Person:

Milamed, Debra

The shift to ambulatory surgery has taken decades. The history and causation of the move are complex. Key enablers are recounted. The complex interchange of ideas, and physicians, between Belfast and Boston was important in the development of relevant facilitating standards. US and UK governmental and hospital statistics in the increase of ambulatory surgery are presented. The transition of surgery away from hospitals was not all plain-sailing. Insurance companies, governments and hospital administrators hindered and then acquiesced. The shift to ambulatory surgery has not resulted in increased patient morbidity and mortality.

In 1894 Ulsterman and pathologist Almroth Wright described the citation of blood. Twenty-one years later it was introduced into wartime and clinical practice. Harvard Medical School had a large part in providing Colonel Andrew Fullerton, later Professor of Surgery, Queen's Belfast, with the intellectual and practical help for the Allies to deploy blood on the post-Somme Western Front and in Salonika. The key investigators and clinicians were Americans and Canadians who with Fullerton and Wright instructed the Allies. The key enablers were two Harvard-trained surgeons surnamed Robertson—Oswald H. (“Robby”) and L. Bruce (no relation). Physician Roger I. Lee of Harvard, surgeon George W Crile of Cleveland, Peyton Rous of the Rockefeller Institute and Richard Lewisohn of Mount Sinai Hospital, both located in the Upper East Side of New York City, played key roles. By Armistice in 1918, indirect citrated nutrient-enhanced blood transfusion was widely used by the Allies. Geoffrey Keynes was taught the techniques of blood transfusion by Dr. Benjamin Harrison Alton of Harvard at a Casualty Clearing Station near Albert at the time of the Battle of Passchendaele. Professor “Robby” Robertson, DSO, Sir Geoffrey Keynes and Sir Thomas Houston established blood banking.

The severe bombing of Belfast in 1941 had far-reaching consequences. Harland and Wolff was crippled. The British Merchant Ship Building Mission to the USA was being constrained by the UK treasury. On being told of the Belfast destruction, the British Mission and the United States Maritime Commission were emboldened. The result was 2,710 Liberty Ships launched to a British design. The necessary asbestos use associated with this and other shipbuilding, after a quarter century or more latency, is a genesis of malignancy killing thousands. Reversal of studies on asbestos limitation of fire propagation was crucial to Allied strategic planning of mass-fires which resulted in the slaughter of one to two million civilians. Boston and Belfast institutions made seminal discoveries about asbestos use and its sequelae.

In the decade 1935-45 the treatment of lobar pneumonia in the developed and warring world underwent a series of evolutions—anti-sera, specific anti-sera, refinement of sulpha drugs, sulpha and anti-sera, the introduction of penicillin for bacteriology, then ophthalmology, and then for penicillin-sensitive bacterial infections such as lobar pneumonia with its many Cooper types of Streptococcus pneumoniae. Penicillin for civilian use was essentially banned in World War II, a ban that early in 1941 two Musgrave Park physicians tried to circumvent. Strict secrecy on the details of penicillin production was enforced. The treatment option chosen by the Musgrave Park physicians in 1941, and the non-availability of penicillin led to sequelae affecting the post-Belfast careers of both patient and physicians.

Musgrave Park Hospital in 1942 was the site of an Anglo-American Vitamin A caper. A threatened court-martial was pre-empted. Subsequently the Queen's lecturer in Anatomy, JW Millen, who was the other lecturer to the first editor of this journal, RH Hunter, did much distinguished work. The neurological effects of Vitamin A were elucidated. Further work on cerebrospinal fluid (CSF), placenta, thalidomide and poliomyelitis led to the pre-eminence in applied anatomy and teratology of now Reader James Wilson Millen and Professors JD Boyd and WJ Hamilton, all Queen's Medical School graduates. Training of RH Hunter, JH Biggart and JD Boyd at Johns Hopkins University profoundly influenced these seminal discoveries. The Garretts, a family of Lisburn, County Down origin, saved Johns Hopkins Hospital and Medical School from financial disaster. The Garretts founded a commercial and mercantile empire that took control of the Baltimore and Ohio (B and O) Railroad and enabled the Garretts to dictate that women should be admitted to the Hopkins Medical School and Hospital on exactly the same terms as men. All women and men should already be university honours graduates. Winston S Churchill on his progress up and down the B and O main line in March 1946, recounted to President Harry S Truman and Harry Hopkins his mother's tales of the Garrett boys' adventures.

SUMMARY: The aim of the Modicum mission from the United States was to determine the fate of the Western World, the Second Front and the Manhattan Project plans for development of atomic weapons. The Modicum mission was appointed in March 1942 by Franklin Delano Roosevelt as President and Commander-in-Chief of the US forces. The journey via the Anglican Cathedral in Bermuda, to Gander, to London, to Ulster was eventful. There was a clay-pigeon shooting contest in Gander. Generals Marshall, Eisenhower, Clark and Averell Harriman were outshot by their pilot. In Ulster, an escorting US sergeant killed a Londonderry bus driver with three shots. At a house party requested by King George VI and General Marshall, at Ashbrook, Ardmore, near Londonderry, it is alleged Averell Harriman was poisoned with Salmonella schottmülleri. He was delirious and ‘gravely ill’ for three weeks at 3 Grosvenor Square next to the American Embassy. He subsequently married his “other nurse”, Pamela. Ambassador Pamela Churchill Harriman, a long-time ardent supporter of the Clintons, died in February 1997 following a stroke.

The planning for surgery in war was revisited in 1937 when Ian Fraser was elected a member of the Surgical Travellers. At their 1938 Surgical Travellers meeting in Vienna, Ian and Eleanor Fraser were evicted from their hotel room by the Nazis. The 1939 meeting in Belfast discussed the organization of surgery and the conduct of Emergency Medical Service Hospitals in the United Kingdom; the vast majority were to be under civilian government and military control.

From 1943 lengthy and informative organizational meetings were held at least monthly under the chairmanship of Sir Alexander Hood, KBE, Head of the RAMC. Surgical Consultants, now Major Generals, Brigadiers or Full Colonels in the British and U.S. Armies stationed in the UK, prepared for the invasion of Europe. The allocation of medical, surgical, nursing and auxiliary responsibilities was delineated. Liaison with the RAF and US Army Air Force was close as it was with the proposed leaders, Ulstermen Brooke and Montgomery. Montgomery chose Arthur Porritt as Surgeon in Chief to Supreme Headquarters Allied Expeditionary Force (SHAEF), and Eisenhower, General Albert W. Kenner.

Just after D-Day, Porritt met Ian Fraser, who had waded in on Arromanches Beach. The triage and evacuation plans for Allied casualties had been controversial, particularly as regards Landing Ship Tanks (LSTs). The dispute with the Hood-selected surgeons on one side, against medical and surgical deployment of LSTs, and Admiral Ernest King and Winston Churchill on the other, favouring LST use for surgery and evacuation. King and Churchill were correct but total Allied air superiority allowed wide use of many of the Allies' Dakotas; 10,000 DC-3s were eventually in service. Supported by forty Allied combat planes to each Luftwaffe, the dispute about Landing Ship Tank use in about a fortnight became moot. The multifaceted role of the Princess Royal in the Emergency Medical Services of the United Kingdom and her close liaison with the Consultant Surgeons was of great value to the Allies.