Written by Vere Carlin
I met Stephen Richards late on in 1978. Having been living in the afterglow of actually qualifying and becoming a doctor, like most of my friends, I had paid scant attention to “what happens next”. Career advice was almost non-existent at that time, and you were left to fend for yourself, in the mistaken belief that we were all intelligent people and could make these choices unaided. As a result I had pressed the default button and opted for the GP training scheme along with my wife, who had rationally made a conscious choice to be a GP some time before. I, on the other hand, had thought I was most suited to a more practical specialty, however climbing the greasy pole in general surgery, even if I had been fortunate enough to land a decent training job, was singularly unappealing. Only a few GP education sessions later, after I had had time to absorb what general practice was about, did it dawn on me that it was the wrong choice. I simply didn’t have the patience required to be a good GP.
Fortunately, my wife and I had been allocated the same house job rotations. The surgical six months was three months of renal surgery and three months of ENT. For better or worse my wife preceded me on the rotation and I followed her into the ENT three months.
I started on Mr Richard’s firm with some prior knowledge of what to expect but no real idea about ENT surgery. I had been told that Mr Richards was somewhat demanding and a little eccentric. However, under the expert guidance of Marcus Brown, who was Stephen Richards’s senior registrar I managed to avoid the usual Mr Richards pitfalls that befell most junior house officers. The more I saw of the surgery the more I enjoyed it, I was even given some simple surgery to do by both Marcus Brown and Stephen Richards. With some considerable patience they guided me through tonsillectomy and a number of other things. However, one of my duties was on the hypophysectomy list and it was my job to “harvest” the fascia lata and muscle from the leg. This was used to fill the sphenoid after pituitary
surgery and prevent cerebrospinal fluid leaks. I also attended the joint pituitary clinic with the formidable endocrine physician Dr Picton Thomas who would have a wry smile and a joke at the “brutal surgeons” as these poor patients were still hobbling around many weeks after their surgery because of the harvesting of muscle and fascia, but not bothered in any way by the long healed pituitary access incision on the side of the nose.
Stephen Richards, I discovered, was an otologist and a pituitary surgeon. I have never forgotten watching him carry out a stapedectomy in twenty minutes with only local anaesthetic. This had huge impact on me later in my career, when I had reached the dizzy ontological heights of carrying out stapedectomy myself. He was a delight to watch and 30 years on, at the end of my career, still remains the most gifted ear surgeon I had had the pleasure to observe and learn from.
Towards the end of my three months ENT in January 1978, I was summoned into Mr Richard’s office by his secretary over a lunchtime, she did not warn me that I would find him lying down on a mattress in the corner, as was his usual practise at lunchtime for a “little nap”. So I knocked on the door and a muffled come in was heard, so I entered and was immediately taken aback by the fact that he was not to be seen, until I had had the time to look around and observed him covered in a blanket in the corner. We had this slightly bizarre conversation, with me towering over him, not quite knowing where to look. There was no doubt about the conversation though, he told me that for some time he had been trying to persuade the hospital to fund an ENT training rotation which consisted of one year as senior house officer and two years as registrar . They had, out of the blue, agreed and interviews were to be held in a few month time. Furthermore, he expected that I should and would apply. Not wishing to prolong the conversation, I simply said yes sir and my audience was over. I did apply though, and was appointed, my escape from being a forever disgruntled GP assured and the beginning of a new and immensely enjoyable career as an ENT surgeon began. In retrospect I must have managed to impress him, though goodness knows how.
I spent quite an amount of time with Stephen Richards as I was also senior registrar with him, and this is when I learnt about pituitary surgery.
The era of hypophysectomy for breast cancer treatment was over by the time I came to work for him, CT scans had just been introduced and MR scans had not yet become available. The surgery was for functioning and non-functioning adenomas. The technique used was trans-ethmoidal, trans-sphenoidal approach through the side of the nose. This was the technique originally described by Chiari in 1912 but had been heavily modified by the use of the operating microscope. It had fewer nasal complications than the neurosurgery favoured trans-septal route pioneered by Harvey Cushing in the mid 30’s . There was this odd division in access between ENT and Neurosurgery, and of course multi-disciplinary procedures were unheard of in these days, though latterly they were, and are the norm. The opening and subsequent removal of the ethmoidal air cells gave a surprisingly large access, enough to use a long lens on the microscope and two instruments, a third hand was often employed with a suction device up the nose. The advantages of the microscope were that you had a magnified view from either right side or left side. If the patient had a right sided tumour or a lateral extension, the approach would be from the left side and vice versa. The disadvantages were that it was impossible to see upwards very far, so that tumours with a supra sella extension were much more difficult to clear completely and more dangerous to tackle. Stephen Richards’s results, which he gave in the Semon lecture in 1989, were some of the best in the world at the time and he also had at that time the largest series of pituitary operations carried out this way (over 400).
I progressed under his tuition to performing the procedures myself in my later years as senior registrar, and when I came to apply for consultant jobs my first application was to a hospital which had a Neurosurgical department and a professorial endocrine unit. I was appointed in 1986 and until 1994 I carried out hypophysectomies in the same way I had been taught by Stephen Richards, with greater success than the Neurosurgeons who were also undertaking the procedure! My hypophysectomy workload grew. In 1994 My friend and colleague Elgan Davies who worked close by, rang me and said he wanted to show me a video of a sphenoid tumour he had removed (and had made a video of the procedure). He had managed to remove a large benign tumour from the sphenoid, entirely via the nose with an endoscope. The point of watching the video though was clear, the endoscope gave an amazing, clear, close up view of the pituitary bulge into the sphenoid, and the implication was that it would be possible to remove a pituitary tumour via an entirely endoscopic, trans-nasal procedure, with a superior view from the microscope technique.
A few days later we did just that! I performed probably one of the first completely endoscopic trans-nasal hypophysectomies. Since then, in my series of 600 endoscopic pituitaries, I have never had to resort to the microscope. The whole field of endoscopic anterior skull base surgery had begun. The point of this though is to remember the pioneering expertise of people like Stephen Richards and the way in which he passed on his expertise to the next generation.
I am forever grateful to Stephen Richards, both for my career as an ENT surgeon but also as a pituitary surgeon. I was not alone in this of course, many other senior registrars passed through his firm over the ten to fifteen year period and they all ended up as prominent surgeons within the speciality. A lasting legacy!