Hunterian Professorship Symposium: A new frontier in Surgery ¡V Challenges & Opportunities in MAS
¡§ Hunterian Scholars and Surgery in Hong Kong¡¨

Speech by Dr. C.H. Leong delivered on 5 February 2010

          May I begin by thanking the organizers for inviting me to this very meaningful symposium. Let me also take this opportunity to congratulate Dr. Michael Li on being elected to the Hunterian Professorship of this Royal College of Surgeon of England. It is a great honour indeed not just for Dr. Li, but for surgery in HK, for as far as I can recall, other than Michael, there are up till now only 4 other Hunterian Professors from and in HK. They are:

          Prof. Francis E. Stock, Professor of Surgery, University of HK up to 1964. His Hunterian Lecture was entitled ¡V ¡§Porta-caval anastomosis for cirrhosis of Liver¡¨. Next came G. B. Ong, Prof. of Surgery succeeding Francis Stock ¡V his lecture was entitled ¡§Colocystoplasty for Bladder Reconstruction¡¨. The third one is myself in 1976. The title is ¡§The use of the Stomach for Bladder Reconstruction¡¨. These 3 attained the accolade from their work and research while in HK. The other Hunterian Professor is Dr. David Mann who obtained the Professorship while working, as I understand it, in U. K.  

          The format of the Hunterian Lecture I was told is different today than what it used to be. Today the Lecture is delivered as part of a surgical symposium, in one of the major teaching hospitals in UK. In the past, it is a stand alone function taking place in the Edward Lumley of the Royal College of Surgeons of England. Such changes, I believe, is a change for the better. At least there will be a sizable audience as the lecture is part and partial of a surgical symposium. Let me elaborate to you the situation in the past basing on my personal experience.

          To taste the mood of this distinctive lecture, I went to London a week before my turn to attend another Hunterian Lecture delivered by a professor from Singapore. The appointed time was 5:00pm in the Edward Lumley Hall. I went there at 4:30pm, thinking that the Hall might be packed and I was unable to secure a seat. The Hall could at least house 500-600 persons but I was there alone. There were no increases in audience approaching 5:00pm. On the dot at 5:00pm, an elderly distinguish gentleman in full tails appeared and said:

          ¡§Ladies and gentleman, please rise for the

          President of the Royal College of Surgeon

          and the Hunterian Lecturer!¡¨

          3 persons walked in, all in full academic gowns ¡V the President, the Lecturer, a senior member of the Council ¡V in that order. The 2 officials set in the front role looking very stately indeed. The lecturer went up stage and delivered the lecture oblivious to the fact that there were only a total of 3 members in the audiences.

          On my D-day, I was asked to present myself at the President¡¦s suite at 4:45pm. After a few exchanges of pleasantry, we were all properly robed and marched down to the Hall. I was nervous, will there be anyone in the audiences? To my present surprise, there were almost a 100 attendees, many from HK, some are from outside London, some non-surgeons. To them, I was and shall remain forever grateful. 

          What follow the lecture was even more interesting. We went back to the President¡¦s suite in the reverse order. I was offered a glass of sherry. ¡§Would a dry one do, sir?¡¨ I was asked. After 15 minutes of small talks, the President rose, came forward to me and offered me an envelope and congratulated me and we parted. When I subsequently opened the envelope, it was a cheque for 1 guinea ( 21 shillings) payable to C.H. LEONG from the Royal College of Surgeons of England.

          There were no publicity, no fanfare, definitely no media coverage, very few people in HK were even aware of that ¡§grand¡¨ occasion.

          Situation is altogether different today. The society demands transparency. Any event, be it positive or negative will be revealed if not announced. Modern technology too has changed the whole scene. With advance telecommunication, Michael Li¡¦s lecture delivered in U.K. today will be properly televised in HK, so that we 6,000 miles away can absorb his wisdom and share his glory in real time.

          Let me now move to answer a few burning questions in some of your minds.

•           Who is John Hunter of the ¡§Hunterian Lecture¡¨
•           Why does the Royal College of Surgeons of England pay so much tribute to this man (there is also a Hunterian Orator, perhaps ever more prestigious.)
•           How are lecturers selected?

          John Hunter (1728-1793) hailed form Scotland. Numerous articles and books have been written on this man. John Hunter received very little in the way of a formal education. In fact, he left school at the age of 16. Despite never studied in a university, he moved on to become surgeon par excellence. It may be unfair that he was best known by his experiment on venereal diseases for which he wrote the ¡§Treatise of venereal disease¡¨. He was interested in whether gonorrhea and syphilis were 2 diseases or one disease in different phase of manifestation. He investigated this by inoculating himself with ¡§venereal matter from a prostitute¡¨ 2 puncture wounds on the glans and prepuce. It was said that he developed first the typical gleets of gonorrhea and then a chancre. Obviously that prostitute had both gonorrhea and syphilis.

          Looking at the issues in a positive way. The incidence actually reflected Hunter¡¦s believe and his quest for knowledge. He once told Edward Jenne (of small pox vaccination fame).

          ¡§I think your solution is just. But why think? Why not try the experiment?¡¨ He tried on himself, submitting himself to be the guinea pig.

          British anatomists of the 18th century, like those elsewhere, had to satisfied with the cadavers of the hanged, but even for this they still needed the permission of the authorities. Though hangings were quite numerous, the many anatomy schools and the surgeons¡¦ guilds resulted in inadequate supply of bodies. The condemned, the executioners and their assistants all had to be bribed in order to obtain cadavers.

          A simpler method of acquiring study material for the anatomist is body snatching. Paupers were usually buried in communal graveyard and their corpses could easily be taken from their coffins. And the surgeons¡¦ guilds paid well. London had entire gangs of so-called resurrectionists; at fixed rates, they stole bodies from mortuaries, John Hunter was involved in such activities. In 1783, John Hunter bribed an undertaker 500 pounds to obtain the corpse of an Irish giant who had made his name as a circus attraction in London. The unfortunate Irishman¡¦s skeleton is still on display in the Hunterian Museum Royal College of Surgeons in London.

          While all these show Hunter to be somewhat of a ¡§non-conformist¡¨. Yet, it also highlights his guest for knowledge, where no thing could stop him. His determinations get to basis of any problem where he would go at all lengths to discover. It was John Hunter then who set the framework for the practices of surgery on a scientific foundation. It came to no surprise that the College set up the Hunterian Professorship to honour this ¡§Father of Scientific Surgery.¡¨

          In essence, Hunterian Professorships are not offered to renown surgeons who have performed world stunning surgical procedures, but to individual whose discoveries were made after careful scientific considerations and with evidence based scientific support. 12 Hunterian Professorship are awarded every year only, for those whose work demonstrates solid scientific thoughts on top of being a surgical triumph. Such professorships are only awarded to ¡§Fellows of the English College¡¨. Very exceptionally, would the award be conferred on non-fellows. That accounted for the limited numbers in HK. I am confidant, Mr. Chairman, Colleagues, that if this criteria could be relaxed, then many in HK will be so honoured and assume the Hunterian Professorship.

          I am confidant, Mr. Chairman, Colleagues, that if this criteria could be relaxed, then many in HK will be so honoured and assume the Hunterian Professorship.

          Mr. Chairman, colleagues, are we in any way inspired?

          I believe that an analysis of John Hunter and the contribution of our Hunterian Professors do reflect certain characteristics and development of HK Surgery:

          I. Surgery is not just about a technique, but a scientific approach to treatment of disease using surgical skills. Colocystoplasties and gastrocystoplasties are for example technically feasible, yet will they perform the role of a bladder anatomically and physiologically; or will any other hollow organ fare better? A detail knowledge of the physiology of the small and large bowel compare with that of the stomach will show that possible electrolyte imbalance after colocystoplasty will occur that could be avoided with gastrosystoplasty.

          II. There are no lacks of surgical ¡§firsts¡¨ in HK. The procedures described in those few Hunterian Lectures are by no means exhaustive of HK¡¦s firsts. Other outstanding examples are:

          Anterior spinal fusion.

          Transoral approach to surgery of the cervical spine.

          Split liver in liver transplantation.

          Split maxilla approach to the nasopharyngnx

          Just to mention a few.

          III. Surgical Developments mirror ethnical and cultural needs.

          Cirrhosis of liver is by no means uncommon in HK. Advance cirrhosis is associated with portal hypertension, often leading to uncontrolled bleeding oesophageal varices. Decompression of the portal hypertension could prevent the bleeding. It was on this base that Francis Stock developed the Porta-caval anastomosis winning him a Hunterian Professorship.

          Chinese abhors an external ostium. The apprehension of requiring a urinary diversion using an ileostomy had led many patients with advanced carcinoma of bladders to refuse total cystectomies. Bladder Reconstruction is therefore a ¡§necessity¡¨ though the procedure is much more complicated than an ileal conduit.

          Colocystoplasty can answer the call. Given time, however, it became evident that electrolyte imbalance in particular acidosis, are not too uncommon, due to the absorption function the colonic mucosa. Gastrocystoplasty, using the antrun of the stomach could be a better alternation. Furthermore, secretion of the antrun is not too acidic to erode the urinary lining. the stomach.

          IV. Radicalism versus conservatism

          Surgeries and surgical procedures of today are very different from those of the 70¡¦s. There are probably due to advancement in technology, changes in culture of both the surgeons and the patients, and perhaps new scientific evidence. Colocystoplasties and gastrocystoplasties, for example, were done with extended long abdominal incision, following total cystectomies for bladder cancers. Radical surgery was thus the order of the day. Radical surgery means real radical surgery - removing the whole organ involved by the disease together with extensive regional lymph dissections and remove also of any organ that is in close proximity. Prof ONG use to remark ¡§ if it is in your way, remove it¡¨ and ¡§there is no compromise for cancer surgeon¡¨. Today, however, as exemplified by Dr Michael Li¡¦s Hunterian Lecture, minimal invasive surgery could be the gold standard.

          Take carcinoma of the breast as another example: Radical mastectomies and extended radical mastectomies were the order of those days. Today, the pendulum has swing to ultra-conservatism. - Local excision together with sentinel node excision is the accepted conservative approach. It was said that ¡§ Big surgeons use big incision¡¨. Today this is no more true.

          V. Natural Defense barrier is replaced by potent antibiotics.

          The human body is a complicated issue in that it often develops its own natural defense mechanism. The peritoneum, for example, is a natural barrier to the spread of diseases. Basing on this surgical physiology, this old surgical drawing is for surgery of organism outlasts the peritoneal cavity, try to stay away form that cavity. Furthermore post-operation ileums is much redirect, giving peritonea better comfort.

          Surgical physiology too has taught us that the organs in the peritoneal cavity, in particular, the omeutium will surround an infection to localize it to prevent spread into the general peritoneal cavity. We are taught therefore doing surgery for infection, not to disturb the localize mechanism at all possibilities.

          Today, with laparoscopic surgery, pathology involving retroperitoneum organs are often removed through the peritoneal cavity. Localization of infection by the body¡¦s natural defense mechanisms are often broken down when the peritoneal cavity is distended by CO2 for the laparoscopic procedures. Obviously, the availability of potent antibiotics act as coverage.

          Mr. Chairman, Colleagues, in the last 20 minutes so I have attempted to use the work of the Hunterian Professors of HK to trace some of the development of surgery. It would be too presumptions of me to place any value judgment. Suffice it to say that any new development is done with the betterment of our patients in mind and that all changes are based on proper scientific and evidence base backing.

          In the last 20 minutes or so, I have been talking about Hunterian Professors and their contribution, yet HK surgery and the development is the effort and dedication of all in the surgical community of which these Hunterian Lecture only form a part.

          Finally, ladies and gentlemen, the purpose of our gathering tonight is to witness the glory of Dr. Michael Li and to whom we all offer our heartiest congratulations.