p

In this issue Leading article Laparoscopic vagotomy: an operation for the 1990s? Review-Lymphocele NZ Orthopaedic surgery N\N . IAII. 41 . ..," fl The Manchester Orthopaedic Database .y -I.Q, t. 1. - Audit of arthroscopy \,e .-k A. 11 .-- e -. _ Teaching undergraduates orthopaedics and trauma -,\- " 4$ Head and neck surgery Facial basal cell carcinoma treated by microvascular tissue transfer Neck swellings which mimic branchial cysts in HIV-positive patients Gastrointestinal surgery Cell proliferation and tumour growth in intestinal cancer Outcome of biliary surgery in unknown cirrhotics Vascular surgery Lower limb ischaemia in the octogenarian: is limb salvage surgery worthwhile? Surgery in general Cost-effectiveness of treatments for deep vein thrombosis An emergency daytime theatre list: utilisation and impact on clinical practice 437 Intraperitoneal bupivacaine for effective pain relief after laparo- scopic cholecystectomy Tarig Chundrigar, A Richard Hedges, Russ Morris and Jeffrey D Stamatakis 440 Surgical technique-A simple technique of umbilical port closure in laparoscopic cholecystectomy Arifullah Khan, M N Siddiqui and Mushtaq Ahmed 441 An emergency daytime theatre list: utilisation and impact on clinical practice A P Barlow, D A Wilkinson, M Wordsworth and I A Eyre-Brook 445 Lower limb ischaemia in the octogenarian: is limb salvage surgery worthwhile? T S O'Brien, P M Lamont, A Crow, D R Gray, J Collin and PJ Morris 448 Letters to the Editor 449 Comment How long do patients convalesce after inguinal herniorrhaphy? Current principles and practice-Non-woven disposable theatre gowns for 'high-risk' surgery-Comparative vascular audit using the POSSUM scoring system-An improved method for oesophageal intubation -Gunshot wounds of the colon: ballistic considerations-Benign thyroid disease and vocal cord palsy-Blood transfusion does not have an adverse effect on survival after operation for colorectal cancer-Pro- vision and acceptability of day case breast biopsy: an audit of current practice 453 Books received 455 Author index 460 Subject index

Copyright ( 1993 by the Annals of The Royal College of Surgeons of England This publication is copyright under the Berne Convention and the International Copyright Convention. All rights reserved. Apart from any relaxations permitted under national copyright laws, no part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the prior permission of the copyright owners. Permission is not, however, required to copy abstracts of papers or of articles on condition that a full reference to the source is shown or to make single photocopies of articles provided the copy is for the personal use of the copier or of a client library. Multiple copying of any of the contents of the publication without permission is always illegal. Advertisements. All communications should be addressed to ADmedica, Stevenson, Haddington, East Lothian EH41 4PU Telephone 062 082 3383, Fax 062 082 3325. While every effort is made by the publishers and Editorial Committee to see that no inaccurate or misleading opinion or statement appears in this Journal, they wish to make it clear that the opinions expressed in the articles, correspondence, advertisements, etc, herein are the responsibility of the contributor or advertiser concerned. Accordingly, the publishers and the Editorial Committee and their respective employees, officers and agents accept no liability whatsoever for the consequences of any such inaccurate or misleading opinion or statement. Published by The Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London WC2A 3PN Printed and bound in Great Britain by Headley Brothers Ltd, The Invicta Press, Ashford, Kent TN24 8HH Typeset by Apek Typesetters, Avon House, Blackfriars Road, Nailsea, Bristol BS19 2DJ Subscription rates. United Kingdom and Ireland £82.00 per annum post free. Overseas £94.00 per annum post free. Payments for subscriptions to overseas addresses must be paid in sterling by cheque drawn on a bank in the UK. Orders can also be placed locally with any leading subscription agent. Single copies: Inland £15.00, Overseas £17.00 per copy post free. Quotations for full volumes and back numbers will be given on request. All enquiries concerning subscriptions and sales should be addressed to the Subscription Manager, Annals of The Royal College of Surgeons of England, c/o Headley Brothers Limited, The Invicta Press, Queens Road, Ashford, Kent TN24 8HH. Claims within 6 months of issue dates. THANKS TO REFEREES

Once again I should like to thank most warmly the referees who give freely and most generously of their time to read and improve the quality of the papers published in the Annals. It is often a seeming thankless task, especially if a submitted paper has underlying quality but needs major revision before it can be published. I realise that many referees spend a considerable time on making constructive suggestions and I know that the authors, as well as the Editor, appreciate this enormously. My sincere thanks to you all. BARRY JACKSON Editor The following have reviewed papers between August 1992 and 31 August 1993

Ackroyd C E Darke S G Heatley F W Matthews J A Sauven P D Adam A N Davies D M Hennessy T P J Maurice-Williams R S Schofield P F Addison N V Davis P K B Henry M M Mayou B J Scott K W M Akle C A Dawson J L Hilton C J McBrien M P Senapati A Alexander-Williams J Deane G Hobbs K E F McCloy R F Shand W S Ayers A B Devlin H B Hobsley M McColl I Shorthouse A J Dewar E P Hogbin B M McDonald P J Skipper D Bailey M E Doig R L Hoile R W McKelvie P Slater N G P Baird R N Donaldson D R Holme T C McKibbin B Smith M A Baird P R E Donnell S C Horrocks M Menzies-Gow N Spencer G T Bancewicz J Donovan I A Howard E R Mercer D Stableforth P G Barrie J L Dowling B L Huddy S P J Meyrick-Thomas J Strahan J D Bartolo D C C Dudley N E Humphreys W V Miller R A Swann M Baskerville P A Duffett R H E Hurst P A E Monson J R T Sweetnam D R Bates T Duffy T J Irving M H Morgan B D G Baum M Dunn D C Morris P J Taylor B A Beard J D Dussek J E Jackson S A Mortensen N J M Taylor P R Bell P R F Jamieson C W Mosley J G Taylor T V Earlam R J P Temple J G Benjamin I S Ede R Jeffery J Motson R W Bennett J P J Johnson C D Mulholland R C Thomas M H Edwards P Thomas P A Benson E A Kapila L Mulligan P J Bentley G Emberton M Thompson R P H Espiner H J Keighley M R Negus D Thompson M R Blandy J P Kelly M J Neoptolemos P Boggon R P Evans D S J Thomson J P S Evans J N G Kerr A G Timmons M Bolton J P Kester R C Odling-Smee G W J Boulos P B Eykyn S J Owen W J Tiptaft R C Kettlewell M G W Owen E Treacher D F Bowen Wright R M Faber R G Kingsnorth A N RTC Bown S G Farndon J R Kirby R S Parks T G Venables C W Britton D C Farrands P A Kirk R M Pearson J B Vickers R H Browett J P Fentiman I S Pearson T C Kirkham J S Wade P J F Brueton R N Finan P J Kissin M W Peel A L G Bultitude M I Fitzgerald Phipps A R Ward H C Burge D M O'Connor A F Lam S J Pietroni M C Wastell C Burnand K G Fixsen J A Lane R H S Pither C E Watkin D F L Foley R J E Layer G T Price Thomas J M Weir N F Leaper D J Wells A D Callum K G Fowler C G Quick C R G Carruth J A S Leopard P J Wellwood J M Carter D C Gallanaugh S C Lettin A W F Raftery A T Wickham J E A Charlton J E Gardham J R C Lewis A A M Redmond A D Willatts S M Clark J Gardner B P Linton R A F Rees B I Williams N S Cobb R A Gazet I-C Lloyd-Davies R W Rennie J A Williams D J Cochrane J P S Giddings A E B Lodge J P A Reynolds D A Williams T G Cochrane T D Glass R E Lord P H Ribeiro B F Williams K N Glazer G Rickett J W S Williamson R C N Collins R E C Goldman M MacLennan I Collins C D Mansel R E Robins R H C Wilson A W Coltart D J Grace R H Mansfield A 0 Rogers K Windsor C W 0 de Cossart L M Halliday A W Marks C G Rowsell A R Yates D W Craven J L Hardcastle J D Marston A Russell R C G Yeo R Crosby D L Harrison T A Mason R C Sagor G R Young A E Crumplin M K H Hawley P R Mason M A Salaman J R Young H L Cuschieri A Heald R J Matheson N A Sales J E L Young C P

iv 392 K S Metcalf and K R Peel 55 Aronowitz J, Kaplan AL. The management of a pelvic NR. Povidone iodine sclerosis of pelvic lymphoceles: a lymphocele by the use of a percutaneous indwelling catheter prospective study. Urol Radiol 1988; 10: 203-6. inserted with ultrasound guidance. Gynecol Oncol 1983; 16: 67 Williams G, Howard N. Management of lymphatic leakage 292-5. after renal transplantation (letter). Transplantation 1981; 31: 56 Edelstein G, Wadsworth DE. Retroperitoneal lymphocyst: 134. demonstration by lymphangiography. Urol Radiol 1983; 5: 68 Pope AJ, Ormiston MC, Bogod DG. Sclerotherapy in the 123-5. treatment of recurrent lymphocele. Postgrad Med j 1982; 57 Patel BR, Burkhalter JL, Patel RB, Raju S. Interstitial 58: 573-4. lymphoscintigraphy for diagnosis of lymphocele. Clin Nucl 69 Teruel JL, Escobar EM, Quereda C, Mayayo T, Ortuno J. Med 1985; 10: 175-6. A simple and safe method for management of lymphocele 58 McCullough CS, Soper NJ. Laparoscopic drainage of a post after renal transplantation. J Urol 1983; 130: 1058-9. transplant lymphocele. Transplantation 1991; 51: 725-7. 70 Zaontz MR, Firlit CF. Pelvic lymphocele after pediatric 59 Puyau FA, Adinolfi MF, Kerstein MD. Lymphocele renal transplantation: a successful technique for preven- around aortic femoral grafts simulating a false aneurysm. tion. Jf Urol 1988; 139: 557-9. Cardiovasc Intervent Radiol 1985; 8: 195-8. 71 DeCamp MM, Tilney NL. Late development of intractable 60 Braun WE, Banowsky LH, Straffon RA et al. Lymphoceles lymphocele after renal transplantation. Tranplant Proc associated with renal transplantation. Report of 15 cases 1988; 20: 105-9. and review of the literature. Am j Med 1974; 57: 714-29. 72 All Khan S, Hu KN. Internal drainage of lymphocele by a 61 Zincke H, Woods JE, Aguilo JJ et al. Experience with pedicled omental flap. Int Urol Nephrol 1983; 15: 333-8. lymphoceles after renal transplantation. Br J Plast Surg 73 Byron RL, Yonemoto RH, Davajan V, Townsend D, 1975; 77: 444-50. Bashore R, Morton OG. Lymphocysts: surgical correction 62 Basinger GT, Gittes RF. Lymphocysts: ultrasound diagno- and prevention. Am J Obstet Gynecol 1966; 94: 203-7. sis and urologic management. J Urol 1975; 114: 740-5. 74 Nicholson ML, Veitch PS. Treatment of lymphocele asso- 63 Henry RJW, Crandon AJ. The use of a functioning omental ciated with renal transplant. Br J Urol 1990; 65: 240-1. flap to drain a recurrent pelvic lymphocyst after radical 75 Silk YN, Goumas WM, Douglass HOJr, Huben RP. hysterectomy. Br J Obstet Gynaecol 1988; 95: 306-8. Chylous ascites and lymphocyst managed by peritoneo- 64 Malovrh M, Kandus A, Buturovic-Ponikvar J et al. venous shunt. Surgery 1991; 110: 561-5. Frequency and clinical influence of lymphoceles after kid- 76 Smellie GD, Wallace JR. Lymph fistulas and lymphocysts ney transplantation. Transplant Proc 1990; 22: 1423-4. after peripheral vascular surgery. J R Coll Surg Edinb 1981; 65 Gilliland JD, Spies JB, Brown SB, Yrizarry JM, 26: 78-81. Greenwood LH. Lymphoceles: percutaneous treatment with povidone iodine sclerosis. Radiology 1989; 171: 227-9. 66 Cohan RH, Saeed M, Schwab SJ, Perlmutt LM, Dunnick Received 23 March 1993

NOTICE

It has come to the attention of the Editorial Committee that an author's letter which accompanied an article submitted to the Annals contained several forged signatures. The Committee point out that forging another person's signature is illegal. Any detection of such an occurrence will result in automatic rejection of the article. Books received

Cardiothoracic Atlas of Human Anatomy by Frank H Netter. Illustrated. Farrand Press. 1993. £75.00. ISBN 0 914 16818 5. Fundamentals of Cardiac Surgery by Charles Marks and Peter H Marks. 241 pages, illustrated. Chapman & Hall Medical. Connective Tissue and Its Heritable Disorders: Molecular, 1993. Paperback, £19.95. ISBN 0 412 54310 9 Genetic, and Medical Aspects by Peter M Royce and Beat Steinmann. 709 pages, illustrated. Wiley-Liss. 1993. $225.00. Disorders of the Cardiovascular System by David Patterson ISBN 0 471 58819 9. and Tom Treasure. 357 pages, illustrated. Edward Arnold. 1993. £29.95. ISBN 0 340 53593 8. Surgical Decision Making by L W Norton, G Steele and B Eiseman. 3rd Ed. 342 pages, illustrated. W B Saunders. 1993. Coloproctology £55.00. ISBN 0 7216 6598 5. Modern Coloproctology. Surgical Grand Rounds from St Operative techniques Mark's Hospital edited by Robin Phillips and John Northover. 195 pages, illustrated. Edward Arnold. 1993. £22.50. ISBN 0 340 Laparoscopic Cholecystectomy. Problems and Solutions by 552588 1. D C Dunn and C J E Watson. 143 pages, illustrated. Blackwell Scientific Publications. 1993. £29.50. ISBN 0 632 03444 0. General surgery Medical Lasers and their Safe Use by David H Sliney and Stephen L Trokel. 230 pages, illustrated. Springer-Verlag. Current Surgical Practice, Volume 6 edited by M Hobsley, 1993. DM118. ISBN 0 387 97856 9. A Johnson and T Treasure. 203 pages, illustrated. Edward Arnold. 1993. £32.50. ISBN 0 340 55153 4. Minimally Invasive Surgery by John G Hunter and Jonathan M Sackier. 358 pages, illustrated. McGraw-Hill. 1993. £71.50. Modern Concepts in Surgery by S K Srivastava. 494 pages, ISBN 0 07 031372 5. illustrated. Tata McGraw-Hill Publishing Co Ltd, New Delhi. 1992. US$24.95. ISBN 0 07 460350 7. Orthopaedics Head and neck and reconstructive Orthopaedic Trauma Protocols edited by Sigvard T Hansen Jr and Marc F Swiontkowski. 409 pages, illustrated. Raven Microvascular Surgery and Free Tissue Transfer edited by Press. 1993. $189.00. (No ISBN Number). David S Soutar. 267 pages, illustrated. Edward Arnold. 1993. £85.00. ISBN 0 340 54925 4. Surgical Repair and Reconstruction in Rheumatoid Disease edited by Alexander Benjamin, Basil Helal, Stephen Copeland Atlas of Microvascular Surgery. Anatomy and Operative and Jo Edwards. 2nd Ed. 251 pages, illustrated. Springer- Approaches edited by B Strauch and Han-Liang Yu. 560 Verlag. 1993. DM280. ISBN 0 387 19727 3. pages, illustrated. George Thieme Verlag. 1992. DM340. ISBN 3 13 783001 X. ABC of Spinal Cord Injury by David Grundy and Andrew Swain. 2nd Ed. 61 pages, illustrated. BMJ Publishing Group. Miscellaneous 1993. £8.95. ISBN 0 7279 0760 3. Alan Pollock and Evans. 2nd Ed. 278 Major Fractures of the Pilon, the Talus, and the Calcaneus. Surgical Audit by Mary and Butterworth-Heinemann. 1993. £32.50. ISBN 0 7506 0774 2. Current Concepts of Treatment edited by H Tscherne J pages. Schatzker. 247 pages, illustrated. Springer-Verlag. 1993. Surgical Decision Making by F T de Dombal. 157 pages, DM198. ISBN 0 387 55837 3. Butterworth-Heinemann. 1993. £14.95. ISBN 0 7506 paperback. Current Practice in Foot and Ankle Surgery by Glenn B 0704 1. Pfeffer and Carol C Frey. 292 pages, illustrated. McGraw-Hill. Imaging for Surgeons by David Lisle. 296 pages, illustrated. 1993. £37.00. ISBN 0 07 049732 X. Edward Arnold. 1993. £65.00. ISBN 0 340 55170 4. A Short Practice of Spinal Surgery by H V Crock. 2nd Ed. Borderlands of Normal and Early Pathologic Findings in 338 pages, illustrated. Springer-Verlag. 1992. DM228. ISBN 3 Skeletal Radiography by Hermann Schmidt and Jurgen 211 82351 4. Freyschmidt. 4th Ed. 883 pages, illustrated. Georg Thieme Verlag. 1992. DM348. ISBN 3 13 784104 6. Paediatric surgery Teaching Atlas of Thoracic Radiology by Sebastian Lange Infections and Immunologic Disorders in Pediatric Surgery and Paul Stark. 290 pages, illustrated, George Thieme Verlag. by Fonkalsrud Krummel. 292 pages, illustrated. W B 1992. DM198. ISBN 3 13 791701 8. Saunders. 1993. £70.00. ISBN 0 7216 4278 0. 454 Books received Surgical teaching Urology MCQs for the FRCS Examinations in Applied Basic Sciences Laparoscopic Urology edited by Ralph V Clayman and by J Pegington, F J Imms, D R Davies and P B Boulos. 105 Elspeth M McDougall. 450 pages, illustrated. Quality Medical pages, illustrated. Edward Arnold. 1993. Paperback £12.99. Publishing, Inc. 1993. $90.00. ISBN 0 942219 41 4. ISBN 0 340 57317 1.

Tutorials in Clinical Surgery in General. Volume 2 by F G Transurethral Resection by John P Blandy and Richard G Smiddy. 292 pages. Churchill Livingstone. 1992. Paperback. Notley. 3rd Ed. 169 pages, illustrated. Butterworth- £22.50. ISBN 0 443 04796 0. Heinemann. 1993. £39.50. ISBN 0 7506 1327 0. INDEX TO VOLUME 75 JANUARY-NOVEMBER 1993

Author Index

The first figure indicates the issue; the second figure indicates the page

A Bowyer GW, (Comment), (6)450 Adams DCR, et al, Surgical discharge summaries: improving Bradbrook RA, Obituary. Charles Clyne, (5)375 the record, (2)96 Bradley JWP, see Jahangiri M, (1)34; (Comment), (5)376; and Adamson AS, et al, Coagulopathy in the prostate cancer Mitchenere P, (Comment), (5)376 patient, (2)100 Bradpiece H, et al, Novel means of securing a laparoscopic Ahmed M, see Hamid S, (6)434; see Khan A, (6)440 port in the obese patient, (4)252 Al-Shareef ZH, et al, Laparoscopic ligation of varioceles, Bramhall SR, et al, Improved method for oesophageal (5)345 intubation, (3)189 Al-Tayeb A, see Al-Shareef ZH, (5)345 Brearley R, (Book review), (5)381 Aldridge MC, and Homer J, (Comment), (1)67 Brickley M, see Shepherd J, (1)69 Allen-Mersh TG, Should primary anastomosis and on-table Brindley NM, see Qureshi MA, (5)349 colonic lavage be standard treatment for left colon Bristol JB, see Adams DCR, (2)96 emergencies?, (3)195 Broe PJ, see Qureshi MA, (5)349 Allum RL, see Burnett R, (4)229; (Book revtew), (5)382 Brown AA, and Wilson MF, (Comment), (3)215 Aly TF, see Al-Shareef ZH, (5)345 Buckels JAC, see Deakin M, (5)339 Anderson J, see Robinson AHN, (4)254 Bull AR, Audit and research, (Leading article), (5)308 Andrews SM, see Bradpiece H, (4)252 Burke PE, see Qureshi MA, (5)349 Armstrong JS, see Nicholson S, (1)8 Burnett R, and Allum RL, Relevance of history of injury to Armstrong MWJ, see Dawson C, (2)83 diagnosis of meniscal tears, (4)229 Atkins P, see Taylor JD, (3)168 Burney PGJ, see Gulliford MC, (1)57 Atkins RM, (Book review), (5)383 Burton PR, see Robertson GSM, (1)30 Atkinson M, see Iftikhar SY, (6)411 Attard AR, see Corlett MP, (5)330 C Attwood S, and Stephens R, (Comment), (4)299 Callander C, see Stephenson BM, (4)249 Atwell JD, (Invited comment), (1)36 Campbell I, et al, Management of screen-detected breast Aubrey DA, see Billings PJ, (3)205 cancer: audit of the first 100 cases in the Southampton and Salisbury breast screening programme, (1)13 B Canpbell SH, see Robertson GSM, (2)137 Baird RN, see Davies AH, (3)178 Carli F, see Jakeways MSR, (2)142 Baker DM, et al, (Comment), (3)216; and Lamerton AJ, Carruth JAS, (Book review), (3)219 Outcome of surgical management of thoracic outlet Carty NJ, et al, Surgical debate-Colostomy is no longer compression syndrome in a district general hospital, appropriate in the management of uncomplicated large (3)172 bowel obstruction: true or false?, (1)46; et al, Surgical Bancewicz J, (Book review), (5)380 debate-Restorative proctocolectomy is a major advance Banerjee A, (Comment), (4)302 in the management of ulcerative colitis, (4)275 Barber ND, and Hoffmeyer UK, Cost-effectiveness of Chadwick SJD, see Jakeways MSR, (2)142 subcutaneous versus intravenous heparin for DVT, (6)430 Champ CS, (Comment), (4)302 Barlow AP, et al, Emergency daytime theatre list: utilisation Chandiramani VJ, see German K, (1)70 and impact on clinical list, (6)441 Charters P, see Phillips DE, (5)378 Barnes AD, (Comment), (3)215 Cheng LHH, and Parle J, (Comment), (4)302 Barrie WW, see Payne SPK, (5)354 Cheng TO, (Comment), (4)299 Basu PK, see Taylor JD, (3)168 Cherry JR, (Comment), (5)379 Basyouni A, see Al-Shareef ZH, (5)345 Cherry R, see Sharma AK, (4)245 Beard JD, (Book revtew), (3)220 Chundrigar T, et al, Intraperitoneal bupivacaine for effective Beckingham IJ, see Wilson GR, (6)405 pain relief after laparoscopic cholecystectomy, (6)437 Bell PRF, see Madira W, (1)26; see Payne SPK, (5)354; see Coady MSE, et al, Provision and acceptability of day case Sayers RD, (4)303 breast biopsy: audit of current practice, (4)281 Benjamin IS, (Comment), (2)140 Coddington R, see Campbell I, (1)13 Bennett JR, and Dakkak M, (Comment), (6)449 Coghlan B, see Nicholson S, (1)8 Benson EA, see Coady MSE, (4)281; (Comment), (6)452 Cole RP, (Comment), (1)70 Bentley G, see Robinson AHN, (4)254 Collin J, see O'Brien TS, (6)445 Berg JD, see Kingsnorth AN, (1)38 Copeland GP, et al, Comparative vascular audit using the Bhandarkar DS, see Taylor TV, (6)386 POSSUM scoring system, (3)175 Billings PJ, et al, Audit of preoperative investigation of Corder A, see Carty NJ, (4)275 surgical patients, (3)205 Corder AP, see Carty NJ, (1)46 Birch NC, et al, Closing the audit circle: effect of continuing Corlett MP, et al, Reduction in incidence of glove perforation audit on arthroscopic practice, (6)422 during laparatomy wound closure by 'no touch' technique, Birchall MA, see Whitworth IH, (6)417 (5)330 Blake JRS, see Harriss DR, (4)268 Corner NB, et al, Morning emergency operating list: effects Bouchier-Hayes DJ, see Qureshi MA, (5)349 of implementation, (3)201 Boulter PS, (Invited comment), (1)12 Cotton MH, (Commnent), (5)376 456 Author index Counsell D, see Sarkar PK, (3)213 Gordon AC, and Gough MH, Case report. Oesophageal Crow A, see O'Brien TS, (6)445 perforation after button battery ingestion, (5)362 Cuschieri RJ, see Paraskevopoulos JA, (3)217 Gorey TF, see Egleston CV, (1)52 Gough MH, see Gordon AC, (5)362 D Gough MJ, (Book review), (5)384 Dakkak M, see Bennett JR, (6)450 Gourevitch D, see Bramhall SR, (3)189 Dark JH, see Waller DA, (4)237 Grace PA, see Qureshi MA, (5)349 Davies AH, et al, Preliminary experience of angioscopy in Grant A, see White A, (5)333 femorodistal bypass, (3)178 Gray DR, see O'Brien TS, (6)445 Davies JD, see Nicholson S, (1)8 Gray MR, see Kingsnorth AN, (1)38 Davies JP, see Billings PJ, (3)205 Gregori A, (Comment), (3)214 Davies SJM, see Kong KC, (1)23 Grundy HC, see Kutarski PW, (3)181 Davis HT, see Stoddard GJ, (4)296 Gulliford MC, et al, Can efficiency of follow-up for Dawson C, et al, Breast disease and the general surgeon. superficial bladder cancer be increased?, (1)57 Effect of audit on referral of patients, (2)83; et al, Breast Gunson BK, see Deakin M, (5)339 disease and the general surgeon. Referral of patients, (2)79 Guyer P, see Campbell I, (1)13 Dawson J, (Comment), (2)140 Guyer PB, see Hoe AL, (1)18 Deakin M, et al, Factors influencing blood transfusion Gwynn BR, see Smith FCT, (2)144 during adult liver transplantation, (5)339 Dickson RA, (Book review), (2)99 H Dixon JM, and Thompson AM, (Comment), (6)451 Hameed K, see Khan A, (6)448 Doran J, see Corner NB, (3)201 Hamid S, et al, Outcome of biliary tract surgery in unknown Dorgan J, see Phillipson A, (2)142 cirrhotics: case-control study, (6)434 Dorrell JH, see Birch NC, (6)422 Hardcastle JD, see Iftikhar SY, (6)411 Dove J, (Comment), (2)141 Hardy JG, see Travers JP, (2)119 Drew RS, (Comment), (6)449 Harris PL, see Copeland GP, (3)175 Drew S, see Robinson AHN, (4)254 Harris R, see Jones DR, (3)154 Duffett RHE, (Comment), (4)300 Harrison TA, (Book review), (3)218 Dunn JA, see Deakin M, (5)339 Harriss DR, and Blake JRS, Computerised audit for colorectal cancer, (4)268 Hartley MN, see Coady MSE, (4)281 E Harvey M, see Livingstone JI, (3)211 Earnshaw JJ, (Book review), (5)383 Haynes IG, see Robertson GSM, (1)30 Egleston CV, et al, Gastrointestinal complications after Hedges AR, see Chundrigar T, (6)437 cardiac surgery, (1)52 Herbert A, see Campbell I, (1)13 Elias M, (Comment), (1)72 Hilton CJ, (Book review), (2)122 Ellis PDM, et al, Surgical relief of snoring due to palatal Hinson F, (Comment), (5)377 flutter: a preliminary report, (4)286 Hinson FL, (Comment), (6)451 England DW, see Corlett MP, (5)330 Hitchin D, see Ricketts D, (6)393 Evans DF, see Iftikhar SY, (6)411 Hoddinott C, see White A, (5)333 Eyre-Brook IA, see Barlow AP, (6)441 Hoe AL, et al, Breast size and prognosis in early breast cancer, (1)18 F Hoffmeyer UK, see Barber ND, (6)430 Faber RG, see Dawson C, (2)79, (2)83 Holl-Allen RTJ, (Comment), (6)450 Fairgrieve J, and Withycombe JFR, Obituary of Philip Hollis S, see Yates DW, (5)321 Ghey, (2)139 Holme TC, (Book review), (3)221 Fakih AR, see Puntambekar SP, (3)213 Horner J, see Aldridge MC, (1)67 Farndon JR, see Nicholson S, (1)8 Horrocks M, see Davies AH, (3)178 Farrell RJ, (Comment), (3)214 Hughes LE, see Williamson MER, (3)161 Fawcett AN, see Baker DM, (3)216 Ffowcs Williams JE, see Ellis PDM, (4)286 I Fielding JWL, see Sharma AK, (4)245 Iftikhar SY, et al, Bile reflux in columnar lined Barrett's Fitzgerald EJPG, see Scriven MW, (1)43 oesophagus, (6)411 Fixsen JA, see Maffulli N, (2)105 Inglefield CJ, see Porter JM, (5)325 Forty J, see Waller DA, (4)237 Iqbal SJ, see Madira W, (1)26 Fowler S, see Ricketts D, (6)393 Isberg P, see Payne-James, (4)296 Francis JL, see Adamson AS, (2)100 Fraser IA, see Corlett MP, (5)330 J Jackson B, The Annals: the editorial process revealed G (Editorial), (2)73 Galland RB, see Michaels JA, (5)358 Jaffe V, and Young AE, Surgical techniques-Strap muscles Gartell PC, see Merrett ND, (4)272 in thyroid surgery: to cut or not to cut?, (2)118 Gateley CA, (Comment), (1)69 Jafri W, see Hamid S, (6)434 Gatland DJ, (Comment), (2)141 Jahangiri M, et al, Infantile hypertrophic pyloric stenosis: Gazet J-C, (Comment), (6)452 where should it be treated?, (1)34 Gazet JC, Provision and acceptability of day case breast Jakeways MSR, et al, (Comment), (2)142 biopsy: audit of current practice (Invited comment), (4)281 Jayatunga AP, see Jahangiri M, (1)34 German K, et al, (Comment), (1)70 Jeacock J, see Kingston RD, (5)335; see Sene A, (4)261 Gibson JM, see Mitchell AW, (2)143 Jenkins AMcL, see John TG, (4)257 Gilmore OJA, (Comment), (3)216 Jeyagopal N, see Kong KC, (1)23 Glazer G, see Williams RJL, (2)87 John TG, et al, Above-knee femoropopliteal bypass grafts Goldman MD, see Mosquera DA, (2)115 and consequences of graft failure, (4)257 Author index 457 Johnson CD, see Carty NJ, (1)46, (4)275 McGovern EM, see Egleston CV, (1)52 Johnstone S, see Redmond AD, (5)317 McLean NR, see Wilson GR, (6)405 Jones D, see Copeland GP, (3)175 McMaster P, see Deakin M, (5)339 Jones DR, et al, Non-woven disposable theatre gowns for Madira W, et al, Comparison of 'intraoperative' 'high-risk' surgery, (3)154 parathormone measurement with frozen section during parathyroid surgery, (1)26 K Maffulli N, et al, Callotasis for lengthening congenital limb Kapadia S, see Payne-James, (4)296 length discrepancy, (2)105 Kapila L, see Williams N, (4)301 Magee TR, see Davies AH, (3)178 Karanjia ND, and Rees M, Coca-Cola in management of Makin GS, see Travers JP, (2)119 bolus obstruction and benign oesophageal stricture, (2)94 Markus AF, see Smith WP, (3)164 Keating JP, and Schroeder D, (Comment), (1)67 Maryosh J, see Redmond AD, (5)317 Kelly MJ, and Wadsworth J, What price inconclusive clinical Mason RC, (Book review), (3)218, (5)382 trilas?, (Editorial), (3)145; and Warren RE, (Book review), Menzies D, Review-Postoperative adhesions, treatment and (5)380 relevance in clinical practice, (3)147 Kelman J, see John TG, (4)257 Merrett ND, and Gartell PC, A totally diverting loop Khan A, et al, (Letter), (6)448; et al, Simple technique of colostomy (4)272 umbilical port closure in laparoscopic cholecystectomy, Metcalf KS, and Peel KR, Lymphocele, (6)387 (6)440 Michaels J, see Dawson C, (2)83 Khan H, see Hamid S, (6)434 Michaels JA, and Gailand RB, Case mix and outcome of Kidner NL, see Corlett MP, (5)330 patients referred to the vascular service at a district Kilby JO, (Letter), (6)448 general hospital, (5)358 Kingsnorth AN, et al, A novel reconstructive technique for Mitchell AW, and Gibson JM, (Comment), (2)143 pylorus-preserving pancreaticoduodenectomy: avoidance of Mitchell D, see Toynton S, (2)141 early postoperative gastric stasis, (1)38 Mitchenere P, see Bradley JWP, (5)376; see Jahangiri M, Kingston RD, see Sene A, (4)261; et al, Physical status as (1)34 determinant of outcome after emergency surgery Morris GE, see Nicholson KEA, (4)303 admission of patients with colorectal cancer, (5)335 Morris PJ, see O'Brien TS, (6)445 Kirk RM, (Book review), (3)220 Morris R, see Chundrigar T, (6)437 Kirkup J, Surgical history. From ffint to stainless steel: Morris RW, see Spencer JD, 426 observations on surgical instrument composition, (5)365 Morritt GN, see Waller DA, (4)237 Kitchin N, see Livingstone JI, (3)211 Mosquera DA, and Goldman MD, Surgical audit without Klein R, The NHS reforms so far, (2)74 autopsy: tales of the unexpected, (2)115 Koneru SR, see Al-Shareef ZH, (5)345 Mullee M, see Taylor I, (4)300 Kong KC, et al, Should we stitch the subcutaneous fat layer? Mullee MA, see Hoe AL, (1)18 A clinical and ultrasound assessment in 50 hip operations, Murie JA, see John TG, (4)257 (1)23 Myers NA, (Comment), (6)449 Kumar V, see Winslet MC, (3)186 Kutarski PW, and Grundy HC, Possible degradation in N preoperative skin preparation through wiping skin dry, Newey M, see Ricketts D, (6)393 (3)181 Newland CJ, see Payne SPK, (5)354 Nicholson KEA, and Morris GE, (Comment), (4)303; and L Morris GE, Propofol anaesthesia for day case hernia Lamerton AJ, see Baker DM, (3)172 surgery, (4)303 Lamont PM, see Davies AH, (3)178; see O'Brien TS, (6)445 Nicholson ML, see Corner NB, (3)201 Lancashire MJ, see Dawson C, (2)79 Nicholson S, et al, Will screening for breast cancer reduce Landrup K, see Iftikhar SY, (6)411 mortality? Evidence from the first year of screening in Lane IF, see Stephenson BM, (5)308 Avon, (1)8 Larsson N, see Payne-James, (4)296 Lavelle-Jones M, (Book review), (3)221(2) 0 Lea RE, see Sen A, (4)293 Obeid ML, see Winslet MC, (3)186 Leahy AL, see Qureshi MA, (5)349 O'Brien TS, et al, Lower limb ischaemia in the octogenarian: Ledingham S, see Iftikhar SY, (6)411 is limb salvage surgery worthwhile?, (6)445 Lee JR, and Temple JG, The Angelchik prosthesis behaves O'Connor AFF, see Toynton S, (2)141 as a fundoplication, (2)90 Orr KB, (Comment), (3)214 Leighton SEJ, see Rowe-Jones JM, (4)241; (Comment), (5)379 Osborne DH, see Qureshi MA, (5)349 Leyland M, and McCloy R, Surgical face masks: protection Osborne MJ, see Jahangiri M, (1)34 of self or patient?, (Leading article), (1)1 Oshodi TO, (Comment), (4)301 Livingstone JI, et al, Role of pre-admission clinics in a Owen WJ, (Book review), (5)380 general surgical unit: a six month audit, (3)211 Locker A, see Baker DM, (3)216 P London NJ, see Madira W, (1)26 Paraskevopoulos JA, et al, (Comment), (3)217 London NJM, see Payne SPK, (5)354 Parker MC, and Phillips RKS, Repair of rectocoele using London PS, (Comment), (2)141 Marlex mesh, (3)193 Lyons K, see Williamson MER, (3)161 Parle J, see Cheng LHH, (4)302 Paterson IS, see Smith FCT, (2)144 M Patterson M, see Ricketts D, (6)393 McClelland P, (Comment), (1)71 Pattinson RC, see Maffulli N, (2)105 McCloy R, see Leyland M, (1)1 Payne SPK, et al, Investigation and significance of short Macfarlane R, (Book review), (5)382; Review-New concepts saphenous vein incompetence, (5)354 of vascular headache, (4)225 Payne-James, et al, (Comment), (4)296 McGeachie JK, see Tennant M, (1)3 Peel KR, see Metcalf KS, (6)387 458 Author index Pentlow BD, see Webb JM, (4)291 Schroeder D, see Keating JP, (1)67 Peters WJN, see Smith WP, (3)164 Scott-Coombes DM, et al, General surgeons' attitudes to the Petruckevitch A, see Gulliford MC, (1)57 treatment and prevention of abdominal adhesions, (2)123 Phillips DE, and Charters P, (Comment), (5)378 Scriven MW, et al, Hepatic 'pseudotumours': an important Phillips RKS, see Parker MC, (3)193; Blood transfusion does diagnostic pitfall, (1)43 not have an adverse effect on survival after operation for Sen A, and Lea RE, Spontaneous oesophageal haematoma: colorectal cancer (Invited comment), (4)261 review of the difficult diagnosis, (4)293 Phillipson A, and Dorgan J, (Comment), (2)142 Sene A, et al, Blood transfusion does not have an adverse Pietroni M, Guidelines and standards in surgical training, effect on survival after operation for colorectal cancer, (Leading article), (5)305 (4)261 Pindborg JJ, Epidemiology and oral manifestations of HIV Shah H, see Hamid S, (6)434 infection, (2)111 Shah N, see Livingstone JI, (3)211 Porter JM, and Inglefield CJ, Audit of peripheral nerve Shandall A, see Scriven MW, (1)43 blocks for hand surgery, (5)325 Shandall AA, see Stephenson BM (2)133, (5)308 Poskitt KR, see Adams DCR, (2)96 Sharma AK, et al, Randomised trial of selective or routine Powles DP, see Birch NC, (6)422 on-table cholangiography, (4)245 Price BA, (Comment), (1)71 Shearman CP, see Smith FCT, (2)144 Psaila JV, see Paraskevopoulos JA, (3)217 Shehata ZM, see Al-Shareef ZH, (5)345 Puntambekar SP, and Fakih AR, (Comment), (3)213 Shepherd J, and Brickley M, (Comment), (1)69 Puntis MCA, see Scriven MW, (1)43 Shneerson JM, see Ellis PDM, (4)286 Shute K, see Stephenson BM, (2)133, (5)308 Q Siddiqui M, see Hamid S, (6)434; see Khan A, (6)440, (6)448 Qureshi MA, et al, Post-cholecystectomy symptoms after Simson JNL, (Book review), (3)219 laparoscopic cholecystectomy, (5)349 Singer GC, (Comment), (1)71 Siriwardena A, and Samarji WN, Cutaneous tumour seeding R from previously undiagnosed pancreatic carcinoma after Rabbi F, see Sarkar PK, (3)213 laparoscopic cholecystectomy, (3)199 Radcliffe SN, see Taylor JD, (3)168 Smellie WAB, see Soin B, (1)62 Rainsbury RM, see Ray SA, (3)157 Smith FCT, et al, (Comment), (2)144 Rathbone BJ, see Robertson GSM, (2)137 Smith RD, (Comment), (4)299 Ratliff DA, see Williams N, (2)129 Smith WP, et al, Submandibular gland surgery, audit of Ray SA, and Rainsbury RM, Patient tolerance of early clinical findings, pathology and postoperative morbidity, introduction of fluids after laparotomy, (3)157 (3)164 Redmond AD, et al, A trauma centre in the UK, (5)317 Snell ME, see Adamson AS, (2)100 Reece-Smith H, see Dawson C, (2)79 Soin B, et al, Informed consent: a case for more education of Rees M, see Karanjia ND, (2)94 the surgical team, (1)62 Rennie JA, see Bradpiece H, (4)252 Spencer JD, and Morris RW, Does teaching audit improve Rew DA, Cell proliferation, tumour growth and clinical standards in undergraduate trauma and orthopaedic outcome in intestinal cancer, (6)397 tuition, (6)426 Rhodes JE, see Travers JP, (2)119 Stafford ND, see Whitworth IH, (6)417 Richards R, see Billings PJ, (3)205 Stamatakis JD, see Chundrigar T, (6)437 Richardson J, and Sabanathan S, (Comment), (2)143 Steele RJC, see Iftikhar SY, (6)411 Ricketts D, et al, Markers of data quality in computer audit: Stephens R, see Attwood S, (4)299 the Manchester Orthopaedic Database, (6)393 Stephenson BM, (Comment), (6)451; et al, Acute intestinal Rider MA, see Baker DM, (3)216 ischaemia: options in surgical management, (5)312; et al, Ridgway GL, see Robinson AHN, (4)254 Day case laparoscopic cholecystectomy, (4)249; et al, Robertson GSM, see Madira W, (1)26; et al, How long do Diabetic tibial disease: the case for revascularisation, patients convalesce after inguinal herniorrhaphy? Current (2)133 principles and practice, (1)30; et al, Surgical technique-a Stephenson TP, see German K, (1)70 safe method for removal of palliative oesophageal tubes, Stoddard GJ, and Davis HT, (Comment), (4)296 (2)137 Stonebridge PA, see John TG, (4)257 Robinson AHN, et al, Suction tip contamination in the ultraclean-air operating theatre, (4)254 T Robinson C, see Sene A, (4)261 Tabaqchali MA, (Comment), (3)213 Robinson PD, Articular cartilage of temporomandibular Taylor HW, and Warren S, (Comment), (4)301 joint: can it regenerate?, (4)231 Taylor I, see Campbell I, (1)13; see Hoe AL, (1)18; and Rosswick RP, see Rowe-Jones JM, (4)241 Mullee M, (Comment), (4)300 Rowe PH, (Book review), (3)218 Taylor JD, et al, Iodine therapy for high thyroid-stimulating Rowe-Jones JM, et al, Benign thyroid disease and vocal cord hormone values after thyroidectomy, (3)168 palsy, (4)241 Taylor TV, and Bhandarkar DS, Laparoscopic vagotomy: an Royle G, see Campbell I, (1)13 operation for the 1990s?, (Leading article), (6)385 Royle GT, see Hoe AL, (1)18 Temple JG, see Lee JR, (2)90 Rubin C, see Campbell I, (1)13 Templeton J, see Redmond AD, (5)317 Ruckley CV, see John TG, (4)257 Tennant M, and McGeachie JK, Lipoprotein(a) and its role Russell RCG, (Comment), (1)68 in occlusive vascular disease, (1)3 Thomas AJ, see Stephenson BM, (5)308 S Thompson AM, see Dixon JM, (6)451 Sabanathan S, see Richardson J, (2)143 Thompson JF, see Davies AH, (3)178 Sage M, see Stephenson BM, (4)249 Thompson JN, see Scott-Coombes DM, (2)123 Samarji WN, see Siriwardena A, (3)199 Thompson MM, see Sayers RD, (4)303 Sarkar PK, (Comment), (5)377; et al, (Comment), (3)213 Thomson HJ, see Soin B, (1)62 Sayers RD, et al, (Comment), (4)303 Thorpe AP, (Comment), (2)144 Author index 459 Tinckler L, (Comment), (6)449 White A, et al, Blood contamination of feet during Tinckler LF, (Comment), (5)378 orthopaedic procedures, (5)333 Tisone G, see Deakin M, (5)339 Whitworth IH, et al, Neck swellings which mimic branchial Titley OG, (Comment), (4)303 cysts in HIV-positive patients, (6)417 Tovey FI, (Comment), (1)67 Wicks AC, see Bramhall SR, (3)189 Toynton S, et al, (Comment), (2)141 Widdison AL, (Comment), (1)70 Travers JP, et al, Postoperative limb compression in Wilcox A, see Copeland GP, (3)175 reduction of haemorrhage after varicose vein surgery, Wilkinson DA, see Barlow AP, (6)441 (2)119 Williams N, and Kapila L, (Comment), (4)301; and Ratliff DA, Gastrointestinal disruption and vertebral fracture associated with use of seat belts, (2)129 V Williams RJL, and Glazer G, Splenic cysts: changes in Varga Z, see Davies AH, (3)178 diagnosis, treatment and aetiological concepts, (2)87 Veitch PS, see Bramhall SR, (3)189; see Madira W, (1)26 Williamson MER, et al, Multiple fibroadenomas of the Vellacott KD, see Stephenson BM, (4)249 breast, (3)161 Vipond MN, see Scott-Coombes DM, (2)123 Wilson GR, et al, Management of extensive facial basal cell carcinoma, (6)405 Wilson K, see Jones DR, (3)154 w Wilson MF, see Brown AA, (3)215 Wadsworth J, see Kelly MJ, (3)145 Wilson RG, (Comment), (2)143 Waller DA, et al, Videothoracoscopy in treatment of Winslet MC, et al, On-table pneumoperitoneum in spontaneous pneumothorax: an initial experience, (4)237 management of complicated incisional hernias, (3)186 Walsh S, see Sene A, (4)261 Witherow RO'N, see Adamson AS, (2)100 Walsh SH, see Kingston RD, (5)335 Withycombe JFR, see Fairgrieve J, (2)139 Warren RE, see Kelly MJ, (5)380 Wood AE, see Egleston CV, (1)52 Warren S, see Taylor HW, (4)301 Woodford M, see Yates DW, (5)321 Warwick J, see Deakin M, (5)339 Wordsworth M, see Barlow AP, (6)441 Wastell C, see Livingstone JI, (3)211 Wyatt JP, (Comment), (2)141 Webb Al, see Nicholson S, (1)8 Webb B, (Comment), (2)142 y Webb JM, and Pentlow BD, Double gloving and surgical Yates DW, et al, Trauma audit: clinical judgement or technique, (4)291 statistical analysis?, (5)321 Welply GAC, (Comment), (2)140 Yoruk Y, see Waller DA, (4)237 Wheeler MH, (Comment), (5)376 Young AE, see Jaffe V, (2)118 Subject Index The first figure indicates the issue; the second figure indicates the page

A Basal cell carcinoma, facial, excision and free tissue transfer Abdominal adhesions, treatment and prevention of, attitudes with microsurgery in the elderly, (Wilson et al) (6)405 to, (Scott-Coombes et al) (2)123 Bile duct, malignant obstruction of, endoscopic stenting as Adhesions, postoperative, treatment and clinical relevance, initial treatment, (Benjamin) (Comment), (2)140 (Menzies) (3)147 Biliary tract surgery, outcome in unknown cirrhotics, (Hamid Aged, limb salvage surgery in lower limb ischaemia, in the et al) (6)434 octogenarian, (O'Brien et al) (6)445; management of facial Bladder cancer, superficial, efficiency of follow-up, (Gulliford basal cell carcinoma in, by microvascular tissue transfer, et al) (1)57 (Wilson et al) (6)405 Blood contamination, of feet during orthopaedic procedures, Alcohol, hand injuries and, (Comment), (Shepherd and (White et al) (5)333 Brickley) (1)69 Blood transfusion, blood loss and, in joint arthroplasty, Amputation, in diabetics, (Comment), (Tovey) (1)67 (Comment), (Singer), (1)71; during adult liver Anaesthesia, peripheral nerve blocks for hand surgery, transplantation, (Deakin et al) (5)339; and survival after (Porter and Inglefield) (5)325 operation for colorectal cancer, (Sene et al) (4)261, Anaesthetics, propofol, for day case hernia surgery, (Invited comment) (Phillips) (4)266, (Comment), (Comment), (Nicholson and Morris) (4)303 (Stephenson) (6)451 Angelchik prosthesis, acts as a fundoplication, (Lee and Bolus obstruction, in benign oesophageal stricture, Coca-cola Temple) (2)90 in management, (Karanjia and Rees) (2)94, (Comment), Angioscopy, in femorodistal bypass, (Davies et al), (3)178 (Cotton) (5)377, (Comment), (Sarkar) (5)377 Annals, editorial processes of, (Jackson) (1)73 Arthroplasty, blood loss and transfusion requirement in, (Comment), (Singer) (1)71 BOOK REVIEWS Atherosclerosis, role of lipoprotein(a) in, (Tennant and Advice for House Surgeons, (Johnson) (5)383 McGeachie) (1)3 Arterial surgery (Eastcott) (5)383 Audit, comparative, in vascular surgery, POSSUM scoring Atlas of Operative Surgery: Gallbladder, Bile Ducts, system for, (Copeland et al) (3)175, (Comment), (Myers) Pancreas, (Kramer) (3)219 (6)449; computerised, for colorectal cancer, (Harriss and Atlas of Surgery of the Stomach, Duodenum and Small Blake) (4)268; computers and, for surgical discharge Bowel, (Thompson) (1)33 summaries, (Adams et al) (2)96, (Comment), (Banerjee) Churchill's House Surgeon's Guide, (Gompertz et al) (1)7 (4)302, (Comment), (Cheng and Parle) (4)302; continuing, Creativity and Disease: How Illness Affects Literature, Art effect on arthroscopic practice, (Birch et al) (6)422; effect and Music, (Sandblom) (5)381 of regular morning emergency operating list, (Corner et Handbook of General Surgery, (Bevan and Donovan) (3)218 al) (3)201; in management of screen-detected breast HIV Infection: Hazards of Transmission to Patients and cancer, (Campbell et al) (1)13; Manchester Orthopaedic Health Care Workers during Invasive Procedures, Database, markers of data quality in, (Rickeetts et al) (Banatvala) (3)220 (6)393; of pre-admission clinics, in general surgical unit, Infection in Surgical Practice, (Taylor) (5)380 (Livingstone et al) (3)205; of preoperative investigation of Laparoscopic Biliary Surgery, (Cuschieri and Berci) (5)380 surgical patients, (Billings et al) (3)205; and research, Laparoscopic Cholecystectomy: difficult Cases and Creative complementary but distinct, (Leading article), (Bull) Solutions, (Cooperman) (3)218 (5)308; of submandibular gland surgery, (Smith et al), Lasers in Neurosurgery (Lasers in Medicine and Surgery (3)164, (Comment), (Cherry) (5)379, (Comment), Series), (Jeffreys) (5)382 (Leighton) (5)379; surgical, autopsy and, (Mosquera and Operative Cancer Surgery Volume 1, Gastro-intestinal tract, Goldman) (2)115, (Comment), (Champ) (4)302, (Comment), (Burn and Wellwood) (5)382 (Hinson) (5)377; of teaching, effect on MCQ results and Operative Manual of Endoscopic Surgery, (Cuschieri et al) undergraduate tuition, (Spencer and Morris) (6)426; of (5)380 theatre use and clinical practice with daytime emergency Principles of Cardiac Diagnosis and Treatment Guide to surgery, (Barlow et al) (6)441; of trauma management, Surgeons, (Ross et al) (2)122 (Yates et al) (5)321; of vascular surgery case mix and Surgery of the Ear and Temporal Bone, (Nadol and outcome, (Michaels and Galland), (5)358 Schuknecht) (3)219 Autopsy, surgical audit and, (Mosquera and Goldman) Surgery of the Oesophagus, (Hennessy and Cuschieri) (3)220 (2)115, (Comment), (Champ) (4)302, (Comment), (Hinson) Surgery of the Spine. A Combined Orthopaedic and (5)377 Neurosurgical Approach, (Findlay and Owen) (2)99 Surgical Management of Vascular Disease, (Bell et al) (5)384 B Technologies in Vascular Surgery, (Yao and Pearce) (3)220 Bacterial contamination, of suction tip in ultraclean-air The Immunological Basis of Surgical and Practice, (Eremin operating theatre, (Robinson et al) (4)254 and Sewell) (3)221 Subject index 461 The Impact of HIV on Surgical Practice. Studies in Surgery, laparoscopic, laser, (Comment), (Keating and Schroeder) Volume 1, (Cochrane and Wastell) (3)221 (1)67; laparoscopic, simple technique of umbilical port The Knee and the Cruciate Ligaments, (Jakob and Staubli) closure in, (Khan et al) (6)440; laparoscopic, symptoms (5)382 after, (Qureshi et al) (5)349; laparoscopic, versus open, Transosseous Osteosynthesis: Theoretical and Clinical (Comment), (Jakeways et al) (2)142, (Comment), (Webb) Aspects of the Regeneration and Growth of Tissue, (2)142, (Comment), (Richardson and Sabanathan) (2)143, (Ilizarov) (5)383 (Comment), (Wilson) (2)143, (Comment), (Attwood and Tutorials in Clinical Surgery in General, (Smiddy) (3)218 Stephens) (4)299 Cirrhosis, found at biliary tract surgery, outcome in, (Hamid Bowel, intestinal ischaemia, acute, options in surgical et al) (6)434 managment, (Stephenson et al) (5)312; intestinal Clinical trials, inconclusive, (Editorial), (Kelly and ischaemia, in unconscious patients in intensive care, Wadsworth) (3)145 (Comment), (Price) (1)71; large, obstructed, colostomy in Coagulopathy see Disseminated intravascular coagulation management of, (Carty et al) (1)46; large, obstructed, Colitis ulcerative, restorative proctocolectomy in, (Carty et al) colostomy in management of, (Comment), (4)275 (Paraskevopoulos et al) (3)217; small, acute obstruction, Colon, gunshot wounds to, primary repair, (Comment), water-soluble contrast radiology in management, (Mitchell (Gregori) (2)214, (Comment), (Bowyer) (6)450; left colon and Gibson), (Commtent), (2)143; small, acute obstruction, emergencies, primary anastomosis and on-table colonic water-soluble contrast radiology in management, lavage for, (Allen-Mersh) (3)195; see also Bowel (Comment), (Orr) (3)214; small, acute obstruction, water- Colorectal cancer, cell proliferation in, (Rew) (6)397; soluble contrast radiology in management, (Comment), computerised audit for, (Harriss and Blake) (4)268; (Thorpe) (2)144; small, injuries to with seat belt use, and emergency surgery for, physical status and outcome, spinal injuries, (Williams and Ratliff) (2)129; small, (Kingston et al) (5)335; surgery for, perioperative blood phytobezoar as cause of obstruction in, (Comment), transfusion and survival, (Sene et al) (4)261, (Invited (Tabaqchali) (3)213 comment) (Phillips) (4)266, (Comment), (Stephenson) Breast biopsy, acceptability of day case surgery for, (Coady et (6)451 al) (4)281, (Invited comment) (Gazet) (4)285, (Comment), Colostomy, loop, totally diverting, (Merrett and Gartell) (Dixon and Thompson) (6)451, (Comtment), (Hinson) (4)272; in management of large bowel obstruction, (Carty (6)451, (Comment), (Benson) (6)452, (Comwent), (Gazet) et al) (1)46; in management of large bowel obstruction, (6)452 (Comment), (Paraskevopoulos et al) (3)217 Breast cancer, early, breast size and prognosis in, (Hoe et al) Computers, for audit in colorectal cancer, (Harriss and (1)18; screening for, and management, audit, (Campbell et Blake) (4)268; for surgical discharge summaries, (Adams al) (1)13; screening for, mortality rate and, (Invited et al) (2)96, (Comment), (Banerjee) (4)302, (Comment), comment), (Boulter) (1)12; screening for, mortality rate (Cheng and Parle) (4)302 and, (Nicholson et al) (1)8 Corticotomy, in callotasis for congenital limb length Breast disease, the general surgeon and, audit and referral in, discrepancy, (Maffuli et al) (2)105 (Dawson et al) (2)83; the general surgeon and, referral in, (Dawson et al) (2)79; multiple fibroadenomas of, incidence D and management, (Williamson et al) (3)161 Bupivacaine, intraperitoneal, for pain relief after laparoscopic Day case surgery, for breast biopsy, acceptability of, (Coady et al) (4)281, (Invited comment) (Gazet) (4)285, cholecystectomy, (Chundrigar et al) (6)437 Button batteries, ingestion of, oesophageal perforation after, (Comment), (Dixon and Thompson) (6)451, (Comment), (Gordon and Gough) (5)362 (Hinson) (6)451, (Comment), (Benson) (6)452, (Comment), (Gazet) (6)452; for hernia, propofol anaesthesia for, Bypass, femorodistal, angioscopy in, (Davies et al) (3)178; femorodistal, non-reversed, prevention of malalignment (Comment), (Nicholson and Morris) (4)303 Diabetes mellitus, amputations in, (Comment), (Tovey) (1)67; in, (Smith et al) (Comment), (2)144; femoropopliteal, critical ischaemia of lower limb in, revascularisation in, above-knee, (John et al) (4)257 (Stephenson et al) (2)133, (Comment), (Sayers et al) (4)303 Discharge, computerisation of summaries for, audit and, C (Adams et al) (2)96, (Comment), (Banerjee) (4)302, Callotasis, in congenital limb length discrepancy, (Maffuli et (Comment), (Cheng and Parle) (4)302 al), (2)105 Disseminated intravascular coagulation, in prostate cancer, Cannulas, type of, and development of peripheral vein tumour markers and, (Adamson et al) (2)100 thrombophlebitis, (Comment), (Stoddard and Davis) Duplex scanning see Ultrasound, duplex (4)296, (Comment), (Payne-James et al) (4)298 Cartilage, regeneration of in temporomandibular joint, (Robinson) (4)231 E Cholangiography, in laparoscopic cholecystectomy, need for, Education, see Training (Aldridge and Horner) (1)67; on-table, selective versus Elderly see Aged routine, (Sharma et al), 245 Elective surgery, audit of preoperative testing, (Billings et al) Cholecystectomy, laparoscopic, cholangiography in, (Aldridge (3)205; pre-admission clinics, audit of, (Livingstone et al) and Homer) (1)67; laparoscopic, cutaneous tumour (3)205 seeding from undiagnosed pancreatic tumour after, Emergency surgery, in colorectal cancer, physical status and (Siriwardena and Samarji) (3)199; laparoscopic, day case, outcome, (Kingston et al) (5)335; daytime, utilisation of (Stephenson et al) (4)249; laparoscopic, intraperitoneal theatre and impact on clinical practice, (Barlow et al) bupivacaine for pain relief after, (Chundrigar et al) (6)437; (6)441; regular morning list, (Corner et al) (3)201 462 Subject index Epidemiology, and oral manifestaions of HIV infection, L (Pindborg) (2)111 Laboratory tests, before surgery, audit of, (Billings et al) (3)205 F Laparoscopy, for cholecystectomy, intraperitoneal Face masks, surgical, for protection of self or patient?, bupivacaine for pain relief after, (Chundrigar et al) (6)437; (Leading article)(Leyland and McCloy) (1)1, (Comment), for cholecystectomy, simple technique of umbilical port (Smith) (4)299 closure in, (Khan et al) (6)440; ligation of varicoceles by, Femorodistal bypass see Bypass (Al-Shareef et al) (5)345; technique for securing port in Fibroadenomas, multiple of breast, incidence and obese patients, (Bradpiece et al) (4)252; for vagotomy, management, (Williamson et al), (3)161 (Letter), (Kilby) (6)448; for vagotomy, (Leading article), Fundoplication, Angelchik prosthesis acting as, (Lee and (Taylor and Bhandarkar) (6)385; (Welply) (Comment), Temple) (2)90 (2)140 Laparotomy, early introduction of oral fluids after, (Ray and G Rainsbury) (3)157 Gastro-oesophageal reflux, Angelchik prosthesis in Lasers, in laparoscopic cholecystectomy, (Comment), (Keating prevention, mechanism of action, (Lee and Temple) (2)90 and Schroeder) (1)67 in the Gastrointestinal tract, problems of, after cardiac surgery, Limb salvage surgery, for lower limb ischaemia, (Egleston et al) (1)52; selective decontamination, to reduce octogenarian, (O'Brien et al) (6)445 infection in pancreatitis, (Comment), (Widdison) (1)70 Limbs, lengthening of by callotasis, in congenital length Gloves surgical, double gloving and surgical technique, discrepancy, (Maffuli et al) (2)105 (Cole) (1)70; (Webb and Pentlow) (4)291; technique to reduce Limbs lower, exsanguination of, (Comment), incidence of perforation during wound closure, (Corlett et ischaemia of, in diabetes, revascularisation for, al) (5)330 (Stephenson et al) (2)133; ischaemia of, and limb salvage surgery in the octogenarian, (O'Brien et al) (6)445 Gunshot wounds see wounds Lipoprotein(a), role of in occlusive vascular disease, (Tennant and McGeachie) (1)3, (Comment), (Farrell) (3)214, H (Comment), (Oshodi) (4)301 Hand, injuries to, alcohol related, (Comment), (Shepherd and Liver, radiological 'pseudotumours' of, a diagnostic pitfall, Brickley) (1)69; surgery of, audit of peripheral nerve (Scriven et al) (1)43 blocks for, (Porter and Inglefield) (5)325 Liver transplantation, adult, blood transfusion during, vascular, new concepts, (Macfarlane) (4)225 Headache, (Deakin et al) (5)339 versus for treatment of Heparin, subcutaneous intravenous, and Peel) (6)387 deep-vein thrombosis, (Barber and Hoffmeyer) (6)430 Lymphocele, (Metcalf Hernias, day case surgery, propofol anaesthesia for, (Comment), (Nicholson and Morris), (4)303; incisional, (Letter), (Khan et al) (6)448; incisional, on-table M pneumoperitoneum in management, (Winslet et al) (3)186; Mastectomy, modified radical, non-tumour morbidity and inguinal, repair of, need for convalescence after, mortality after, (Comment), (Singer) (1)69 (Robertson et al) (1)30, (Comment), (Baker and Rider) Meniscii, lesions of, relevance of history of injury to (3)216, (Comment), (Gilmore) (3)216, (Comment), diagnosis, (Burnett and Allum) (4)229 (Tinckler) (6)449; paraoesophageal, Angelchik prosthesis and, (Lee and Temple) (2)90 History, of surgery, surgical instruments from ffint to N stainless steel, (Kirkup), (5)365 National Health Service, effects of reforms, (Klein) (2)74 Human immunodeficiency virus, infection with, neck swellings in, (Whitworth et al) (6)417; infection with, oral manifestations, epidemiology patterns, (Pindborg) (2)111 0 Hypothyroidism, after thyroidectomy, iodine therapy for, Obesity, laparoscopy in, technique for securing port, (Taylor et al) (3)168 (Bradpiece et al), (4)252 Obituary, of Charles Clyne, (Bradbrook) (5)375; of Philip I Ghey, (Fairgrieve and Withycombe), (2)139 Infertility, male, laparoscopic ligation of varicoceles, (Al- Occupational health, blood contamination of feet during Shareef et al) (5)345 orthopaedic procedures, (White et al) (5)333; see also Informed consent, of patients for operations, education of Gloves surgical surgical team and, (Soin et al) (1)62 Oesophagus, Barrett's, columnar lined, bile reflux in, Injuries see part affected eg Hand (Iftikhar et al) (6)411; benign stricture of, and bolus Instruments see Surgical instruments obstruction, Coca-cola in management, (Karanjia and Intensive care, and intestinal ischaemia in unconscious Rees) (2)94, (Comment), (Cotton) (5)377, (Comment), patients, (Comment), (Price) (1)71 (Sarkar) (5)377; cancer of, intubation in, improved Intestine see Bowel; Gastrointestinal tract method, (Bramhall et al) (3)189, (Comment), (Bennett and Intubation, in oesophageal cancer, improved method, Dakkak) (6)450; haematoma spontaneous, difficulty of (Bramhall et al) (3)189, (Comment), (Bennett and Dakkak) diagnosis, (4)293; perforation of, after button battery (6)450 ingestion, (Gordon and Gough) (5)362; safe removal of Ischaemia, of lower limb, critical in diabetes, palliative tubes from, (Robertson et al) (2)137 revascularisation for, (Stephenson et al) (2)133, Operating theatres, ultraclean-air, suction tip contamination (Comment), (Sayers et al) (4)303 in, (Robinson et al) (4)254 Subject index 463 p Sepsis, prevention of in pancreatitis, by selective Pancreatic tumour, undiagnosed, cutaneous tumour seeding decontamination of digestive tract, (Comment), (Widdison) from after laparoscopic cholecystectomy, (Siriwardena and (1)70 Samarji), (3)199 Short saphenous vein, incompetence of and ulceration, Pancreaticoduodenectomy, pylorus-preserving, (Kingsnorth (Payne et al) (5)354 et al) (1)38 Skin, preoperative preparation of, effect of wiping skin dry Pancreatitis, acute severe, prevention of bacterial infection after, (Kutarski and Grundy), (3)181 and sepsis in, (Comment), (Widdison) (1)70 Snoring, due to palatal flutter, surgical relief for, (Ellis et al) Parathyroid surgery, 'intraoperative' parathormone (4)286 measurement, (Madira et al) (1)26, (Comment), (Barnes) Spine, fractured, seat belts and, and bowel injury, (Williams (3)215, (Comment), (Brown and Wilson) (3)215, and Ratliff) (2)129 (Comment), (Wheeler) (5)376 Splenic cysts, diagnosis and management, changes in, Patients, and informed consent for operations, education of (Williams and Glazer) (2)87 surgical team and, (Soin et al) (1)62 Stapling, with EEA device, in rectal adenocarcinoma Peptic ulcers, surgery for, (Leading article), (Taylor and resection, and cutaneous recurrence, (Dawson) (Comment), Bhandarkar) (6)385 (2)140 Peripheral nerve block see Anaesthesia Sternum, fractures of, (Dove) (Comment), (2)141, (Comment), Pharyngolaryngectomy, emergency treatment of tracheal tear (London) (2)141, (Comment), (Phillipson and Dorgan) during, (Comment), (Elias) (1)72, (Gatland) (Comment), (Comment), (2)142, (Comment), (Sarkar et al) (3)213 (2)141, (Toynton et al) (Comment), (2)141, Submandibular glands, surgery to, audit of, (Smith et al) (3)213(Comment), (Puntambekar and Fakih) (3)213 (3)164, (Comment), (Cherry) (5)379, (Comment), Phytobezoar, cause of small bowel obstruction, (Wyatt) (Leighton) (5)379 (Comment), (2)141, (Comment), (Tabaqchali) (3)213 Surgical instruments, from flint to stainless steel, (Kirkup) Picolax, body weight, haemoglobin levels, and cardiovascular (5)365 variables with, (Comment), (German et al) (1)70 Pleurectomy, videothoracoscopic, for spontaneous pneumothorax, (Waller et al) (4)237 Pneumoperitoneum, on-table, in management of incisional T hernias, (Winslet et al), (3)186 Temporomandibular joint, regeneration of cartilage of, Pneumothorax, spontaneous, videothoracoscopy in treatment, (Robinson) (4)231 (Wailer et al) (4)237 Theatre gowns, disposable non-woven for 'high-risk' surgery, Povidone-iodine, in preoperative skin preparation, effect of (Jones et al) (3)154, (Comment), (Drew) (6)449 wiping skin dry after, (Kutarski and Grundy) (3)181 Thoracic outlet compression syndrome, outcome after Pre-admission clinics, for general surgery, (Livingstone et al) surgery for in a district general hospital, (Baker and (3)205 Lamerton) (3)172 Preoperative tests see Laboratory tests Thrombophlebitis, peripheral vein, type of cannula and, Proctocolectomy, restorative, in ulcerative colitis, (Carty et (Comment), (Stoddard and Davis) (4)296, (Comment), al) (4)275 (Payne-James et al) (4)298 Propofol, for anaesthesia in day case hernia surgery, Thrombosis, deep-vein, cost-effectiveness of subcutaneous (Comment), (Nicholson and Morris), (4)303 versus intravenous heparin for, (Barber and Hoffmeyer) Prostate cancer, coagulopathy and, and tumour markers, (6)430 (Adamson et al) (2)100 Thyroid, surgery of, strap muscles and, (Jaffe and Young) Pyloric stenosis, infantile hypertrophic, where should it be (2)118, (Comment), (Titley) (4)303, (Comment), (Phillips treated?, (Jahangiri et al) (1)34, (Invited comment), and Charters) (5)378, (Comment), (Tinckler) (5)378 (Atwell) (1)36, (Comment), (Bradley) (5)376, (Comment), Thyroid disease, benign, and vocal cord palsy, (Rowe-Jones (Bradley and Mitchenere) (5)376 et al) (4)241, (Comment), (Holl-Allen) (6)450 Thyroidectomy, postoperative hypothyroidism, iodine therapy for, (Taylor et al) (3)168 R Trachea, tear in during pharyngolaryngectomy, emergency Radiology, contrast, water-soluble, in acute small bowel treatment of, (Comment), (Elias) (1)72, (Comment), obstruction, (Comment), (Mitchell and Gibson) (2)143, (Gatland) (2)141, (Comment), (Toynton et al) (2)141, (Comment), (Thorpe) (2)144, (Comment), (Orr) (3)214 (Comment), (Puntambekar and Fakih) (3)213 Rectocoele, repair with Marlex mesh, (Parker and Phillips) Training, audit of and results, (Spencer and Morris) (6)426; (3)193 medical, and informed consent of patients, (Soin et al) Rectum, adenocarcinoma of, cutaneous recurrence, after (1)62; surgical, guidelines and standards in, (Leading resection using EEA stapling device, (Comment), (Dawson) article), (Pietroni) (5)305 (2)140 Trauma, audit of, (Yates et al) (5)321; centre for in UK, Revascularisation, for critical lower limb ischaemia in (Redmond et al) (5)317 diabetes, (Stephenson et al) (2)133, (Comment), (Sayers et al) (4)303 U Ultrasound, duplex, in investigation of short saphenous vein S incompetence, (Payne et al), (5)354; hepatic Seat belts, gastrointestinal disruption and vertebral fracture 'pseudotumours' with, a diagnostic pitfall, (Scriven et al) with, (Williams and Ratliff) (2)129 (1)43 464 Subject index

V Videothoracoscopy, in treatment of spontaneous Vagotomy, laparoscopic, (Leading article), (Taylor and pneumothorax, (Waller at al) (4)237 Bhandarkar) (6)385, (Letter), (Kilby) (6)448 Vocal cord palsy, benign thyroid disease and, (Rowe-Jones et Varicoceles, laparoscopic ligation of, (Al-Shareef et al) (5)345 al) (4)241, (Comment), (Holl-Allen) (6)450 Varicose vein surgery, haemorrhage after, postoperative limb compression in reduction of, (Travers et al) (2)119 Varicose veins, short saphenous vein incompetence and, (Payne et al) (5)354 w Vascular disease, occlusive, role of lipoprotein(a) in, Wound closure, subcutaneous fat stitch and haematoma (Tennant and McGeachie) (1)3 formation, in hip surgery, (Kong et al) (1)23; technique to Vascular surgery, comparative audit, POSSUM scoring system reduce incidence of glove perforation during, (Corlett et for, (Copeland et al) (3)175, (Comment), (Myers) (6)449; al) (5)330 surgical audit of case mix and outcome in, (Michaels and Wounds, gunshot, to colon, primary repair, (Comment), Galland) (5)358 (Gregori) (2)214, (Comment), (Bowyer) (6)450 Instructions to Authors

Manuscripts should be sent to: The Editor, Annals ofThe Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London WC2A 3PN, UK. Authors submitting original scientific papers for publication in the Annals should consult 'Uniform requirements for manuscripts submitted to biomedical journals' produced by the International Committee of Medical Journal Editors and published in the British Medical Journal, 6 February 1988, 401-56. These are designed to save time and expense and to enable authors to resubmit papers to other journals without extensive alterations. Only manuscripts which conform to this, the Vancouver style, will be considered. The text of observational and experimental articles is usually-but not necessarily-divided into sections with the headings Introduction, Methods, Results and Discussion. Long articles may need sub-headings within some sections to clarify their content. Case reports are only rarely accepted. Three good quality plain paper photocopies ofall written and tabular material must be submitted. A covering letter must be signed by all authors. If the article is accepted for publication, this letter will be deemed to transfer the copyright to the College. The manuscript must be typed double spaced with 3 cm margins on ISO A4 (210 x 297 mm) paper in the following order: 1 Title page with name ofauthor(s). Please give the appointment of each author at the time ofthe performance of the work reported. If an author has since moved on, the new appointment should be given as a footnote. 2 Key words Three to 10 words or phrases using terms from Index Medicus. 3 Summary This should be concise, complete in itself and outline the aim, results and conclusions of the paper. 4 The text All articles should be short and to the point. 5 References In the text, references should be numbered consecutively in parentheses. The list ofreferences at the end ofthe Article must conform to the Vancouver Style. Consult the January issue ofIndex Medicus for the form oftitle. Ifnot listed give the full title. 'Unpublished observations' and 'personal communications' may not be used as references. 'In press' may only be used when the article has been accepted and the journal specified. 6 Tables Each table should be typed on a separate sheet and must have a Roman identifying number and a short descriptive title. Refer to present as much as possible in the text and use a simple table to highlight the main points. A table should not duplicate the text. 7 Illustrations All illustrations should be submitted in triplicate. Photographs must be of the highest professional quality, unmounted glossy prints. Original line drawings may be sent instead of photographs but we do not normally return illustrations. Send high quality reduced photographic prints of radiographs but make sure essential detail is not lost. For photomicrographs either insert internal scale markers or state the degree of magnification in the caption; also give staining techniques. Use transfers or stencils to arrow points in photographs, or apply a transparent overlay carrying the symbol. Never write on the front or back of drawings or photographs with either pen or pencil. Do not apply paper clips directly to them, since the marks remain in the published article. Most illustrations have to be reduced to column width (84 mm) and it is important to remember this when adding print to a figure as it may be unreadable when reduced. All illustrations must have a label pasted on the back indicating the number of the figure, the names of the authors and the top of the figure. Type legends for all illustrations on a separate sheet double spaced using Arabic numbers corresponding to the number on the label. All illustrations should be trimmed to remove redundant areas. 8 Pagination All pages should be numbered in the sequence, title page, key words, summary, text, acknowledge- ments, references, tables and legends for illustrations. Colour illustrations These can be published only at the author's own expense, which may be considerable. Colour prints accompanied by the original transparencies or negatives are required. A drawing indicating to the printer the orientation of each negative or transparency is desirable. Prints should be labelled as in 7 (above). The Production Editor will advise regarding costs. SI units, numbers and abbreviations SI units are used except for measurement of blood pressure (mmHg), haemoglobin (g/dl). The decimal point, not a comma, is used. A space, not a comma, follows thousands and multiples thereof: 20 000 not 20,000. Consult Br Med J7 1978; 1:1334-6 or Baron D N (comp), Units, Symbols and Abbreviations: a Guide for Biological and Medical Editors and Authors, 3rd ed. London: Royal Society of Medicine, 1977. Drugs should be given their approved, not proprietary, names and the source of any new or experimental preparation or instrument should be given. Comment The text should be typed in the style of the Comment section on one side of A4 paper with double spacing and wide margins. A covering letter to the Editor must be signed by all the contributors giving their appoint- ments and no more than two qualifications. Rejected manuscripts and illustrations will not be returned unless a specific request to do so is made at the time of submission. -.A b, ~ ~ ~ ~ ~ ~ A

- 0A

* :Mit,tiii COI1 li 1CAUdL ,~I I. ti ,st- ir;I rll J 0tcu iS Ic 194 College Diary

NOVEMBER Tuesday 7 Friday 5 ARNOTT DEMONSTRATION by Mr George C Cormack JOSEPH TOYNBEE MEMORIAL LECTURE by Dr C A FRCS entitled 'The vascular basis of flaps'. To be delivered at van Hasselt entitled 'Mastoid Surgery and the Hong Kong the College at 5.00 pm Flap'. To be delivered at The Royal Society of Medicine, 1 Wimpole Street, London at 9.30 am Wednesday 8 HUNTERIAN LECTURE by Mr Christopher Ward BSc Monday 15-Friday 19 FRCS MA entitled 'Ethics in surgery'. To be delivered during COURSE: CLINICAL SURGERY IN GENERAL the British Association of Plastic Surgeons Meeting at the College, followed by Tuesday 16 OPEN MEETING OF ADVISERS AND TUTORS COLLEGE DINNER 7.00 pm for 7.30 pm: Entertainment ANNUAL GENERAL MEETING at 12.00 noon from the Abracadabarets. followed by COLLEGE DINNER 6.30 pm for 7.00 pm Thursday 9 Speaker: The Countess of Limerick WOOD JONES LECTURE by Professor A E W Miles DSc LRCP MRCS FDSRCS entitled 'Reading the bones'. To be Thursday 18 delivered at the College at 5.00 pm JOHN KINMONTH LECTURE by Dr Ray Gosling enti- tled 'The mechanics of atherosclerosis'. To be delivered Monday 13 during the Annual Meeting of the Vascular Surgical Society CHRISTMAS HOLIDAY LECTURE (details to be con- of Great Britain and Ireland at the Royal Northern College of firmed) to be delivered at the College at 3.00 pm Music, 124 Oxford Road, Manchester at 5.30 pm Tuesday 14 Friday 19 CHRISTMAS HOLIDAY LECTURE by Mr A E Brown COURSE: BASIC SURGICAL TECHNIQUES entitled 'Putting on a new face'. To be delivered at the FACULTY OF DENTAL SURGERY Menzies Campbell College at 3.00 pm Lecture entitled 'John Hunter and the early history of odontology'. To be delivered at the College at 5.00 pm Wednesday 15 CHRISTMAS HOLIDAY LECTURE (details to be con- Monday 22 November-Friday 3 December firmed) to be delivered at the College at 3.00 pm COURSE: CLINICAL SURGERY IN GENERAL COURSE: APPLIED PHYSIOLOGY AND ARNOTT DEMONSTRATION by Mr John A Rennie PATHOLOGY FOR SURGEONS FRCS entitled 'The surgical anatomy of the sympathetic nervous system'. To be delivered at the College at 5.00 pm Wednesday 24 ERASMUS WILSON DEMONSTRATION by Professor J Thursday 16 L Turk MD DSc FRCP FRCS FRCPath entitled 'The medical CHRISTMAS HOLIDAY LECTURE by Dr Sheila Willatts museum and its relevance'. To be delivered at the College at FRCA entitled 'Intensive therapy in the '90s-The cost of a 1.00 pm life'. To be delivered at the College at 3.00 pm Thursday 25 ARNOTT DEMONSTRATION by Mr Nicholas Goddard CECIL JOLL LECTURE by Mr John Wickham MS MB BSc FRCS entitled 'The anatomical basis of neurological problems FRCS entitled 'Minimally invasive therapy and its impli- after surgery'. To be delivered at the College at 5.00 pm cations for surgery'. To be delivered at the College at 5.00 pm Monday 27 COLLEGE CLOSED Saturday 27-Monday 29 ATLS INSTRUCTOR COURSE Tuesday 28 COLLEGE CLOSED Wednesday 29 COLLEGE CLOSED DECEMBER Monday 6-Friday 17 Thursday 30 COURSE: APPLIED ANATOMY FOR SURGEONS COLLEGE CLOSED Monday 6 Friday 31 COURSE: WRITING A SURGICAL PAPER COLLEGE CLOSED 195

From the President

A single voice

Professor Norman Browse

Rarely does a week go by without a national newpaper group is made up of different people but because each carrying a story which is critical of the medical pro- group has a different purpose with different priorities. fession. Doctors have never claimed to be infallible, they Within the Senate, I hope that the Associations will have always made mistakes. Biological systems, and both appreciate the Colleges' role in the generality of surgery, patients and doctors fall into this classification, are especially in relationship to government, and the extraordinarily difficult to assess, measure and infinitely Colleges appreciate and respond to the Associations' role variable in their response to interference. in promoting their individual specialties. Nevertheless, the public demands that we, as sur- Why call it the Senate of the Royal Colleges? Because geons, be far more open about the standard of care that the Colleges have certain obligations, governed by the we expect our profession to provide, about the rigour and laws of the land and their Charters-(eg, the right to quality of the training we undergo, and the continuing award a primary medical qualification is enshrined in the education and revision that we believe is necessary to Medical Act), which they cannot, even if they wanted to, ensure the maintainance of top-class clinical practice. relinquish or designate to any other organisation. We all know, even when we provide in the light of our College Councils must retain the right to approve any present knowledge a perfect service, that things will go Senate proposal which might affect their legal obligations wrong, and that there will always be individuals who but, such matters apart, I hope that all the topics the disregard or abuse their professional obligations, but this Senate will discuss will be fully debated in College and must not prevent us publishing our criteria of quality and Associations' Councils well before they reach the Senate service. so that the Senate can produce a common view. Who is to do this? The Colleges' Charters all require The first problem before us all is the definition of the them to work for the common good and promote the art quality and standard of care that the NHS should and science of surgery. All the many Surgical Specialty provide. Every College and every Association has Associations are dedicated to the promotion of their addressed some aspects of this problem. I have asked specialty. But three Colleges and over 20 Associations, Charles and Richard Collins to collect all this data speaking individually and not always unanimously, pro- together and I hope that a review of all our views and the duce a weak and sometimes discordant voice. compilation of an agreed document, covering the whole We live in the United Kingdom of Great Britain and of surgery, will be one of the first tasks the Senate will we must have a united voice on quality and standards. undertake. The public want it; Government, Purchasers On September 29 representatives of the three UK and Providers want it, and I continue to be embarrassed Surgical Colleges, plus the Irish College, the Royal by its absence. College of Ophthalmologists, the'raculties, and the There can be little doubt that the topics which will Presidents of the major Monospecialty Associations met occupy most of the Senate's time will be training and together as the Senate of the Royal Surgical Colleges of education. These will provide ample opportunities for Great Britain and Ireland. My hope is that this will the exchange of ideas and objectives, helped by the become the single surgical voice of the UK that we all revised Joint Committee for Higher Surgical Training want. Its constitution is reproduced at the end of this and the Joint Committee for Intercollegiate newsletter. Examinations which will report directly to the Senate. It is an experiment which will be reviewed in two This venture will work if the participants want it to. years' time. Each member is equal in standing and there This is not a time to be defensive of our individual rights has been no attempt to provide proportional represen- and privileges but a time to put all our efforts into tation. We are all members of a College-or Colleges- improving surgical standards for the common good. If and all members of two or three Associations or Societies, the Senate succeeds, the prestige and authority of all its so our divisions of opinion do not arise because each constituent parts will rise with it. I wish it every success. 196 From the President

CONSTITUTION OF THE SENATE

1. Title The Senate of The Royal Surgical Colleges of Great Britain and Ireland. 2. Purpose To foster, co-ordinate and unify within Great Britain and Ireland the endeavours and aims of the Royal Colleges of Surgeons and the Specialty Associations representative of the European Community (EC) Surgical Monospecialties, and/or the Specialty Advisory Committees (SACs) of the Joint Committee for Higher Surgical Training, of supporting and advancing the Art and Science of Surgery for the public good. 3. Composition (a) Thirteen members representing the four Royal Surgical Colleges, namely, The President and two Councillors or Office Bearers from each of the four Colleges, and one Dental Dean from one of the Colleges. (b) One member shall be The President of the Royal College of Ophthalmologists. (c) One member shall be the Dean of the Intercollegiate Faculty of A & E Medicine (when constituted). (d) Nine members shall be the Presidents or their representatives of the nine Surgical Specialty Associations most relevant to the nine EC monospecialties and/or the Specialty Advisory Committees currently recognised in Great Britain and Ireland, namely: General Surgery - The Asociation of Surgeons of Great Britain and Ireland Orthopaedic Surgery - The British Orthopaedic Association Otolaryngology - The British Association of Otolaryngologists Urology - The British Association of Urological Surgeons Plastic Surgery - The British Association of Plastic Surgeons Paediatric Surgery - The British Association of Paediatric Surgeons Neurosurgery - The Society of British Neurological Surgeons Cardiothoracic - The Society of Cardiothoracic Surgeons Maxillofacial Surgery - The British Association of Oral and Maxillofacial Surgeons. (e) The Chairman of the Joint Committee for Higher Surgical Training shall be an ex officio member. 4. Method of Election Presidents of Colleges and Associations, Deans of Faculties and other College Office and Term of Office Bearers may serve during their Collegiate or Association term of office. The Dean representing Dental Surgery will be chosen by the Joint Meeting of Royal College Dental Faculty Deans. Representatives of Association Presidents and the Councillors nominated by each College may serve for three years. 5. Deputies Members unable to attend a meeting may nominate a deputy. 6. Secretariat The Secretary shall be chosen by the Senate. 7. Administration The administration shall be conducted by the Secretary. and Finance The Secretary's Office and staff shall be housed in one of the Royal Colleges.

The cost of the Secretariat shall be divided between the Colleges. The cost of members' attendance (travel, accommodation, subsistence, etc) shall be borne by each member's sponsoring College or Association. From the President 197

8. Meetings There will be four meetings each year. 9. Site Meetings will be held in rotation in the four Royal Colleges in London, Edinburgh, Glasgow and Dublin. 10. The Chairman The Chairman shall be the President of the College hosting the meeting. The Chairman shall have a deliberative and a casting vote. In the absence of the host President, the Chairman of the previous meeting will take the Chair. 11. Remit (a) The Senate may consider any item relevant to the practice of surgery. (b) All agenda items should, whenever possible, be debated in individual College and Association Councils before being discussed in the Senate. (c) Decisions on matters governed by their Charters may not be implemented until ratified by individual College Councils. (d) The Senate may not discuss Surgeons' contractual terms and conditions of service, save to the extent that any such terms and conditions may affect the best provision and practice of surgery. (e) The composition, administration, remit and all features of the Senate shall be reviewed two years after its inauguration and modified where appropriate, subject to the provision of clause 11(c). 12. Committees and The Senate shall have two standing Committees: Working Parties 1. The Joint Committee for Higher Surgical Training UCHST) Composition - as now, plus the Presidents of the Royal Colleges (ex officio). The Chairman of the JCHST shall be appointed by the Senate. The JCHST shall have 10 Specialty Advisory Committees as currently constituted. The Chairman of each SAC shall be elected by its members. The secretariat and financial arrangements shall be as they are at present. 2. The Joint Committee for Intercollegiate Examinations (JCICE) Composition - as now, plus the Presidents of the Royal Colleges (ex officio). The Chairman of the JCICE shall be appointed by the Senate from its Royal College members (Presidents and Councillors). The JCICE shall have 10 Intercollegiate Specialty Boards as currently constituted. The Chairmen of these Boards shall be elected by the Board members from the College representatives. The secretariat and financial arrangements shall be as they are at present. 3. The Senate may set up further Committees and Working Parties as it sees fit. Annals of The Royal College ofSurgeons ofEngland (Suppl) (1993) vol. 75, 198-199

For Debate Evaluation of surgical training-Urgent improvement Evaluation of surgical training ~Urgent improvement needed

M W R Reed FRCS Senior Lecturer Royal Hallamshire Hospital

One of the commonest complaints amongst surgical result in termination of training. Objective criteria and trainees is the lack offeedback from consultants. There is independent assessment to avoid the problems of a little formal or informal feedback on individual progress, personality conflict are essential. and the closed system of references may result in a Likewise where a trainer is failing to provide training, trainee being unwittingly blighted by a poor reference action should be taken to try and improve the situation due to a weakness about which he or she has not been and if this fails, the trainee should be removed. This counselled or given the opportunity to correct. Surgical latter function has traditionally been the role of the SAC training is currently facing wholesale changes due to the and this should continue although five yearly assessments impact of a series ofinitiatives within the NHS. The New are clearly inadequate and the presence of a member of Deal on junior doctors' hours means that training will the SAC from outside the region at the annual assessment soon be confined to a 72-hour week, and further reduc- process will be necessary to give legitimacy to the tions may follow. The belated compliance with European assessment process. Directives dating from 1975 may lead to the duration of It is likely that the problem of a poor trainee will be training in some specialties being halved. Postgraduate infrequent, and that the level ofconcern surrounding this Deans now hold 50 per cent of the basic salary of all problem is exaggerated. More often good quality trainees trainees and will demand the introduction of formal will fail to be appointed due to competition and may be postgraduate education during working hours. forced to undertake inappropriate service or research However, Trust Hospitals are constrained by the need work whilst waiting to reapply. to win and fulfil contracts, and the move towards a The format of the annual assessment requires careful consultant provided service and compliance with the attention. Trainee logbooks are inadequate and a sum- Patients' Charter may result in consultants being too mary of experience is necessary. In many pilot surveys, busy to provide even the current level of training. the logbook has been abstracted, using the BUPA scale of The introduction of a continuum of higher surgical procedures. This is inappropriate, because it gives no training, in response to the Calman report, will remove reflection of specialist experience and trainees are un- one of the major career hurdles and, possibly, the familiar with the categories (complex major, major, incentive to continue to produce research. Furthermore, intermediate and minor) and are therefore likely to be the appointment to a continuum post will effectively inconsistent in their classifications. ASIT have produced equate to the selection of a future consultant. a logbook summary form which aims to provide infor- There is apprehension concerning what to do about mation of total experience within a sub-specialty and also trainees who perform badly in the new training pro- more detailed information of a range of procedures gramme. All these factors mean that it is now imperative appropriate to higher surgical training within each sub- that a meaningful system of evaluation of surgical train- specialty. Distinction is made between solo operating, ing be introduced as soon as possible. Such a system supervised operating, teaching and assisting, and also must identify those who are failing to make progress and emergency and elective experience. This should be trainers who provide inadequate training. Where prob- reviewed in the light of the professed specialist interest lems are identified with the trainee, remedial action must and overall workload of the firm, which can be derived be taken with counselling, and stratagems for improve- from audit data available at the assessment. This form is ment agreed jointly. Failure to achieve these goals may to be piloted in four regions at the request of the SAC, For Debate 199 and the data collated by the Comparative Audit Office. reflection is to be obtained, this must be anonymous. This will provide a valuable data base reflecting the Where such assessments indicate inadequate training, current experience of surgical trainees. It is essential that steps must be taken to improve the situation and, if this we establish what is actually happening at the moment is not forthcoming, to withdraw the trainee. before we prescribe quotas for given procedures in At the end of the assessment, objectives for the response to the specialist associations' blueprints for following year should be set and agreed by both trainee training and the Calman Committee's requirement for and Training Committee. The introduction of a conti- training guidelines. Simple analysis of numbers of cases nuum of higher surgical training represents a commit- performed ignores the importance of both outcome and ment to the trainee and will allow longer term planning, case mix. It is important that these factors are con- and permit the organisation of periods of training in sidered, but this should more appropriately take place in another centre or overseas. Clearly, the local Training team and specialty audit meetings and should only come Committee, in co-operation with the Postgraduate Dean to the attention of the Training Committee when there is and the SAC, will play a crucial role in making these a serious problem reflecting poor progress. schemes a success. The committee will need to meet In addition to a logbook summary, there should be a frequently and be provided with clear guidance for subjective assessment of all aspects of the trainee's establishing and supervising the schemes. If training is to performance by the trainer and this should be discussed be adequate, more consultants will be necessary so that openly with the trainee. Furthermore, the Training supervision can be improved. Committee should assess the progress in research with Surgical training in the United Kingdom is in tran- particular reference as to whether half days are available sition from a protracted apprenticeship where endurance for study, and opportunities to attend national meetings is eventually rewarded, to a shorter, more intense, have been provided and taken up. residency style programme. Careful evaluation of this The trainee should also submit a detailed assessment of training is essential if we are to continue to produce high the training to the Training Committee and if an honest quality surgeons in the new system. Annals of The Royal College ofSurgeons ofEngland (Suppl) (1993) vol. 75, 200-202

Surgical Training

The assessment of competence in surgical trainees

Michael Pietroni Associate Dean of Postgraduate Medicine (North East Thames Regional Health Authrit)rity)YyS University of London

Key Words: Competence; Surgical training; Medical education; Formative assessment; Summative assessment

Trainers have an increasingly important role in the assess- be structured carefully, validated, documented and ment of competence in their surgical trainees. This article retained. outlines the philosophy behind the assessment of com- petence, and offers a range of such tests from which to select The second reason why assessments are important is what is valid, reliable and feasible. that they are the single strongest determinant of what students actually learn (2) (as opposed to what they are taught). The information must be fed back to the trainee who needs this information, not only as a guide to the The organisation of higher specialist training is in a state expectations of the specialty, but also as a measure of of flux. Calman is upon us and the changes envisaged are progress being made. Feedback is a proper part of the radical. Training will be more of a continuum and there education cycle and in itselfis an educational opportunity will be fewer interviewing committees to negotiate. The which should not be missed. Constant feedback to new concept of competent completion of a training pro- trainees probably helps to reduce stress (3). gramme is introduced (1). When choosing a method of assessment from a menu of possible tests, there is a need to ensure that the test '... CCST (will) be awarded by the GMC on advice selected is valid (actually tests what you want to test), from the relevant Medical Royal College that the reliable (ie, reproducible) and discriminates between doctor has satisfactorily completed specialist training candidates along a range of abilities (4). based on an assessment of competence . . .' There are many tests available and of these, examin- This is a radical departure from present practices. ations are probably the easiest to construct but in many Completion of a minimum number of years of higher instances the least valid. Too often they become the training entitles a senior registrar to become accredited, purpose of education and training and it was Sir William but even this accreditation is not a requirement for Osler who said 80 years ago 'Are examinations the best appointment to a consultant post and hence independent means to an end or at worst are they the end itself?' (5). practice at the present time. The validity and reliability of examinations can be The new concept of competent completion of a pro- improved, but they often suffer from the introduction of gramme of training identifies a need to certify com- bias. This is best removed by constructing the examin- petence. This throws a burden on individual trainers who ation in such a way as to examine the candidate against a not only have to certify that the trainee completed a set of standards previously defined and by making them period of training but that he did so competently. There as objective as possible (2). Whilst Universities and Royal may be situations where trainers may find themselves Colleges may strive to achieve this when examining large medico-legally responsible for this opinion should prob- groups, the problems of bias will always be present when lems arise later, and they may have to justify this opinion one or more trainers test the competence of individual in a court of law. trainees. The assessment of competence will therefore need to Nevertheless, there is a menu of tests from which to Surgical Training 201 select and although total objectivity is not possible, Table I. giving the test structure allows more rigour in the Table I. assessment of competence. Physical examination A series of confidence rating scales, as used in the The doctor tends to fail to The doctor is selective in current PRHO book (6), can outline a trainee's assess- expose the part properly, is examination but systematic. ment of his own abilities. Simple 0-5 scales of confidence not always thorough and The regions/systems/organs sometimes does not re-check examined reflect the history are applied to clinical statements, eg, 'I am confident doubtful findings. He misses that has been established. with the initial management and resuscitation of a patient important physical signs. Important physical signs are with a haematemesis presenting with a systolic blood elicited. pressure of 50 millimetres mercury.' A list of such statements with their corresponding confidence rating Coping with uncertainty scales allows the initial assessment of confidence over a The doctor having failed to The doctor having excluded particular clinical field. Having established the initial reach a firm diagnosis shows immediate risks is prepared to score, training can be directed and a further assessment intolerance of uncertainty by use time as a tool while giving at the end of a period of time will show any gain. hurried, rushed treatment, the patient support and gain- These are crude but valid tests which guide educa- investigation or referral, with- ing his trust. When this is not tional direction. More detailed assessment of knowledge, out thought for the patient's possible, investigations, man- skills and attitudes can be obtained by random case convenience, or a concern for agement and referral reflect analysis. The notes, X-rays, laboratory tests of an indivi- economy. the urgency of the situation. dual case are reviewed in meticulous detail with the trainee, testing and probing the applications of know- ledge, the skills demonstrated in information gathering, Comprehensive testing along this line can also guide any problem solving, clinical judgement and whether the restructuring of rotations that might be necessary. trainee used time and money with economy. Trainees themselves need to be trained in self assess- A more exhaustive analysis can be performed using ment. Self-directed learning and assessment is a feature audit of project work. Here a whole area is specifically of many undergraduate training programmes. A state- examined, eg, management of intestinal obstruction, ment of a clinical problem appears on a computer screen management of the critically ischaemic limb. It would be followed by a question about the next relevant step. appropriate to review the case notes of the last 10 of 15 Often the candidate may be given four possible options patients managed by the trainee to see whether an audit from which to choose. Having chosen, he/she may be of this activity reveals any deficiencies in knowledge, given a breakdown of the answers given by his peers, skills and attitudes. An audit of project work done in this followed by the 'correct' reply and an analysis of the way can also alter attitudes, identify skills that require advantages and disadvantages of choosing the options. A development and expose gaps in knowledge. large bank of such assessments allows repetition and the Logbook analysis helps not only in identifying gaps in charting of progress along a particular field. Self assess- experience, but also perhaps exposes any deficiencies in ment can and should always form part of the educational the institution and especially in areas in the surgical review of out-patient/in-patient/operating theatre-per- spectrum that are not available to the trainee. formance. In self assessments, even if the performance of Some countries in Europe and some specialties in this the trainee was not entirely satisfactory, it is the power of country wish to specify a specific number and a specific directed and supervised self analysis that changes the spectrum of operations that need to be performed to event into a learning opportunity. The trainee retains justify competence. Advances in surgery and changes in ownership of his own assessment and in a way presents attitude often make these lists out of date by the time his own feedback and retains control over the direction of they are developed. It might be best to make 'broad further education that might be needed. brush' statements about the range and case mix that is This article will not review MCQs, modified essay required, rather than be too prescriptive. Such an questions, essays and vivas. These four forms of assess- approach has been used in the Guidelines for Basic ments are more appropriate within the overall umbrella Surgical Training, published by The Royal College of of examinations. Nor does surgery, with its emphasis on Surgeons of England. physical signs, lend itself very easily to the use of Lastly, a system of criterion referenced scales (7) is a simulated patients. Nevertheless, simulated patients are way of converting subjective opinion into a form of useful in the assessment of the skills associated with measured analysis. Two sets of statements are made history taking, rapport with patients, ability to commu- which characterise the favourable and unfavourable ends nicate, problem solving, informed consent and discus- of a behaviour spectrum and the trainer marks the trainee sion of alternative options in treatment (2). Supple- on an arbitrary scale of 0-10 along this line. Two mented by video recordings (8) and subsequent video examples of this are given in Table I. Criterion refer- analysis, trainer and trainee can more readily agree on enced scales have been in use in general practice assess- skills that may require further development. ments of trainees for some time. Their value is in In surgery, more than in any other branch ofmedicine, identifying weaknesses in the candidate, in giving infor- we have the option of using validated, simulated techni- mation about rate of progress and the range of skills. cal tests; and yet the test bed is usually the real patient. 202 Surgical Training Table In Subject: The management of intestinal ing and a statement about what will be in place at the end obstruction of that period. Such assessments allow the trainer and the trainee to pace progress and allow feedback to both. The Clinical Prac- assessment should be documented, countersigned by the Know- appli- Problem tical Atti- trainee and retained and reviewed on the next occasion. Test ledge cation Solving Skills tudes Trainers will require to develop skills in formative assessment for another reason. In the post-Calman seam- Confidence + + + less training world interview barriers disappear. It will be rating scales vital to assess trainees carefully and only allow those to Random + + + + + proceed who have a reasonable chance of success. It is case likely that the first 18 months of Higher Specialist analysis Training should be especially carefully monitored. Any Audit of + + + + + trainee whose competence to proceed is in doubt, and project work who is advised to choose an alternative career path will Logbook + justifiably require validation of this opinion. analysis It is important that the detailed structure of formative assessment should be left to local trainers. It is they who + + + + Criterion will decide which tests selected are acceptable, feasible, referenced valid and reliable in their hands. Universities, colleges scales and other standard setting institutions should confine Self + + + + their activity to offering advice and training for trainers assessment in how to appraise. Once trained it is the trainer who will Simulated + + + choose from a menu of tests the most appropriate test in patients his institutions and in his hands. a as in Video + + + + In achieving this end design matrix (4), shown analysis Table II, may be useful. Each parameter that requires testing is matched with the most appropriate form of Simulated + assessment. technical Structured, formative assessments of competence is tests time-consuming and expensive. Done well it identifies strengths and weaknesses not only in the trainee, but also in the trainer and the institution. When documented and retained, frequent assessments gathered together act as a Anastomosis and laparoscopic workshops, ATLS courses summary of a trainee's competence. In this way these and the like, are excellent areas in which assessment can assessments have the potential of producing more accur- be structured. Unless we structure the assessment of ate data on competence than do exit examinations and operative skills along these lines soon, we may well find references. Such assessments, furthermore, when cen- that the public will impose them upon us in a way we trally collated, allow universities and colleges to develop may not like. and direct training programmes, identify weaknesses in funding and identify areas in which trainers themselves require further education. Formative and summative assessments Tests performed at the end of a period of training are References called summative. They are qualitative (and perhaps I Hospital Doctors: Training for the future. The report of the quantitative) judgements about the past and are generally Working Group on Specialist Medical Training, HMSO, used as a statement about competence. The conclusions April 1993. 2 Lowry S: Assessment of students. Bnt MedJ_ 1993; 306: 51- are too late to be of any use to the trainee and when they 4. take the form of examinations run by Universities and 3 Hale R, Hudson L. The Tavistock study of young doctors: Royal Colleges, feedback to the trainee is very limited. report of the pilot scheme phase. BritJ Hosp Med 1992; 47: As an educational tool they have severe limitations. 452-464. These limitations are almost entirely absent with forma- 4 Harris D. Assessment of students. BritJ7 Hosp Med 1992; 48: 586-589. tive assessments. These occur at the start of the post and 5 Osler W. Examinations, examiners, examinees. Lancet throughout the period of training. They answer the 1913(ii); 1047-59. question 'where are you and where do you want to get 6 Pre-registration House Officer Training. British to?' Formative assessment is hard work. It should Postgraduate Medical Federation, 1990. preferably occur at four to six monthly intervals and 7 Rating scales for Vocational training in General Practice. should involve the trainer and trainee. The form of the Royal College of General Practitioners, 1989. 8 Cox J, Mulholland H. An instrument for assessment of assessment should be a statement about the present videotapes of general practitioners' performance. Brit Med competencies, the objective for the next period of train- 1993; 306: 1043-6. Annals of The Royal College of Surgeons of England (Suppl) (1993) vol. 75, 203-206

Surgical Practice

Who should code orthopaedic inpatients? a comparison of Junior Hospital Doctors and Coding Clerks

D Ricketts Registrar J Hartley Senior House Officer Department of Orthopaedics, The Central Middlesex Hospital W Harries Registrar Department of Orthopaedics, Northwick Park Hospital D Hitchin Statistician Computing Service, Arts B, University of Sussex Key words: Computer systems; Medical audit; Orthopaedics

Our principal aim was to determine whether coding for produced guides to coding practice. Junior orthopaedic billing purposes is adequately completed by hospital doctors. staff code for departmental records with about 75 per We also wanted to determine whether events during the cent completeness (4). inpatient stay prompted coding. ICD9 (International classification of diseases, 9th We investigated the completeness and accuracy of ICD9 revision) (5) and OPCS4 (Office of Censuses and OPCS4 coding at two departments of orthopaedics. Population Coding was for billing purposes only; retrieval of clinical data and Surveys, 4th revision) (6) coding are commonly used was limited to individual cases. Junior Hospital Doctors computer-based coding systems (7,8). With the introduc- JHDs) undertook coding at one department, coding clerks at tion of resource management, some hospitals have the other. At each side 100 sets of notes concerning inpatient required doctors to provide ICD and OPCS codes for admissions were reviewed. patients purely for billing purposes. In many of these Coding clerks returned coding data of higher completeness hospitals the codes generated cannot be used for a clinical and quality (completeness x accuracy) than JHDs, but of database, for retrieval of series of cases or for audit. lower accuracy. Completeness of data from JHDs reflected The effect of these circumstances on doctors' motiva- motivation to code and this was influenced by events during tion to code correctly (or code at all) is unknown. The the course of admission. JHDs coded best for patients repercussions regarding departmental funding are undergoing elective surgery, and worst for patients managed important as managers often assume coding to be 100 per non-operatively. Coding clerks coded for all groups equally well. cent complete and accurate. In the current study coding data returned by JHDs was of To investigate this we assessed coding at two hospitals lower completeness and accuracy than has been described who calculate the bill for inpatient orthopaedic care from for other coding systems. We attribute the lower complete- ICD9 and OPCS4 coding. JHDs undertook coding in ness to the low motivation of JHDs when coding for billing one hospital; coding clerks were employed in the other. purposes and the lower accuracy to difficulty in using the Our principal aim was to compare the quality, complete- system. Motivation could be increased by incorporating ness and accuracy of coding in each hospital. We also coding into departmental audit, the generation of discharge wanted to determine whether coding was influenced by summaries and record collection for personal logbooks. events during the inpatient stay.

Coding is a tool employed by hospital doctors to quantify Method their work, enabling rapid and accurate analysis of data Two departments of orthopaedics from geographically (1). Coding is increasingly viewed as an essential part of adjacent hospitals (A and B) in the same region of JHD training; both The Royal College of Surgeons of London were investigated. The population served and England (2) and the Department of Health (3) have staffing levels were similar in each department. At each hospital we studied the notes of 100 sequential ortho- paedic inpatients admitted after December 1 1991 (both Correspondence to: D Ricketts, Department of Orthopaedics, Bristol elective and emergency admissions). From each set of Royal Infirmary, Bristol BS2 8HW notes we obtained a list of the 'true' orthopaedic diag- 204 Surgical Practice noses and procedures performed. From the coding Table I. Overall results of coding at hospitals A and B computer the 'actual' orthopaedic diagnoses and ope- rations listed for that individual were retrieved. Complete Accurate Quality The results of coding were assessed according to the (%) (%) (%) method devised by Barrie (9). The completeness, accur- Hospital A (completeness x accuracy) of the 'actual' Diagnosis (n= 100) 63/112(56) 56/63(89) 50 acy and quality Procedure (n= 67) 55/81(68) 49/55(89) 61 versus 'true' data were calculated. We were careful to use Total 118/193(61) 1051118(89) 54 the same (fairly free) definitions of completeness and accuracy throughout. The code was complete if any code Hospital B was entered for that particular diagnosis or procedure. Diagnosis (n= 100) 100/104(96) 73/100(73) 70 was accurate enough for data Procedure (n =92) 87/100(87) 72/86(83) 74 The code was accurate if it 187/204(92) 145/187(78) 72 retrieval. Total Statistical analysis was performed using Chi-squared tests (without correction for continuity). We regard results with p-values better than 0.05 as significant, but calculated p-values are printed in full so that readers emergency and operative/non-operative data shows that preferring to work at different significance levels can some differences are still present when these factors are draw their own conclusions. taken into account. We imagined the best coding opportunity to arise whilst writing the operation note during an elective list. 2. Quality of data Orthopaedic inpatients who have non-operative or The overall quality of data (Table I) from hospital B (72 emergency operative treatment may not be coded as this per cent) was significantly higher than the quality of data opportunity may not present itself. We therefore com- from hospital A (54 per cent) (p<0.001). This was pared the coding of patients who had non-operative and mainly due to poor completeness of coding data at operative treatment and the coding of patients who hospital A relative to hospital B. Coding for diagnosis underwent elective and emergency operations. was 40 per cent less complete at hospital A and coding for At hospital A (a Trust) JHDs were required to procedures was 19 per cent less complete. complete all coding without training. A telephone help- Concerning overall accuracy of data, hospital A per- line was available but this was staffed only intermit- formed 11 per cent better than hospital B (89 per cent vs tently from 7 am to 3 pm on weekdays. No help was 78 per cent; p < 0.012). Hospital A had diagnosis data 14 available outside these hours. per cent more accurate than hospital B (89 per cent vs 75 Coding at hospital A was linked to the Hospital per cent; p < 0.0 16). At hospital A procedure data was 6 Information System. A working knowledge of the soft- per cent more accurate than hospital B (89 per cent vs 83 ware ('Precision alternative') was necessary to derive the per cent; p < 0.373). patient's 'episode number' and initiate coding. It was not possible for medical or computer staff to retrieve clinical 3. Coding after elective and emergency operations data for more than one patient at a time from the coding The data for patients undergoing elective or emergency computer. operation is shown in Table II. Throughout, the quality At hospital B, coding clerks were given a copy of the of data for hospital B exceeded A (p < 0.047). Regarding house officer's handwritten discharge summary; from this they derived ICD and OPCS codes and entered them into a computer. Consultation with JHDs was occasion- Table II. Comparison of coding data for patients under- ally necessary to clarify a diagnosis or procedure. All going procedures (elective vs emergency) other details of coding procedure were the same as for hospital A. Complete Accurate Quality (%) (%) (%) Results Hospital A Elective procedure 1. Differences in populations of patients at the two Diagnosis (n = 29) 27/34(79) 22/27(81) 64 hospitals Procedure (n = 29) 25/31(81) 22/25(88) 71 Forty-eight per cent of hospital A and 22 per cent Emergency procedure = 32/55(58) 31/32(97) 56 hospital B cases were emergency admissions. These Diagnosis (n 48) Procedure (n = 48) 30/50(60) 27/30(90) 54 patients had significantly worse data than elective admis- sions. Similarly only 67 per cent of hospital A patients Hospital B had operations compared to 92 per cent at hospital B. Elective procedure data for treated patients was Diagnosis (n= 70) 69/72(96) 48/69(70) 67 Again non-operatively Procedure (n= 70) 65/75(87) 57/65(88) 76 worse. The measures of overall accuracy, completeness Emergency procedure shown below not be due to and quality may entirely Diagnosis (n = 22) 23/24(96) 17/23(74) 71 differences in coding, but might be confused with these Procedure (n = 22) 22/25(88) 15/22(68) 60 background factors. Individual analyses of elective/ Surgical Practice 205 the accuracy of data, figures for emergency operations at Table III. Comparison of diagnosis coding data (ICD9) hospital A (97 per cent and 90 per cent) were significantly from operatively and non-operatively treated patients better (p < 0.002) than for hospital B (74 per cent and 68 per cent). The accuracy of data for coding of elective Complete Accurate Quality procedures was the same in both hospitals (88 per cent). (%) (%) (%) Hospital A 4. Coding for operatively and non-operatively treated Operative (n= 77) 59/89(86) 53/59(90) 59 patients Non-operative (n = 23) 4/23(17) 3/4(75) 13 In Table III the completeness and accuracy of data for Hospital B operatively and non-operatively treated patients is Operative (n = 92) 92/96(96) 65/92(71) 68 shown. Again, in both categories the data for hospital B Non-operative (n= 8) 8/8(100) 8/8(100) 100 (68 per cent and 100 per cent) was of significantly higher quality than for A (59 per cent and 13 per cent; p<0.001). These differences are most marked with regard to the completeness of coding for patients managed without operation (100 per cent vs 17 per cent; cent). Further tuition, consultation with medical staff p <0.001). and improved quality of medical documentation might improve their accuracy. In the current study JHDs completeness (61 per cent) and accuracy (89 per cent) is lower than for other systems Discussion (70 per cent and 96 per cent for the Manchester In the current study coding clerks return ICD9 and Orthopaedic Database) (9). We attribute the low comple- OPCS4 coding data of higher quality than JHDs. The teness of data in our study to low motivation, the low reason for this is the 31 per cent higher overall complete- accuracy we attribute to the difficulty experienced by ness of coding clerk data (Table I). We attribute this to untutored JHDs in using the complex OPCS4/ICD9 poor motivation of JHDs. Plainly, coding for a system system. that allows no retrieval of useful clinical data engenders There are two solutions to the problem of low coding disillusionment and poor coding practice. quality by JHDs at hospital A. The first is to employ In contradiction to previous studies (10), coding clerks coding clerks to code at the point of discharge. The returned data of lower accuracy than JHDs. The poor second is to provide the JHDs with a clinically useful accuracy of coding clerks for emergency admissions was coding system and harness the enthusiasm many JHDs the principal reason for this. Poor quality of medical staff have for coding and audit. The quality of data would documentation for emergencies may have caused difficul- improve (12) and the data could also be used for billing ties in documenting the correct code. purposes. An ideal system would rely on recorded speech As all coding was for billing purposes, the poor for data entry and generate personal operating logbooks, completeness returned by JHDs represents a significant departmental audit figures and discharge summaries. loss in revenue for the department. Accuracy of coding Periodic audit of figures would identify patients who may also influence departmental income but coding for escape coding. elective procedures, financially valuable to many ortho- We conclude that ICD9 and OPCS4 coding for billing paedic departments, was similarly accurate for both purposes is best undertaken by coding clerks. If under- JHDs and coding clerks (Table II). taken by JHDs significant numbers of patients will not We found that coding by JHDs was influenced by be coded and departmental remuneration will be lost. events during the inpatient stay (Tables II and III). For JHDs are clinicians first and managers second and they elective procedures 79 per cent of diagnoses were coded; see coding for billing purposes as peripheral to their for emergency operations and non-operatively treated clinical duties. We suggest JHDs will only provide more accurate coding data than coding clerks if it benefits their patients the completeness was 58 per cent and 17 per cent clinical respectively. In comparison, coding clerks at hospital B practice. This could be achieved by using coding similar for all to facilitate the generation ofdischarge summaries and by returned completeness groups (elective capturing data for personal logbooks and departmental operation 96 per cent, emergency operation 96 per cent audit. and non-operative treatment 100 per cent). This reflects their practice of coding from the notes after discharge. We conclude that coding clerks had higher motivation to code than JHDs and that motivation was the same for all patient groups. References In previous studies completeness and accuracy of 88 I Ricketts, D. The AO classification of fractures. IntJ per cent and 98 per cent (using OPCS) (8) and 81 per cent Orthop Trauma 1992; 2(20): 124. and 80 per cent (Hospital Activity Analysis) (9-11) have 2 Guidelines for Surgical Audit by Computer. Royal been returned by coding clerks. In comparison the College Surgeons Eng. May 1991. coding clerks of hospital B return data of high complete- 3 The Standing Medical Advisory Committee. The ness (92 per cent), but relatively low accuracy (78 per Quality of Medical Care. London; HMSO, 1990. 206 Surgical Practice 4 Ricketts D, Hitchin D, Patterson M, Fowler S and quences for resource management. J Public Health Newey M. Markers of Data Quality in Computer Med 1991; 13(1): 40-1. Audit; The Manchester Orthopaedic Database. In 9 Barrie JL and Marsh D. Quality of data in the Press; Ann R Coll Surg Eng. Manchester Orthopaedic Database. Brit Med J 1992; 5 World Health Organisation. International Classi- 304: 159-62. fication of Disease, 9th Revision. Geneva; WHO, 10 James NK and Reid CD. Plastic Surgery Audit 1990 (available from NHS Manpower Exeuctive, Codes: are the results reproducible? BrJ Plastic Surg HMSO, London). 1991; 44(1): 62-4. 6 Office of Population Census and Surveys Classi- 11 Rees JL. Accuracy of hospital activity analysis data in fication of Surgical Operations, 4th revision. London; estimating the incidence of proximal femoral frac- HMSO, 1987. tures. Brit Med J 1982; 284: 1856-7. 7 Woods WG and Earlam RJ. Breast Cancer data 12 Castleden WM, Norman PE, Stacey MC, McGechie Collection for Surgical Audit. Ann R Coll Surg Engl D, Brooks JG, Fisher J and Lawrence-Brown MM. 1991; 73(6): 364-71. How accurate is computerised Surgical Audit when 8 Smith SH, Kershaw C, Thomas IH, and Botha JL. resident medical staff collect the data? Aust N-Z J PIS and DRG's: Coding inaccuracies and their conse- Surg 1992; 62(7): 563.

CRYPTIC CORNER 6 The Famous Five

DIRECTORY ENQUIRIES Carruthers, who has been listening to this exchange and who is always truthful, tells him that the number You can visualise the scene. The Famous Five have does not contain a zero. hardly had time to lapse into a glazed silence as the Dalrymple concentrates ostentatiously on an article 8.05 am jolts out of Sidcup station when Elphinstone on vegetable marrows in the Sidcup Bugle but commits the solecism of speaking. He has forgotten Arbuthnot thrives on such arcane discussions and says Bullivant's office telephone number and asks him what that at least he knows Bullivant's office telephone it is. number. Bullivant is not prepared to tell Elphinstone the that he will Although my opinion of the Arbuthnot grey matter number but says reply alternately truthfully has and untruthfully to any questions that Elphinstone may gone up, you should not find it too taxing to work care to ask. out Bullivant's telephone number. What is it? Elphinstone knows that the number is less than 9200, A prize of a bottle of champagne will be awarded by the although he cannot remember how many digits it Editor to the sender of the first correct answer to be drawn contains, and he asks Bullivant to answer 'Yes' or 'No' from a hat. All entries must be received by 25 November to three questions about the number. 1993. Answer and winner in the January 1994 issue. Is it a perfect square? SOLUTION TO CRYPTIC CORNER 5 Is it a multiple of 19? Is it the product of five different primes Amanda Arbuthnot (other than 1)? Daphne Bullivant Edwina Carruthers Elphinstone, mistaking the truthfulness of Bulli- Belinda Dalrymple vant's first answer and having no reason to change his Cecilia Elphinstone opinion after brooding on all three answers, says 'If I knew that there were at least one zero in the number, I A bottle of champagne to S. Namasivayam FRCS of would know what it is'. Leeds, the winner from eight correct entries. Annals of The Royal College ofSurgeons ofEngland (Suppl) (1993) vol. 75, 207-208

Surgical Audit

Use of management techniques to control elective surgery

J. G. Mosley FRCS Consultant Surgeon Leigh Infirmary, Lancashire

From January 1989 the new outpatients seen each year have For planning of operation time one intermediate equi- been restricted to 1 540. It was predicted that this would valent approximates to one hour's operation. This create 770 intermediate equivalents of operating time. includes anaesthetic and turnover time as well as the time Throughout 1991 and 1992 each patient seen in Outpatients for the operative intervention (5). was given a scheduled date for his/her operation. During It was found that over a preliminary three-year analysis 1992 89 per cent of patients listed were operated upon on the every two new outpatient referrals generated one inter- planned date. mediate equivalent (IE) of theatre time. Each year approximately 90 IE procedures performed during an The Patients' Charter stipulates that from 1 April 1992 elective list are on patients admitted as an emergency, eg each patient should be guaranteed admission by a specific intestinal obstruction. I do not have an emergency date (1). This date should be no longer than two years operating room available during normal working hours, from the day of the consultation at which the patient was neither do I have a dedicated day case theatre. In placed on the waiting list. Certain districts are striving to addition, on average 30-40 IE per year are inpatient exceed the recommendations by reducing the waiting referrals from other clinical firms. times to one year. I have 41 operating sessions each week. These include Computer models are available to predict the workload an all day list in which I am able to operate through lunch derived from emergencies, inpatient referrals and out- and finish on average at 6.00 pm. The operating theatres patients (2). are closed for theatre maintenance or bank holidays for Adjustments in routine outpatient referrals were made two weeks each year. In addition 92-1 sessions were to anticipate theatre activity. The aim was to provide cancelled for audit meetings. This allowed my team 912 each patient with a planned admission date within nine hours operating time during the year or 912 IE. No months of listing. Each patient has subsequently been operating session was cancelled. In addition I have one prospectively followed to evaluate the success of this endoscopy session per week but this has not been policy. included in this analysis. As consultant referrals and admissions cannot be Resource planning model reduced, it was decided to restrict new outpatient refer- Source data were derived by analysis on a Casemix rals to 35 per week (1 540 per year). Each patient.listed System (3). Following scrutiny of the results it was was given an appointment day which varied between two possible to predict the number of patients who would weeks and nine months, depending upon the clinical and require an elective operation and whether the operation social urgency of the operation. This system has been would be minor, intermediate, major, major plus or running for over two years. It has now been tested to find complex major, BUPA Classification (4). what proportion of admission dates were honoured. Using the BUPA Classification every operation was given a relative value. Results Minor -0.5 During the 12-month period 1 January to 31 December Intermediate -1.0 1992 there were 927 IE performed during elective operat- Major -1.75 ing periods. There were no cancelled operating sessions. Major plus -2.2 Seven-hundred-and-thirty-eight IE were listed in the Complex major A-3.10 outpatient department and were given a planned admis- Complex major B-4.0 sion date. Over 90 per cent of the CMO, intermediate Complex major C-5.0 day cases and minor cases were performed on schedule 208 Surgical Audit Table . Planned outpatient listing compared to performance Operation Planned Performed on Delayed code (IE) schedule I week 1-4 weeks >4 weeks No % No % No % No % CMO 204 192 94 8 4 4 2 0 Major plus 86 66 77 8 9 6 7 6 7 Major 62 49 79 11 17 2 4 0 Intermediate: (a) Day cases 245 230 94 7 3 7 3 1 0.5 (b) Admitted 59 42 71 0 16 27 1 2 Minor 82 78 95 1 0.8 2 3.4 1 0.8

Total 738 657 89 35 4.6 37 5 9 1

(see Table). Over the year only 1 per cent of the total able contribution to the overall waiting list as predicted scheduled were delayed for over four weeks from the date from queuing theory (8). Further improvement might be they had been given in the outpatient department. expected if a dedicated emergency operating theatre was available. It is highly unlikely the same degree of success could Discussion be achieved if every general practitioner referral was seen One of the main functions of a manager is to solve within eight weeks. The basic fault in health care in the problems. There are three basic steps to tackling a UK is that it has been chronically under-funded for many problem: years. However many reorganisations are undertaken, 1. Decide what needs doing things will not improve until this fundamental problem is 2. Do it addressed. 3. Check that is has worked In this project it had been decided to introduce a policy of offering each patient a scheduled date for an operation Acknowledgement during the forthcoming nine months. Clearly there are The author wishes to thank the nursing staff on the inherent constraints on the system that require each wards and operating theatres and the department of operating list to be fully utilised. In addition there are anaesthetics. unpredictable demands in the form of emergencies, in patient referrals from consultant colleagues, junior staff holidays or illness, surgical beds being occupied by References medical cases and finally, managerial meetings at which I Patients' Charter. Department of Health, 1991. consultant attendance is required. This limits choice (6). 2 Ellis BW. Factors influencing waiting lists and costs of However, it is practicable and does not contravene the surgical treatment. Ann Roy Coll Surg Eng (Suppl) Patients' Charter to control input through regulation of 1991; 73: 14-77. new outpatient appointments. 3 Mosley JG and Fairbanks R. Using audit in a district During 1992 outpatient attendances were controlled to wide management system. Health Services Management yield an anticipated 770 IE. In fact, only 738 IE were 1992; 88; 27-9. listed from outpatients, which was 4 per cent less than 4 BUPA Schedule of Procedures. The British United predicted. Completion of the control loop (7) has deter- Provident Association, London 1991. mined that it was possible to achieve over 90 per cent S Collins CD. Providing the ideal surgical services. Ann success in every elective case being done within seven Roy Coll Surg Eng (Suppl) 1992; 74: 126-9. days of the day scheduled. 6 Stewart R. Choices for managers, McGraw-Hill, 1982. The day case ward has been very successful as it 7 Handy C. Understanding Organizations. Penguin provides an assured six empty beds each morning for the Business, 1985. minor and intermediate cases. This was reflected in 94 8 Dudley HAF. Queuing theory and the waiting list. per cent of these cases being operated on on the date Guidelines for Day Case Surgery. The Royal College of given in outpatients. This facility has made a consider- Surgeons of England, 1985. 209

Reports

Women In Surgical Training Conference 1993

Maria Coonick WIST Administrator

A second highly successful WIST Conference was held at College had arranged its first ever creche to be available the College on 21 May 1993. More than 150 women and a for participants. handful of men made up an enthusiastic and colourful audience, of whom over a third were Senior House 'It's becoming too heterosexual' Officers. The first speaker of the morning was Baroness Julia The Conference not only developed some of the Cumberlege, the Parliamentary Under Secretary of State themes from the previous meeting, such as part-time for Health in the Lords. She empathised with the training and job-sharing, but also addressed new issues audience by comparing her own minority status in the on women and surgery in the talks given by Dr Linda House of Lords, where women still made up only 5 per Phillips from the USA and Baroness Cumberlege from cent of the peers. She told the audience how she had been the Department of Health. greeted in the Lords with the comment 'It's becoming The audience was welcomed to the meeting by too heterosexual'. Professor Norman Browse, President of the College, who She then addressed the issue of the small number of also chaired the morning session. He re-stated the women consultants and stated the government's aim to College's commitment to WIST and was loudly increase the number of consultant posts held by women applauded by the audience when he announced that the from 16 per cent to 20 per cent by 1995. She added that although 90 per cent of qualified women doctors conti- nued to work after having a family, a considerable proportion worked only 1 or 2 sessions per week, thereby failing to meet their potential. It was unclear, she continued, whether this was by choice or through an anticipation of discrimination. She hoped that WIST would look into these issues in the near future. She commented on the issues of maternity and child- care, stating that these were beneficial experiences which added a different perspective to women's professional lives. She ended her talk with a call for equal partnership with men and the comment that for women to succeed they would have to find themselves comfortable at the top, and that this included the top table of The Royal College of Surgeons of England! 'Men don't learn to stitch in primary school' There followed a series of presentations by women consultant surgeons, from three different specialties. Averil Mansfield and the President talking to Baroness Julia Cumberlege, Parliamentary Under Secretary of State for Health in the Miss Judy Evans, Consultant Plastic Surgeon at Lords, and one of the speakers. Plymouth (whose talk, due to an unavoidable commit- 210 Reports

Group photograph of the Conference delegates ment, was admirably given by her Senior Registrar, Miss setters'. She felt that being female often helped in her Parry-Davies) provided the audience with a personal specialty. view on plastic surgery and part-time training. She felt Mrs Lennox then spoke about job-sharing. Although very strongly that if she could become a surgeon anyone she was very keen to stress that WIST was not just about who tried could do the same. She told the audience how job-sharing and part-time training, she believed that it she had surmounted obstacles such as fainting during her was important to know about their availability. After first visits to the operating theatre and resuming work as outlining the advantages of job-sharing as opposed to an SHO only 12 weeks after the birth of her first child, part-time training, she explained the steps needed to be when she had worked every other night on call! Life, she taken to acquire such a post, commenting that a job- continued, greatly improved after her discovery of part- share should be seen as a temporary situation. However, time training, although this would take her two years to she added that the odds of finding a partner would organise. probably be 1 in 1400. She also warned the audience of Today, she was very pleased that she persevered with the horrendous phone bills she had to pay during her job- her training as she thoroughly enjoyed her work as a sharing experience. consultant and she is now also an official counsellor for the Plastic Surgery Specialist Advisory Committee on Change the rules! part-time training. Miss Evans strongly urged other The consultant surgeons were followed by two young women who wanted to make a career in surgery 'to go for women surgeons in training. Dr Meryl Davis, an SHO it'; after all she added 'men don't learn to stitch in from the UK, spoke on the attributes required for primary school'. surgery and told of how she had once been advised that Miss Deirdre Watson, a thoracic consultant surgeon the qualities needed were 'the eyes of an eagle, the heart from Birmingham's Heartland's Hospital, spoke on car- of a lion and the hands of a woman'. She also spoke on diothoracic surgery. She briefly outlined the aspects the perceived differences between men and women and which made up the work of a cardiac and a thoracic ended with the observation that many of the problems surgeon and the training involved. She added that experienced by trainees were common to both sexes, although until now this specialty had attracted very few such as the hours, the long training and the lack of women she felt that cardiothoracic surgery could offer a morale. great deal for women in future. Dr Nathalie Kaunda, an SHO from Zambia, working The next talk was given by Mrs Catherine Lennox, in the UK, gave an overseas perspective. She spoke ofthe Consultant Orthopaedic Surgeon at Hartlepool General problems experienced by surgeons in Zambia, where Hospital. She told the audience that she had used the there were too few operations, performed by too few system to her advantage and had achieved both career people, who were inadequately trained and had to cope and family. She outlined the work of an orthopaedic with limited resources. However, she assured the surgeon adding that orthopaedics was an exciting spe- audience that women experienced similar problems in cialty and those who practised it were not just 'bone Africa as in the UK, although extended families certainly Reports 211 helped with the burdens of childcare. She concluded that it was up to women to set the agenda and do what men do so well which was to 'change the rules'! After a group photograph and lunch, during which there was an opportunity to meet old friends and make new ones, the afternoon session was chaired by the Chairman of WIST, Miss Averil Mansfield. 'Dr Mum is OK' The Chairman warmly welcomed the first speaker of the afternoon, Dr Linda Phillips, President of the Association ofWomen Surgeons of the US (AWS) and an Associate Professor in Plastic Surgery. Dr Phillips began her talk by posing the question whether WIST or AWS was really needed. She believed that the low numbers MNt were an indication that they were and contrasted the UK's low figures for women surgeons with the equally Mrs Glare Newton (DoH) explaining part-time trining to participants. low figures ofwomen surgeons in the US, which was only power to make changes, stating 'Make your presence in 10 per cent. Obstacles, she added, included experiences surgery known, make your role worthwhile and make of gender bias, a lack of role models, a perception that surgery better for all surgeons'. having a surgical career and family was difficult and even sexual harassment. She shocked the audience by stating A level training field that a recent survey had shown that 8 per cent of surgical The last speaker of the day was Dr Trevor Bayley, resident pregnancies were voluntarily terminated due to Chairman of the Committee of Postgraduate Medical fears that the pregnancy would have a negative effect on Deans. His talk focused on part-time training. He began the women's career. The Residency programmes in the by expressing his concern that his own region had a very US, she added, were very structured and it was very poor response to part-time registrar training. difficult to break them on any grounds. He felt strongly that each unit should have the capacity She then asked how WIST and AWS could facilitate for flexible training, and that trainees should be assessed and promote women surgeons. She suggested the import- not just on examinations and time served but on the ance of networking, the availability of information for quality of their training. He also called for a change in women to make more informed choices, the promotion of attitudes towards doctors in flexible training. He ended women's accomplishments, workshops, and newsletters. by re-stating the Postgraduate Medical Deans' support of Dr Phillips stated that women should not refuse leader- the WIST Scheme. ship roles and that the successful ones should become visible role models. She added that women's minority Discussion status in the profession inevitably made them high profile The remainder of the afternoon was devoted to open people. discussion. Issues raised included the funding of part- She believed that junior colleagues should be shown time consultant posts and the suggestion that funding that they could have a career and a family and that 'Dr could be linked to each trainee from the start ofhis or her Mum is OK'. Dr Phillips ended by saying there would be training, thereby making the transition to and from a need for personal courage and that women did have the flexible training easier and less bureaucratic. The meeting agreed with the Chairman's concern over the detrimental effects of the age-stage relationship. This was not only a problem when women applied for jobs but also when they applied for various prizes and fellowships where age limits were imposed. There was general agreement that age limits often inadvertently discrimi- nated against women, as progress in a woman's career would often be delayed by the birth of children. Other topics discussed included research and the availability of locums to provide maternity cover. The meeting came to a close with final words of thanks from the Chairman to the speakers and participants whose contributions had made this an interesting and stimulating meeting. She also thanked Meadox UK Ltd for their financial support of the Conference and the Department of Health for its continuing support of the Averil Mansfield and the President chatting to Dr Linda Phillips, to President of the Association of Women Surgeons of the US, who was a scheme. The Chairman ended by urging women guest speaker. contact WIST with their comments and suggestions. 212 Reports Clinical applications of molecular oncology

Report on Conference held at University of Liverpool, May 1993

J H R Winstanley FRCS G J Poston MS FRCS Consultant Surgical Consultant Surgical Oncologist Oncologist Royal Liverpool University Hospital

The molecular basis of cancer has been the subject of tiation progresses, the greatest expression being seen in much research in recent years. At times the application of myoepithelial cells. In malignant cell lines, however, this to the practical management of patients has not been epithelial cells express basic FGF-like growth factor and obvious. On 5 May a conference entitled 'Clinical appli- high affinity receptors. Low affinity receptors are found cations of molecular oncology' sought to address this on weakly metastatic epithelial cells but not those with problem. The meeting was hosted by the University of more metastatic potential. Liverpool and included a Hunterian Oration by Mr Sam Leinster, Reader in Surgery, University of Professor G Poston. The meeting was divided into three Liverpool, described the role of p53 in familial breast sections devoted to breast cancer, new treatment modali- cancer. In the normal individual p53 levels increase with ties and gastrointestinal cancers; a feature of each section cell damage which stop cell cycling and allow repair. In was a balanced representation of clinicians and basic malignancy a mutant form appears which has a longer scientists. half-life but is inactive. Studies of serum levels of p53 The breast session was opened by Professor Philip determined using an ELISA technique were conducted Rudland, Department of Biochemistry, University of on patients with breast cancer, normal individuals but Liverpool, who described the development of the normal with a family history of breast cancer and normal and malignant breast. Normal breast tissue contains individuals. These revealed that in patients with breast epithelial, alveolar and myoepithelial cells which can be cancer 26 per cent had serum antibodies to mutant p53, differentiated using specific immunocytochemical stain- whereas in patients with a familial history of breast ing. Studies on the developing breast have suggested that cancer this figure was only 11 per cent and in normal cells follow a differentiation pathway from epithelial to controls 1 per cent. If patients with cancer alone were myoepithelial types. A feature of invasive carcinomas is considered 30 per cent overall expressed mutant protein loss of the myoepithelial cell element and cell culture compared with only 9 per cent with familial cancer. experiments have suggested that this is due to a failure of Abnormalities in p53 relate to both histological grade and epithelial cells to differentiate fully down the pathway to the Nottingham Prognostic Index. Although mutations myoepithelial cells. Differentiation down this pathway in p53 are reported to be more frequent in familial breast was associated with production of growth factors and cancer the results suggest that the p53 in sporadic cancers their receptors by the various cell types. Loss of myo- may be different from that observed in familial cancer. epithelial cells in carcinomas may be associated with Oestrogen receptors remain an enigma within breast compensatory changes to allow growth of the epithelial cancer and Dr Chris Green, University of Liverpool, elements. Department of Biochemistry, described some of the most The theme of growth factor expression was taken up recent attempts to unravel their mystery. His starting by Dr David Fernig, also of the University of Liverpool premise was the concept that the apparent presence of Department of Biochemistry, who talked specifically oestrogen receptors does not always equate with response about fibroblast growth factor expression in the breast. to hormone therapy. One means of refining this is to Although eight members of the family have been identi- study the expression of oestrogen responsive genes which fied, basic FGF has been most associated with the breast. indicate the presence ofan intact signal pathway, a classic Both high and low affinity receptors have been identified example of this being pS2. More recently a PLIV 1 gene for the growth factor; it appears that the low affinity has been described. High correlations have been receptors act as a capture mechanism allowing the high observed between the expression of this gene and the affinity receptors to bind and effect signal transduction. presence of oestrogen receptors. Tumours positive for Expression ofboth basic FGF and its receptors have been pS2 and PLIV 1 are always oestrogen receptor positive. studied in cell culture. This has revealed that in cell lines An interesting observation is that PLIV 1 positive derived from the normal breast no expression is seen in tumurs are not only oestrogen receptor positive but also epithelial cells but increasing amounts appear as differen- associated with presence of metastases in the axillary Reports 213 lymph nodes. The association with survival remains to be metastatic disease. Recent studies have investi- established. gated the role of adhesion molecules in metastasis, The second session was devoted to new treatment E-Cadherin being one such molecule. The absence of modalities in cancer. Dr David Tidd, CRC Oncology E-Cadherin appears to correlate with poorly differen- Research Unit, University of Liverpool, outlined the tiated tumours and more invasive malignant cell lines. concept of drugs targeted at one strand of mRNA from These studies are only in their infancy, their full poten- activated oncogenes or mutant suppressor genes, the tial as a prognostic indicator needing further investi- potential being to interfere with their disturbed function gation. Bombesin is an amphibian peptide with human and so provide a novel means of specifically targeted homologues Gastrin releasing peptide and Neuromedin tumour therapy. Mr Peter McCulloch, Department of B. The expression and relevance of these in gastrointesti- Surgery, University of Liverpool, entitled his talk nal cancers was described by Mr Sean Preston, 'Immunotherapy, past, present and future'. Although Department of Surgery, University of Leeds. Receptors the pitential of recognising tumour cells as different for both are expressed in both gastric and colon cancers from normal has been an attractive medium for therapy, together with cell lines derived from gastrointestinal this has not been reflected in practice, with the scant cancers. The effects of bombesin antagonists on the exceptions of BCG in bladder cancer, IL2 in renal growth of cell lines was associated with conflicting carcinoma and Interferon in hairy cell leukaemia. results, a colon cell line being inhibited and the reverse However, new developments in molecular biology will being true for a gastric cell line. The mechanisms for this identify new targets for antibody therapy to such targets phenomena need elucidation before such antagonists can as oncogene products and specifically related tumour be used clinically. antigens. Gastrin is well recognised as an important peptide in Dr John Green, Clatterbridge Centre for Oncology, gastic acid secretion but recently as Dr Sue Watson, described the practical use of growth factors, namely Department of Surgery, University of Nottingham, Granulocyate Colony Stimulating Factor ((G-CSF) in explained it has also been shown to promote the growth tumour therapy. The use of such agents alone and in of human gastrointestinal cancers. Antagonists and anti- combination with other factors such as IL-3 are now secretory agents such as Enprostil and SMS 201 995 have being used to mitigate the adverse effects of high-dose been shown in vivo to inhibit tumour growth. A more chemotherapy in solid tumours and as such increase the novel development has been the use of Gastrimmune therapeutic potential of cytotoxic therapy. which is an antigen derived from the amino acid terminus The question of metastasis was addressed in two of G17 lined to diphtheria toxoid. In rats immunisation papers. Dr Roger Barraclough, Department of Bio- with this inhibited the growth of a rat colon cancer cell chemistry, described a series of experiments in which line; injection of harvested antibodies had a similar a small calcium-binding protein p9Ka had been identi- effect. Gastrimmune is about to be evaluated in a clinical fied and shown to be associated with malignant and not trial on colorectal cancer. benign breast cell lines. In experiments based on trans- The final paper of the day before the Hunterian genic animals, expression of this protein was not only Oration was given by Dr Dan Beauchamp, University of associated with malignancy but aggressive metastatic Texas Medical Branch, Galveston, Texas, whose subject potential. Currently the clinical application of this obser- was antigene therapy in pancreatic cancer. Mutations of vation to prognosis is being investigated. the Ras oncogene have been identified in up to 95 per Dr David West, Department of Immunology, took as cent of human pancreatic cancers. Disruption of the his starting point the concept that tumour vascularisation pathway initiated by these mutations might inhibit their was an important step in the growth and metastasis of deleterious effects. One means investigated has been the solid tumours. Agents interfering with angiogenesis use of Lovastatin which interferes with the cholesterol might inhibit the growth of solid tumours however, this synthesis pathway by preventing mevalonic acid synthe- would also interfere with normal tissue repair mecha- sis; this in turn prevents signal transduction by interfer- nisms. A more sophisticated approach is to identify ence with Ras protein binding to the cell membrane. antigens specific to the endothelium of tumour vascula- This approach has inhibited the growth of several pan- ture to act as targets for therapy. Current experiments creatic carcinoma cell lines, an effect which is reversible focus on screening malignant and normal cell lines with a by addition of mevalonic acid. These effects were also series of monoclonal antibodies that have been identified observed in animal experiments following tumour inocu- as potential targets for such therapy to determine their lation. It is hoped that this work will lead to more specificity. precisely targeted therapy for pancreatic cancer. The final session of the meeting was devoted to Overall the meeting demonstrated the close union gastrointestinal cancers. Colon cancer was the subject of which is now developing between surgeons and basic Dr Anne Kinsella's talk (Department of Surgery, sciences, the fruits ofwhich are potential improvement in University of Liverpool). The multi-step progression to cancer therapy. malignancy is well illustrated in the colon and mutations The meeting concluded with a Hunterian Oration by on chromosomes 5, 12, 17 and 18 have all been docu- Professor G Poston entitled 'Somatostatin and the treat- mented in the development of localised malignancy. In ment of pancreatic cancer', the text of which will be practice though the problem in all cancers is that of published separately. 214 Reports The Royal College of Surgeons Foundation Inc New York Travelling Fellowship

Principles of colon and rectal surgery

Richard Miller Consultant Surgeon

Addenbrooke's Hospital, Cambridge

I would first like to thank the College for the opportunity no overnight stay. In contrast, in the UK patients to travel to the USA that the Fellowship provided. It has normally stay 3 or 4 nights in hospital. There are been an extremely valuable and enjoyable time. In the implications for aftercare which have to be taken into middle of the visit I had to return home for a consultant consideration but the patients are very happy with this interview at Addenbrooke's Hospital in Cambridge at approach and it is clearly a more efficient use of beds. which I am glad to say I was appointed. In the area of biofeedback, I saw how it is applied to For the first four days I attended and spoke at the patients with a variety of anorectal disorders. This annual Principles of Colon and Rectal Surgery course technique involves providing the patient with real-time which has been running in Minneapolis for over 50 years. information about some aspect of bodily function which This was an excellent start to the trip and I was also able they do not normally have. The therapist then can train to talk to many medical and surgical gastroenterologists the patient to modify this as required. The technique is from all over the USA. I spent most of the next two useful in treating some conditions which have a poor months in the twin cities of Minneapolis and St Paul with outcome if treated surgically. The Minneapolis group a group of 12 colorectal surgeons who function as a have a full-time nurse who performs this treatment and I corporation and offer a complete specialist service in am sure many patients I am likely to see in the UK would coloproctology to a population of 3 million. The benefits improve on treatment. were in three main areas. Research Clinical surgery Three studies were undertaken during my stay. Two This was my first opportunity to experience another were comparing anorectal physiology in patients after surgical tradition that in many areas is considerably surgery for prolapse and incontinence and accrued suffi- different to that in the UK. Even simple things like the cient numbers in the time I was there. A clinical fellow is position of the patient in the operating room is different now reviewing the results and we will both co-operate in and in many instances allowed better access for both the subsequent publications. The third study will require surgeon and assistant for trans-anal surgery. I saw and more patients and so I have left some equipment behind performed two different techniques for the treatment of so that it can be completed. The physiology laboratory rectal prolapse which I am convinced are better than was located in one of the mid-town hospitals and initially current UK practice and which I will be keen to develop I taught the research fellow how to perform some of the myself. I was also shown the role of different kinds of techniques required. It was not long, however, before he treatment (cutting seton and mucosal advancement) for could be left to his own devices and therefore for most of treating high anorectal fistulae which are generally not my stay I only needed to be present for an hour or two popular in the UK. These techniques have two advan- first thing in the morning (7 am!) to arrange ambulant tages. Firstly they do not involve large perineal wounds anorectal physiology and then was free for the rest of the and therefore require minimal stay in hospital and day to attend either clinics or operating sessions. secondly, mucosal advancement does not damage the I took the opportunity to go down to the Mayo Clinic anal sphincters in any way and therefore the functional towards the end of my stay as I wanted both to see the results should be better. general set-up and discuss with two of the surgeons their The need to get patients home as soon as possible to research techniques. Again, this was extremely useful as minimise hospital charges has a profound effect on I am now more aware of the advantages, disadvantages treatment. For example, haemorrhoidectomies are routi- and practicalities of a number of methodologies which I nely performed under sedation and local anaesthetic with am likely to use in the future. Reports 215 General their patients after discharge, usually by phone on The surgeons in the group have a great commitment to alternate days in the early postoperative period. This is teaching. For the vast majority of the cases they would partly the result of the need to discharge them so early assist the trainee in the operating room rather than doing but talking to the patients themselves they find it very the cases themselves which resulted in them attracting reassuring that they have such easy access to their high quality candidates for their training program. Also hospital doctors. for most of the major cases two staff surgeons would Lastly, I have made some good friends in Minneapolis work together with the trainee which resulted in a St Paul and I am sure that this will be of lasting benefit, relaxed atmosphere and gave the trainee superb assist- both professionally and socially. ance. How this could be applied to the UK is another In summary, the trip has been fascinating. I have both matter but it is certainly an approach I would want to taught and been taught in very many areas of mutual emulate. interest. I will encourage anyone in a similar position to They also keep in very close personal contact with travel abroad for an extended time.

Ethicon Foundation Fund Visit to the Royal Children's Hospital, Melbourne

Andrew J Carr FRCS Consultant Orthopaedic Surgeon Nuffield Orthopaedic Centre, Oxford

I visited the Royal Children's Hospital in Melbourne are still in the process of preparation on the subject of between May and December 1992. I was attracted to this Sprengel's shoulder and osteogenesis imperfecta. Centre because of its reputation for providing excellent I learnt a considerable amount about alternative orthopaedic care to children from a large catchment area systems of health care and was able to observe at close and to its proven record in clinical and basic science hand the workings of the Australian medical care system research. and feel I have benefited from this. I was able to learn a I worked closely with Professor W G Cole, Chief variety of new operative techniques and see a large Orthopaedic Surgeon, and was involved in regular clini- number of pathological conditions as a result of my visit cal sessions involving children with inherited disorders of to the Royal Children's Hospital. I was very fortunate to the musculoskeletal system, including osteogenesis be able to work with Prof Cole who has subsequently imperfecta and the skeletal dysplasias. I also attended taken up the position as Professor of Orthopaedic operating sessions whenever surgery was required on any Surgery, at the Hospital for Sick Children in Toronto. of these patients. A large proportion of my time was He has considerable research experience in the field of spent in research activity and I undertook studies in collagen biochemistry and molecular biology. I hope to chronic multifocal osteomyelitis, Ehlers-Danlos syn- be able to pursue these interests now that I have returned drome and in osteogenesis imperfecta. The department to Oxford. I have been fortunate to have been appointed held regular clinical and teaching meetings, which I also to a consultant post in Oxford and I hope that clinical and attended. research links can be maintained both with Melbourne I found the department very friendly and helpful and I and with Professor Cole in Toronto. was immediately taken on as a member of the research We were provided with accommodation by the Royal and clinical team and provided with necessary facilities to Children's Hospital in Melbourne, which was very satis- carry out my research work. Thq projects I was given had factory, consisting of a two-bedroomed flat, which easily been carefully considered prior to my arrival by Professor accommodated my family. The accommodation was close Cole. As a result of my research activities I was able to to the Hospital and the cost was within our means. present papers at the Australian Orthopaedic Association During the visit we were able to do some travelling meeting in Hobart and at the meeting of the combined around Australia and New Zealand and found it a most Orthopaedic Associations English Speaking World in exciting and exhilarating country to visit. Many of the Toronto. A paper has been accepted for publication in sights and scenery are quite spectacular and it certainly the Journal of Bone and joint Surgery on the subject of added to enjoyment of our visit. chronic multifocal osteomyelitis. A further paper has I would wholeheartedly recommend the Orthopaedic been accepted for publication in the Journal of Medical Department of the Royal Children's Hospital to ortho- Genetics on my work on Ehlers-Danlos syndrome. Papers paedic trainees wishing to further develop their skills. 216 Reports

Extracts from Health Service Commissioner's Report 1992/93

The Joint Consultants Committee has asked that Royal Remedy Colleges should draw the attention of their Fellows to The health authority agreed to ensure that adequate relevant examples of matters brought before the Health alternative arrangements would be made for the counsell- Service Commissioner during 1992/93. The following ing of patients when key personnel were not available. three cases are extracted from his report HC70X refer- Apologies were offered for the shortcomings I found. ring to cases for the period October 1992 to March 1993. 1. Failure in communications before surgery 2. Delay in following up diagnosis of breast cancer Matter considered Matter considered Removal of lymph glands without formal consent during a mastectomy Delay in seeing a patient after a diagnosis of breast cancer and further delay in telling her of the Summary of case diagnosis Before undergoing a mastectomy, a woman signed a consent form believing that only her breast would be Summary of case removed. During her recovery she discovered that some A woman was admitted to hospital as a day patient for the lymph glands had been removed also. She maintained removal of a breast lump. A histology report produced that she had not been told before the operation about the three days later showed that the lump was cancerous. removal of glands, nor had she consented to that. The Although the hospital notified the woman's GP of the health authority's reply to her complaint had been less diagnosis, and told him that she would be seen for follow- than reassuring that mistakes made in her case would not up care as an outpatient, she was not seen for over 15 recur. months. Then a further three months passed before she was told-in response to her own enquiries-of the Findings diagnosis which had been made soon after her operation. I found that the woman would normally have seen the When she wrote to complain about what had happened it consultant to discuss the operation in detail, but he had took the hospital over four months to reply definitively. been absent and she had learnt of the need for surgery during a brief consultation with a registrar. He had made Findings a note in her medical records for the consultant to see and There was no dispute that the woman should have been decide what course to follow, but there was no evidence seen as an outpatient as soon as the histology results that any action had been taken. The woman would became known. A request for a follow-up outpatient normally have been offered an opportunity to see the appointment had not been included in the operation breast care nurse but she was absent also. The first real record as it should have been. The nursing records opportunity to discuss her concerns had arisen a few days suggested that the need for an appointment had been before the operation when a house officer saw her to considered, but a failure in communications meant that obtain formal consent. I was unable to ascertain whether no action was taken. The GP was led to believe that the removal of the lymph glands had been discussed follow-up action was in hand, and the woman thought then, but I upheld the complaint to the extent that the the lump was benign so assumed that a decision had been arrangements for counselling before the operation had made that she did not need to be seen again. I attributed been inadequate. I also found that a business manager to the consultant concerned the blame for the woman not had not investigated the complaint with sufficient vigour, being told sooner about the diagnosis reached after her and the vague and brief reply to the woman's letter of operation-although I did not find that the information complaint had quite understandably led her to conclude had been deliberately withheld. The time taken to reply that her complaint had not been taken seriously. to the woman's complaint had been excessive and I Reports 217 criticised the substance of the reply which tended to play and given medication in preparation, but the operation down the responsibility of the hospital staff, glossed over was not carried out. the question of the delay in notifying the diagnosis, and included a wholly unacceptable reference to the part Findings which the GP might have played in the failures which My investigation revealed that lack of beds was indeed gave rise to the complaint. the cause of two of the cancellations, and on the occasion when the woman was admitted and the operation not Remedy done the consultant concerned had had insufficient The health authority apologised for the shortcoming I theatre time to complete the operations listed for that found. They agreed to remind staff of the importance of day. I found that the woman had not been warned that recording and acting on information which is crucial to such cancellations might occur. The consultant said that patient care, and undertook to review the operation of he tried to keep patients whose operations had been their discharge procedure in order to be sure that it dealt cancelled at the top of his list but explained that, in adequately with the special circumstances of day addition to planned admissions, he had to deal with patients. They also agreed to review the operation of emergencies from the fracture clinic and the accident and their complaints procedure. emergency department. Patients whose operations had to be cancelled were put on his theatre list-for three weeks ahead. 3. Repeated cancellation of an operation The Trust's chief executive said that no patient should have an operation cancelled on three successive Matter considered occasions. Because of a breakdown in communication it was not realised that the woman had had previous Action following cancellation of admission for cancellations. I upheld the complaint. surgery Remedy Summary of case The Trust apologised for their shortcomings and agreed A woman complained that she suffered mental and to review and monitor their procedures in order to meet emotional anxiety because of the repeated cancellation of the national Charter standard that if, exceptionally, an her knee operation. That happened three times-on two operation is postponed twice the patient will be admitted occasions because, when she telephoned the hospital on to hospital within one month of the second cancellation. the morning of the operation, she was told that no bed They agreed, too, to ensure that patients were warned was available. On the third occasion she was admitted that their operation might be cancelled at short notice. 218 College News

ADMISSION OF HONORARY FELLOWS Wednesday, July 7 1993

The President admitting Dr John L Cameron MD to the Honorary Fellowship of the Coliege (Right)

Dr Cameron is Head of Surgery at Johns Hopkins University School of Medicine, Baltimore and has an international reputation in abdominal surgery, both clini- cal and research, and especially in surgery of the pancreatico-biliary system.

The President admitting Dame Margaret Turner- Warwick DM FRCS to the Honorary Fellowship of the Coliege (Below) Dame Margaret has recently been President of the Royal College of Physicians of London and has had a highly distinguished career in thoracic medicine, often working in close collaboration with cardiothoracic surgeons, most notably at the Brompton Hospital, London.

The President admitting Dr Hans Huysmans to the Honorary Feliowship of the Coliege (Above)

Dr Huysmans holds the Chair of Cardiac Surgery in the University. Hospital, Leiden, and has made many important contributions in the field of cardiac surgery. He is a past-President of the European Association for Cardiothoracic Surgery. College News 219

MEETING OF COUNCIL, JULY 8 1993

ACCREDITATION Both the BUPA and the Glaxo Research Fellowships Certificates of Accreditation were granted to the follow- are awarded for a one-year, full-time research project in ing: any of the specialty fields of surgery and may be held in any surgical department in the UK. The Fellowships Accident and Emergency Medicine cover salary, pension contributions, technical and other Ian Geoffrey KENDALL associated costs. General Surgery Sarah CHESLYN-CURTIS * That Regent Travelling Scholarships be awarded to: David Francis GRAHAM Rodney Ingvar HALLAN W A Kmiot Michael Timothy HALLISSEY Paul Gibb Simon Philip John HUDDY Bruce Braithwaite Nicholas John Milton LONDON Richard MILLER The Regent Travelling Scholarship grant is awarded to Richard Hywel MORGAN enable one or two young surgeons to study for between 3 Michael Lennard NICHOLSON and 12 months abroad and to acquire surgical expertise Clifford Paul SHEARMAN not readily available to them in the UK. Adam STACEY-CLEAR Robert SUTTON * That Royal College of Surgeons Foundation Inc Jeremy James Thompson TATE New York Travelling Fellowships be awarded to: John Frederick THOMPSON Michael Richard WILLIAMS S Ashley D Deardon Neurological Surgery N C Hickey Timothy John Drummond PIGOTT The Royal College of Surgeons Foundation Inc New Ophthalmology York Travelling Fellowships were instituted in 1985 and Kimberley Neal HAKIN are funded by the RCS Foundation, to enable young Carl David Greenaway MORSMAN surgeons or dental surgeons to visit the United States for study or research. The level of the awards is determined Orthopaedics by the RCSF. The grants are awarded to cover transat- Derek Richard BICKERSTAFF lantic travel and to assist with living expenses. Hugh James CLARKE Huw Ceri HODDINOTT * That The Royal College of Surgeons Foundationl Christopher Brian Dyce LAVY General Motors Trauma Fellowship be awarded to H Noordeen. Otolaryngology The Royal College of Surgeons Foundation/General James Anthony COOK Motors Trauma Fellowship enables young surgeons and Simon Alexander HICKEY dental surgeons to visit the USA for study or research. Candidates for this award should have an interest in the Plastic Surgery mechanisms and prevention of injury, and specifically in Henry James Crispin Rashleigh BELCHER nervous system injuries, neck injuries and the prevention of paediatric injuries. These form ongoing programmes AWARDS at the University of Michigan Hospitals. It was resolved: * That the Porritt Fellowship be awarded to R Carbon. * That the BUPA Surgical Research Fellowship be The Porritt Fellowship was founded in 1982 by a gift awarded to G Giddins. of the Winthrop Foundation in honour of The Rt Hon The Lord Porritt GCMG GCVO CBE FRCS President 1960- * That the Glaxo Research Fellowship be awarded to J 63 and Olympic athlete, to encourage the study of sports McClashan. medicine and injuries in sport. 220 College News * That the Lionel Colledge Memonal Fellowship in J J Corkery The British Association Otolaryngology be awarded to M Wake. of Paediatric Surgeons The Lionel Colledge Fellowship was endowed by Miss Deborah Eastwood Surgeons in Training Cecilia Colledge in memory of her father Lionel Colledge FRCS. The income from the Trust Fund is used to LECTURERS provide a Fellowship, the aim of which is to promote Professor Miles Irving was appointed as the Hunterian studies abroad and in the field of head and neck surgery Orator for 1993 with an emphasis on laryngology, rhinology or otology. Dr Ray Gosling was appointed as the John Kinmonth Lecturer for 1993 * That Ethicon Foundation Fund awards be made to: Mr M K H Crumplin was appointed as the Jessie Dobson Memorial Lecturer for 1994. J Blanshard A J Botha I Bottrill NEW FELLOWS S J S Brough Diplomas of Fellowship were granted to the following. H Y Chan We warmly welcome them to the College family. D Edwards M P Grevitt ABEYSINGHE, Jayantha Dharmapriya Peradeniya J I Livingstone ADUFUL, Henry Kofi Ghana A Mavor AL-DUBAISI, Muhammed Shakir Baghdad AL-GAILANI, Muhammad J R Novell Abdul-Munim Baghdad N Tolley ALI, Fazal Muhammad West Indies James The London The Ethicon Foundation Fund was endowed by ALLIBONE, Bernard Ethicon Ltd with the aim of promoting international AMIN, Shwan Niazi Omar Al Mustansiriyah in financial assistance ANAND, Mahadevan Madras goodwill surgery, by providing ANDERSON, Peter John Edinburgh towards travel abroad. APPLETON, Shaun Grendon UC&MSM AZIE, Nnamdi Nigeria * That the 1993 Sir Henry Morris Studentship be BADIUDDIN, Mohamed Karnatak awarded to S W J Cochrane. BAKER, Andrew William Bristol The Sir Henry Morris Studentships were founded in BANTICK, Giles Lawrence Barts 1967 by Miss R M Lysaght in memory of her Godfather, BARAGWANATH, Philip Birmingham Sir Henry Morris Bt FRCS to assist students of medicine. BARTON-HANSON, Nicholas Guy Liverpool BATH, Andrew Paul Nottingham * That the Hallett Prize be awarded to Cornelia Carr BHOYRUL, Sunil Aberdeen following the results of the FRCS Examination in BLACK, Andrew James Merrington Guy's Applied Basic Science in April 1993. BOSE, Rumia Calcutta The Hallett Prize was founded by Council in apprecia- BYRNE, Ruth Louise Nottingham tion of the services of Sir Frederick Greville Hallett OBE CAPLIN, Scott Sheffield JP in connection with the examinations for the CARAPETI, Emin Assatour Guy's Fellowship and Licence in Dental Surgery from 1877 to CHEEMA, Imtiaz Ahmad Bahauddin 1927. Zakariya CHITNAVIS, Bhupal Prabhakar Guy's CLARK, David Ian Sheffield * That Sir Terence English KBE PPRCS and Dame CLARK, Stephen Charles Nottingham Kathleen Raven DBE be elected Members of the COLE, Simon John St George's Court of Patrons. COLQUHOUN-FLANNERY, William Southampton COMMINS, Dermot John Stellenbosch * That the following Invited Members be appointed to COOK, Timothy Alan Oxford Council with effect from July 1993: CREW, Jeremy Paul Cambridge DAVIS, Peter Alexander Cambridge M K H Crumplin The Court of Examiners DERRY, Fadel Baghdad R E Robinson The Royal College of DODENHOFF, Ronald Martin St Mary's Obstetricians and DORWARD, Neil Lawrence St Mary's Gynaecologists EL-FAROK, Mohammed Omar Ain Shams C H Paine The Royal College of EMERY, David Frederick George UC&MSM Radiologists ENGLISH, Hugh William Dundee J Douglas Miller The Society of British ESPOSITO, Ivan Malta Neurological Surgeons FARRELL, Roy William Robert Dublin College News 221 FAWCETT, Adrian Char X & West MOORE, Richard Hugh Cambridge FELDMAN, Adam Yehudalev Bristol MOSTAFID, Amir Hossein St Thomas' FERNANDES, Helen Marie Newcastle MOUSTAFA, Ahmed Kamal Cairo FLANAGAN, Philip Morgan Liverpool MUONEKE, Hyginus Ejikeme Nigeria FLOYD, David Clifford Cambridge NG, Roy Lip Hin Oxford FOTHERINGHAM, Timothy King's NISSEN, Justin James Nottingham FURLONG, Andrew John Birmingham O'NEILL, Kevin Sean St MaTy's GARNHAM, Ian Roy The London O'SULLIVAN, John Timothy Patrick NUI GEARY, Philip Michael Manchester OMAR, Azmi Omar Mahmood Ain Shams GHOSE, Sharon Ishika Calcutta ONG, Chun Chiang Dublin GIBBONS, Catherine Margaret NUI, Dublin PALLISTER, Ian Newcastle GILLIES, Tracy Elizabeth Bristol PANCHAL, Ramesh Rajasthan GILMORE, Marianne Elise Manchester PATTISON, Roger Michael St Thomas' GRAY, Alexandra Emma Cambridge, PINTO, Moragodage Narendrakumara Colombo Char X & West PLATT, Alastair James Oxford GREENLAND, Jonathan Edward Birmingham PRACY, John Paul Myles London GRIFFIN, Damian Russel Oxford QURESHI, Mohammad Shamim Karachi GRIFFITHS, Steward John Royal Free QURESHI, Nadeem Ahmad Karachi HAMPTON, Richard William Dudley St Thomas' RATNAIKE, Nimal Dushyantha St Mary's HASHEMI, Majid Manchester Anthony HENNAYAKE, Supul Priyantha Colombo RAVINDRAN, Jambulingam Madras HEWIN, David Fitzgerald Bristol REDDY, Kalakata Pratap Kumar Sri Venkateswara HICKS, Robert Charles Jackson St Thomas' REVINGTON, Peter John Char X & West HIRIGOYEN, Martin Bernard Barts ROBERTS, David Newton St Thomas' HOFFMANN, Brad Robert Frederick Witwatersrand SALMAN, Saad Masud Karachi HOLT, Gavin Montgomery Aberdeen SARKAR, Sandip Prasad St Thomas' HROUDA, David UMDS SAUNDERS, Michael William Bristol HUAT, Za Mang Rangoon SMITH, Kevin Robert Hodson Birmingham HUBBLE, Matthew Jonathon Wakelin St Thomas' SMYTH, Elizabeth Helen Edinburgh HUCHZERMEYER, Philippa Margarete Capetown SREEKUMAR, Nhatuveetil Madras HUGHES, Bridget Claire NUI, Galway STANTON, Jeremy Simon Cambridge HUTCHINS, Robert Rayner Barts SUDHAKAR, Joseph Ebenezer Kerala INGRAMS, Duncan Richard Oxford TAN SWEE CHUAN, Peter Southampton JENKINS, David Philip Middlesex TAY, Huey Ling Oxford JENKINS, Michael Philip UC&MSM TIERNEY, Paul Alexander Oxford JOHNSON, David Sands Manchester UGLOW, Michael George St George's JOHNSON, Ian James MacDonald London VELMURUGIAH, Velupillai Colombo KHAN, Nasir Bahauddin WALKER, Roger Michael Haydn Char X & Zakariya West KOAY, Cheng Boon London WARD, Simon Jonathan Edinburgh KULKARNI, Rohit Mysore WEINER, Graeme Martin Birmingham Kuo, Michael Jeo-Ming Birmingham YEATMAN, Mark St Thomas' LAHIE, Yoosoof Kamil Mohamed Colombo LALL, Kulvinder Singh King's LANIADO, Marc Elie Guy's LARKIN, Edward Brendan Cambridge NEW APPOINTMENTS LENNOX, Penelope Ann Oxford LIVINGSTONE, James Alexander King's SURGICAL TUTORS MALLUCCI, Conor Laurence UCH N W Thames N J Standfield vice C B Wood MALLUCCI, Patrick Lawrence Leicester N E Thames P W Allen vice M A Clifton South Western A J S Knox vice M J Cooper MANDER, Brian James St Thomas' West Midlands D C Jaffray vice J H Patrick MARTIN-HIRSCH, Dominic Paul Nottingham West Midlands I D L Fraser vice A 0 B Johnston MCANDREw, Helen Fiona King's MCCLEARY, Alistair John Oxford MCNAB, Ian Stuart Hugh The London MIDDLETON, Robert Gordon Cambridge, MEMBERS OF COUNCIL Guy's Sir Rodney Sweetnam and Mr Adrian Marston were MITCHELL, Andrew Duncan Newcastle readmitted as Members of Council and Mr Peter C May MOHAMED ALI, Hossam Ahmed Cairo was admitted as a new Member of Council as a result of Fouad the election held on 1 April 1993. 222 College News DEATHS FRCS RESULTS 1993 We report with regret the death of the following Fellows and Diplomates: No of No ACHAYA Sita FRCS Exam Month Candidates Approved BARKER Eric Anthony CBE FRCS BIRT Alan Beckett CBE FRCS BOYD Thomas Alexander Somerville FRCS ABS January 195 60 (31) April/May 344 121 (35) DUNLOP Sir Edward CMG OBE FRCS CS-i-G January 204 57 (28) DuTT Group Captain Marcel Charles FDSRCS April/May 314 120 (38) HAMER William Anthony FRCS CS-i-G/O January 20 5 (25) JACK Robert Cecil FRCS April/May 38 18 (47) O'BRIEN Bernard McCarthy CMG FRCS PARKINSON Roy FRCS ABS = Applied Basic Science PETTY Harold FRCS CS-i-G = Clinical Surgery-in-General ROPER Brian Arnold FRCS CS-i-G/O = Clinical Surgery-in-General with Otolaryngology SPENCER-PAYNE Herbert Hartnall LDSRCS STUBBS John FRCS RESPONSE TO COLLEGE APPEAL APPOINTMENT OF FELLOWS TO 25 June-24 August 1993 CONSULTANT AND SIMILAR POSTS GEORGE C D FRCS DONATIONS TO THE ONGOING APPEAL Consultant in Diagnostic Radiology, Epsom General FOR USE BY THE COLLEGE Hospital General Funds: £ GLUCKMAN P G C FRCS 1 General Covenant payment totalling 1,500.00 Consultant Otolaryngologist, Dartford and Gravesham 6 Legacies and 15 further bequests totalling 219,955.27 Acute Health Services Unit 43 Donations under £500 totalling 2,361.84 JONES D J FRCS S Donations over £500 totalling 132,500.00 Consultant Surgeon, South Manchester Health Research Fellowships Fund: Authority 7 Donations, totalling 58,335.11 LANCASTER J FRCS 13 Covenants, total annual payments 2,350.00 Specialist Staff Surgeon, Hervey Bay-Maryborough Special purposes and projects: Health Service, Queensland, Australia Cancer Research Fund 60.00 SCOTT D J A FRCS Dental Research (Deposited Covenant for 4 Consultant Vascular Surgeon, St James's University years, first year value) 20.00 Hospital Trust Spinal disease and injuries 65,000.00 College News 223

COLLEGE DINNERS 1993-1994 1993

Tuesday College Dinner Speaker: 16 November The Countess of Limerick Chairman British Red Cross Society

Wednesday College Dinner Entertainment from 8 December The Abracadabarets

1994

Wednesday College Dinner Speaker: Professor John 19 January (Diplomates Day) Alexander-Williams

Wednesday Buckston Browne Dinner To be announced 9 February (by invitation)

Wednesday Museums Evening The English Piano Trio 9 March

Wednesday Council, Court and 11 May Regional Advisers Dinner (by invitation)

Thursday College Evening Pre-Dinner Lecture by 9 June (in collaboration Sir Leon Brittan with Lincoln's Inn)

Wednesday College Dinner Speaker: Sir Peter Beale 13 July (Diplomates Day) Surgeon General 224 College News

The Erasmus Wilson and Arnott Demonstrations

J L Turk

Sir William Collins Professor of Human and Comparative Pathology The Royal College of Surgeons of England

The Erasmus Wilson Trust was set up in May 1869 to three in number and may be held by more than one enable Council to endow not less than six lectures on the person if Council thought fit. The remuneration should pathology together with the anatomy and physiology of be an honorarium of 5 guineas per lecture and in addition the skin and its appendages. The endowment consisted the lecturer should receive in respect of the research to be of the income provided by an investment of £5000. The lectured on such a sum as the Council having regard to 'Professorship' was held by Sir Erasmus Wilson himself the value of the research and to the expenses incurred for until 1878, when an Erasmus Wilson Trust Committee it shall after delivery of the lecture see fit to award. If at was set up under the Chairmanship of Sir James Paget as any period for appointment the Council found no appli- Erasmus Wilson no longer sought re-election. It was then cation which it deems acceptable it would refrain from considered that instead of being permanently restricted making an appointment under the Trust. The first two to dermatology alone, it should be widened to the whole recipients under the revised Trust were Henry Trentham subject matter of pathology and 'especially if the Butlin who received 60 guineas for two lectures 'On the Professorship in its future form were constituted under relations of sarcoma to carcinoma' and Frederick Treves such conditions that the hope of holding it might who received 30 guineas for one lecture 'On the patho- influence members of the College as a stimulus to original logy of scrofulous affections of the lymphatic glands'. At research in the sciences that are fundamental to surgery'. the same time Sir Erasmus Wilson proposed to Council As at that time the income from the Trust was only £150 that the Erasmus Wilson Trust might be used in part as per annum it was considered important to use the money payment of the salary of an Assistant Conservator of the to encourage research in pathology. It was therefore museum and in part for the payment of lectures or recommended to Council: demonstrations on the pathological contents of the museum to be given either by the Assistant Conservator (1) That the field of application be pathology or some other person only appointed for the purpose. The lectures continued to be given, generally at the (2) that within this field the special aim be to encour- rate of one a year, by distinguished young surgeons until age original research 1908. In 1908 the College received an endowment of £1000 from the will of Mr James Moncrieff Arnott, (3) that lectures be not an object of the scheme except President of the College in 1850 and 1859, who had died as means for first promulgation from time to time in 1885. This was invested in Transvaal 3 per cent stock results which the researches may have gained to bring in an income of £30 per annum. In 1908 Sir Arthur Keith was appointed Conservator (4) that payments out of the fund be assigned quite and the Museum Committee recommended that a syste- subordinately to the lectures as such, and be matic course of lectures be given on advanced surgical mainly applied to remunerate the research. pathology, illustrated by the specimens in the museum, and that lectures might be delivered by the Conservator It would evidently be essential that as regards the of the museum if a pathologist, or by the Pathological individual persons and researches to be benefited under Curator and that the honorarium might be provided from the Trust, the administrators should within the fixed the Erasmus Wilson Fund, the Arnott Bequest and other conditions be at liberty to vary from year to year to what funds at the disposal of the College. particular aims the money could be most usefully Council resolved that six of these be given by Sir applied. The year's lectures should not be more than Arthur Keith and three by the Pathological Curator Mr College News 225 S. G. Shattock, in addition to the three given by him as Council minutes that no rules exist in the endowment of Erasmus Wilson lecturer. In 1909 it was reported that the Erasmus Wilson Trust or the Arnott Bequest that as Professor Shattock had given three museum demon- many as six demonstrations have to be given on the strations on hypertrophy, atrophy and lipoma as contents of the museum annually by the Conservator or Erasmus Wilson lecturer, and under the Arnott Bequest other qualified persons (Arnott Demonstrations- three museum demonstrations on fibroma, myxoma and Standing rules Sect. X, 5) or six demonstrations be given chondroma and osteoplastic inflammation of bone. annually on advanced pathology illustrated by specimens Professor Keith had given three demonstrations under in the museum (Erasmus Wilson Demonstrations- the Arnott Bequest on: Standing rules Sect. X, 4). In addition it is of interest that the fee of £5 set for these lectures continued to be (1) Specimens illustrating malformations of the rectum that laid down in 1879, although this was not adhered to and anus in 1881 (since when £30 per lecture was the assigned fee). It can be seen therefore that the form by which these (2) Specimens illustrating malformations of the urethra lectures have been administered is that which Sir Arthur and genital passages Keith and the Museum Committee of 1908 found suited the needs of their period and the fees given are related to (3) Specimens illustrating ectopia vesicae and allied con- the income brought in by the Arnott Bequest in that year ditions. (3 per cent of £1000 for six lectures). Following the establishment of the Institute of Basic Later in the year he gave three further demonstrations Medical Sciences (IBMS), later the Hunterian Institute, on: in the early 1950s, it was policy for the Professor of Anatomy and Pathology to recommend to Council dis- (a) Specimens illustrating various degrees and forms of tinguished anatomists and pathologists for invitation to cleft palate and hare lip. The relationship of clefts to give six anatomy and six pathology lectures a year. incisor teeth and to the premaxilla. Specimens from Although these were officially gazetted as demonstrations the comparative anatomy series showing the nature of illustrated by specimens in the museum, they were often palatal clefts. on more generally related scientific subjects. More (b) Specimens illustrating congenital fissures of the face recently these lectures have been reduced to three ana- and malformations of the nose, epignathus, cyclops, tomy and three pathology lectures. In addition the agnathia. lecturers have been presented with a College medal (c) Specimens illustrating malformations of the ear rather than a fee. Twenty years ago it was possible to accessory auricles, cervical fistulae and cysts and attract audiences of up to 100 by making them of interest malformations connected with the pharynx and thyr- to students attending the IBMS Courses. These lectures oid gland. For these he received £5 per lecture. have recently been placed under the control of the Education Board who have recommended potential lec- Both Trusts were then used mainly as teaching media, turers to Council. Council have now decided to discon- a role that was later taken on within the College by the tinue the Erasmus Wilson demonstrations and reduce the FRCS Course lectures. Moreover it can be seen from Arnott Demonstrations to one a year as from 1994. 226 College News RCS Fellowships Fund past the million but a long way to go

New gifts and pledges to the Research Fellowships Fund Gifts have come from a wide variety of sources. from legacies, companies, trusts and foundations plus the Existing endowments for surgical research of more than gifts from Fellows, Members of the Court of Patrons and Lim will provide an annual income of £70,000 and recent other friends who responded to the President's appeal, legacies will provide a further £140,000 for next year's together with income from existing College endowments Research Fellowships. to the Fund now exceeds £1.2 million. Glaxo Holdings plc has pledged £90,000, a further The Fund will enable the College to award seven £95,000 has been donated by the Leopold Muller Fellowships each year, but we need the help of many Foundation and the Frances and Augustus Newman more Fellows if we are to match the support of those who Foundation has promised £150,000. BUPA has given a have already given to the Fund and we are a long way yet first Fellowship of up to £50,000 and the Shepherd from our target of two Research Fellows in each Regional Building Group have pledged £20,000 for three years. Health Authority by the year 2000, for which we need an Support from the United States has come with a gift of annual income of well over £1.5m. Our surveys last year $20,000 from the RCS Foundation to go towards a demonstrate the overwhelming need for a much greater Fellowship in sports medicine. emphasis on surgical research in many different fields. At least £25,000 will come from the proceeds of the There are many essential projects which are in desperate Gala Premiere Concert at the Royal Festival Hall, spon- need of support and the number of applications we have sored by Glaxo, and supported by a number of healthcare had already from young surgeons is a measure of that and other companies. Classic FM have recorded the need. The President will be writing shortly to those concert, and further funds are hoped for from the sale of Fellows who have not given, inviting them to do so. records.

Research Fellowships Fund Update

Donors to the Fund from May 5 to September 3

(including legacies, trusts, foundations and companies omitted from the May report)

Council Industry and commerce Prof J Alexander-Williams BUPA Prof A G Johnson Glaxo Holdings plc Shepherd Engineering Smiths Industries Fellows and other supporters Court of Patrons Mr J P Bolton Miss Cecilia Colledge Mr R Brearley Mr C D Collins Trusts and Foundations Mr G J Fellows Leopold Muller Foundation Mrs H E Gregg Frances and Augustus Newman Foundation Prof P J Gregg Royal College of Surgeons Foundation Mr M Handley Ashken Mr B J Harries Legacies Prof M Hobsley Miss E D Bloomfield Mr A R L May Mrs Y E Cornick Mr I T Miller Miss M E Davis Mr J R Nash Miss M Ellin Mr J H Penrose Miss M M Hiller Mr B G Reynolds Mrs R M Kennard Mr A B Richards Miss L M Sear Mr T L Thomas Dr M Lea Thomas Sir James Watt College News 227 Research Fellowships Fund Financial Summary to 3 September 1993 Council Ist Year 5-year Period Covenants & donations £ 36,137 £ 52,953 Court of Patrons Covenants & donations £ 5,800 £ 9,000 Fellows, Trusts and Companies Covenants & donations £ 37,354 £ 123,226 Tax recoverable £ 8,824 £ 44,120 on above Total £ 88,115 £ 229,299 Gifts from Industry and Trusts Companies and trusts £255,434 £ 422,100 (includes pledges) Gala Charity £ 25,000 £ 25,000 Concert (estimated outcome) Legacies Legacies £140,000 £ 140,000 Forecast income from endowed legacies £ 70,000 £ 350,000 Total £578,549 £1,166,399

Glaxo and BUPA Fellowships announced

Julian McGlashan Grey Giddins

The benefits of the RCS Research Fellowships Fund are the unstable bone prosthesis interface with particular now being felt with the announcement of the award of reference to the role of cytokines in response to measured two new Research Fellowships. Glaxo Holdings plc and micromovement. BUPA are each supporting a Research Fellowship. These Fellowships are, we hope, among -thefirst of Mr Julian McGlashan FRCS, Senior Registrar in many to come. The Leopold Muller Foundation has also Otolaryngology at Guy's Hospital, London, has won the made a substantial donation to fund a three-year research RCS/Glaxo Fellowship for his project on developing a fellowship project in the Department of Orthopaedics, new way of assessing the function of the vocal folds University of Manchester. The aim of the study, which which he will undertake at City University. Using image began in September 1992, is to determine the effect of processing computer software, Mr McGlashan hopes to surface neuromuscular electrical stimulation of hip mus- devise a method of analysing the three cyclical move- cles in children with spastic diplegia'. ments of the vocal folds which could become a diagnostic Mr David Bamford FRCS was appointed as the first aid and provide accurate information on the responses to Leopold Muller Research Fellow and he was replaced on treatment. 1 October 1993 by Mr Robert Jeffrey FRCS, Senior The BUPA Research Fellowship has been awarded to Registrar in Orthopaedic Surgery at the Hope Hospital. Mr Grey Giddins FRCS, Senior Registrar at the Institute of Orthopaedics, Stanmore, who has begun his study on Paul Baker Appeal Director 228

Correspondence

So you want to be on Council? Quality Assurance and Surgical Audit in Wessex 27 August 1993 Dear Sir Regrettably an error has crept into Roger Duffett's paper 13 August 1993 'So you want to be on Council?' (College and Faculty Dear Sir Bulletin, September 1993, pp 177-178). Airborne, in fact, won the 1946 Derby and not the Grand National. I was interested to read Mr Karran's paper in the July Airborne was indeed grey (not, I hope, a prerequisite for issue of the Bulletin but disappointed in the research election to Council) and started at the handsome odds of methodology. The paper contains a great deal of anecdo- 50-1. The 1946 Derby field was, in all probability, a tal evidence that represents a number of personal opi- pretty indifferent one. Although Airborne subsequently nions which are not shared by the majority of Mr won the St Leger in a slowish time, he never won another Karran's colleagues, at least in Southampton. race after that, and proved impossible to train as a four The fundamental problem with this piece of work is year old. Although a filly sired by Airborne was a close that the authors compare the opinions of senior and second in the 1957 Oaks, he generally proved a sad junior surgeons based on the response to two completely failure at stud. Would Airborne FRCS really prove to be different questions. The registrars and senior registrars a suitable Member of Council! were asked about the importance of collecting clinical Yours faithfully outcome information with four possible responses avail- A T RAFTERY able, while their consultant colleagues were given a Consultant Surgeon statement about criteria affecting meaningful surgical Northern General Hospital audit and quality assurance with a Yes/No response. The Sheffield only common factor in these two questions is that they are both leading questions. The importance of this cannot be underestimated in the absence of reliability and validity testing because of the ambiguity of the statement about clinical outcomes. The authors may have a very clear understanding of what they mean by this term but there is no way that they can be sure, in the Intercollegiate examination in General absence of a definition, that all the respondents shared Surgery the same understanding. It is therefore not surprising that their perceptions of the commitment of consultant, 2 September 1993 nursing and management colleagues were so variable and Dear Sir 8 per cent had admitted that they didn't know. The only statistical test in this paper was applied to this result and I feel that the ASIT are in danger of being accused of reported as a significant trend in attitudes. I am not sure 'pulling up the ladder' by arguing the case for 'old' what this means. Fellows to be exempt from the part three examination I counted no less than eight statements based solely on (Baigrie et al, College and Faculty Bulletin, September anecdotal evidence such as: 1993). When I was awarded the 'new' Fellowship, I too * nurses giving themselves titles of 'Quality Assurance was told it was 'the highest diploma the College could Managers' award' but neither it nor the 'old' diploma certified its * clear evidence from 'free text' that surgeons are being holder to be adequately trained for independent clinical frustrated in their aspirations for quality assurance practice. * 'a great deal of activity but no action by management' Either an exit exam is a good thing or it isn't, but don't -more than one speaker in Oxford pretend the old Fellowship exam was one. This last 'quote' leads the authors to reference Southampton's application for Trust status and conclude Yours faithfully that quality assurance and surgical audit are far from S. ROBERTS MA FRCS being a 'cornerstone' of surgical services but rather that a Russels Hall Hospital great many 'smokescreens' are being raised across the West Midlands country! Correspondence 229 One of the problems that is at the heart of any initiative improving the quality of care we are trying to provide for continuously to improve the quality of the care that we our patients. Perhaps, indeed, if more efforts were made deliver, is overcoming tribal loyalties because these by those who are responsible for helping surgeons and attitudes are short-sighted and counter-productive. other 'providers', then these perceptions will eventually Articles such as Mr Karran's do not help the develop- be changed. Sue is certainly correct in asserting that ment of an understanding of the variety of professional positive moves have, within the last year or two, been skills and backgrounds that different generic 'tribes' can made to improve on the previously negligible support bring to collaborative team working. provided to clinicians. She is also more than aware of the I understand the frustration and disappointment that isolation that many have felt who have battled for many Mr Karran and his colleagues sometimes feel about their years to address these issues, with either little support, or perceived lack of progress in this very important field. even active discouragement. She will, also, have hope- However, things are changing for the better, and I fully, observed that this little study is, primarily, highly believe we have actually come a very long way in a self-critical. It would indeed be irresponsible of us if we relatively short time. did not examine the beam in our own eye before Yours faithfully criticising any lack of support which we perceive coming SUE LYDEARD from our administrative colleagues. Clinical Audit Co-Ordinator Secondly, this study was not specifically an attempt to Southampton University Hospitals NHS Trust document the (undoubted) problems in our district alone, but was a truly regional study. If she actually doubts the validity of the widespread malaise which we recorded, then I believe there really are problems of communication! Whilst she also deprecates the import- ance of informal communication, how can we ignore the 15 September 1993 widespread 'anecdotal' comments on these matters that Dear Sir surgeons who actually speak to each other, make with I was delighted to see the letter from Sue Lydeard, monotonous regularity? clearly demonstrating the concern of a thankfully Thirdly, with regard to the actual questionnaire, I am increasing number of individuals about this vitally sure the reader will decide for himself whether the important problem. Contrary to what she claims, how- questions asked were, indeed, relevant or important. The ever, these views expressed in our study are the opinions comparison of the perceptions of one group of surgeons of our colleagues, and we have taken the trouble to (ie those in training) as to the commitment of their document them! We do not, I fear, though, understand various colleagues is valid, even if unpalatable. It is also her reference to 'tribal loyalties'. encouraging when comparing the different groups of No surgeon should need the repeated exhortations of surgeons (ie consultants cfsurgeons in training), that the reports such as the recent CEPOD to know that all is not former perceived that they themselves were not, in fact, well with surgery, and with other branches of medicine achieving the desired goal as well as their juniors thought probably just as much! We were reminded this week that that they were! Surely, this is the first requirement for John Hunter, more than 200 years ago was exhorting us progress! as a profession to get our act together in just this area. Fourthly, the comments made from the platform at the Anyone who has ever had the slightest interest in clinical recent meeting in Oxford, about widespread 'activity but audit knows full well that in every hospital worldwide, no action' and 'administrative smokescreens' were made patients either die or suffer major morbidity that could, with reference to authorities outside Wessex. Many in the and should, have been avoided, if only currently avail- audience, however, appreciated the generality of their able knowledge and resources had been applied properly comments! (1). When many thousands of pounds are spent annually Finally we are aware of, and grateful for, the commit- on 'audit' which ignores this fundamental problem, ment of Sue and her colleagues in Southampton over the surely this must be condemned? Are there really more last year or two to start addressing these issues. Others, important priorities for our administrators than trying to however, have been struggling for far longer to do so, help medical, nursing and allied professions to address without the help that is desperately needed, and, which, these issues? Absolutely no apologies, therefore, for hopefully they may now bring. If not, the perceptions so trying to find out exactly where we are along this stoney clearly documented in our survey will not change! path. Yours faithfully Whilst always delighted to discuss important matters S J KARRAN of technique and methodology, the major features of our Reader in Surgery survey should be kept firmly in mind. Firstly, this survey was an attempt to document in a more objective way than by mere 'anecdote', what the Reference PERCEPTIONS of surgeons of all grades within one McDonald PJ, Royle GT, Taylor T and Karran SJ. region were; as to how much progress, if any, we had Mortality in a University Surgical Unit: what is an made in the gathering of information which is critical to avoidable death? J Ray Soc of Med 1991, 84; 213-7 230

Faculty of Dental Surgery

Report of the afternoon session of the Faculty of Dental Surgery's Conference of Dental Specialty Associations held on Friday 14 May 1993

Report by Professor C D Stephens, Dental School, Lower Maudlin Street, Bristol

Participants Prof Martin Curzon: Representing the European Association of Paediatric Dentistry Mr David Hillam: Representing the European Federation of Periodontology Dr Paul Wright: Representing the European Prosthetic Association Dr Frazer McDonald: Representing the European Orthodontic Society Mr Peter Leopard: Representing the European Board in Oral and Maxillofacial Surgery Mr Ken Ray: Dean of the Faculty of Dental Surgery Mr D Seel: Immediate past-Dean of Faculty

The afternoon session began with an introduction by Mr bodies such as the Federation Dentaire Internationale, Ken Ray, Dean of the Faculty, as follows. the International Association of Dental Research, and the This session deals with our interface with Europe. EC Dental Liaison Committee. There is a statutory EC Advisory Committee on the In another dimension, usually without formal recogni- Training of Dental Practitioners which has been in tion, there are the specialist societies which in many existence for 10 years, on which there are three sets of respects are setting the pace in moves towards unifying representatives for each country. These cover the inter- standards of specialist training in Europe. ests of practising dentists, universities and kindred insti- tutes and the 'competent' (licensing) authority. The European Academy of Paediatric Dentistry Faculty of Dental Surgery is represented as 'kindred Professor M Curzon institutions'. The European Academy of Paediatric Dentistry arose as The purpose of the Committee is to advise the a result of a series of informal meetings of like minded European Commission and thence the Council of individuals, largely private practitioners, over a number Ministers. Initially it concentrated on assessing basic of years. As is often the case there was much talk undergraduate training with a view to harmonisation of concerning the need for a European group but little training and this work continues. More recently it has concrete action. Ultimately a group of paediatric dentists produced reports on vocational training, postgraduate (British, French, Greek and Spanish) initiated a meeting and continuing education, and on the field of activity and of some 28 dentists in May 1990 to form a nucleus of a training of specialists. There are also moves to establish a European Academy. Although based initially on specia- European College of Dentists. This initiative has been list practitioners it has subsequently enlarged to include driven forward in recent years under the leadership of academics and community based dentists. All members Professor Derry Shanley, Dean of Dental Affairs of however are required to be exclusively in the practice of Trinity College Dublin. A working group of the paediatric dentistry. Committee has been set up with a view to defining the The first Scientific and Clinical Congress of the aims of such a College and its relationship with the Academy was held in Leeuwenhorst (Netherlands) in Association of Dental Education in Europe and other March 1992 and attended by some 65 members. At that Faculty of Dental Surgery 231 meeting a provisional constitution was approved subject lead in the establishment of European standards. Was to further review by the time of the Second Congress this the case and if so how should we proceed? Professor which is to be held in Athens in June of 1994. Curzon agreed that this was his view and urged British The Academy is organised on the basis of a Council members active in Europe to speak up and not let the with representatives in each country. Officers of the opportunity pass! Academy are presently: President: Martin Curzon (Leeds), President-Elect: Goran Koch (Jonkoping), European Federation of Periodontology Co-President: Constantine Oulis (Athens), Treasurer: Mr D Hillam John Roberts (London). The European Federation of Periodontology began in Over 145 dentists have become members (as of 1988 when Prof Ubele van der Velden called together January 1993) representing 12 European countries. representatives of all the European national periodontal Membership is available for all dentists in Europe and societies. The aim was to co-ordinate the activities and elsewhere who are in the exclusive practice of paediatric policies of the various societies. The Federation was dentistry. Dentists wishing to be members apply either formally constituted and its Aims and Objectives agreed through their Council representative or directly to the upon in 1991. Secretary. Active members are those who have com- The member societies are now the Belgian, British, pleted a minimum of two years full time training or its French, German, Irish, Italian, Dutch, Portuguese, equivalent in terms of clinical and didactic experience. Spanish, Swiss and Scandinavian periodontal societies. For an interim period active membership is also available The Scandinavian Society currently represents the inter- to paediatric dentists who have not completed a post- ests of Denmark, Finland, Norway, Sweden and Iceland. graduate two-year programme but who may have had a The Federation consists of one representative from one-year training but with additional years of exclusive each of the national societies who normally serves for at practice experience. Senior academic members of the least five years. Representatives are usually accompanied specialty who have an established record of teaching, by a member of the governing body of their society to research and clinical treatment are also eligible. Associate ensure that views expressed, and agreements made, carry membership is available to any dentist in Europe not the full authority of the society which they represent. meeting the requirements for active membership and also The official language is English. The Constitution also for paediatric dentists practising outside Europe. Student provides for the General Secretary and Treasurer to serve membership is available for dentists during their training for three years each, but the Chairmanship changes on application by their course director. annually. The Academy's aim is to promote high standards of Discussions so far have been wide-ranging and pro- dental care for children and to be a forum for the ductive. They have included surveys on the content of exchange of ideas between dentists in specialist practice. undergraduate and auxiliary education, specialisation in Following the example of the orthodontists, a steering periodontology and discussions on the length and content committee has been formed to develop guidelines for of training programmes for intending specialists. It has postgraduate training in paediatric dentistry. This com- been agreed that programmes such as those already in mittee will be meeting during the next few months to place in Holland, Switzerland and Sweden can provide study existing programmes and to identify common areas models for any proposed minimum standards in Europe. of interest. A set of possible guidelines will then be These are three-year programmes, mostly full time, prepared for presentation at a workshop to be held in devoted almost entirely to periodontology but with some association with the Academy's Second Congress in 1994. implantology. Most national periodontal societies affi- Answering a question from Professor Smith, Professor liated to the EFP would like to see these requirements for Curzon stated that there was at present great diversity in specialist training implemented immediately, but some postgraduate courses in paediatric dentistry in Europe would prefer them to be phased in over 5-10 years. ranging from 5 years in Sweden to one year in some of the On completion of the training programme the EFP UK Schools. Similarly the emphasis placed on clinical, considers that the trainee should present fully docu- didactic and research components of the available courses mented reports of completed cases to the appropriate varied greatly from country to country. He agreed that licensing body for specialist recognition. The Federation whilst EC and foreign students were very keen to obtain also considers it important that specialists, in order to Royal College diplomas-the number of students taking maintain their specialist status, should demonstrate a the Canadian diploma was an indication of this-there continuing commitment to their subject not only by was also pressure from those coming from outside attending meetings but also actively contributing to them Europe to have very flexible courses to meet their and by publishing research in relevant refereed journals. countries' varying needs. Such a requirement could, he On the subject of hygienists, a policy statement has felt, be accommodated by the use of credits and at Leeds been produced which states that: it had already become University policy for taught 1. The EFP supports the use of properly trained courses to adopt a credit system. His own in paediatric auxiliary personnel, including hygienists. dentistry had now been structured in this way. 2. Those countries which do not currently have hygie- Mr J K Williams stated that it appeared that Professor nists should be encouraged to legalise them. Curzon was suggesting that the Colleges should take a 3. The qualification should be at least Diploma level. 232 Faculty of Dental Surgery 4. Hygienists should work to the prescription of and 100 academics, while the United Kingdom has the largest under the direction of a dentist. number of hospital based specialists (n = 170), Turkey A major international periodontal conference is now in has the next largest number of hospital-based personnel the final stages of preparation, and will be held in Paris in (n = 40). May 1994. This will be the first occasion when members In all countries training is linked to a University; in of all the European periodontal societies will be assem- UK, France, Spain and Hungary training is also linked bled together and promises to be a highly important to hospitals. In 15 countries the period of training is 3 scientific event. It is expected that further conferences of years, in four it is 4 years. In Portugal and Austria there this nature will be held at intervals of three to five years. is no defined period. Other objectives which will be pursued in the medium Not all countries formally assess the candidates on to long term include the compilation of a directory of completion of their training (Austria, Belgium, Portugal European periodontal specialists, improving public awar- do not). There is an average of 9.3 training centres per eness of periodontology, establishing guidelines for rele- country producing an average of 30 specialists per year. vant products and the promotion of professional con- The types of examinations vary with 17 countries requir- tacts, not only by conferences, but also by collaborative ing cases, 15 holding a written paper and 16 using an oral research and exchanges. examination. The majority of countries employ all three forms of examination. The examining body also varies but is usually either the University, Dental Association, European Orthodontic Association Ministry of Health, or Specialist Society. Dr Fraser McDonald Twenty countries have a register of orthodontic specia- The European Orthodontic Society has been in existence lists. This may be governed by a variety of professional for almost 70 years as a focus of co-operation between organisations (University, Dental or Specialist Associa- European countries both within the EC and beyond. tions or Ministry). However only 10 such bodies have Recently the Society has taken a more active role in disciplinary powers and are able to monitor standards. postgraduate training. In 1989 the Society obtained The most notable regional variation is in the case load funding under the ERASMUS Bureau of European of each specialist. Portugal has approximately 60 patients Cultural Foundation to carry out joint development of a in active treatment while Germany had 500-600 patients new three-year curriculum of postgraduate education in in active treatment. Fifteen countries allow the use of orthodontics. This was finally agreed in 1991 and has auxiliaries who are either DSAs or Hygienists. already been adopted by a number of European countries The funding for orthodontic services varies. In including the United Kingdom, where the requirements Switzerland it is totally private while in Poland and closely follow those already in existence for the MOrth Romania it is wholly government supported. The cost of examination. In 1992 a Conference on postgraduate treatment varies from an equivalent of £3,650 in France education and orthodontic specialisation was held as part to £30 in Romania. The overall view obtained is one of the European Orthodontic Society's Annual Meeting which demonstrates the lack of uniformity throughout to carry forward these proposals. Europe. In order to establish a baseline for further planning in The Dean stated that he had heard that there are orthodontics a survey was carried out by Professor J P moves to set up a pan-European assessment Board for Moss, Secretary of the European Orthodontic Society. orthodontists. Dr McDonald replied that there was such This was circulated to 26 countries of whom all but three a proposal before the European Orthodontic Society replied (Albania, Bulgaria, Luxemburg). The areas of Council. If established on the lines which had been interest were: proposed it would involve the submission of records of (a) orthodontic specialisation treated cases and would provide an internationally recog- (b) orthodontic societies nised standard of treatment which at present did not (c) orthodontic practice, and exist. (d) the future of orthodontics. The results confirmed a general recognition of ortho- dontics as a specialty but with a very variable population to orthodontist ratio. The mean ratio per country was one UEMS (The European Union of Medical orthodontist to 116,000 head of population and a mean Specialists) total of orthodontists of 347 per country. Mr P J Leopard The upper limits to these values consisted of Iceland Founded in 1958, one year after the Treaty of Rome, the who had a population/orthodontist ratio of 20,000 and 13 UEMS became the first European Medical Association to specialists, to Romania with 40 specialists but a ratio of be created. Its objective is 'to defend at international 600,000. Germany had the greatest number of specialists level, the title of the Specialist and his professional status with 2,000 recorded. in society'. Only one professional organisation per The modes of service delivery varied with an average country (the BMA for the UK) is allowed to send of 233 private practitioners, 92 community orthodon- representatives to the UEMS committee structures. tists, 16 hospital-based specialists and 33 academic staff Since 1992, EFTA countries are included in this rep- per country. Germany claimed 1,900 practitioners and resentation. Faculty of Dental Surgery 233 UEMS has a Management Council and Executive has set up separate Boards for Stomatology and for Oral Committee, representing all specialties. The and Maxillofacial Surgery, the statutes and regulations Secretary-General is currently Dr Robert Peiffer, a max- for which have been agreed. illofacial surgeon from Brussels. Upward representation Each member state sends two representatives to the from UEMS can only be via the important EC Advisory monospecialty section and two to the Board. There is in Committee on Medical Training (ACMT), thence to the the UK a strong move to have the Board Representatives European Commission and eventually to the Council of nominated by the SACs in consultation with the Ministers. Specialty Associations to ensure adequate clinical and The EC is concerned chiefly with free movement of academic input. labour and has left the professions to develop their own There is now unanimous agreement within the standards of training compatible with reciprocity. Thus International Association of Oral & Maxillofacial the ACMT, in which each member state has two rep- Surgeons, the European Association and the UEMS resentatives from the competent authorities (DH and section that Oral & Maxillofacial Surgery will require a GMC), two from the profession (BMA) and two from the dual qualification world-wide by the end of the century. universities, has charged UEMS with the development of Within Europe, the Board, as a working group of training standards. UEMS, will devise agreed pan-European assessment of The Harmonisation Committee of UEMS has worked trainees to ensure a more equal delivery of care and to hard to collect data and promulgate acceptable minimum facilitate free movement of specialists of comparable duration and standards of specialist training across the standard. board but has left the individual monospecialty sections of UEMS to specify detailed standards for each specialty. European Prosthodontic Association (EPA) There is enormous variation across Europe as to the Mr Paul Wright number of recognised specialties in each member state. The EPA was formed in 1977 at the initiation of certain In Italy, for example, there are some 130 medical members of the British Society for the Study of specialties, whereas in the UK there about 30, repre- Prosthetic Dentistry. From small beginnings it has sented by the various Specialist Advisory Committees. In grown to a membership in 1992 of 357 representing 23 order for a specialty to be recognised in Europe by having different European countries both within and outside the a UEMS monospecialty section, 8 of the 12 member European Community. Membership is individual and states have to have that specialty recognised in their own open to all members of National Prosthodontic country under the Medical Directives. Thus, in UEMS, Associations automatically. Other applicants submit a there are now 30 monospecialty sections, including the brief curriculum vitae to indicate their special interest in section of 'Stomatology and Oro-maxillofacial Surgery'. prosthodontics. Anomalies abound for those of us familiar with tradi- The objectives of the EPA are to 'Further knowledge tional UK specialties; for example, cardiothoracic sur- and promote the teaching and practice of prosthodontics gery and A&E medicine do not have UEMS monospe- in Europe'. Prosthodontics was defined to include 'com- cialty sections. plete and partial dentures, crown and bridge work and Stomatology as a medically based specialty is recog- maxillofacial prosthodontics'. However, this definition, nised in the EC Medical Directives in France, Italy, culled from the minutes of the meeting held to form the Spain, Portugal and Luxembourg, although the training Association, has not been incorporated into the EPA varies greatly. Oro-maxillofacial surgery appears as Constitution and the definition of prosthodontics has 'Dental Oral and Maxillofacial Surgery' in the EC become blurred with time and has often been interpreted Medical Directives of Germany, Belgium, the UK and more widely. The main work of the Association has been Ireland, in which countries full medical and dental concerned with the Annual Conference where both training is required. In Italy, France and Spain it appears clinical and research presentations from all countries in as 'Maxillofacial Surgery', requiring a medical but not a Europe are presented and discussed. full dental qualification. In the Netherlands, Denmark More recently, the development of co-operation and Luxembourg it is not yet a recognised specialty at all, between the different countries in Europe has been whereas in Greece it is based on dentistry and in Portugal encouraged by the formation of the Joint National is a 'subspecialty'. Committee of the EPA under the chairmanship of Dr Bill The Management Council of UEMS has charged its Murphy. This is a committee of representatives of monospecialty sections with setting up European Boards autonomous national European prosthodontic societies to try to set minimum agreed standards of training, or equivalent associations with one representative from encourage exchanges and if necessary to devise assess- each country. The aims of this committee are described ments or RQs (Recognition of Quality) which may take briefly as follows: To advise Council (EPA) about ways of the form of examinations. About half the UEMS sections establishing and fostering communication and co- now have Boards and some have already started their operation between the EPA and national prosthodontic examinations (Urology, Anaesthetics and Plastic societies so that the EPA becomes a focus for European Surgery). These Board examinations are not compulsory prosthodontics. nor are they a pre-requisite to free movement. The Following considerable efforts by its chairman, data Section of Stomatology and Oro-maxillofacial Surgery has been collected regarding the specialty of prosthodon- 234 Faculty of Dental Surgery tics in 18 European countries under the following head- (c) Co-ordinate basic dental training with specialist pros- ings: Pre-specialist training, Specialist training, thodontic training and with other specialist training. Assessment/certification, Specialist status, Regulation of (d) Maintain a Register of Specialists. Monitor the specialty, Scope of specialty, Type of practice and number of specialists on the register and make appropriate Patients. recommendations. The specialty of prosthodontics is recognised by law in (e) Co-ordinate specialist prosthodontic training between countries. Iceland, Sweden, Poland, Yugoslavia and Turkey. In 7. The EC Advisory Committee on the Training of Dental Switzerland, the specialty is recognised by the Swiss Practitioners should produce a report on the Specialty of Prosthodontic Association but not by the government. In Prosthodontics and make general recommendations on train- nine other countries training programmes exist but these ing programmes. These recommendations should form the are not recognised. basis for the Specialty of Prosthodontics throughout Europe. Based on the guidelines for orthodontics and oral surgery of the Advisory Committee on Dental Training of the Commission of European Communities, guidelines for prosthodontics are proposed, some of which are summarised: 1. The specialty of Prosthodontics should have the same The Specialists' vote and voice in their standing as the specialties of Orthodontics and Oral Surgery academic home throughout Europe and should be recognised by law, special Mr Derek SeeI, Immediate past-Dean of Faculty regulations or other administrative provisions. The title of I have been asked by the Dean to relate what we have specialist, eg, 'Specialist in Prosthodontics, Specialist in heard to the future activity of the Faculty. It is clear that Restorative Dentistry, Specialist Practitioner in great changes are afoot affecting the delivery of dental Prosthodontics', etc, is for discussion and may differ in each healthcare. We are moving towards a unified system of country. The title should be comparable with other specialist delivery in which there will be increasing emphasis on titles. health gain and quality of care. I believe the Faculty is 2. The specialty should encompass Fixed and Removable the body which has the authority, resource and will to Prosthodontics, Maxillofacial and Implant Prosthodontics, carry out the responsibility of focusing upon the com- Endodontics, Periodontics, Occlusal rehabilitation and treat- plexities of the problems of specialisation. The authority ment of Temporo-mandibular dysarthrosis. 3. Specialty training programmes may emphasise one or of the Colleges in the past has come from their indepen- more ofthese subjects and this training may be demonstrated dence and their unique and elite membership of all in the title used by the specialist. Training of Prostho- consultants through their Fellowship status. The Faculty dontists should take place mainly within University Dental is now inviting all holders of Memberships and other Teaching institutions. There should be an obligatory core postgraduate Diplomas who do not hold fellowships training programme, common to all trainees followed by (almost 1000 in all) and who will form the basis of training to suit career and sub-specialty interest. The mini- specialists of the future, to join the Faculty and add mum duration of full-time training should be three years to strength through their vote and their subscriptions. bring it into line with existing specialty programmes. The reforms in the NHS are aiming to produce a Trainees should satisfy appropriate requirements for entry to unified system of health care delivery to which I have specialist training. After completion of training, entry to the already referred. Primary and secondary care are likely to Specialist Register should be preceded by an appropriate assessment of specialist status. Proof of continuing education be purchased through the same purchaser. The role of should be required for retention on the Specialist Register. the GDP in the NHS is therefore likely to be restricted to 4. Part-time training should be available provided it is a core structure which will exclude many more sophisti- equivalent in content to full-time training. cated services. The need for specialists will if anything 5. Trainees should be remunerated or funded during the increase. The Faculty is anxious that these services shall period of training. be available and spread so as to be both convenient and 6. Each country should establish a competent authority for equitable to the public. The Faculty's traditional role of Specialist training in Prosthodontics. This authority should concern for both standards of training and the facilities have wide participation of representatives of education and available within training units will need to be extended to the practising profession. If a competent authority already ensure that trained specialists are able to practice outside exists for other Dental Specialties, Prosthodontics should the hospital service in an environment in which they can come within its control. This authority should: (a) Establish requirements for entry to specialist training, maintain appropriate standards of care. All are urged to and determine standards and contents of training pro- ensure that the invitation circulated under the title 'New grammes. Benefits for Members and Diplomates-your oppor- (b) Accredit training programmes in recognised Institu- tunity to share your Faculty and your future' is widely tions. understood and supported. Faculty of Dental Surgery 235

Summary Bowdler Henry Scholarship The Dean, Mr Kenneth Ray European Committee of the Faculty of Dental Applications are invited for the award of the Surgery Bowdler Henry Scholarship which is available to This conference of Dental Specialty Associations has those who are registered on the Medical or Dental demonstrated the need for a forum on European Dental Registrar and who are seeking to pursue a career in Affairs within the UK. The Faculty's European Oral and Maxillofacial Surgery. Candidates must Committee has the following remit to take matters have spent at least one year in a Senior House forward. Officer or equivalent post in Oral Surgery or Surgery. The Royal College of Surgeons of England The purpose of the Scholarship is to enable the Faculty of Dental Surgery selected candidate with a primary dental or medical European Committee qualification to add a medical or dental qualifica- Terms of Reference tion respectively and to receive support for a maximum of three years of his or her course (unless 1. To advise the Faculty generally on matters relating to its receipt results in the abatement of public sup- Dentistry and Dental Policy in the context of Europe. port). The Scholarship will become operative on 1 2. To establish links and ensure communication with September 1994. other professional organisations in the UK, which also Conditions of the award and application forms represent dental interests in Europe. are available upon request from the Faculty Office. 3. To co-ordinate consultation, discussion and commu- The forms and two references, including one from nication between the Faculty and the Specialist the Dean of the Medical or Dental School at which Associations in the EC and non-EC European the applicant was trained, must be received in the Countries on matters relating to dental policy, educa- Faculty Office not later than 1 February 1994. The tion and examinations in the context of Europe. Bowdler Henry Scholarship Committee will meet 4. To monitor the development of the dental specialties to interview short-listed candidates in early spring in the context of Europe. and at that time candidates must be able to inform 5. To co-ordinate on behalf of the Faculty conferences, the Selection Board whether or not they have meetings and other events relating to the professional gained admission to a Medical or Dental School if development of dentistry in Europe. they are not already undertaking a medical or The Faculty thanks all those taking part in the dental course. Conference and looks forward to their continuing co- operation in European affairs. 236

Notices

Ethicon Foundation Fund 1994 on the advice of a Selection Committee appointed Applications are invited for grants from the Ethicon by Council, with representatives of the British Foundation Fund, which was established by the genero- Orthopaedic Association, the British Society for Surgery sity of Ethicon Limited for the purpose of promoting of the Hand, and a Trustee of the Medical Commission international goodwill in surgery by providing financial on Accident Prevention. It is designed to enable the assistance to Fellows who are travelling abroad for selected candidate to pursue a research project involving research or training purposes. travel to or from the United Kingdom, commencing in Applicants should be surgeons in training or within 1994. one year from their appointment as consultant. Preference will be given to applicants who are enrolled Applications are adjudicated upon by an Advisory for Higher Surgical Training in Orthopaedic Surgery, or Board which meets twice yearly. The Board favours who have recently completed a course in orthopaedic or applications which demonstrate that applicants are using hand surgery. Applicants need not be Fellows of The their initiative to obtain experience above and beyond Royal College of Surgeons of England. that which they would derive from routine exchange or Applications should be submitted to the Secretary of secondment to an overseas centre. On occasions, grants the College. They should be accompanied by a brief may be made to senior applicants who may be visiting an curriculum vitae, an account of the proposed research overseas centre to teach rather than learn. It does not, in project and where it is to be carried out, a statement of general, favour grants to enable an applicant to attend a the estimated costs to be incurred (including details of meeting or conference overseas, neither does it favour stipend or other resources available or applied for) and a grants to support the travel of an applicant's family. letter of support from the consultant under whom the Applications will only be considered from those who are applicant is working, or from a colleague in the case of Fellows of The Royal College of Surgeons of England. consultants. Successful candidates will be asked to submit a report on Applications should reach the College by 31 January return from their visit. 1994. Those who are shortlisted for interview will be Applications must include the following (6 copies of advised accordingly. each); (a) A letter of application, to include details of the nature, purpose, and date of proposed visit. (b) Curriculum vitae, including a list of publications. The Royal College of Surgeons of England (c) A letter of support from the head of department or and consultant under whom the applicant is working at The Royal College of Physicians of London present. (d) A financial statement showing (i) expenses to be Sir Ratanji Dalal Research Scholarship incurred, with special reference to the cost of Applications are invited for the above research travel, (ii) financial resources already available, Scholarship, which on this occasion is due to be awarded and (iii) other grants or fellowships being sought. to support a project in tropical surgery. All expenses should be given in sterling. The Scholarship, tenable for one year in the first (e) Please state where you saw the fund advertised. instance, to an initial value of £13,000 is open to all Applications for the next meeting should be sent to the medical practitioners registered in any part of the Secretary of The Royal College of Surgeons of England Commonwealth. It may be held in any institution in not later than 1 December for the January meeting, Britain or overseas that is approved by The Royal College and not later than 1 May for the June meeting. of Surgeons of England and Royal College of Physicians of London, by whom the Scholarship is awarded. The Scholarship may be renewed annually for up to a total of Norman Capener Travelling Fellowship three years, subject to satisfactory progress. The Council invites applications for the sixth biennial Candidates must be sponsored by a head of depart- award of the above Fellowship, the capital for which was ment who can offer facilities and technical assistance for subscribed by friends and admirers of the late Norman research in the appropriate field. Capener, past Vice-President and Honorary Medallist of Applications must reach the Secretary of The Royal the College. College of Surgeons of England by 29 January 1994 and The Travelling Fellowship will be awarded in March must include: Notices 237 (a) Curriculum vitae, including publications. Teaching Day on Amputations (b) A brief account (500 word maximum) of the Monday 17 January 1994 research project. A one-day course on amputations, organised by The (c) A supporting letter from the applicant's current Royal College of Surgeons of England in association with consultant or Head of Department in which the The National Association for Limbless Disabled, will be applicant intends to work. held at the College on Monday 17 January 1994, for peri- and post-Fellowship surgeons. The programme will consist oflectures covering a wide The Royal College of Surgeons of England range of topics related to amputations, including back- and ground information, surgical aspects, specialised surgery The Royal College of Physicians of London and sequelae and rehabilitation. The course fee is £95 for consultants and £70 for other Streaffeild & Mackenzie Mackinnon Research delegates. Fund Application forms are available from: The Education Applications are invited for the above research Department, The Royal College of Surgeons of England, Scholarship, which was founded to promote, assist and 35-43 Lincoln's Inn Fields, London WC2A 3PN. Tel: encourage research in medicine and surgery or either of 071-405 3474, ext 4601/4603/4607. those arts and sciences. Applicants must hold a medical qualification, registr- able in Britain or Ireland, or a university degree (not Writing a Surgical Paper necessarily in medicine). Although the project may be A one-day course on 'Writing a Surgical Paper' will be conducted at any institution acceptable to the awarding held at the College on Monday, 6 December. Topics committee, applications must be supported by the Dean include: Why do it?; How to start; The first draft; of a medical school or institute or a Postgraduate Dean. Revision and polishing; Figures and tables; References Applications must reach the Secretary of The Royal and statistics; and what an editor is looking for. College of Surgeons of England by 31 January 1994, and The course conveners are Mr A G Apley and Mr P C must include: Fulford and the fee of £95 includes lunch and coffee. (a) Curriculum vitae, including publications. (b) A brief account (500 words maximum) of the Anastomosis Craft Workshop research project. Tuesday 8-Friday 1 1 February 1994 (c) A statement of the facilities and funding available Details of this four-day course are available from the and of the expenditure for which the grant is Education Department, The Royal College of Surgeons sought. of England, 35-43 Lincoln's Inn Fields, London (d) A supporting letter from the applicant's consultant WC2A 3PN, tel: 071 405 3474 ext: 4601/4603/4607. The or head of department (or, in the case of a closing date for receipt of applications is Monday, 20 consultant, an independent referee) and from the December 1993. Dean or Postgraduate Dean as appropriate. Each award is of approximately £4,000 to support a 7th Annual Meeting of the Surgical Infection medical or surgical research project by a contribution to Society Europe emoluments or expenses or the purchase of apparatus May 26-28, 1994 (the ownership of which may rest with the Fund). This meeting is to be held at the Congress Center Awards may be renewed on up to two occasions. Hofburg, Vienna. Topics for discussion include: Infections in abdominal surgery; Peritonitis; Necrotizing pancreatitis; Antibiotic prophylaxis; Immunomodulation British Association of Plastic Surgeons and infections; Monoclonal antibodies in surgery; Biomaterials and infection; Antiseptics; HIV infections ADVANCED COURSE IN PLASTIC SURGERY in surgery. The Semmelweis Lecture on 'Trauma and 5(5) infection; will be delivered by L W Baker of South Head and Neck Cancer Africa. Further information is available from Professor Dr F 23-24 March 1993 (Glasgow) Schulz, c/o Wiener Medizinische Akademie fur Arztliche These courses are aimed at consultants and trainees in Fortbildung, A-1090 Vienna, Alserstrasse 4. plastic surgery, to whom places will initially be offered. Other medical graduates are encouraged to apply, and 2nd Stanmore Spinal Injuries Course will be offered any remaining places. The content is at an 22-23 April 1994 advanced level. The second Stanmore Spinal Injuries Course will be held Further details from British Association of Plastic at The Royal National Orthopaedic Hospital Trust, Surgeons, The Royal College of Surgeons, 35-43 Stanmore, Middlesex. The fee is £150.00 and further Lincoln's Inn Field, London WC2A 3PN. Telephone: details can be obtained from Carol Winston, tel: 071-831 5161/2, fax: 071-831 4041. 081 954 2300, ext 350. 238 Notices Norfolk & Norwich Insitute for Medical 14th Annual Study Day Education The role of the plain abdominal radiograph Orthopaedics and Fractures Part Ill FRCS in the acute abdomen Course Friday, 3 December 1993 10-11 March 1994 This annual study day, organised by Dr Stuart Field and This course, organised by Mr J K Tucker, designed to Mr R E C Collins, will be held at the Kent Postgraduate highlight important areas in orthopaedics and trauma in Medical Centre at Canterbury. It comprises a compre- an examination setting, will be held at Norfolk & hensive and critical analysis of the plain abdominal Norwich Hospital. It is limited to 12 delegates and those radiograph and its correlation with operative and post- interested should contact Mrs M Heron, Hospital mortem findings. Medical Staff Administrator, NANIME, Norfolk & It is aimed at SHOs, Registrars and Senior Registrars Norwich Hospital, Norwich NR1 3SR. in Surgery and Radiology, particularly those preparing for Fellowship examinations. Courses at the Institute of Laryngology and Fee £50.00 including coffee, lunch and tea. Details Otology from the Postgraduate Administrator, Kent Postgraduate Medical Centre, Kent & Canterbury Hospital, Nasal Plastic Surgery Course Canterbury, Kent CT1 3NG. Tel: (0227) 766877 ext 9-11 February 1994 4361. Organised by The Institute of Laryngology & Otology in association with the Royal National Throat, Nose & Ear The European Society for Surgery of the Hospital, this three-day surgical teaching course in prac- Elbow and Shoulder tical rhinoplasty includes lectures and operations. There London, 16-28 February 1994 are colour television demonstrations for the operations, 1. An advanced course on shoulder and elbow sur- cadavar dissection and video tape teaching sessions. gery. This course takes place in London on Wednesday The course organisers are Mr T R Bull and Mr I 16 and Thursday, 17 February 1994 and is open to any Mackay and the registration fee of £510 includes £200 orthopaedic surgeon interested in shoulder and elbow booking fee. surgery. It will comprise a full lecture programme plus discussion groups and workshops. 2. Annual Scientific Meeting of the British Elbow & Head, Neck and Facial Reconstruction Shoulder Society. This follows the advanced course on Course Friday, 18 February. It comprises free papers together 17-19 February 1994 with lectures. The scientific element of the meeting is This course has been organised by the Institute of open to any surgeon interested in shoulder or elbow Laryngology & Otology in association with the Royal surgery but the business meeting which follows is res- National Throat, Nose & Ear Hospital and the Royal tricted to members only. Marsden Hospital. A three-day practical course in head, Both events are directed by Mr M Watson, consultant neck and facial reconstruction it will emphasise the uses orthopaedic surgeon at Guy's Hospital. Details from: of pedicled and free microvascular flaps, problems and MetaPhor, 21 Kirklees Close, Farsley, Pudsey, West limitations. Cadaver dissection/teaching will be available Yorkshire LS28 5FT, tel: 0532 550752. in two evening sessions for some applications at an extra cost. The clinical and operative management of Course organisers: Mr Nicholas Breach, Mr David hand problems Howard and Mr Peter Rhys Evans. Fees: £445 without Wednesday, 1 December 1993 dissection; £600 with dissection. (Both include £200 This course, to be held at the Gordon Museum, Medical booking fee). School, Guy's Campus, is aimed at senior trainees and consultants in orthopaedic and plastic surgery. The Facial Soft Tissue Surgery Course organising faculty comprises: Mr P Burge, Mr J 14-16 February 1994 Compson, Mr D Elliot, Mr D Evans, Mr M Laurence, Organised by the Institute of Laryngology & Otology in Mr I Lowdon, Mr P Lunn, Prof A McGrouther, Mr P association with the Royal National Throat, Nose & Ear Monahan, Mr J Spencer, Mr R Wetherell and Mr D Hospital. A three-day surgical teaching course in practi- Yanni. cal otoplasty mentoplasy, including surgical techniques Topics to be covered include fractures, carpal instabili- for excision and repair of facial lesions, and surgical ties, wrist arthroscopy, primary and secondary manage- techniques for the ageing face. Course organiser: Mr T R ment of the cut flexor tendon, nerve repair, microsurgical Bull, course fee £510, including £200 booking fee. techniques, skin cover, congenital hand problems, sports For all above three courses, applications with booking injuries, Dupuytren's contracture, rheumatoid and fee must be sent by the end of November to: osteo-arthritis. The course fee is £75 and further details Administration, Institute of Laryngology & Otology, are available from Mr J Spencer or Mr D Yanni, 330/332 Gray's Inn Road, London WC12X 8EE. TEl: Department of Orthopaedics, Guy's Hospital, London 071 837 8855, ext 4214; fax: 071 837 9279. SEI 9RT. Tel: 071 955 5000, ext 5606/5607. 239 INDEX TO VOLUME 75 JANUARY-NOVEMBER 1993

Author Index

The first figure indicates the issue; the second figure indicates the page A Dennison A, see Maddern G, (3)67 Ashley S, awarded Royal College of Surgeons Inc New York Devlin HB, see Meredith P, (3)72; Regional Audit Travelling Fellowship, (6)219 Roadshow, Leicester, (5)170 Donovan IA, (Comment), (3)92 B Dorsch NWC, (Comment), (3)92 Bagshawe AF, New Year Honours, (2)45 Duffett RHE, (Comment), (4)124; So you want to be on Baigrie B, et al, (Comment), (5)187 Council?, (5)177 Baigrie R, and Reed MWR, (Comment), (2)51 Baker R, (Comment), (5)187 E Bamford D, Leopold Muller Research Fellow, (6)227 Edwards D, Ethicon Foundation Fund award, (6)220 Barabas AP, and Marcuson RW, report on Congress of Emberton M, see Meredith P, (3)72; see Rockall T, (4)129; Society of Hungarian Surgeons 1992, (3)87 report of meeting for medical audit assistants and co- Barker CPG, awarded Gilbert Blane Medal, (1)15 ordinators, (1)19; and Rockall T, (Comment), (3)91 Beeley JM, New Year Honours, (2)45 English T, elected Master of St Catharine's College Bide A, College Appeal chairman, (2)46 Cambridge, (5)173; elected to Court of Patrons, (6)220; Billing JS, awarded Hallett Prize, (1)14 Valete: Professor Sir Stanley Peart, (1)12 Birch J, Macloghlin Scholarship presented to, (3)81 Black J, elected Honorary Fellow of College, (3)81 G Blacklock N, Knighthood, (4)114 Gale R, awarded Macloughlin Scholarship, (1)14 Blanshard J, Ethicon Foundation Fund award, (6)220 Gibb P, awarded Regent Travelling Scholarship, (6)219 Booth MI, see Grogono JL, (4)101 Giddins G, BUPA Research Fellowship, (6)227 Botha AJ, Ethicon Foundation Fund award, (6)220 Goldberg S, elected Honorary Fellow of College, (3)81 Bottrill I, Ethicon Foundation Fund award, (6)220 Gosling R, appointed John Kinmonth Lecturer, (6)220 Braithwaite B, awarded Regent Travelling Scholarship, Gregg-Smith SJ, awarded Laming Evans Orthopaedic (6)219 Fellowship Fund, (3)43 Brough SJS, Ethicon Foundation Fund award, (6)220 Grevitt MP, Ethicon Foundation Fund award, (6)220 Browse N, From the President. A Single Voice, (6)195; Grogono JL, et al, Service need versus training need, (4)101 From the President. Setting the Agenda: an Audit, (5)143; From the President. Why have Royal Colleges?, (4)111; Report of CMO Working Party, (3)74; The Audit H Roadshow. Harrogate, 168; The College and Research, Hardcastle JD, report as chairman of Education Board, (2)41 (1)3; The College and Surgical Education, (2)39 Harland G, Eton College, (2)32 Bruggen N van, and Proctor E, (Book review), (3)86 Harries W, see Ricketts D, (6)203 Harris I, admitted to Council, (1)14 C Hartley J, see Ricketts D, (6)203 Cameron JL, elected Honorary Fellow of College, (3)81 Heaton N, Visit to US transplant centres, (5)163 Carbon R, awarded Porritt Fellowship, (6)219 Hickey NC, awarded Royal College of Surgeons Inc New Carr AJ, Visit to the Royal Children's Hospital, Melbourne, York Travelling Fellowship, (6)219 (6)215 Hillam D, report of Faculty of Dental Surgery Conference of Carr C, awarded Hallett prize, (6)220 Dental Specialty Associations, (6)231 Chan HY, Ethicon Foundation Fund award, (6)220 Hitchin D, see Ricketts D, (6)203 Cheshire N, awarded Peter Clifford Travelling Scholarship, Hopkins R, Faculty of Dental Surgery. First Annual Faculty (3)95 Audit Day, (4)119 Cloherty JK, awarded Lady Cade medal, (1)15 Hunter J, bicentenary of death, (1)15, (2)45, (3)85, (4)133 Cobb R, see Baigrie B, (5)187 Huysmans H, elected Honorary Fellow of College, (3)82 Cochrane SWJ, Sir Henry Morris Studentship, (6)220 Collins CD, (Comment), (1)22 I Collins REC, Organisation of general surgery services in a Ingham-Clark C, (Comment), (2)51 population, (2)33 Irving M, appointed Bradshaw Lecturer, 43; appointed Coonick M, Women in Surgical Training Conference 1993, Hunterian Orator, (6)220; report as chairman of External (6)209 Affairs Board, 42 Corkery JJ, Invited Member of Council, (6)220 Corson RJ, Management of groin hernias in adults, (4)125 J Cotton MH, (Comment), (2)52 Jackson B, appointed Thomas Vicary Lecturer, (3)81; (Book Crumplin MKH, appointed Jessie Dobson Memorial review), (5)176 Lecturer, (6)220; Invited Member of Council, (6)220 Jeffrey R, Leopold Muller Research Fellow, (6)227 Curzon M, report of Faculty of Dental Surgery Conference John HH, New Year Honours, (2)45 of Dental Specialty Associations, (6)230 Jones CB, see Pozo JL, (5)152 Jones SM, Regional Audit Roadshow, (4)131 D Judd R, McNeill Love Medal presented to, 81 Deardon D, awarded Royal College of Surgeons Inc New Juniper R, Report from Conference of Dental Specialty York Travelling Fellowship, (6)219 Associations, (5)182 240 Author Index K Parmar JR, Waiting list initiative in general surgery, (1)4 Karran A, see Karran SJ, (4)104 Patel AG, et al, Inadequacies of hospital medical records, Karran SJ, (Comment), (6)229; et al, Wessex region staff (1)7 perceptions of status of quality assurance and surgical Pietroni M, Assessment of competence in surgical trainees, audit, (4)104 (6)200 Kelly MJ, see Lear JT, (1)9 Pollock D, admitted to Council, (1)14 Khan Z, see Lovell ME, (3)91 Pozo JL, and Jones CB, Analysis of elective and trauma Kirk RM, appeal for offers of instruction in new techniques workloads, (5)152 for overseas senior surgeons, (2)52; Teaching Aids, (4)110 Preece PE, Update on tumour biology and the surgeon, (2)47 Kmiot WA, awarded Regent Travelling Scholarship, (6)219; Proctor E, see Bruggen N van, (3)86 et al, Research in Higher Surgical Training--The West Midlands View, (5)147 R Raftery AT, Audit of the surgical workload on a renal unit, L (3)69; (Comment), (6)228 Langkamer V, awarded Laming Evans Orthopaedic Ranaboldo CJ, see Karran SJ, (4)104 Fellowship Fund, (3)43 Raven K, elected to Court of Patrons, (6)220 Lavy BD, visit to L'Institute Francais de la Main, (5)158 Ray K, Faculty of Dental Surgery, Dean's address to annual Lear JT, et al, Disruption caused by the house officer's meeting, (1)13; report of Faculty of Dental Surgery bleep: a simple solution, (1)9 Conference of Dental Specialty Associations, (6)235; Leopard P, report of Faculty of Dental Surgery Conference Summary of Conference of Dental Specialty Associations, of Dental Specialty Associations, (6)232 (5)185 Levy PR, MBE awarded to, (2)46 Reed M, see Baigrie B, (5)187 Lishman IV, award, (5)173 Reed MWR, see Baigrie R, (2)51; Evaluation of surgical Livingstone JI, Ethicon Foundation Fund award, (6)220 training-urgent improvement needed, (6)198 London PS, (Comment), (4)124 Richardson GB, Audit Conference for Registrars and Senior Lovell ME, and Khan Z, (Comment), (3)91 Registrars, (5)169 Lydeard S, (Comment), (6)228 Ricketts D, et al, Who should code orthopaedic inpatients?, (6)203 M Ridley DS, New Year Honours, (2)45 McCue J, see Baigrie B, (5)187 Roberts S, (Comment), (6)228 McDonald F, report of Faculty of Dental Surgery Robinson RE, Invited Member of Council, (6)220 Conference of Dental Specialty Associations, (6)252 Rockall T, see Emberton M, (3)91; and Emberton M, Audit, McGlashan J, RCS/Glaxo Fellowship, (6)227 Protocols, Guidelines and Outcomes, (4)129 Maddern G, et al, A practical approach to surgical training Rule D, Report from Conference of Dental Specialty abroad, (3)67 Associations, (5)183 Marcuson RW, see Barabas AP, (3)87 Marston A, elected to Council, (3)84, (4)98; readmitted to Council, (6)221 S Mavor A, Ethicon Foundation Fund award, (6)220 Sackville T, Address to conference in management of major May PC, admitted to Council, (6)221; elected to Council, trauma, (5)165 (3)84, (4)98 Seel D, Faculty of Dental Surgery, report of Consultants' Meredith P, et al, Value of patient's experience of surgery to Discussion Group meeting, (2)53; report of Faculty of surgeons, (3)72 Dental Surgery Conference of Dental Specialty Mihaescu T, (Comment), (3)92 Associations, (6)234 Miles AEW, awarded Wood Jones Medal, (3)81 Seward M, Report from Conference of Dental Specialty Miller JD, Invited Member of Council, (6)220 Associations, (5)180 Miller R, Principles of colon and rectal surgery, (6)214 Singer GC, and Whitlock MR, (Comment), (1)21 Miller SS, appointed College Adviser in Scotland, (5)174 Smith B, Report from Conference of Dental Specialty Moreny MH, Medal of Order of Australia awarded, (4)114 Associations, (5)183 Morrison MCT, (Comment), (1)21, (4)123 Souka HM, awarded Hallett Prize, (1)14 Mosley JG, Explanation of role of individual performance Stain S, see Maddern G, (3)67 review in surgical training, (5)150; Use of management Stanley D, Visit to Mayo Clinic, Rochester, Minnesota, techniques to control elective surgery, (6)207 (4)132 Mould T, see Patel AG, (1)7 Stephens CD, report of Faculty of Dental Surgery Mumtaz FH, see Grogono JL, (4)101 Conference of Dental Specialty Associations, (5)179, (6)230 N Strahan D, Report from Conference of Dental Specialty Neoptolemos JP, see Kmiot WA, (5)147 Associations, (5)179 Newman JH, (Comment), (2)52 Strahan JD, admitted to Council, (1)14 Noordeen H, awarded Royal College of Surgeons Sweetnam R, appointed Robert Jones Lecturer, (2)43; Foundation/General Motors Trauma Fellowship, (6)219 election to Council, (3)84, (4)98; readmitted to Council, Novell JR, Ethicon Foundation Fund award, (6)220 (6)221 0 T O'Connell M, Confidential comparative audit service at Royal Tang AT, awarded Hallett Prize (1)14 College of Surgeons of England, (2)49 Taylor G, Faculty of Dental Surgery, report of Oral Health O'Flynn D, elected Honorary Fellow of College, (3)82 Promotion Study Day, (2)55; Report from Conference of Dental Specialty Associations, (5)184 p Taylor I, Opportunities for research in surgical training, Paine CH, Invited Member of Council, (6)220 (2)31 Parc RF, elected Honorary Fellow of College, (3)82 Temple JG, see Kmiot WA, (5)147; proposals on junior Park CA, (Comment), (5)188 doctors' hours, (4)99 Author Index 241 Thomson HJ, Visit to Duke University Medical Center, Watkinson JC, Visit to the Johns Hopkins Medical School, North Carolina, (5)160 Baltimore, (5)161 Tolley N, Ethicon Foundation Fund award, (6)220 Watts JC, Philip Mitchiner-Surgeon Extraordinary, (4)108 Turk JL, Erasmus Wilson and Arnott Demonstrations, Webb PJ, see Patel AG, (1)7 (6)224 West J, retirement as Examinations Secretary, (4)116 Turner-Warwick M, elected Honorary Fellow of College, Whitlock MR, see Singer GC, (1)21 (3)82 Wickham J, awarded Cecil Joll Prize, (3)81 Williams DI, Subjects of portraits in the Council room, (3)76 V Williams JK, Report from Conference of Dental Specialty Vaughan G, elected Honorary Fellow of College, (3)82 Associations, (5)181 Winstanley JHR, Clinical applications of molecular oncology, w (6)212 Wake M, awarded Lionel Colledge Memorial Fellowship in Winston RML, awarded Victor Bonney Prize, (3)81 Otolaryngology, (6)220 Worley C, see Lear JT, (1)9 Warwick D, awarded Laming Evans Orthopaedic Fellowship Wright P, report of Faculty of Dental Surgery Conference of Fund, (3)43 Dental Specialty Associations, in McDonald F, report of Watkin DFL, (Invited comment), (4)103 Faculty of Dental Surgery Conference of Dental Specialty Watkins T, admitted to Honorary Fellowship, (2)41 Associations, (6)233

Subject Index The first figure indicates the issue; the second figure indicates the page A British Orthopaedic Association, report, Management of Accreditations, Certificates awarded, (1)14 Skeletal Trauma in the United Kingdom, (Comment), Annual General Meeting, (2)40 (London) (4)124 Appeals Office see College Appeal BUPA Fellowship, (6)227 Audit, coding of orthopaedic inpatients, by junior hospital doctors and by coding clerks, (Ricketts et al) (6)203; of C College objectives, (Browse) (4)143; conference for CMO's Working Party Report, (Browse) (3)74 registrars and senior registrars, (Richardson) (5)169; Coding, of orthopaedic inpatients, by junior hospital doctors confidential comparative audit service at College, and by coding clerks, (Ricketts et al) (6)203 (O'Connell) (2)49; evaluation of surgical training, (Reed) Cognizance banquet, (2)35 (6)198; Faculty of Dental Surgery audit day, (Hopkins) College, A Barber-Surgeon's Signboard, (1)28; annual (4)119; inadequacy of hospital medical records, (Patel et accounts, (2)42; the ceremonial mace, (4)140; Committee al), (1)7; management techniques in control of elective Room clocks, (3)96; John Hunter's statue, (5)192; surgery, (Mosley) (6)207; protocols, guidelines and Listeriana, (2)64; Membership granted, (5)173; Research outcomes, RCS meeting, (Rockall and Emberton) (4)129; Fellowships, Glaxo and BUPA, (6)227; Research Regional Audit Roadshow, Bath, (Jones) (4)131; Regional Fellowships Fund, (4)117, (6)226, see also Fellowship; Audit Roadshow, Harrogate, (Browse) (5)168; Regional From the President Audit Roadshow, Leicester, (Devlin) (5)170; report of College Adviser in Scotland, appointment of first, (5)174 meeting for medical audit assistants and co-ordinators, College Appeal, Chairman, Sir Austin Bide, (2)46; Christmas assurance and in (Emberton), (1)19; surgical, quality fundraising, (2)38; new leaflet to promote legacy income, Wessex, (Karran et al) (4)104, (Comment), (Lydeard) (1)17; response to, (1)16, (2)45, (3)84, (4)116, (5)174, (6)228, (Comment), (Karran) (6)229; of surgical workload (6)222 in a renal unit, (Raftery) (2)69; value of patient's College News, (1)14 experience to surgeons, (Meredith et al) (2)72; workloads Colon and rectal surgery, principles of, (Miller) (6)214 in elective and trauma surgery, scoring systems for, (Pozo Condolences, (1)15, (3)82 and Jones) (5)152 Council, admissions/readmissions to, (1)14, (6)221; elections Award to College, (1)16 to, (4)98; elections to, (Duffett) (5)177, (Comment), Awards and presentations, (3)81, (4)112, (4)113, (5)171, (Raftery) (6)228; Invited Members appointed, (6)220 (5)172, (6)219, (6)220 Council meeting, (2)42 Council visits, regional, to Halifax, (2)45, (4)114, (5)173; B regional, to Whipps Cross Hospital, (1)15 Barber-Surgeon's Signboard at College, (1)28 Creutzfeldt-Jakkob disease, notice from Department of Bicentenary of death of John Hunter, (1)15, (2)45, (3)85, Health regarding treatment of patients with, (2)62 (4)133; The Creation by Hadyn at Royal Festival Hall, Cryptic Corner, (1)20, (2)50, (3)90, (4)115, (5)178, (6)206 (3)85, (5)176 Board of Faculty of Dental Surgery, election to, (4)121 Book review, As I Remember, (Bridges) (3)86; Look Back in D Happiness: a surgeon's life--Michael Harmer, (Harmer) Day case surgery, waiting lists and, (Parmar), (1)4 (5)176 Deaths, (1)16, (2)45, (3)83, (4)114, (5)173, (6)222 British Association of Surgical Oncology, report of joint Dental Surgery, Faculty of, conference of dental specialty meeting with, (Preece) (2)47 associations, (Stephens) (5)179, (Stephens) (6)230; 242 Subject Index consultants discussion group, (4)122; Consultants' L Discussion Group, effects of the reformed health service, Lady Cade medal, awarded, (1)15 (Seel) (2)53; Dean's address to annual meeting, (Ray), Laming Evans Orthopaedic Fellowship Fund, awards from, (1)13; first Faculty audit day, (Hopkins) (4)119; oral (2)43 health promotion study day, (Taylor) (2)55 Lecturers, appointment of, (2)43, (4)112, (5)172, (6)220 Diplomas of Fellowship see Fellowship Legacy income see College Appeal Donations see Gifts and donations Lister, marble bas-relief of in college, (2)64

E M East European Medical Journal, (Comment), (Mihaescu) (3)92 Medical records, hospital, inadequacies of, (Patel et al), (1)7 Education see Training Mitchiner Philip see Philip Mitchiner Education Board, report of Chairman, (Hardcastle) (2)41 Motions from Fellows, (2)42 Energy Saving Award see Awards Music and medicine, The Creation by Hadyn at Royal Erasmus Wilson and Arnott Demonstrations, (Turk) (6)224 Festival Hall, (3)85, (5)176 Eton College, links with College, (Harland) (2)32 Eurosurgery/Eurochirugie, 3rd European Congress of Surgery, London meeting, (1), 24, (2)59, (4)137 N Examinations, Intercollegiate in General Surgery, (Comment), National Health Service, effect of reforms on dentally based (Baigrie et al) (5)188, (Comment), (Roberts) (6)228 specialties, (Seel) (2)53 Examiners, appointment of, (2)42 National Tuberculosis Survey, plans for, (2)59 External Affairs Board, report of Chairman, (Irving) (2)42 New Year Honours, (2)45

F 0 Faculty of Dental Surgery see Dental Surgery Oncology, molecular, clinical aplications of, (Winstanley and Fellowship, by election, (4)113; diplomas granted, (1)15, Poston) (6)212; tumour biology and the surgeon, joint (2)43, (3)83, (4)113, (6)220 meeting with British Association of Surgical Oncology, Fog factor, in writing, (Comment), (Duffett) (4)123, (Preece) (2)47 (Comment), (Baker) (5)187 Overseas Doctors Training Scheme, appeal for placements, From the President, A Single Voice, (Browse) (5)195; Setting (Kirk) (2)52 the Agenda, an Audit, (Browse) (4)143; The CMO's Working Party's Report, (Browse) (3)74; The College and p Research, (Browse) (1)3; The College and Surgical Patients, experience of surgery, value of to surgeons, Education, (Browse) (2)39; Why have Royal colleges?, (Meredith et al) (3)72 (Browse) (4)111 Philip Mitchiner, surgeon extraordinary, (Watts) (4)108 Portable telephone in theatres, (Comment), (3)91 G Presentations see Awards and presentations General surgery, organisation of services in a population, (Collins) (2)33 Gertmann-Straussler-Scheinker Syndrome, notice from R Department of Health regarding patients with, (2)62 Regional Advisers and Surgical Tutors, appointed, (1)15, Gifts and donations, (6)222; from Cutlers Company, (3)80; (2)43 Glaxo's donation to Hadyn's Creation, (3)86 Research, College and, (1)3; in higher surgical training, Gilbert Blane Medal, awarded, (1)15 (Kmiot et al) (4)147; in surgical training, (Taylor) (2)31, Glaxo Fellowship, (6)227 (Comment), (Emberton and Rockall) (3)91, (Comment), (Morrison) (4)123 H Retirements, John West, as examinations secretary, (4)116; Hallett Prizes, awarded, (1)14 Professor Sir Stanley Peart, (English), (1)12 Health Service Commissioner's report, 1992/93, (6)216 Royal College of Surgeons, AGM motions from Fellows, Hernias, managment of in adults, RCS meeting, (Corson) (2)42, (Comment), (Morrison) (4)123 (4)125 Royal College of Surgeons Inc., 25th anniversary, (1)18 History of surgery, Philip Mitchiner, (Watts) (4)108; and Royal London Hospital Helicopter Emergency Medical subjects of portraits, (Williams) (3)76 Service, (Comment), (Singer and Whitlock) (1)21 HJ Windsor Prize, awarded, (2)43 Honorary Fellows, election of, (3)81 S Honorary Fellowships, Rt Hon Sir Tasker Watkins, (2)41 Senate of Royal Surgical Colleges, constitution of, (6)196; set Honours reported, (2)46, (4)114, (5)173 up, (Browse) (6)195 House officers, reduction of inappropriate bleep calls, (Lear Sir Alexander McCormick Travelling Fellowship, awarded, et al), (1)9 (2)43 Hunter John, see John Hunter; Bicentenary Surgery, elective, management techniques to control, (Mosley) (6)207; elective and trauma, scoring systems for J workloads in, (Pozo and Jones) (4)1152; post-communist, John Hunter, celebration of bicentenary of death of, (1)15, in Eastern Europe, (Barabas and Marcuson) (3)87; (2)61, (3)85, (4)133; The Creation by Hadyn at Royal providing the ideal surgical service, (Comment), (Collins) Festival Hall, (3)85, (5)176 (1)22 Junior doctors' hours, new deal for, (Temple) (4)99 Surgical Tutors see Regional Advisers and Surgical Tutors Subject Index 243 (Sackville) (5)165; skeletal, (Comment), (5)188; skeletal, Teaching aids, (Kirk) (4)110 BOA report, (Comment), (London) (4)124 Things about College see College Tumour biology see Oncology Training, see also Teaching aids; CMO's Working Party Report, (Browse) (3)74; continuing medical education, V data required, (Mansfield) (5)174; evaluation of, (Reed) Valete, Professor Sir Stanley Peart, (English) (1)12 (6)198; higher surgical, integrated scheme in general Visits, by Council see Council visits; reports of, Mayo Clinic, surgery, (Baigrie and Reed) (Comment), (2)51, (Ingham- (Stanley) (4)132; reports of, to Duke University Medical Clark) (Comment), (2)51; higher surgical, research in, Center, North Carolina, (Thomson) (5)160; reports of, to (Kmiot et al) (4)147; Junior doctors' hours, new deal for, the Johns Hopkins Medical School, Baltimore, (Temple) (4)99; (Comment), (Morrison) (1)21; role of (Watkinson) (5)1161; reports of, to L'Institut Francais de individual performance review in, (Mosley) (4)150; service la Main, (Lavy) (5)158; reports of, to The Royal versus training need, (Grogono et al) (4)101, (Invited Children's Hospital, Melbourne, (Carr) (6)215; reports of, comment) (Watkin) (4)103; surgical, abroad, practical to US transplant centres, (Heaton) (5)163 approach, (Maddern et al) (3)67; surgical, assessment of competence in trainees, (Pietroni) (6)200; surgical, College w and, (Browse) (2)39; surgical, in developing countries, Waiting lists, in general surgery, reduction of in a District (Cotton) (Comment), (2)51; surgical, final year General Hospital, (Parmar), (1)4, (Newman) (Comment), undergraduates and CSiG candidates compared in a (2)52 multiple choice test, (Comment), (Dorsch) (3)92, Women, Women in Surgical Training, conference, (Coonick) (Comment), (Donovan) (3)92; surgical, research in, (6)209 (Taylor) (2)31, (Comment), (Emberton and Rockall) (3)91, Workloads see Audit (Comment), (Morrison) (4)123 Writing, clear writing and the fog factor, (Comment), Trauma, major, management of, address to conference, (Duffett) (4)123, (Comment), (Baker) (5)187 244

THINGS ABOUT THE COLLEGE 11. THE TRAVELLING MACE

Less ornate and less grand but several years older than the Ceremonial Mace described in the July Bulletin is the Travelling Mace, the two faces of which are pictured above. Made of silver (hallmarked 1803) on an ebony shaft this mace dates to the emergence of the College in 1800 from the former Company of Surgeons. The Great Seal was affixed to the Charter creating the Royal College of Surgeons in London on 22 March 1800, an event recorded on one face; the other shows the unofficial coat of arms used both by the old Company and the new College in its early years. The present coat of arms dates from 1822 and is broadly similar though differing in detail. Although now colloquially known as the Travelling Mace, being lighter and more easily transportable than the Ceremonial Mace, it should correctly be called the Beadle's Staff. The Court of Assistants of the new College (the forerunner of Council) agreed to obtain a staff for the Beadle on 3 May 1801 but it took three years before it was received in 1804 at a cost of £20.10 shillings. Originally there was a cross surmounting the orb at the top but this has vanished over the years. That it has much travelled is indicated too by the damage seen in the left hand illustration which is soon to be repaired.