24 I Medical histories [email protected] Imperial College London, London, UK Ara service. a disjointed coffee break fuelled the ward but instead experienced anaesthetic room and returning to flow of new patients arriving at the didn’t have a smooth and constant I wanted to why understand we pushed back our lists at St Mary’s. up our operating theatres and inefficiencies that notoriously held with the delaysfrustrations and was to and ease my understand apparel of my porter colleagues the scalpel and scrubs to don the year. leading upto this65thanniversary great achievements we have made instead be celebrating the many Service at a time when we should the history of the National Health our way through a deep slump in feels as though we are navigating public this year. Regrettably, it our NHS workforce and the UK statistics that have bombarded headlines, and questionable official reports, shocking tabloid as I considered the stream of to the memory of that evening several years ago. I was drawn undercover as a hospital porter memorable shift that I spent I encountered during the or confrontational experience certainly put me in my place. this list is running behind.” He and hurry . . . it’s because of you and bring down the next patient, and pull . . . then go up to the ward commanded, “You grab the feet When Undercover surgeon: thenightporter chronicle

My motivation for putting down This wasn’t the only humbling

Darzi right through me as he medical student looked London, but the third year of surgery in at St Mary’s might have been the professor Paul Hamlyn chair of surgery, Ara Darzi decided to try being ahospital forhelearnt anight, porter morethan heexpected about team relationships from the view of my medical shift I effectively disappeared mytransfer patient of the first and walked into theatres to The moment I put on the uniform Becoming invisible within the hospital. environmentsometimes strained professionalism in a busy and and maintain high standards and people’s determination to achieve often simply a consequence of Particularly, I noted that this was between staff in the hospital. tense and frayed relationships I had expected about the often I learnt a great deal more than with a bit of creative thinking. But find out what might be improved the challenges involved, I could hand first what the job entailed and hospital. I thought that by seeing busy Friday shift as a porter in my enlightening to put my hand to a I decided it might be fun and in their own organisation, but someone would go undercover wouldn’t be the last occasion that as it was certainly and not the first of reality television equivalents, was called to the emergency the patient flow. the clinical team were hampering because of a real detachment from sense of diminished accountability communication channels and a of the theatres system. Delayed playing in the inefficiency a part capacity as a surgeon, was surely unknowingly contributed to in my barrier, a factor that I will have the close knit clinical team. This I at once felt dismembered from no longer look me in the eyes, and my and the students would peers students. I was astonished that colleagues and now irreverent Later in the busy shift, I Later in the busy shift, I cannot claim to be a forebearer the tending were nurse, given the healthcare assistant and then assistance, initially directed to my requests for information and entering the patient’s cubicle, full swing, but immediately on an emergency in department had experienced the bustle of that it had been a while since I the obstetric ward. I will admit woman with hyperemesis to to a young department transfer a serious upper gastrointestinal patient with what seemed to be which had been activated for a of a major haemorrhage protocol, for tests and cross matching as part of blood samples to the laboratory occasion, I was asked to take a set the emergency On this department. I once shift, again found myself in interdisciplinary conflict can have. that failed teamwork and on patients and their experiences unintended yet detrimental effect but it serves to emphasise the or shocking to many clinical staff, sure this example will not be new quite ill on the bed next to us. I’m remained unamused and feeling credit of neither of us—the patient extended telling-off—and to the advance. Throughout this quite rebuked me for failing to call in intended arrival and who sternly was seemingly unaware of my faced who another senior nurse, On arrival at the obstetric ward I her parting dose of medicine. she hadn’t yet benefited from ward it was clear—twice over—that ward. However, en route to the and still nauseous patient to the I took the clearly uncomfortable administering some antiemetic, whosenior nurse, had just finished a thorough handover from the identified the patient and received Once I had formally shrift. short Nearing the end of my busy BMJ

| 21-28 DECEMBER 2013 DECEMBER 21-28 | VOLUME 347

DUNCAN SMITH Medical histories bmj.com/podcasts ЖЖGrowing up over the shop. Author John Jones talks about his paper at http://www.bmj.com/multimedia/podcasts bmj.com/video ЖЖWagner’s migraine. Carl, Anna, and Hartmut Göbel show how Wagner interwove migraine attacks into his music and libretti

bleed. After handing in the tubes to the laboratory and remaining on standby for a short period, I rounded off my shift. It was 3 o’clock in the morning, and I made my way home after what I considered to be a busy and exhausting shift.

Back to the day job Shortly after 6 am I received a Professor Ara Darzi moonlighting as a porter on the Friday night shift telephone call from the surgical registrar on call at the hospital in DENNIS ADRIAN my capacity as the named out of hierarchy to have their moment Later that morning, once the busy hospital and the necessity hours consultant for surgery. I was to speak, seek clarification, and patient’s bleed had been managed for speed and efficiency that informed that a middle aged man raise concerns. We now have and I had returned home, I received become the determinants that with a background of alcoholic strong evidence to show that a call from my gastroenterology compromise the unity and variceal disease with an acute such practices, and empowering colleague. He warned me in a spirit of staff and lead to the upper gastrointestinal bleed had members of the wider clinical and somewhat sarcastic tone, “As progression of inefficiency. All been resuscitated successfully non-clinical team, reduce mortality professor of surgery, Ara, you must too often, this is to the detriment and now required surgical and morbidity significantly.1 be informed . . . there’s a porter in of our personal interdisciplinary management. I immediately However, at the time we relied the hospital who is operating on relationships and ultimately the recognised the clinical details from on soft communication and the your patients—and the thing is . . . patient’s experience. It became the blood tubes I had deposited ease with which we interact on an he’s not that bad.” quite clear to me that the high earlier that morning. On arrival at interpersonal level to mitigate the pressure atmosphere inherent theatre, now dressed in scrubs and risks and provide members of the Value the whole team within many operating theatres clearly identifiable as a surgeon team with the voice and confidence It was an eventful shift and not and clinical settings often leads ready to operate, I received quite a to raise concern. Indeed, outside one I will forget in a hurry. I try us to underestimate the value that different welcome from that I had the operating theatre, where to hold in mind some of the others bring—whatever their role. I had only hours before. checklists are not routinely used, lessons I learnt that evening to learnt a great deal about inclusion During the short time for we still rely on these skills today. inform my practice as a surgeon and the importance of working preparation before surgery, I In my contrasting roles as a porter today. Of course, I can’t speak together for the common goal, but had the opportunity to reflect and the surgeon in theatre, I for all staff in the NHS, but if my also, crucially, the reality that you and consider the important role noticed that much more could be experiences are anything to go can never be completely certain of communication in relation to done by all levels of the hospital by, I think we should remain who you might be dealing with. patient safety. Back then, we didn’t team to empower each other and reassured that compassion is very Full details including references and competing interests are in the version on have checklists or a dedicated support better interdisciplinary much alive within the NHS. Often bmj.com. “time out” for each member of the communication. it is the frenetic atmosphere of a Cite this as: BMJ 2013;347:f7277 Slipper ulcers A patient with diabetes developed of the risk of using non-prescribed a foot ulcer after wearing new footwear, including slippers. slippers. Fourteen patients with Helen Hopkinson, Diabetes new ulcers were seen in the Department, Victoria Infirmary, Glasgow diabetic foot clinic in the first 10 G42 9LF, UK working days of 2012. Seven of Katherine Gardner, Medical School, University of Dundee, Dundee, UK them stated that new slippers for Gillian Harkin, Podiatry Department, Christmas were implicated in their Victoria Infirmary, Glasgow, UK ulceration. Appropriate footwear is Competing interests: We have read and a critical component of diabetic foot understood the BMJ Group policy on care. Patients are educated about declaration of interests and have no relevant interests to declare. the need for adapted shoes and Patient consent obtained. insoles, but also need to be aware Cite this as: BMJ 2013;346:f7376

BMJ | 21-28 DECEMBER 2013 | VOLUME 347 25 Medical histories

Growing up over the shop Living in hospital accommodation as a child gave Gareth Jones an unusual insight into his future career

It is Christmas Day in the workhouse . . . to administer City Lodge and lived and the guardians and their ladies, in a three storey mansion in the Although the wind is east, grounds. Have come in their furs and wrappers, Immediately above the hospital To watch their charges feast. entrance, our flat opened on to a George R Sims dark stairwell running up to the clock tower and down to the foyer Many medical families in mid-20th and a maze of terrazzo corridors, century Britain grew up in hospital excellent for roller skating. Within residence. I lived with my family the entrance were levers to open in what had been Cardiff Union the gates. Christmas day in the workhouse, built for 900 inmates. former workhouse had changed The workhouse was a feature of little since the turn of the century. British life until 1930. I was born The mayor, the former guardians six years later in this institution, and their wives, and the master now renamed City Lodge Hospital, were the main actors; the mayor where my father was senior carved the turkey in the dining resident medical officer, and we hall, served lunch, then toured lived there until he retired 18 the wards with his entourage. My years later, when I went to medical father brought up the rear. school. My home still had the features of Adjusting to war the workhouse: three storey stone My bedroom had three lancet buildings surrounded by high windows to monitor hospital walls, iron gates, and railings; a comings and goings by night and church; and a terrace of 12 cottages day. The composer Ivor Novello in which elderly couples could live. lived opposite the building. Soon Tall double wooden doors divided hospital gates and railings were the grounds into lawned exercise removed with oxyacetylene yards. These doors were closed at burners for the “war effort.” Coal night to isolate the hospital from was still delivered daily to the the outside world. The hospital hospital by horse drawn cart, continued to accommodate some which stopped on the weighbridge of the former workhouse inmates. beneath my window. Walls of Male and female inmates were sandbags or blast shutters covered segregated in wards, where the ground floor windows to reduce dominant colours were bottle green the implosion of glass fragments. and cream. I sampled the green Air raid shelters, including one leather padded cells (his ’n’ hers) deep underground, were built in in the male and female “mental” the grounds. Newly excavated From the land of lost content wards. Male vagrants, or casuals, deep water tanks supplied the were still housed in a building hospital’s mobile fire tender; I was night (January 1941) a parachute supplemented by Minadex tonic, with 45 cells and an adjacent warned that it was impossible to mine detonated above the streets malt, and Marmite. My father stone breaking yard. Ambulant climb out if I fell in and told never opposite the hospital killing 50 was physician, obstetrician, inmates ate in the hospital dining to pull my cap on too tightly so that people. and anaesthetist but had no hall under a barrel vault ceiling. it would float off and mark where My mother, formerly a City postgraduate qualification. Next to This, with its permanent stage, was I had drowned. One ward, empty Lodge ward sister, knew most of his armchair was a desk, radio set, the venue for the staff Christmas of patients, stood ready for air raid the staff and inmates. She kept ashtray, telephone, and obstetric ball and concert. The former casualties. I remember only one ready a small case to take to the and medical textbooks alongside workhouse master, Mr Roffey, air raid. Men in helmets carried me air raid shelter with our identity BMJs, most still rolled in brown married to the matron, continued off in the night to the underground cards, ration books, savings, and wrappers. He was permanently shelter lit with paraffin lanterns, birth certificates. I wore a metal “on-call,” and mid-mornings J Gareth Jones professor, Cambridge, UK where I was surrounded by identity disc and chain in case would often find him still in [email protected] babies in baskets. The same I was incinerated. My diet was pyjamas under a mixture of day

26 BMJ | 21-28 DECEMBER 2013 | VOLUME 347 Medical histories

My model aeroplane engine ran on a mixture of ether, paraffin, castor oil, and amyl nitrate available from the hospital pharmacist. This mixture came in handy on one caravan holiday when a cat presented itself with a fishhook in its mouth

that “Text books on gas attacks are My mother said that my now out of date.” father was a good anaesthetist Ambulant wounded soldiers were because he “never had a death dressed in “convalescent” sky blue on the table.” When I was 11 uniforms with red ties. Male inmates years old, he began taking me wore grey serge hospital suits and to the accident unit where he caps. One, with shell shock since the gave anaesthetics. I was soon first world war, rode his bicycle on holding the Schimmelbusch errands across the busy road junc- mask, pouring McFarlane’s tion to the shops opposite the hos- anaesthetic ether on to the gauze, pital, his arms see-sawing violently, and maintaining the airway much to the alarm of strangers. while someone else applied a Another had a gait that my father plaster of Paris. I gave a dozen told me, without enlarging, was typi- such anaesthetics before I was a cal of tabes dorsalis. Another, had teenager. syringomyelia and painless cigarette In 1948, with the introduction Eight years later he was giving burns on his fingers; the next time I of the National Health Service, the general anaesthetics saw a case was in the MRCP clinical. master disappeared; we moved into his mansion, and my father frogs. These, reeking of formalin, You can tell a Bart’s man became medical superintendent. he dissected to show me the A frequent visitor to the mess, and The 12 cottages were converted anatomical features. But this friend of my father, was Emrys into radiology and pathology did not arouse as much interest Harries (“Paget was at Barts, Pott departments. The vagrants’ as his eclectic book collection, was at Barts, and I was at Barts”), block became the occupational particularly my surreptitious superintendent of the City Isolation therapy workshop, where I readings of forensic medicine Hospital.1 They were regular users built a kayak and learnt to use texts and a book on morbid of the doctors’ billiard room. I was a lathe. The upper floor became anatomy that described how to the scorer and runner to the mess the asthma and allergy research carry out domiciliary postmortem for more cigarettes. Emrys had a unit. My anaesthetic practice examinations: “Block the key phenomenal memory, and their con- ended, although I had one more holes with paper, find a large flat versation, equally fluent in Welsh tutorial. My model aeroplane surface, like a grand piano, cover or English, ranged from poetry to engine ran on a mixture of ether, it with a rubber mackintosh . . .” clinical anecdotes. Thus, a patient’s paraffin, castor oil, and amyl family requested that a London neu- nitrate available from the hospital News of the world rologist should be asked to see their pharmacist. This mixture came Years later, after the hospital relative who was under Emrys’s care. in handy on one caravan holiday had been demolished, the listed He met the great man at Cardiff sta- when a cat presented itself with a entrance block was being con- tion and introduced himself, saying: fishhook in its mouth. My father verted into luxury flats. I had a look “Sir Francis Walshe, I’m Emrys Har- showed me how to remove the around. Workmen were putting the ries. There’s a mistake on page [x] hook by wrapping the cat in a finishing touches to what had pre- of your neurology textbook.” After towel then anaesthetising it by viously been the billiard room. As a game of billiards Emrys and my holding its muzzle in a jam jar I left one said, “You are from the father would adjourn to the wards containing an inch of model News of the World aren’t you?” I clothes, a white coat topped off to see interesting patients. aeroplane fuel. responded, “How did you know?” with a raincoat, tin hat, and gas Emrys’s forte was giving My father hoped that I might “Oh, we guessed because Charlotte mask. One of his notebooks had streptomycin by cisternal puncture become a doctor, although I had Church [the singer] is living in the 50 pages of comments from a for tuberculous meningitis. I planned to be an aeronautical clock tower and she’s just thrown Major Anderson dealing with became his patient when I had engineer. One day, we collected out her boyfriend.” explosives and gas attacks, of scarlet fever. In the same ward was from the mortuary a glass Competing interests: None declared. which my father had had firsthand Harold Watkins, economist and specimen jar containing a human Provenance and peer review: Not experience in the Royal Army BBC Wales broadcaster, recovering brain in formaldehyde that he commissioned; not externally peer reviewed. Medical Corps in France during from pneumonia.2 Emrys plied had put aside for me years before. 1 G Emrys Harries obituary. BMJ 1960;2:952. www.bmj.com/ the previous war. After mentioning him with anecdotes and cigarettes Later a human foot, obtained after content/2/5203/952.1. that “nitrogen mustard smells and later put me in an iron lung so an industrial accident, appeared 2 Watkins HM. Life has kept me young. Watts and Co, 1951. of onions and Lewisite of that I could experience it closing in a bucket in our kitchen together geraniums,” the major pointed out around my neck. with various dogfish, rabbits, and Cite this as: BMJ 2013;347:f6922

BMJ | 21-28 DECEMBER 2013 | VOLUME 347 27 Medical histories

Surgery and anaesthesia during the heroic age of Antarctic exploration (1895-1922) During the heroic age of Antarctic exploration, general anaesthesia was given on at least 11 occasions. H R Guly describes some of the surgical procedures performed, including on the doctors themselves

uring the heroic age of Antarctic­ exploration, there were 18 exploring and scientific expeditions to the Ant- arctic: 14 of these took doctors who performed at least 11 surgical proce- Ddures under general anaesthesia (table).1‑14 Other surgery is described with no mention of the type of anaesthesia. This paper describes, for histori- cal interest, some of the operations performed.

Surgery under general anaesthesia The upturned boat on Elephant Island that served as the operating theatre for an amputation The first general anaesthetic recorded as hav- ing been given on an Antarctic expedition was The worst conditions for surgery undoubt- [photographer Frank] Hurley took charge of the during Robert Scott’s Discovery expedition edly occurred during Ernest Shackleton’s second fire and succeeded in keeping it going without (1901-04). The chief engineer required a den- expedition (on the Endurance in 1914-17). After making any smoke in the hut. We managed to tal extraction for an abscess and anaesthetist the ship had been trapped in the pack ice and get the temperature up to 80° [Fahrenheit; 27°C] Edward Wilson described: eventually crushed, the men were forced to camp and the CHCl3 vaporised splendidly. We had on the ice for six months. When this ice broke up, only 8 oz [227 g] of chloroform, but although He will not undergo any treatment at all— the operation lasted 55 minutes, I only used they sailed and rowed for a week in small boats to simply will not stand the pain of having his an ounce . . . The operating table consisted of Elephant Island where two upturned boats were gum lanced or a stump drawn. So . . . I gave him packing cases, and I had another one for a stool. ether, and [surgeon Reginald] Koettlitz drew converted into huts in which the 22 men lived in We had no sterilised overalls to get into: we a tooth and we made a job of it. He was under squalor (figure, above). Percy Blackborrow, who merely stripped to our vests . . . Blackboro’ was nearly 25 minutes and the whole thing was very had been a stowaway but after being discovered soon round from the anaesthetic and asked for successful. He knew absolutely nothing of what was incorporated into the ship’s crew, developed that now rare luxury—a cigarette.6 had been done, went off almost immediately. frostbite on the boat journey and his toes became There was much amusement on deck over his gangrenous. A month later, it was decided that he Leonard Hussey, a meteorologist but who loud and amusing songs and unparliamentary needed surgery, which anaesthetist Alexander qualified late as a doctor, gave more informa- remarks as he was recovering from the effects Macklin described in his diary: tion: “The patient’s head was placed as near to of the ether. He was only sick once, and had our little oil-drum stove as was possible and the practically no after effects.1 Today [surgeon James] McIlroy operated on Blackboro’, amputating all the toes of the stove was then stoked up with lavish supplies of One wonders whether the patient would have seal-blubber. This helped the chloroform to vola- left foot. I gave CHCl3: he took his anaesthetic been reassured by Wilson’s further note: “I gave very well and was not at all sick afterwards. tilise, which otherwise would have been difficult it him on the practical experience I had gained We managed to sterilise instruments pretty owing to the cold.”7 Hurley added a bit more col- by receiving it myself last year” (when having an well by using a primus and hoosh-pot [cooking our, describing “the feeble glimmer of blubber axillary abscess incised).1 pot]. We heated up water over the stove and lamps” and “[maintaining] the temperature of

Surgery performed under general anaesthesia Expedition Operation Surgeon Anaesthetist Anaesthetic Notes Reference Surgery to people Discovery expedition (1901-04) Dental extraction for abscess Reginald Koettlitz Edward Wilson Ether — 1 First German Antarctic expedition Drainage of prostatic abscess Hans Gazert Non-medical person Chloroform — 2 (1901-03) Nimrod expedition (1907-09) Enucleation of eye for trauma Eric Marshall Alister Forbes Mackay Chloroform — 3,4 Nimrod expedition Amputation of toe for frostbite Eric Marshall Alister Forbes Mackay Not stated — 5 Endurance expedition (1914-17) Amputation of toes for frostbite James McIlroy Alexander Macklin Chloroform — 6-8 Pourquoi Pas? expedition (1908-10) Amputation of fingers Jacques Liouville Ernest Gourdon Chloroform Patient was a whaler, not 9 following trauma (a medical student) an expedition member Pourquoi Pas? expedition Repair of foot wound involving joint Probably Jacques Liouville Probably Ernest Gourdon Chloroform — 10 Second German Antarctic expedition Appendicectomy Wilhelm Goeldel Non-medical person Ether Patient was Dr Ludwig Kohl 11 Australasian Antarctic expedition Dental extraction Leslie Whetter Leslie Whetter Chloroform Patient was 12 (1911-14) Dr Archibald McLean Surgery to dogs Australasian Antarctic expedition Repair of neck wound Archibald McLean Leslie Whetter Chloroform — 13 Endurance expedition Repair of laceration around eye Probably James McIlroy Probably Alexander Macklin Chloroform — 14

28 BMJ | 21-28 DECEMBER 2013 | VOLUME 347 The upturned boat on Elephant Island that served as the operating theatre for the amputation of Blackborrow’s toes TATIANA GLEBOVA, 1928 FROM INSIDE THE RAINBOW, REDSTONE PRESS REDSTONE RAINBOW, THE INSIDE FROM 1928 GLEBOVA, TATIANA

the ‘theatre’ at 50° by stoking up the bogie-fire roform, with leave to act as we thought right. nothing loath to perform the first operation with penguin skins.”8 The unsanitary conditions Found eye collapsed, cornea torn right across in Antarctica, gladly prepared for the event. were added to by the presence of a patient with centre, lens absent, much of the vitreous humour The wardroom table became the operating a discharging buttock abscess who was too sick had escaped and retina torn. We unanimously table. I volunteered as nurse, and rolled up to be moved. decided to excise eye. Operation was success- my sleeves to play the part convincingly, Modern advice would be to wait much longer fully performed although circumstances adverse while Koettlitz brought from their hiding- 3 places a formidable array of knives, before amputating in frostbite, but amputation owing to lack of space, appliances etc.” A typed pincers, scissors, lint, gauze and bandages, (for open fractures as well as for frostbite) was transcript of the diary (presumably by Marshall explaining ghoulishly the exact function resorted to at a much earlier stage in the pre- himself) gives additional details that are not in of each. Armitage took charge of the phial antibiotic era, because of the life threatening his original: “one pair of curved scissors only of patent freezing mixture, and the rest of consequences of infection. were available. I made . . . hooks and retractor the wardroom gathered round. The effort Only one abdominal operation seems to have from rigging wire. Mackay’s Edinburgh method at first was not a success, for the freezing been performed. The second German Antarc- of giving anaesthetics with a towel added to the mixture functioned so thoroughly that the tic expedition (1911-13) sailed with two doc- difficulties. Mackintosh lay on the cabin floor, knife would not penetrate the skin, and while tors and one of them (Ludwig Kohl) developed on which we knelt, and the only light was an oil we waited for it to thaw a little, all joined in appendicitis. Expedition leader Wilhelm Filchner lamp.”4 Interestingly, Marshall had been quali- terrifyingly reassuring remarks to the patient. reports: “Assisted by the captain, the first officer fied about 18 months, during which six months Again the knife was applied, and this time, . . . and the steward, his colleague [Wilhelm Goe- had been spent travelling to the Antarctic: how to our intense satisfaction, blood flowed. ldel] immediately started the operation; it took 90 many modern doctors, much longer qualified Our questions as to whether it hurt or not brought a most emphatic ‘Yes’. But the cyst minutes . . . Occasionally one of the . . . [members than Marshall, would contemplate doing such was removed and the cheek stitched up, and of the mess] would peep down through the sky- surgery? Royds was distinguished for the rest of his light into the operating room, in order to report life by a diminutive scar, a record of the first Local anaesthesia 16 on the progress of the work which was being car- surgical operation performed in Antarctica. ried out on the dining table . . . Fortunately the Much local anaesthetic was obviously used— sea was mirror-smooth and calm throughout the Edward Atkinson of Scott’s Terra Nova expedi- In summary, conditions for surgery in the operation. The engine was stopped during this tion (1910-13) said that more would have been Antarctic during this era were makeshift and far period.”2 Kohl got up two days after his opera- useful, but I have found no mention of its use from ideal. Much local anaesthetic was used but tion, but when the ship reached South Georgia other than for one dental procedure12 (and the it is frustrating that we do not have more details he left the expedition to convalesce. topical use of cocaine in the eye). of these cases. Two general anaesthetics were On Shackleton’s Nimrod expedition (1907- One operation, on the Discovery expedi- given to expedition doctors. Therefore, when 09), second mate Æneas Mackintosh was tion, was performed under what was, presum- planning medical care for an expedition—even struck in the eye by a hook while the ship was ably, ethyl chloride spray, although this was now—consideration needs to be given to the fact unloading stores. Surgeon Eric Marshall’s diary not on the list of medical equipment supplied that a doctor is as likely to become ill or injured says that he “examined him and found what to that expedition.15 Physicist Louis Bernacchi as any other expedition member. appeared to be a portion of retina protruding described: H R Guly retired consultant, Emergency Medicine and through eye. [Ernest] Joyce tells me that when When [first lieutenant Charles] Royds was British Antarctic Survey Medical Unit, Derriford Hospital, Plymouth PL6 8DH, UK [email protected] he fell he saw lens lying on his cheek. Kept him operated upon for a cyst on his cheek, the under, 1st atropine and cocaine, until 2.30, general reaction was one of pleasurable Full details including references and competing interests are in the version on bmj.com. when assisted by [Alister Forbes] Mackay and interest rather than sympathy for the [ship surgeon Rupert] Michell we gave him chlo- unfortunate victim. Dr [Reginald] Koettlitz, Cite this as: BMJ 2013;347:f7242

BMJ | 21-28 DECEMBER 2013 | VOLUME 347 29 Medical histories

A prophet to modern medicine: Ernest Amory Codman Caitlin Hicks and Martin Makary describe the life of the pioneer of healthcare registries

emarkably, the outcomes of medical chief of surgical services, Dr Francis Harrington. procedures are rarely tracked today. In 1900, he was appointed assistant in clinical As a result, establishing the best operative surgery. Through his work with Dr medical treatment can be difficult. Walter­ Bradford Cannon, among others, Codman Trials to establish best practices are developed strong x ray imaging skills, which led Roften isolated, underpowered, and lag behind to a career in orthopedic surgery. He developed widespread adoption. Moreover, standardized an interest in shoulder surgery and pioneered a methods to capture complications are lacking rotator cuff operation. His case based textbook for most interventions. of shoulder surgery, The Shoulder, is still con- This problem is as old as medicine itself. But sidered one of the pre-eminent textbooks on one man boldly sought to challenge the status shoulder disease. quo and tackle the problem—Ernest Amory C­odman (fig 1). Codman was a surgeon who Reality check believed that by prospectively tracking outcomes Codman’s true passion was the science of we can learn from our patients and advance the quality improvement. He proposed that, “If field of medicine quickly. He helped usher in the some arrangement could be made by which Fig 1 | Passionate about quality improvement concept of the regular morbidity and mortality the house officer should see these late results, conference and started the first national registry it would be very instructive for them, for I feel Caitlin W Hicks surgery resident, Johns Hopkins University in American healthcare. Given the challenges of sure that the house officer in graduating from School of Medicine, Halsted 610, Department of Surgery, medicine today—endemic rates of medical errors, this institution gets a very much more favorable Johns Hopkins Hospital, Baltimore, MD 21287, USA wide variations in quality, and an expanding cost idea of the results of surgical operations than director of surgical quality and safety, Johns Martin A Makary 2 Hopkins Hospital, Halsted 610, Department of Surgery, Johns crisis—many physicians are calling for Codman’s he is really justified in having.” Codman was Hopkins Hospital, Baltimore, MD 21287, USA basic tenants to be re-visited and applied. not afraid to challenge the status quo, and he [email protected] Born in 1869, Ernest Amory Codman was a developed the idea of tracking patient outcomes Thanks to Scott H Podolsky, director of the Center for the History of Medicine at Harvard University’s Countway natural academic. He won the prestigious found- further to form the concept of the “end result Medical Library; Jack Eckert, public services librarian at er’s medal at St Mark’s School as a high school system.” He described this concept in a publicly Harvard University’s Countway Library of Medicine; and Wen senior and graduated with honors from Harvard disseminated pamphlet in 1914: “Every hospi- T Shen, assistant professor in residence, Department of 1 Surgery, University of California San Francisco for their help College in 1891. He undertook his medical edu- tal should follow every patient it treats long in obtaining invaluable biographical information and figures cation at Harvard Medical School, where he met enough to determine whether the treatment has related to Ernest A Codman’s life. Harvey Cushing. In 1895, Codman graduated been successful, and then to inquire ‘if not, why Competing interests:: MAM receives publisher royalties for medical books. from medical school and joined the staff at Mas- not’ with a view to preventing similar failures in 1 Provenance and peer review: Commissioned; not externally sachusetts General Hospital as an assistant in the future.” peer reviewed. anatomy, where he became the apprentice of the Codman believed that by understanding the

Fig 2 | The “Back Bay golden goose ostrich” cartoon highlighted how fee-for-service enriched doctors through poor quality care and encouraged overtreatment

30 BMJ | 21-28 DECEMBER 2013 | VOLUME 347 Content of Ernest Codman’s Medical histories end result cards Symptoms or conditions for which the patient seeks relief The diagnosis that the to resign as chairman of the society. Today, rec- treating doctor believes to be ognizing Codman’s achievements and prophetic the cause of symptoms and vision, Harvard has come full circle; the ostrich on which treatment is based cartoon currently hangs in the Harvard medical The general plan or important points of the school library, and the Massachusetts General treatment given Hospital’s quality and safety department is Complications before the named the Codman Center. patient left the hospital The diagnosis that proved Concept of national healthcare registry was born correct or final at discharge Despite these setbacks, Codman pushed on The result each year with his cause. In 1920, he developed the first 9 Fig 3 | Dr Codman’s national registry of patient outcomes afterwards national registry to track bone sarcoma cases after receiving a $1000 gift from a patient’s fam- results of patient care, doctors could change tals” through “the establishment in each hospi- ily (fig 3).1 The American College of Surgeons their practice to improve future care. He also tal of a follow-up system of tracing the outcome (ACS) soon followed with an additional $8000 pushed for transparency of results, so that physi- of treatment given to each individual patient.”2 in support. However, the implementation of cians could learn from each other’s mistakes and To start, the committee asked that all hospitals patient tracking proved more difficult than antici- patients could make informed decisions about adhere to a standardized set of basic guidelines7: pated; despite multiple solicitations to the 7000 where to obtain medical care. • Each hospital should have a medical staff members of the ACS, Codman collected only 17 Unfortunately, the administration at Mas- • The members of the medical staff should cases to add to his database.10 Nonetheless, the sachusetts General Hospital did not entirely be chosen on the basis of graduation from concept of the national healthcare registry was support Codman’s push to implement the end medical school, competency, and character born and has since been adopted throughout result system. But that wasn’t the only thing that • There should be regular staff meetings to the world. frustrated Codman. He disparaged the hospital’s review cases Codman died in 1940 in Ponkapog, paternalistic approach to hiring; he believed • Medical records should be written and filed Massachusetts,­ but his legacy lives on. Cod- in meritocracy and advocated vehemently for for all cases man’s end result system is now the foundation adjusting the hospital’s hiring and promotion • Each hospital should have a clinical for many quality improvement efforts, and policies. He eventually resigned from his full laboratory and radiology section. medical transparency is emerging as a priority time position in 1911 because of disagree- These standards were based on Codman’s for many healthcare systems. In addition, trans- ments about the hospital administration’s lack belief in the value of meritocracy and embodied parency is a first step in current endeavors to of action regarding his ideas on both topics. his end result system, including the concept of tackle dangerous and costly variations in care. morbidity and mortality conferences and patient The problem of overtreatment, which Codman Ends and means tracking. Only 89 of the 692 existing hospitals also warned about, is also the subject of many Codman then started his own hospital, called met these basic standards, and Codman’s efforts new efforts. Most recently, in a major 2012 the End Result Hospital, which required all phy- were widely rebuffed at the time.8 But others saw report, the Institute of Medicine concluded that sicians who practiced there to follow his system.1 the value of Codman’s insights, and eventually as much as a third of all US healthcare costs may Codman kept “end result cards” for each patient his ideas were endorsed. be unnecessary and may not improve health he treated, on which he recorded demographic, Codman’s attempts to promote his system outcomes. disease, treatment, and outcome data (box). were also opposed in the Boston community. To Recent studies have shown how patient out- From 1911 to 1916, he meticulously recorded raise awareness of his cause, Codman presented come registries can lead to scientific discovery the results for all 337 patients treated, during the “Back Bay golden goose ostrich” cartoon at and sustained improvements in quality. Despite which time 123 errors were recorded. Ironically, a meeting of the Suffolk District Medical Soci- these benefits, however, their adoption has this error rate is close to the 25.1% rate described ety in Boston in 1915 (fig 2).8 The controversial been limited. Registries are expensive and they in a 2010 Harvard study.3 cartoon depicted an ostrich (representing the require auditing, outcome definitions, and sound In keeping with his call for transparency, Cod- public/patients, labeled by a section of Boston data collection for outcomes to be measured in a man paid to publish the results of each of the known as Back Bay) laying golden eggs with standardized manner, as well as risk adjustment cases in his landmark book, A Study in Hospital its head buried in the sand. A caricature of the to make benchmarking fair. In a recent review, Efficiency: As Demonstrated by the Case Report of Harvard president, A Lawrence Lowell, contem- we found that only 19 of 117 medical specialties First Five Years of Private Hospital.4 He thought plated whether his employees could continue recognized by the American Medical Associa- that sharing mistakes and experiences in a pub- making money if the truth about the outcomes tion house a clinical registry or are affiliated to lic forum would improve quality and advance of their clinical services was known publicly. a registry (H Lyu and colleagues, unpublished the science of medicine. The cartoon highlighted how the fee-for-service data, 2013). The new transparency movement In 1912, Codman helped develop what is system made doctors rich through poor quality to make healthcare registries more common and known today as the Joint Commission for Accred- medical care and encouraged overtreatment. It more robust should credit the man who pioneered itation of Hospital Organizations (JCAHO).5 noted how Harvard’s leaders oversaw ethical the cause—Dr Ernest Amory Codman. Together with Dr Edward Martin, a Philadelphia actions and suggested that this broken health- All three figures are reproduced with permission from Boston based gynecologist, Codman formed and then care marketplace created a moral dilemma. One Medical Library in the Francis A Countway Library of Medicine. chaired the Committee on the Standardization trustee was depicted scratching his head and References and competing interests are in the version on of Hospitals.6 The committee’s stated purpose questioning the system. The cartoon caused bmj.com. was to raise “the standard of American hospi- much indignation. Codman was quickly asked Cite this as: BMJ 2013;347:f7368

BMJ | 21-28 DECEMBER 2013 | VOLUME 347 31 MEDICAL HISTORIES

“Compulsive plague! pain without end!” How Richard Wagner played out his migraine in the opera Siegfried Carl Göbel and colleagues explain why listening to Wagner can sometimes be a headache

he medical problems of composer and gradually becoming more intense. This rises to poet Richard Wagner have been widely become a directly tangible almost painful pulsa- investigated. He is known to have had tion (fig 1). While the listener experiences this functional disorders, skin disorders, frightening headache sensation, Mime is seen acute infections, and minor ailments, pounding with his hammer, creating the acous- Tas well as heart disease.1‑4 However, the condition tic trigger for the musically induced throbbing,

that Wagner described as the “main plague of painful perception. At the climax Mime cries out: METZNER JÖRG his life”5 was recurring headaches. The details “Compulsive plague! Pain without end!” presented in his writings and letters5‑7 as well as Wagner carves out the temporal and qualita- Fig 2 | Hammered. Anthony Pilavachi’s production the numerous diary records of his second wife, tive aspects of the headache phenotype in aston- of Siegfried at Theater Lübeck (2009) shows Mime Cosima,8 9 confirm that Wagner had a severely ishing detail. This has also been recognised by as a laboratory scientist whose hammering leads to an intense headache disabling migraine disorder producing frequent renowned opera stage directors. In Anthony 10 migraine attacks, sometimes with aura. Here, Pilavachi’s stage direction of Siegfried at Theater I began to sketch the overture [of Siegfried] we show how Wagner deeply interwove his Lübeck (2009), Mime explicitly experiences a on September 22. That time one of the main migraine attacks and auras into his music and severe headache. The musical description of plagues of my life arose, causing critical distress. libretti, using the opera Siegfried (1876), the third migraine is strengthened by Mime’s painful facial A tinker had established himself opposite our part of the Ring Cycle, as an example. expression, the way he holds his trembling head, house, and stunned my ears all day long with and ultimately by avoiding movement and rest- his incessant hammering. In my disgust at never Musical depiction of migraine ing on the floor (fig 2). Similarly, in Claus Guth’s being able to find a detached house protected The first scene of act 1 of the opera Siegfried pro- Siegfried stage direction at Hamburg State Opera from every kind of noise, I was on the point of vides an extraordinarily concise and strikingly (2009), Mime takes an overdose of aspirin tablets deciding to give up composing altogether until vivid headache episode. The music begins with a in a desperate attempt to relieve the pain (fig 3, the time when this indispensable condition pulsatile thumping, first in the background, then www.youtube.com/watch?v=GJbD2Ck0pRY). should be fulfilled. In his memoirs, Wagner gives an account of Carl H Göbel research fellow, [email protected] the symptoms he had in September 1856 when In a letter to Franz Liszt on 27 January 1857,6 Anna Göbel research fellow Hartmut Göbel professor of neurology, Kiel Headache and he was composing these bars. The words show a Wagner voiced the suffering and disability Pain Centre, Heikendorfer Weg 9-27, 24149 Kiel, Germany marked phonophobia5: caused by the “nervous headaches” he had while working on Siegfried:

My health, too, is once more so bad, that for ten days, after I had finished the sketch for the first act of Siegfried, I was literally not able to write a single bar without being driven away from my work by most tremulous headaches. Every morning I sit down, stare at the paper, and am glad enough when at least I get as far as reading Walter Scott. The fact is, I have once more over-taxed myself, and how am I to recover my strength? With Das Rheingold I got on well enough, considering my circumstances, but Die Walküre caused me much pain. At present my nervous system resembles a pianoforte very much out of tune, and on that instrument I am expected to produce Siegfried. Well, I fancy the strings will break at last, and then there will be an end. We cannot alter it; this is a life fit for a dog.

Scintillating aura

PETRUCCI INTERNATIONAL MUSIC SCORE LIBRARY PROJECT LIBRARY SCORE MUSIC INTERNATIONAL PETRUCCI An example of the musical depiction of the visual Fig 1 | “Migraine headache leitmotif” in Siegfried, act 1, scene 1 disturbances of a typical migraine aura can also

32 BMJ | 21-28 DECEMBER 2013 | VOLUME 347 MEDICAL HISTORIES MONIKA RITTERSHAUS MONIKA Fig 3 | Claus Guth’s production at Hamburg State Opera (2009) shows Mime (left) in bed with headache tablets and water within reach

be found in act 1, scene 3 of Siegfried. It is intro- An analysis of the perceived scintillation rate Wagner thought the completed act 1 of duced by a scintillating, flickering, glimmering of migraine aura with an objective task reported S­iegfried exceeded all expectations.13 However, he melody line with an underlying zigzag pattern, that the rate of flicker averages 17.8 Hz.11 Wagner had to interrupt his work a year later in the middle which integrates the previously mentioned composed these bars in two-four time, and the of the second act. In a letter to Otto Wesendonck “migraine leitmotif” (fig 4). Mime, irritated, string instruments responsible for the musical on 22 December 1856, Wagner writes: sings: “Loathsome light! Is the air aflame? What scintillation (violins and violas) play 16 demi- I fear soon everything will leave me—eventually is it flaring and flashing, glittering and whirring, semiquavers per bar. This corresponds to 16 Hz also my desire to work. I cannot motivate what is swirling and whirling there and flickering at an assumed tempo of 120 beats per minute, myself for Siegfried anymore, and my musical around? It glistens and gleams in the sunlight’s close to the experimentally determined rate of sense, just like my mood, is falling into gloom. glow. What is it rustling and humming and blus- flicker during a migraine aura. Most conduc- Everything appears truly flat and superficial! Do tering there?” tors choose a slightly slower tempo, but in the not just think of my loneliness, my health is also The text expresses typical visual disturbances rehearsal remarks for the Siegfried premiere in heavy and leaden. seen in a migraine aura. The music illustrates 1876, Wagner gives clear instructions for faster this further by imitating scintillations and con- tempi to conductor Hans Richter: “If you were not The interruption lasted a total of 12 years— tinuously extending visual disturbances, char- all such tedious fellows Das Rheingold would be act 2 was completed in 1864, and it was acteristics of a typical migraine aura. In Anthony finished within two hours.”12 The experimentally 1871 before Wagner finally completed the Pilavachi’s Lübeck production (2009), the scene determined flicker frequency in migraine prob- opera. The premiere took place in Bayreuth on is intensified by flickering light, from which ably also gives important clues about the perfor- 16 August 1876. Mime tries to turn away in pain. mance speed that Wagner intended. Competing interests: None declared. Provenance and peer review: Not commissioned; not externally peer reviewed. 1 Franken FH. Die Krankheiten großer Komponisten. Niccolo Paganini, Richard Wagner, Georges Bizet, Gustav Mahler, Max Reger. Noetzel, 2004. 2 Otte A, Wink K. Kerners Krankheiten großer Musiker. 6th ed. Schattauer, 2008. 3 Eggebrecht HH. Terminologie der musikalischen Komposition. Steiner, 1996. 4 Gould GM. The ill-health of Richard Wagner. Lancet 1903;162:306-13. 5 Wagner R. Mein Leben. Bruckmann, 1911. 6 Wagner R. Briefwechsel zwischen Wagner und Liszt 1854- 1861. Breitkopf und Härtel, 1887. 7 Friedrich S, ed. Richard Wagner: Werke, Schriften und Briefe. Directmedia Publishing, 2004. 8 Wagner C. Die Tagebücher, Band 1. 1869-1877. Piper, 1976. 9 Wagner C. Die Tagebücher, Band 2. 1878-1883. Piper, 1977. 10 Göbel H. Schwan-Lenz-Abendstern: Wagners schönste Stellen. Frankfurter Allgemeine Zeitung 2013;181:27. 11 Crotogino J, Feindel A, Wilkinson F. Perceived scintillation rate of migraine aura. Headache 2001;41:40-8. 12 Haenchen H. Werktreue und Interpretation. Erfahrungen eines Dirigenten. Brahms, Wagner, Mahler, Zeitgenossen,

PETRUCCI INTERNATIONAL MUSIC SCORE LIBRARY PROJECT LIBRARY SCORE MUSIC INTERNATIONAL PETRUCCI Kulturpolitik. Pfau-Verlag, 2013. 13 Glasenapp CF. Das Leben Richard Wagners in 6 Büchern. Fig 4 |“Migraine aura leitmotif” in Siegfried, act 1, scene 3 uses a scintillating melody line with an Breitkopf and Härtel, 1905. underlying zig-zag pattern Cite this as: BMJ 2013;347:6952.

BMJ | 21-28 DECEMBER 2013 | VOLUME 347 33