George Grey Turner, 1877-1951
305
Ureteric transplantation (Chairnan: D G Melrose FRCS, House Surgeon Professor of Surgical Science, I969)
to
Grey Turner
at
Hammer.smith,
1945;
GREY TURNER'S CONTRIBUTION R Shackman FRCS First Assistant
to
Grey Turner at Hammersmith, 1938; Professor of Urology I96I-75
Although I qualified from Bart's in 1933, I had to wait almost 5 years, until I came to Hammersmith in 1938, before I saw the operation of transplantation of the ureters. At that time there were very few surgeons in the United Kingdom apart from Grey Turner who could talk with authority about it. In those days the ureters were transplanted only for complete ectopia or epispadias, which together occur only once in about every 50 000 births, so it is not surprising that no one surgeon had much experience of the operation.
Even Ogier Ward, a senior urologist, had never seen the ureters transplanted and came to Hammersmith to watch the operation. Grey Turner, who loved teaching, treated him rather as he would a young house surgeon, saying, 'This is what I did five years ago and this is what I have come to believe is the best way to deal with the problem today'. The operation which Grey Turner began to do just before the First World War was that which had been described by Stiles, whom Grey Turner always graciously acknow-
FIG. 3 Grey Turner's technique of ureterocolic anastomosis (1938). The artist is John Robson, who came with Grey Turner from Newcastle to Hammersmith as a laboratory assistant and retired as Chief Technician in 1974. He has preserved the memorabilia and prepared the exhibit of them at the meeting.
306
George Grey Turner, I877-195I
ledgedl3*. He described it as a Witzel gastrostomy technique, designed to ensure that the anastomosis did not leak. It was indeed a very successful operation, but of course it had its complications. When I came to Hammersmith he had come to use the Coffey technique of submucous implantation (Fig. 3). He mobilised the ureters and the pelvic colon with great care, used sutures to hold the bowel so that it was easy to incise it, and treated the blood supply of the ureters with the utmost respect. In his Sir William Macewen Lecture in Glasgow in I939 Grey Turner reported that in 26 years he had transplanted the ureters into the colon in 30 patients4. Four of these died from infection, but most of the others had their lives transformed. Despite this, patients and their doctors either did not realise that such an operation was available, or they did not know how valuable it could be, or they were frightened by its morbidity and mortality. Patients were allowed to remain completely incontinent, miserable, always wet, smelly, and wearing rubber pants by day and by night. One such man, on whom Grey Turner subsequently operated, was between 30 and 40 years of age when he came into Hammersmith in 1939 primarily for treatment of an empyema; the ectopia was discovered when he was examined on admission to the ward. Of course several of Grey Turner's patients developed complications. Somne had ureteric and calyceal dilatation, and when infection supervened the outlook was poor. One patient on whom he had operated when she was 22 went on to have 3 children; 29 years after the ureteric transplantation he removed a stone from the right kidney. There were also others who developed stones. How was it that Grey Turner was so successful and built up his well-deserved reputation for the operation of ureteric transplantation? First, he had had a firm general surgical foundation provided by his own chief, Ru.therford Morison5. Second, his technique was superb: long incisions, wide exposures, and delicate handling of tissues. Unhurried but *The references for this paper will be found end of the section (p. 3I 1)
at
fast, he made it all look so simple. Originally he did the operation in two stages. Using a long vertical incision, he first transplanted the right ureter just proximal to the pelvirectal junction. Then, about 3 or 4 weeks later, he reopened the incision, brought the left ureter through a little hole in the mesocolon, and transplanted it just proximal to, and into the same side as, the right one. I do not remember trouble with the wounds. Later he started to do the operation as a single-stage procedure. Eventually he even omitted the use of drains down to the site of the anastomoses, although he never failed to insert atube into the rectum and insisted on suturing it himself to the perianal skin. Grey Turner was essentially a surgical virtuoso and it was seldom if ever that we saw him in any surgical difficulty. The application of physiology and clinical biochemistry did not feature in his programme because they had not yet made an impact on surgery. But he himself said that transplantation of the ureters initiated a continuing experiment in human physiology. He had thought about the possible significance of urine in the proximal, reabsorptive part of the bowel, having noted that it became alkaline and contained an excessive amount of mucus. But -at that time neither he no(r we, his juniors, pursued these thoughts and observations. We know now that excessive outpouring of mucus from the colon, with loss of potassium, is liable to produce hypokalaemia, while at the same time bicarbonate is excreted from the bomwel and chloride is selectively reabsorbed-ionic exchanges which cause hyperchloraemic acidosis. In addition to this, acidosis is aggravated by the action of the colonic bacteria in breaking down the urinary urea to produce ammonia, which is absorbed and then converted to urea in the liver with the production of extra hydrogen ions. All this is now comprehensible, but such was not the case when Grey Turner practised. Despite the lack of laboratory biochemical determinations he prescribed potassium citrate for several of his patients. He did so because it had been traditional in urological cases; he the knew nothing about hypokalaemia and he never lived to know how much ahead of his
George Grey Turner, 1877-195 1 time he had been-doing the right thing even. for the wrong reason-and possibly helping his patients to survive. Malignant epithelial tumours rarely develop in ectopic bladders, which themselves are uncommon. Grey Turner himself saw only one such malignant case. He was never in a hurry to excise the bladder after transplanting the ureters and was prepared to wait months or even years. One of his patients, the last whose ureters he transplanted and whose bladder I subsequently excised, developed a fatal malignant tumour at the site of the ureterocolic anastomnoses about i8 years later at the age of 20. The growth extended up into one of
307
the kidneys, both of which were atrophic and infected. Although Grey Turner's ureteric transplantations were conceived for congenital abnormalities, in the last decade of his life he recognised that the operation had a place in the management of some patients with acquired conditions and he never failed to encourage his successors to accept the challenges which they evoked6. I consider it was a great privilege to have known Professor George Grey Turner and to have been with you today to pay tribute to that distinguished master surgeon.
THE MIDDLE YEARS H G Hanley CBE
MD
FRCS
House Surgeon to Grey Turner at Hammersmith, I937-38; subsequently Consultant Urologist to St Peter's and St Paul's Hospitals, Dean of the Institute of Urology, and Dean of the Institute of Basic Medical Sciences, Royal College of Surgeons of England
It is a privilege for me to talk about George Grey Turner because he made a great impression on me as a young man. I was one of his first house surgeons here and I quickly recognised in him the absolute master surgeon. I had actually seen two ureterocolic anastomoses before I came here, but my interest in the problem was really aroused by Grey Turner and I saw him perform the operation three times. He was a pioneer par excellence and it took considerable courage to persevere for over 20 years, in the face of considerable opposition, with an operation which he thought was good. Although he was no physiologist, he repeatedly stressed three very important principles. First, he said that the eventual treatment of most diseases would be by some form of 'haemotherapy'-not by X-rays and not by the surgeon's knife. And he was, of course, much impressed by the development of Prontosil in Germany and later by penicillin. Previously we had had nothing that would sterilise the urine. Second, he was very keen on giving intravenous infusions of glucose-'a little sugar, doctor'-to patients undergoing major operations. Third, he told us repeatedly that the postoperative toxicity after ureterocolic anasto-
mosis was due to some alteration in the blood chemistry caused by the absorption of urine from the bowel. He was nearly there, wasn't he? I have stressed these three pints because they are relevant to our approach to urinary diversions in the years 1938-56. Until then the operations were hazardous, with a high operative mortality and a relatively toxic existence afterwards. Only a minority of the patients felt really well. Nevertheless, Grey Turner pinpointed the problems and the changes which were to corne, and these have since made the operation safe. These were: (i) the appreciation of some disturbance in blood chemistry (the term 'hyperchloraemic acidosis' had not been invented); (2) the value of an effective urinary antiseptic; (3) properly balanced administration of fluid; (4) the avoidance of paralytic ileus, with a tube in the stomach if necessary; and (5) the admission that the Coffey-Stiles-Grey Turner operation was imperfect because it leaked and tendeed to stenose. He was very conscious of its defects, but, as he said, it was the best that he had tried. The beginning of the new era in urinary diversion came in I948 with the introduction
305
Ureteric transplantation (Chairnan: D G Melrose FRCS, House Surgeon Professor of Surgical Science, I969)
to
Grey Turner
at
Hammer.smith,
1945;
GREY TURNER'S CONTRIBUTION R Shackman FRCS First Assistant
to
Grey Turner at Hammersmith, 1938; Professor of Urology I96I-75
Although I qualified from Bart's in 1933, I had to wait almost 5 years, until I came to Hammersmith in 1938, before I saw the operation of transplantation of the ureters. At that time there were very few surgeons in the United Kingdom apart from Grey Turner who could talk with authority about it. In those days the ureters were transplanted only for complete ectopia or epispadias, which together occur only once in about every 50 000 births, so it is not surprising that no one surgeon had much experience of the operation.
Even Ogier Ward, a senior urologist, had never seen the ureters transplanted and came to Hammersmith to watch the operation. Grey Turner, who loved teaching, treated him rather as he would a young house surgeon, saying, 'This is what I did five years ago and this is what I have come to believe is the best way to deal with the problem today'. The operation which Grey Turner began to do just before the First World War was that which had been described by Stiles, whom Grey Turner always graciously acknow-
FIG. 3 Grey Turner's technique of ureterocolic anastomosis (1938). The artist is John Robson, who came with Grey Turner from Newcastle to Hammersmith as a laboratory assistant and retired as Chief Technician in 1974. He has preserved the memorabilia and prepared the exhibit of them at the meeting.
306
George Grey Turner, I877-195I
ledgedl3*. He described it as a Witzel gastrostomy technique, designed to ensure that the anastomosis did not leak. It was indeed a very successful operation, but of course it had its complications. When I came to Hammersmith he had come to use the Coffey technique of submucous implantation (Fig. 3). He mobilised the ureters and the pelvic colon with great care, used sutures to hold the bowel so that it was easy to incise it, and treated the blood supply of the ureters with the utmost respect. In his Sir William Macewen Lecture in Glasgow in I939 Grey Turner reported that in 26 years he had transplanted the ureters into the colon in 30 patients4. Four of these died from infection, but most of the others had their lives transformed. Despite this, patients and their doctors either did not realise that such an operation was available, or they did not know how valuable it could be, or they were frightened by its morbidity and mortality. Patients were allowed to remain completely incontinent, miserable, always wet, smelly, and wearing rubber pants by day and by night. One such man, on whom Grey Turner subsequently operated, was between 30 and 40 years of age when he came into Hammersmith in 1939 primarily for treatment of an empyema; the ectopia was discovered when he was examined on admission to the ward. Of course several of Grey Turner's patients developed complications. Somne had ureteric and calyceal dilatation, and when infection supervened the outlook was poor. One patient on whom he had operated when she was 22 went on to have 3 children; 29 years after the ureteric transplantation he removed a stone from the right kidney. There were also others who developed stones. How was it that Grey Turner was so successful and built up his well-deserved reputation for the operation of ureteric transplantation? First, he had had a firm general surgical foundation provided by his own chief, Ru.therford Morison5. Second, his technique was superb: long incisions, wide exposures, and delicate handling of tissues. Unhurried but *The references for this paper will be found end of the section (p. 3I 1)
at
fast, he made it all look so simple. Originally he did the operation in two stages. Using a long vertical incision, he first transplanted the right ureter just proximal to the pelvirectal junction. Then, about 3 or 4 weeks later, he reopened the incision, brought the left ureter through a little hole in the mesocolon, and transplanted it just proximal to, and into the same side as, the right one. I do not remember trouble with the wounds. Later he started to do the operation as a single-stage procedure. Eventually he even omitted the use of drains down to the site of the anastomoses, although he never failed to insert atube into the rectum and insisted on suturing it himself to the perianal skin. Grey Turner was essentially a surgical virtuoso and it was seldom if ever that we saw him in any surgical difficulty. The application of physiology and clinical biochemistry did not feature in his programme because they had not yet made an impact on surgery. But he himself said that transplantation of the ureters initiated a continuing experiment in human physiology. He had thought about the possible significance of urine in the proximal, reabsorptive part of the bowel, having noted that it became alkaline and contained an excessive amount of mucus. But -at that time neither he no(r we, his juniors, pursued these thoughts and observations. We know now that excessive outpouring of mucus from the colon, with loss of potassium, is liable to produce hypokalaemia, while at the same time bicarbonate is excreted from the bomwel and chloride is selectively reabsorbed-ionic exchanges which cause hyperchloraemic acidosis. In addition to this, acidosis is aggravated by the action of the colonic bacteria in breaking down the urinary urea to produce ammonia, which is absorbed and then converted to urea in the liver with the production of extra hydrogen ions. All this is now comprehensible, but such was not the case when Grey Turner practised. Despite the lack of laboratory biochemical determinations he prescribed potassium citrate for several of his patients. He did so because it had been traditional in urological cases; he the knew nothing about hypokalaemia and he never lived to know how much ahead of his
George Grey Turner, 1877-195 1 time he had been-doing the right thing even. for the wrong reason-and possibly helping his patients to survive. Malignant epithelial tumours rarely develop in ectopic bladders, which themselves are uncommon. Grey Turner himself saw only one such malignant case. He was never in a hurry to excise the bladder after transplanting the ureters and was prepared to wait months or even years. One of his patients, the last whose ureters he transplanted and whose bladder I subsequently excised, developed a fatal malignant tumour at the site of the ureterocolic anastomnoses about i8 years later at the age of 20. The growth extended up into one of
307
the kidneys, both of which were atrophic and infected. Although Grey Turner's ureteric transplantations were conceived for congenital abnormalities, in the last decade of his life he recognised that the operation had a place in the management of some patients with acquired conditions and he never failed to encourage his successors to accept the challenges which they evoked6. I consider it was a great privilege to have known Professor George Grey Turner and to have been with you today to pay tribute to that distinguished master surgeon.
THE MIDDLE YEARS H G Hanley CBE
MD
FRCS
House Surgeon to Grey Turner at Hammersmith, I937-38; subsequently Consultant Urologist to St Peter's and St Paul's Hospitals, Dean of the Institute of Urology, and Dean of the Institute of Basic Medical Sciences, Royal College of Surgeons of England
It is a privilege for me to talk about George Grey Turner because he made a great impression on me as a young man. I was one of his first house surgeons here and I quickly recognised in him the absolute master surgeon. I had actually seen two ureterocolic anastomoses before I came here, but my interest in the problem was really aroused by Grey Turner and I saw him perform the operation three times. He was a pioneer par excellence and it took considerable courage to persevere for over 20 years, in the face of considerable opposition, with an operation which he thought was good. Although he was no physiologist, he repeatedly stressed three very important principles. First, he said that the eventual treatment of most diseases would be by some form of 'haemotherapy'-not by X-rays and not by the surgeon's knife. And he was, of course, much impressed by the development of Prontosil in Germany and later by penicillin. Previously we had had nothing that would sterilise the urine. Second, he was very keen on giving intravenous infusions of glucose-'a little sugar, doctor'-to patients undergoing major operations. Third, he told us repeatedly that the postoperative toxicity after ureterocolic anasto-
mosis was due to some alteration in the blood chemistry caused by the absorption of urine from the bowel. He was nearly there, wasn't he? I have stressed these three pints because they are relevant to our approach to urinary diversions in the years 1938-56. Until then the operations were hazardous, with a high operative mortality and a relatively toxic existence afterwards. Only a minority of the patients felt really well. Nevertheless, Grey Turner pinpointed the problems and the changes which were to corne, and these have since made the operation safe. These were: (i) the appreciation of some disturbance in blood chemistry (the term 'hyperchloraemic acidosis' had not been invented); (2) the value of an effective urinary antiseptic; (3) properly balanced administration of fluid; (4) the avoidance of paralytic ileus, with a tube in the stomach if necessary; and (5) the admission that the Coffey-Stiles-Grey Turner operation was imperfect because it leaked and tendeed to stenose. He was very conscious of its defects, but, as he said, it was the best that he had tried. The beginning of the new era in urinary diversion came in I948 with the introduction
