Gordon Smyth
Milestones of Politzer Society

Gordon Smyth 1929 - 1992

Gordon Smyth died on 20th May at the age of 63 and, as he requested, the funeral was private and there was no memorial service. However he had made such a major contribution to otology that his colleagues wanted to recognize this in a public way and hence we are here today. I feel it an honour that I have been asked to undertake this. Gordon had arranged with George Purce that two passages would be read at his funeral. Both are short and I wish to read them to you in full for two reasons. First, most of you were not able to be at the funeral and secondly, if I am not as solemn as one might expect in a memorial lecture, you will understand why.

The first reading was from the writings of Henry Scott Holland, a canon of St. Paul's Cathedral in the early part of this century. It went as follows:

Death is nothing at all. I have only slipped away into the next room. I am I and you are you. What ever we were to each other, that we are still. Call me by my old familiar name. Speak to me in the easy way which you always used. Put no difference into you tone. Wear no forced air of solemnity or sorrow. Laugh as we always laughed at the little jokes we enjoyed together. Play, smile, think of me. Let my name be ever the household word that it always was. Let it be spoken without affect, without the ghost of a shadow on it. Life means all that it ever meant. It is the same that it ever was. There is absolutely unbroken continuity. What is this death but a negligible accident? Why should I be out of mind because I am out of sight? All is well.

The second reading came from the mouth of Mr. Valiant for truth in John Bunyan's Pilgrim's Progress. Then said he, 'I am going to my Father's; and though with great difficulty I am got hither, yet now I do not repent me of all the trouble I have been at to arrive where I am. My sword I give to him that shall succeed me in my pilgrimage, and my courage and skill to him that can get it. My marks and scars I carry with me, to be a witness for me that I have fought His battles who now will be my reward.' So he passed over, and all the trumpets sounded for him on the other side.

My own contacts with Gordon in his early years were minimal. He was a final year medical student when I was in first year, and our paths didn't cross during this time. However I did have occasion to meet him in August 1956 when he was a registrar and I was a student. I was a resident pupil in wards 11 and 12 and had developed an ear infection.The houseman, George Johnston, felt inadequate for the task and advised me to cross the corridor to the old Eye and ENT ward, where I met a kind young registrar, Gordon Smyth, who examined me and advised treatment. I can still clearly remember how impressed I was at the time with his attitude. He gave me the impression that it was no trouble at all to see me and this, of course, was the shape of things to come. I can recall meeting him only once more while I was still a student, and then we didn't meet again until I began in the ENT Department in 1963. Consequently I have had to go to others to find out about his early life.

He was the son of a highly respected consultant physician in this hospital. He began school at Brackenber House and then went to the College of St. Columba in Dublin. I have talked to quite a few who were at school with him and two or three characteristics repeatedly emerge, which of course, have long been apparent to those of us who have worked with him. He was always an enthusiast. If he undertook anything he always did it well. He enjoyed games, was good at them and gave them all he'd got. This was especially true of rugby where he gave so much that he ended up in hospital one Saturday night. At the end of that season he decided that otology was more important to him than rugby and, having played regularly in the Senior League, he suddenly stopped and didn't play again. His rugby career had been a successful one with selection for Leinster Schools while at St. Columba's College, a University Blue in the heyday of Queen's rugby, and then a regular place in the very successful North team. His love of the sport continued until his death, with avid support for the Irish team.

He also was a golfer of no mean repute. In his first year as a consultant he continued to play and I can recall the summer of 1965 when he dashed down to Newcastle late every Wednesday afternoon to compete in a tounament, the Coronation Cup, which he won. However getting there on time was a problem and he felt that the rush was incompatible with his ideal of surgery and the surgeon, and he dropped golf with the same enthusiasm with which he had played it, and took to gardening. Many here will have seen the end result of that enthusiasm in the beautiful gardens at Trench house which remained a source of pleasure to him until his death.

Another early characteristic that has been repeatedly raised was his care for people. This also has been apparent to his coleagues throughout the years. His efficiency and his boundless energy, I suppose, made it easy for us to take these for granted, but he went to endless pains to ensure that his patients were well cared for. It was his practice to do an evening ward round every day. In later years this didn't happen at the weekends but for at least 20 years it included Saturdays and Sundays. He usually was going round as the patients were eating their evening meal and he took an interest in what was being served. If he was unhappy about anything, he was prepared to visit the kitchen and offer what could be called constructive advice.

He qualified from Queen's Medical School in 1953 and after his pre-registration year went straight into his chosen specialty, beginning his career in ear, nose and throat surgery in 1954. At that time, I am told, the general image of the ENT surgeon was of someone who spent his day in pools of pus. Now maybe that wasn't too far wrong for many, as there was a lot of infection in the area. However, antibiotics had arrived and I gather that there were those who were predicting the death of the specialty and who were suggesting that soon there wouldn't be enough infection to keep ENT surgeons in business.

I didn't ever discuss with Gordon his views on the specialty at that time so I don't know how he felt about this. However the same antibiotics that some were suggesting would put him out of work were a contributary factor, along with modern anaesthesia and the operating microscope, in facilitating the renaissance of ear surgery and the opening up of new surgical territories. In any event one must presume that Gordon did not think he was entering a dying specialty and certainly if he did, he made a big contribution towards revitalising it.

In preparing this lecture two potential difficulties have been in the back of my mind. First, with such a person as Gordon I am in grave danger of omitting reference to something or worse still, someone. Secondly I have had to keep in mind the fact that those present would be both medical and lay, and I have tried to steer an appropriate course between simplicity and complexity. However, at this stage let me beg your indulgence where I have failed.

I want to go back to the world of otology at the outset of the second world war. Without antibiotics most of the work of the ENT surgeon was indeed designed to minimise the problems of infections in the ears, nose and throat. In many cases this was life saving because of the dangers of meningitis and brain abscess. And as a result the ear surgeon tended to spend very little time thinking about the hearing. His goal was to control the infection, or at least to minimise its effects.

In addition to these potentially lethal ear infections there was another condition in the ear, not the result of infection, that caused a lot of suffering from severe deafness and that the more visionary of my predecessors dreamed of curing. That was otosclerosis. This is a genetically determined condition that is quite common and that first presents itself in young adults. In those days if both ears were affected it caused considerable suffering, especially as hearing aids were still poorly developed. Pre-war, I am told, it was not uncommon for a good hearing aid to be as big as the small television sets we now see. When I was a student hearing aids tended to be worn in a harness around the body which, along with the large batteries that were needed to work the valves, made the wearer look more as if he were going on a picnic than wearing an aid to hearing.

It was in that climate that Julius Lempert in New York described his one stage fenestration operation for otosclerosis, just before the outbreak of war. The hearing improvement was modest and often had a limited duration. The price of the procedure was high in that many patients were troubled by dizziness after the operation and even more had a problem with infected mastoid cavities. But this was a giant leap forward. Apart from simple aspiration, removing fluid from the middle ear, this was the first time in the long history of ear surgery that an operation had been described that consistently improved hearing. The war delayed widespread application of this solution, especially in Europe, and it was over 10 years later before the fenestration operation was first performed in Ireland. However ear surgeons had now discovered that there could be more to life than treating infections and a new era had started for Otologists and Gordon, therefore, started his ENT career more or less at the beginning of this otological renaissance.

His initial impact on Otology was in the management of cholesteatoma. This is a condition where skin grows into the depths of the middle ear and mastoid, becomes infected and untreated can lead to dreadful complications. Until then surgery was unsatisfactory. It usually consisted simply of opening up the mastoid cavity, with the cholesteatoma, into an ear canal widened by surgery to ensure that good drainage occurred. Thereby the risks of intracranial infections were reduced. Those were the days of long periods in hospital following surgery and it was not uncommon for a patient to go into hospital with a malodorous, discharging, deaf ear, have an operation, spend two to three weeks in hospital recuperating and eventually end up with a malodorous, discharging, deaf ear. The surgeon knew that the risks of complications were greatly reduced but the patients didn't notice any difference.

These surgically created cavities had to be cared for at outpatient clinics and tended to end up with the most junior doctors. Consequently the new recruit to the specialty had to spend many hours cleaning out mastoid cavities in the huge clinics that were held most mornings, and without an appointments system. And this new recruit to the specialty, Gordon Smyth, was dismayed and disturbed by the problems these patients experienced either following the fenestration operation or more commonly following surgery for cholesteatoma. But Gordon didn't just clean out the cavities. He thought about them, and it was in this aspect of otology that he first made an impact. Those here today who have had unsuccessful mastoid surgery will have no difficulty in understanding that control of cavity problems is a suffi­cient motivator of a man's life.

His MD thesis was on a study of fungal infections of mastoid cavities. In this publication (1), 30 years ago and based on his MD thesis, he referred to the 40% incidence of constant or intermittent infection in mastoid cavities and made three interesting points which are certainly very topical. He stressed the time off work for surgery and post-operative care, without any significant change in how the ear feels to the patient. He then went on to draw attention to the expense involved for the health service in materials and especially in nursing and medical time caring for these cavities. Finally he referred to the aggravation of bed shortage problems by the time spent in hospital both for surgery and for further admissions for the intensive local treatment that was often required.

He felt that something had to be done about the standard treatment of cholesteatoma. And, while still a senior registrar he did indeed do something about it. (2)

In this paper, published in 1962, he started out on his long and successful journey to help these patients. He emphasised, however, that this was essentially a preliminary report and that only further experience would confirm the value of the procedure. He described his prototype of the combined approach tympanoplasty whereby he more or less preserved the normal anatomy of the ear and mastoid, and used the new thoughts, at that time, on ear drum repair, to create an almost normal ear. The early results were most encouraging. First, the postoperative discomfort was much less than with the open cavity procedures. Secondly, the ear healed up more quickly because the drum was grafted and there was no longer a wide open space to re-epithelialise. Thirdly, the previously frequent visits to hospital were reduced.

I am going to digress here from the story of cholesteatoma to note that it was at this point that he went to the United States to work in Memphis, Tennessee with John Shea who had only recently described a new and revolutionary operation for otosclerosis that was going to fuel the fires of change in otology. That year had an enormous effect on Gordon in many ways and, although it wasn't why he went, it lead to further developments in his thinking on cholesteatoma surgery.

In Memphis he met David Austin, another young man, also verging on the angry, who unknown to Gordon, had also been thinking along the same lines. The two made a formidable combination and established a friendship that remained until Gordon's death. But they were more than friends. They brought out in each other ideas that were lurking in the recesses of their minds. They often disagreed on what needed to be done but they did so amicably and together were most productive.

Gordon returned from Memphis at the beginning of 1963 full of ideas and ambitions but, sadly, ill. In the heat of Memphis he had picked up an infection that belied all attempts to identify it and therefore treat it. As a result he was forced to be off work for many months, during which time he felt terrible and had intermittently very high temperatures. This was before I came to the ENT Department in Belfast and I was not in contact with him at that time, but I am told he was rather like a caged lion. However his impatience with his own illnesses, which we were to see again quite a few times, got too much for him and the lion sprang out of his cage in July 1963, still far from well. I returned to Belfast in that July, as a very junior SHO, just at the time that Gordon returned to work and I found his enthusiasm infectious. In practical terms it was as if he had just returned from the States, and I can still recall listening to Kennedy Hunter and Bob McCrea asking him numerous questions about American thinking on so many things. I must admit that I didn't understand half of what was being said but I enjoyed hearing it and I got the excitement of the era. Perhaps if I had understood more it would have been unfortunate because what I thought I was hearing was that ear problems were on the run and that soon we would be able to treat almost all ear conditions surgically and successfully. Anyway it was what I wanted to hear.

Gordon continued to be less than well through the autumn of 1963 but his enthusiasm was hard to extinguish. He began by organising classes for the trainees every Monday evening in the old Ophthalmic Hospital. This was the start of his dominating influence on standards, not only in his own unit but in most ENT Departments in Northern Ireland. Again, despite his illness, he was to be found every Saturday morning in the old Top Theatre in the City Hospital, doing another of his new combined approach tympanoplasty operations.

In the autumn of 1964 the Eye and Ear Clinic was opened and Frank MacLaughlin retired. Gordon was appointed to a consultant post in the Royal Victoria Hospital and there now flowed from his pen a series of articles on all aspects of cholesteatoma and middle ear reconstructive surgery. He gathered up almost all of his junior colleagues in his zeal and here is a small sample from these publications.

Sometimes he published alone (3), but more often in association with others. This was in 1963 and was his only publication with David Austin (4). Thiswas in 1964 with Tony Miller (5), in 1965 with Ian Black (6),in 1966 with Roy Gibson and Rodney England (7),in 1967 with Roy, Rodney and me (8). If we jump to 1973 we see him publish with John Byrne (9), Terry Stewart (10), and Mike Cinnamond (11).

The observant will have spotted that this includes every ENT surgeon in the Eastern Board Area over the age of 50.

During this early period there was a constant stream of visitors to Belfast to see him operate. In fact it became almost obligatory in the British Isles, if one wanted to claim to be any sort of otologist, to be able to say that one had been to Belfast to see Smyth. He had the American attitude to his visitors. He was able to differentiate between those who had come to be able to say that they had been, and those who had come to learn.. It didn't matter how junior a visitor was, if he knew the current literature he was welcome. If he didn't, well that was another thing.

He was generous to his visitors and with the help and encouragement of Jessie most of them were entertained in his home. He was generous also to his juniors and he shared his visitors, as it were, with us, both in the hospital and in his home. And most of the great names of Otology came to Belfast at some time during that era.

Gordon was well aware that many good ideas died simply because of poor propagation and he was keen that his ideas got a proper airing. Consequently he sought the help and instruction of a friend who was also a professional communicator. This proved to be very valuable and he developed into an outstanding speaker.

In the late 60s and early 70s a group of enthusiatic combined approach tympanoplasty surgeons started what could be considered to be missions to the unconverted. They ran a series of very successful courses on this new operation both in the United States and Europe, including one particularly famous one here in Northern Ireland. This week long course in Belfast occurred in July 1971, during a time of intense violence and finished just 2 weeks before internment was introduced. I still meet people from all over the world who remind me that they met me in Belfast at that course in 1971. They talk about the bombs but then they quickly change to the course. Most of them had never before experienced anything like either the bombs or the course, but they probably were more impressed by the course. They were enthralled by what Gordon and his group presented to them and by the organisation of it all.

The course included temporal bone dissections and therefore there had to be a limit to the numbers. Initially this was to have been 40 participants but the pressures to get a place were such that Gordon agreed to another 40, non dissecting, participants. Even then he still had to turn people away.

I had always been impressed by Gordon's organising ability but this course was exceptional. He organised temporal bone dissection facilities for 40 people in the Dental School...every one with temporal bones, a drill, a sucker, ear instruments and a microscope. He organised accommodation for them and their wives and for the other 40 non dissecting participants. He organised a social programme during the day for their wives and a social programme in the evenings for everyone. These included functions in the City Hall and Parliament Buildings at Stormont. Closed circuit television links were just coming in in those days but he went one further. He had a television camera fitted to the operating microscope in the Eye and Ear Clinic Theatres, linked to the Irwin Lecture Theatre. This equipment cost in the region of £20,000 and he managed to get it on loan. I remember, at the time, thinking that arranging the television link was, in itself, a greater achievement than most could have managed but to have done it in conjunction with everything else was incredible.

I have dwelt on this course because it illustrates so much of this remarkable man. It also probably did more for Northern Ireland than many of the efforts of the tourist board. He packed in so much during that week that I still feel exhausted just talking about it.

The course had been deliberately timed to precede the four yearly British Academic Conference in Otolaryngology, held on that occasion in Edinburgh. Gordon, still a consultant for under 7 years, was one of the main speakers on a plenary session on otosclerosis and despite all the activity of the previous week gave a superb presentation. Sadly, one week after we got back from Edinburgh, internment was introduced and Northern Ireland fell into turmoil. The dreadful events of the next few weeks were shown on television all over the world and those otologists who had been to Belfast expressed thanks to Gordon for a superb course, gave thanks to God for their lives and promised their families that they wouldn't again do anything so foolish as to go to Northern Ireland. Although there were no further courses in Belfast, Gordon was to play a big part in many courses elsewhere, including regular participation in the famous Nijmegen course in the Netherlands and the Combined British Universities Course in Birmingham.

1971 was probably a watershed in Gordon's career. He had certainly reached the top in terms of British Otology and was established as one of the world speakers at otologic meetings. Those of us given to pride were pleased to be associated with him and to bask in the reflected glory of working in Belfast.

Kennedy Hunter was due to retire in 1972 and in 1971 he agreed to Gordon taking over from him the University responsibility for student teaching. I think that at this point, I ought to refer to something to which Gordon himself often referred, and that is the co-operation of his consultant colleagues. Kennedy Hunter, David Craig, Bob McCrea and Harold Shepperd recognised the potential that was in their midst and not only encouraged Gordon, but also created opportunities for him, and this early vacating of a post is just one example. Gordon undertook the student programme with his usual enthusiasm and set about to reorganise it.

Around that time the idea of tape slide presentations was fairly novel and Gordon, who did nothing by halves, set about making a series of tape slide presentations covering most of Otolaryngology. He enlisted help from one or two others but he did the greater part of the course himself. In the process he so forced his throat that he developed laryngeal granulations and ended up having to rest his voice more or less totally for some weeks. As always, of course, he bounced back and ended up none the worse for his experience, and we all benefitted from the tape slide sets which were used regularly for the next 7 or 8 years. With his customary efficiency, while all the information was already marshalled in his mind, he also set about writing a new student textbook (12) with the problem solving approach, again relatively new at the time. And here it is. Now, if your work is really successful someone translates it. And here is the Spanish edition! (13)

This also was his time of peak activity in training junior staff. There are three aspects to this. Gordon took seriously the training of juniors who took their own training seriously. He would enquire about their reading, research and temporal bone dissections As I have already shown papers flowed from his pen and the juniors were always encouraged to be involved. Not surprisingly those juniors who were not keen found that they didn't get a lot of his time.

The second aspect was the use of his influence and reputation to get overseas fellowships for the senior registrars from Belfast. His achievements here were quite remarkable. Of those working in Belfast at the present time he arranged for Roy Gibson to go to St. Louis in 1965, for me to go to Boston in 1967, John Byrne to go to Detroit in 1971, Terry Stewart to go to Boston in 1972 and for Michael Cinnamond to go to Toronto in 1975. His standing also helped facilitate David Adams' time in Manchester, Peter Walby's in Boston and Bill Primrose's also in Boston, all in the eighties. I have listed 8 out of the 10 consultants currently working in Belfast. What a legacy!

The third special aspect of training was the series of trainees who came to Belfast from abroad to work with him, each one bringing some unique quality and introducing us in Belfast to something new. By and large they made an enormous contribution to our department, and the lives of all of us have been enriched by these visiting trainees who came to spend time in Belfast to work with Gordon Smyth. I am very pleased that two have returned fir this lecture.

There was another group of overseas visitors, those who came to Belfast to spend just a few days here. Unfortunately, this group declined because of the troubles which were so visible in the seventies. Some of these visitors had a higher profile than others. There was one in particular, now an eminent Italian professor of otology who insisted in coming at an especially violent time. He stayed in the University Staff Common Room and Gordon instructed him that he was to travel by taxi each morning and evening between College Gardens and the Royal, and that he was not to stray from that routine. One day this young man decided to see the troubles at first hand and set off into the hinterland of the Royal with a camera. Italian clothes and a camera looked strangely out of place in the Leeson Street of those days and he was picked up by the army. Their suspicions were raised even more when he tried to explain that he was an ear surgeon who had come to learn from Gordon Smyth. Gordon was famous but the rank and file of the British Army still had to hear of him. They were about to take him for questioning when a woman came running from around the corner shouting 'Come quickly, my husband has just had a heart attack'. He was bundled into the land rover and told to prove that he was a doctor. He must have done alright because they let him go after that. His next big mistake was to tell Gordon about the incident!

Gordon had a phenomenal throughput in his operating lists and in any week was doing more chronic middle ear surgery than most British surgeons were doing in a month and he saw these patients personally and completed a record card for every case. This was his greatest strength. His record keeping was unique in the world and we see here so clearly his characteristic of doing nothing by halves. He left nothing to chance. Not only did he have one of the largest series in the world, with extremely accurate records, but his percentage follow up was also exceptionally high, very much higher than in any other comparable series. Apart from his dedication and boundless energy he had another advantage over otologists from all around the world. Most of his patients came from Northern Ireland and it was therefore possible for him to see all of them himself. Perhaps I should digress here to point out that, in the period before 1969 quite a few patients came from far afield for surgery in Belfast but the troubles ended that. However this was probably not a bad thing for his world famous tympanoplasty series, as, without these overseas patients, he was able to continue to ensure a personal follow up.

Patients who failed to come for review were pursued relentlessly. His series wasn't going to be incomplete simply because of the inertia of the wayward patient. If writing to the patient didn't get him back, he wrote to the GP. If that didn't work he got the health visitor to call. If that didn't work or if the patient simply wasn't well enough to come, and if he was a crucial part of a series, Gordon either went personally or sent the registrar involved in that particular study. As a result his follow up percentages were well above those anywhere else and in addition they were generally based on his own observations. It is difficult, if not impossible, to convey the enormous contribution that this made to world otology..

He soon established a reputation for honest and accurate statistics, presented without fear of the consequences.

In the mid seventies, as a result of his own meticulous records, he began to have doubts about the universal application of his combined approach tympanoplasty operation for cholesteatoma. He came to the conclusion that he had been over enthusiastic about the procedure and that the long term results were not going to be as good as he had expected.

In 1975, at the British Academic Conference, in the Queen Elizabeth Hall on London's South Bank, he openly displayed his doubts. I can remember the courage that this presentation required and the impact it made. In some ways he was saying that many of the critics of the new operation had been right all along. Gordon acknowledged that he had been over enthusiastic and, based on his own meticulous records, he concluded that combined approach tympanoplasty needed to be re-appraised. It would be true to say that on that day he became a senior statesman in otology at the age of 46.

He did indeed think again, and again about his results. He used the technical skills that he had acquired in the combined approach procedures, especially in relation to drum grafting and ossicular reconstruction and applied them to different open cavity procedures. He finally settled on an approach to cholesteatoma that was published in one of his last papers. (14) He checked the proofs of this paper during his terminal illness and it has now been published. That he had indeed developed a satisfactory procedure for cholesteatoma is shown in the fact that the incidence of moist ears had fallen to less than 5%, which is quite remarkable compared with the 40% referred to in his publication in 1962.

I have dwelt on cholesteatoma at some length because this was the field where he first became famous. But, as I have indicated, his interests were not confined to this. There was no aspect of otology that did not interest him and where he did not make some type of mark.

The surgical treatment of otosclerosis is one of the great dramas of surgery. Those who for years had been captive to deafness were released by a surgical procedure that was developed over a relatively short period of time. Gordon, again, was in on the ground floor as he had worked for one year as a fellow with John Shea in Memphis, Tennessee. Shea was the first into print of three American surgeons who around the same time found similar solutions for dealing with the problem of otosclerosis.

Gordon continued to be interested in stapes surgery for Otosclerosis. Long term complications began to appear, and he looked for ways of avoiding them. I shall be concluding with a look at his Toynbee lecture which was essentially his last will and testament to otology, but one of the earliest signs of that lecture first appeared in relation to surgery for otosclerosis. Now let me say that the operation for this, the stapedectomy, or more recently the stapedotomy, is a difficult procedure but one that is pleasant to do especially when it goes well. The overall results tend to be good, at least in the short term, so that one is usually dealing with contented patients. But there are problems from time to time. In 1982 (15) he published a paper with the controversial suggestion that one way of reducing these problems was to do fewer operations. He advocated that the surgeon should always press the patient to try a hearing aid before there was any talk of an operation. He then went on to oppose ever operating on the second ear. The maximum benefit came from the first ear and therefore to leave the second ear untouched reduced the risks to the patient. These ideas were opposed in many quarters but Gordon stuck to his guns and eventually was largely influential in convincing most British Surgeons of the merits of his case. Nowadays, in most British units, only one ear is operated upon although with the application of strict criteria the second ear may be considered.

He also looked at the complications of this type of surgery and what could be done to minimise them. He advocated (16) along with some other otologists, a major modification of the stapes procedure, the so-called the small fenestrum operation, where the footplate of the stapes was only perforated instead of being totally or even partially removed and where the prosthesis was reduced in diameter. He was able to use his meticulous follow up figures to prove his case, and he used his influence to help establish this as the main surgical procedure of today in this condition.

I could go on and report his influence in so many areas in otology but time precludes this. However his publications number almost 200 and include original work on glue ear, inner ear fluids, medical treatment of inner ear disorders and, reflecting his productive co-operation with the Department of Neurological Surgery, acoustic neurinoma, surgery for vertigo and the facial nerve.

It would be impossible in this lecture to tell the full story of Gordon Smyth. His influence penetrated every ENT department in Northern Ireland and probably most in the United Kingdom.

Higher degrees have tended to be unusual among otolaryngologists; he not only gained an MD but also an MCh and a DSc. Honours and distinctions were heaped upon him. It would be verging on the monotonous to list these. He was invited to give innumerable eponymous lectures. There were few if any major otology meetings where he was not listed as a speaker. He was elected president of an international group of ear surgeons, the Politzer Society. He won prizes and was honoured by many societies. Probably the main ones were his honorary memberships of the American Otological Society and the Section of Otology of the Royal Society of Medicine.

Five years ago, he had a heart attack and a few months later lost Jessie, his first wife and strong supporter. And yet, despite these setbacks, he continued to be very active. He reduced his surgical workload a little, but still was operating on more ears than most otolaryngologists. He continued to write papers and speak at meetings. He married Penny and again had strong support at home. It was as if he had shrugged off his heart problems.

And then, in the early part of this year he became unwell. It was not until March that the true nature of his condition was known but even then, with the loving help of Penny and his family, he continued to serve otology. I have never seen anyone quite so productive during a terminal illness. He tied up so many loose ends that it would be impossible to recount all of them.. He wrote scores of letters to friends. He wrote to many of his patients. He passed on a list of patients with unsolved problems with his thoughts on how they ought to be dealt with. He completed a chapter on otosclerosis for Scott Brown's otolaryngology and another chapter for an American textbook. He finished some papers for publication and dealt with the proofs of one or two others. And he wrote his Toynbee lecture.(17) The list goes on and on.

I want to finish by saying something about the Toynbee lecture. Joseph Toynbee was the founder of British Otology and was a contemporary of James Yearsley, the first true otolaryngologist and Sir William Wilde, father of Oscar. This lectureship is bestowed by the Royal College of Surgeons of England, is the most prestigious otologic honour in this country and is usually given by a British otologist every 4 years. Gordon had been invited 2 years ago to give it this year at the beginning of May in London. At the time when he became ill he already knew what he wanted to say and indeed, had the slides prepared but had nothing on paper. Unfortunately he was not well enough to deliver the lecture on the prescribed date but he wrote it for publication and arrangements were made for it to be delivered on his behalf after his death. This lecture was essentially the distillation of his life's work and thought. In it he ennumerated five statements that are commonly made to patients by ENT surgeons. He then analysed the facts and asked his audience to think more closely about what they are saying and doing.

I plan to end by repeating the five statements that he made in that lecture and inviting all otolaryngologists to think on their own attitude to those statements. I invite all other surgeons to ask similar questions on their own disciplines.

This is the first statement that he asked us to think about. 'Your child needs its adenoids out to cure its ears'. There certainly is evidence that removing the adenoids is the most effective treatment of glue ears but, despite this, he condemned the tendency to remove adenoids routinely in these children. He reasoned that the simpler procedure of myringotomy and ventilator which, although it had only 70% success, was preferable to the bigger procedure of adenoidectomy with its 90% success because it avoided the risks of the bigger procedure in most cases and also avoided hospitalisation. To do adenoidectomy only on the 30% failures from myringotomy would ease the burdens on the child, the parents and the health service..

Secondly, 'Having your eardrum repaired is simple and the results are good.' Here he first questioned the simplicity of the procedure. Sometimes it is but often it is not and it should not be misrepresented to patients. Secondly he looked at the results and here his own detailed records come into play. He pointed out the value of survival life table analysis. Most surgeons look at their results at one year and rarely go much beyond this. He reported drum repair procedures up to 15 years after surgery and confirmed that, in time, the initially good results deteriorate. This is important in any decision to operate.

Thirdly, 'Infection has destroyed one of your ear bones. We can repair the damage (with a wonderful new prosthesis)'. For most of Gordon's otological career there was, as it were, the possibility of the alchemy that would turn all badly damaged ears into normally functioning and hearing ears. He also believed for a time, and possibly more than most, that there was indeed, 'a famous stone that turneth all to gold', a perfect reconstructive material and he sought diligently for it. But by the end of his career he concluded that this was only a dream that was unlikely ever to come true and that we ought to recognise this and act accordingly. He knew because he knew his own results, and once again, even good early results were not always maintained.

Under this statement he also referred to original work he had done on patient satisfaction with surgical results.(18) All of us had been aware of some patients who had got only small improvements in their hearing but were delighted with the result, and of others whose hearing gain had been much more marked but whose pleasure in what we had achieved was minimal if anything. And in the Toynbee Lecture he made a plea for more intelligent decision making in surgical indications. A good surgical result in the hearing is of little value if the patient isn't aware of it, and of course, as he points out, the secret lies in the end result of the combined hearing in both ears. He produced a rule of thumb to help avoid unnecessary surgery. I'll not even try to explain but the rule of thumb is there for all who care to use it.

Fourthly, 'A closed operation will give you a trouble-free ear and better hearing (some further operations may be necessary)'. We are here moving just a little into the doctrinal and philosophical realms of otology. Gordon was one of those who first described the closed operations for choleateatoma and, as I have already said, because of his meticulous follow up, he knew his own results and is saying 'Beware. Watch your indications for this type of surgery.

Finally, 'More than 90% of stapes operations are successful'. Stapes surgery was the procedure that established the otological renaissance. But the long term results are not as good as many surgeons tend to think and certainly not as good as many surgeons lead their patients to believe. Stapes surgery is marvellous but it is not giving 90% success and we ought to be just be a little less optimistic when talking to patients. Remember that modern hearing aids are excellent and may be the more realistic alternative to surgery.

You will recall that my first real contact with Gordon was in 1963, when he had effectively just returned from his time with John Shea, and when I thought that he believed that ear surgery was going to cure everything. Maybe I misunderstood what he believed but then again, maybe I didn't. In any event, at the end of a most productive life, where he explored scientifically and academically, almost every aspect of ear surgery, he leaves all of us, surgeons and physicians alike, with a clear message. The intelligent and thinking doctor will know what can be achieved and will know his own long term outcomes. In the light of his own results he will offer only effective treatment and will thereby avoid all that is of dubious value.

Let me conclude by saying that I am all too aware of the inadequacy of this appreciation of my teacher and friend, to whom I and so many others are so much indebted. However we are all here today to remember him, and to extend our sympathy to Penny and to all the family, and I would ask you now to stand in a short period of silent remembrance.

Alan G Kerr
Milestones of Politzer Society