.
Some unique features
It displays his thorough command of the English language combined with the romanticism of writers of fiction. He has the license to use words such as "acuter, "commoner" and "sapremia’, "keep the emunctories active", and the ability to describe with uncanny precision "a patient violently intoxicated with bacterial pus". The reader would appreciate further nuances in his graphic descriptions of conditions and disease such as cellulitis, gangrene, the death throes of a patient with tetanus, a passage of almost poetic content in describing a patient with delirium tremens, etc. Most of the clinical states throughout the book appear to be graphic details of the author’s own observations which add a unique and authentic flavour to the teaching/ learning process.
In what must be the only instance in medical history, the author describes a case illustration of a patient with virulent sepsis of the finger spreading up the arm, multiple surgeries, the suffering ("he begged that his arm be cut to tatters", "for the next four days he hung between life and death", and his recovery. He recovered four months later, with a residual ankylosed shoulder. The case was his own experience with infection and near death!
There were no specialities at that time. General surgeons also treated patients with Ear, Nose and Throat (ENT) problems, Venereal diseases (Sexually Transmitted Infections), Orthopaedic problems, Neurosurgical, Vascular, Urology, Leprosy and of course problems of surgical Oncology. In addition to textbook descriptions of these conditions, the reader would recognize and appreciate the author’s unique style of descriptive talents.
How many ulcer clinics, not only in Sri Lanka, but all over the world, need to be reminded, nay, blared to out aloud with this statement "The actual destruction of germs in wounds is impossible with antiseptics in strengths which will not cause actual destruction of tissue cells, as germs are not all on the surface of the wound, but deeper in the tissues". Nevertheless, there are easily over a hundred brands of expensive products for "local treatment" of ulcers in the markets today! He exhorts "gauze should never be pushed into discharging wounds and sinuses for this is the most effective way of preventing pus from escaping". The plugging of wounds with gauze is a common practice even today, and numerous are the patients who have suffered septicaemia as a result, ending in amputation or even death!
The next feature of this launch is the addition of annotations to put the text into modern perspectives. "As undergraduates, we were told that 50% of what we are teaching you today would at some time in the future be proved to be wrong. The problem is that we do not know which 50%!" Prof. Graham Taylor, Imperial College, London. A discerning reader would readily note some of these, if not-all the errors, in what were at that time in history, truisms in surgery. The annotations give evidence based accounts of modern advances compiled by experts to give a "modern twist" to this absorbing book.
It has been a fascinating journey and experience reading the copy and the annotations and whilst thanking the authors, Dr Lakshman Karalliedde and Dr. Philip Veerasingam, for giving me the luxury of writing this foreword, I invite readers to go into this fascinating journey and experience when reading the book.
A. H. Sheriffdeen
M.B.B.S. (Ceylon), F.R.C.S. (England), D.Sc. (Honorary) University of Colombo. Emeritus Professor of Surgery,
University of Colombo.