Holland was the first country to be visited by the Society, in 1925 when the 13 members went to Utrecht, The Hague and Amsterdam. In Utrecht, Professor Lameris was a formidable figure held in awe by his compatriots. He did not wear gloves to operate on clean cases, and took almost obsessive care of his hands, refusing to touch door handles. Dr Schoemacher was seen at work in his private clinic in The Hague. Of international repute, he invented a number of instruments, and his name is still associated with a clamp for the then new operation of gastrectomy. In Amsterdam’s ancient Binnengasthuis hospital, members met Professor Noordenbos, a courteous hospitable man who survived subsequent internment in a concentration camp. In 1935 the visit was to Groningen where a number of cases of intussusception were seen, the result of ascaris infestation. In Amsterdam Professor Noordenbos was again host. In Leiden Professor Suermondt gave a clinical talk in his new lecture theatre which had an epidiascope and also “a contrivance for darkening all windows at a moment’s notice”.
The next visit, in 1952 to Amsterdam, was arranged by Dr Kits van Waveren, a friend of the St Thomas’ surgeon Philip Mitchiner, who was revered for his earthy Cockney comments. A full and varied programme was laid on by Professor Boerema (famous for his anastomotic button) who expressed disappointment that only eight members attended. They moved on to Leiden where Professor Suermondt was still in post, and he gave a paper on the conservative management of 90 cases of renal injury, only 3 of which came to nephrectomy. Dr Noordijk presented simple suture versus gastrectomy for perforated peptic ulcer, with respective mortalities of 3% and 5% though a third of the patients having simple suture came to further operation. Mitral valvotomy was demonstrated by Professor Brom. In 1970 the Society was impressed by the level of free State medical care when it again visited Amsterdam where Professor den Otter hosted the meeting at the Free University Hospital, and Drs Brummelkamp and Greep at St Luke’s Hospital. In Rotterdam the rebuilt and well-equipped Dykzigt Hospital was seen, complete with computers in the intensive care unit. In 1983 the Society returned to Amsterdam, where the new 850-bed Academic Medical Centre was said to be the biggest building in Holland, and conveniently close to Schiphol Airport and the motorway. The Sophia Hospital in Zwolle and the Red Cross Hospital in Beverwijk were also visited.
Our most recent visit, in April 2005, was the sixth to our near neighbour The Netherlands, which was the earliest venue of the Travelling Surgical Society which went there in 1925, a year after our organisation was founded.
Under the Presidency of Geoffrey Glazer and the guiding hand of our new secretary Bill Thomas, the TSS visited three major university hospitals (of the six in Holland): Amsterdam’s Academic Medical Centre, Utrecht’s University Medical Centre, and the Erasmus University Centre in Rotterdam. The oldest was the AMC, built in the early 1980s when it was said to be the largest building in Europe. It boasts an outstanding art collection (with its own on-site curator) recently given coverage by the Journal of the American Medical Association. Healthcare is covered by the Dutch State (9.8% of GNP) for those earning under €32,000: above this, health insurance is compulsory. There is no private healthcare system in this country of 16 million people.
MRSA is not a problem. Holland tackles it aggressively, isolating affected patients and closing wards, and is reaping the benefit of its foresighted policies, for which the UK Press praised the Erasmus Hospital after our return.
Our first visit, on Monday 4 April, was to Utrecht, which like Amsterdam had been the site of the very first visit of our travelling group in 1925. Here in the 1042-bedded UMC Dr Ivo Broeders demonstrated minimally invasive surgery teaching aids – LapSim computers (€30,000 for each instrument holder) taxed the most skilful surgeon! There was also a chance to work the Da Vinci Intuitive device, getting a feel of its light-fingered manipulative capability within its special booth, complete with foot pedals for adjusting the camera. There is no doubt that it permits the extremely precise movements of delicate surgery, but it needs refinement of the feedback from the robot instruments which can easily crush tissues without the operator sensing this: its designation as Intuitive has yet to be justified. We also had a chance to see the Calamiteiten Hospitaal (the Major Incident facility in the military hospital adjoining the UMC whose staff serviced it) which could accommodate 200 casualties
At Amsterdam’s AMC as the guests of Professor Dirk Gouma we were privileged to attend the morning AMC Report, hearing – and seeing on-screen – details of a busy night in which two residents and four senior surgeons had dealt with a number of emergency admissions which included a stabbing, a shooting, a tibial nailing and the stenting of an abdominal aortic aneurysm as well as an appendicectomy. These last three patients were randomised within clinical trials. The quality and extent of the data collection and computerised medical records were also impressive, information being called up and presented instantaneously. Computerisation also permitted detailed analysis of complications, which were recorded and assessed, including the ASA grade, severity of complication, and certain risk factors. The overall complication rate was around 20%, and 10% for those admitted with trauma. It was hoped this system would become national once confidentiality was resolved, as this was apparently a problem despite anonymisation (even photographing the hospital interior was forbidden by security staff). We heard papers on various topics, including refinement of the surveillance of Barrett’s oesophagus and the treatment of high grade dysplasia, the development of a shockroom trolley accelerating the passage of seriously injured patients through the accident department, gene-based treatment of cancer (particularly oesophageal), stenting aneurysms (including the intra-thoracic aorta), resection of pancreatic cancer for palliation, and the management of bile duct injuries. We had a strong impression of depth, competence and ingenuity in a unit which hummed with activity and treated more than 3000 surgical patients (770 day cases) a year, with nearly 30,000 inpatient-days of surgical care.
Our final visit was to the Erasmus Medical Centre in Rotterdam. The complex of modern buildings was largely due to be replaced over the next fifteen years. This University Hospital is fifty-first in the worldwide academic rankings, and claimed primacy in Holland. We had table-top discussions with Professor of Surgery Jan Jeekel (planning retirement shortly despite his youthful appearance, and recently canvassing recruitment from Indonesia to combat Holland’s shortage of doctors) and the Professor of Transplant and Vascular Surgery, Jan IJzermans. We changed into theatre kit to enter the suite of 31 operating theatres but sadly saw no operating although we admired their comprehensive facilities. During the afternoon we glimpsed the lavishly-equipped Basic Skills Laboratory – not in obvious use – and heard papers on a spectrum of problems, including ingenious solutions to the universal transplant dilemma of a lack of cadaveric donors. Endoscopic living donor nephrectomy (the kidney being passed out through a Pfannenstiel incision) and various liver harvesting techniques (for piggyback insertion on the inferior vena cava) were proving helpful. The results of surgery for incisional and umbilical hernia repair indicated that mesh was superior to simple suture, and the risk of a midline incisional hernia was higher if the gap between the recti muscles exceeded 12 mm, as noted on postoperative CT scans. The final presentation, on Sportsmen’s Hernia, tackled the contentious problem of groin pain and strain, with mesh repair producing promising results in some.
Our social programme gave us the opportunity to admire some of those features for which Holland is justly famous: the gardens and bulb fields at Keukenhof, the Kaag lakes, Amsterdam’s canal system, the Aalsmeer flower auction and the Delft pottery factory – and not forgetting its herring and its windmills! We had a taste of Holland’s artistic and historical legacies with informal visits to the Rijksmuseum and van Gogh Museum, and we visited the Anne Frank house on the Prinzengracht where she hid with her family and four others from the Nazis for two years – the more poignant as the sixtieth anniversary of the liberation of the concentration camps was remembered with appropriate ceremonies a week later. Nonetheless, our abiding memories were happy ones: of a friendly, liberal nation – which claims to be the world’s tallest and despite its unique language has a humour and temperament very close to our own – which embraced us with open arms and offers superlative surgical facilities in its major centres. In this they are to be greatly envied.
The Netherlands 2005:previous visits and a little history
The April 2005 visit to the Netherlands takes place in what seems high summer, yet this was only three weeks after the southeast of England had been buried in snow. Spring seemed to have been bypassed, the early Easter (on 27 March) being warm and sunkissed. Sadly the ailing Pope, crippled by Parkinsonism, appeared in the autumn of his years as he struggled to bless the faithful in St Peter’s Square (usually in sixty languages) at the Vatican. He was not able to deliver his traditional Easter message, which was read on his behalf. It was the first occasion in his 26 year reign that the 84 year-old Pope had failed to preside over any of the Easter and Holy week services.
This visit is the Society’s fifth foray to Holland, which had been the site of the very first visit of the TSS, in 1925, when the venues were Amsterdam, Utrecht and The Hague for the thirteen member surgeons. The hosts in each city were respectively Professor Nordenbos (a courteous hospitable Anglophile who survived subsequent internment in a concentration camp), Professor Lameris (held in awe by his compatriots, he was a commanding figure who did not wear gloves when operating on clean cases, and took almost obsessive care of his hands) and Dr Schoemacher, of international repute and an ingenious turn of mind whose name lives on with his gastrectomy clamp. In 1935 Groningen (Professor Michael), Amsterdam (Professor Nordenbos again) and Leiden (Professor Suermondt) were visited. In Leiden, the meeting was largely devoted to the treatment of tuberculosis and the new lecture theatre sported an epidiascope and ”a mechanical contrivance for darkening all windows at a moment’s notice.”
After the hiatus due to the Second World War, Holland was next visited in 1952, the party staying at the Victoria Hotel near Amsterdam’s Central Station. At the new Wilhelmina Hospital a full programme was hosted by Professor Boerema, whose Boerema button for oesophageal anastomosis preceded modern stapling devices. In Leiden Professor Suermnodt was still in post, but in Utrecht – Holland’s oldest city – the host was now Professor Nuboer. In The Hague Professor Schoemaker was again visited though it was noted that “while no less a master of technique than before, his judgement seemed to have mellowed.”
In 1970 the visit arranged by Dr Jan Eeftinck Schattenkerk (working in Amsterdam having been a surgeon in Zwolle) revealed a health service of high quality with minimal State interference. Amsterdam and Rotterdam were visited, as on the present visit. Amsterdam boasted the large modern Free Hospital, whereas in Rotterdam the Dykzigt Hospital had been completely rebuilt since the war and was elaborately equipped, including on-line computers in the intensive care unit. In 1983 the Academic Medical Centre was visited twice; near Schiphol Airport and half-an-hour by tram and train from the centre of Amsterdam, this was the biggest building in the Netherlands. Trips were also made to the Sophia Hospital in Zwolle and the Red Cross Hospital in Beverwijk, where the burns unit and skin bank were admired.
A little history of Holland
The name Holland strictly refers to only the two western provinces of the Netherlands, a European country of 16,000 square miles with a population of less than 20 million. The Netherlands became an independent kingdom in 1815 when the settlement of the Congress of Vienna united the entire Low Countries. Its landmass (bordered by the North Sea and bounded by Germany on the east and Belgium to the south) is built up of sediment carried by the Rhine, Meuse, and other rivers, and much of the country is below sea-level, reclaimed as the polders which are protected from flooding by ditches, dykes and tide-gates as well as a chain of sandbanks. The coast has several estuaries and a large lagoon, the IJsselmeer, partly reclaimed from the Zuider Zee. The rich sediment supports a variety of horticulture and livestock farming. Inland, however, there are peat bogs and patches of heath, forested to help keep the sand in place.
This part of Europe was conquered as far north as the River Rhine by the Romans; the Franks and Saxons moved in during the early 5th century. After the collapse of the Frankish empire in the mid-9th century, there was political fragmentation. Consolidation began in the 14th-century under the dukes of Burgundy, and in 1477 the whole of the Low Countries passed to the House of Habsburg. In 1568 the Dutch Revolts against Spanish Habsburg rule began. The independence of the United Provinces of the Netherlands was finally acknowledged at the Peace of Westphalia in 1648.
During the 17th century Holland was a formidable commercial power, and acquired a sizeable empire. A Dutch colony was established in South Africa in 1652; the settlers were at first known as Boers and later as Afrikaaners, and the Afrikaans language has been referred to as “baby Dutch”. At first the native San and Khoikhoi intermarried with the Boers, but were later displaced by them and forced to become labourers on their farms. The San withdrew into mountainous areas. Some Boers, known as trekboers, moved inland and encountered the Xhosa people, who had a settled, agricultural society. By the end of the 18th century frontier wars had broken out between the Xhosa and the Boers. In the 1830s large numbers of Boers moved northwards in the Great Trek. The Boers refused to form a federation with the British, who had established a colony in 1806, and this led to the Boer Wars.
The Dutch empire began to decline after the Anglo-Dutch wars and the protracted wars against the France of Louis XIV. From 1795 to 1814 the Netherlands came increasingly under the control of France. During those years Britain took over the colonies of Ceylon (now Sri Lanka) and Cape Colony in South Africa, important trading posts of the Dutch East India Company.
At the settlement of the Congress of Vienna the entire Low Countries formed the independent kingdom of the Netherlands, in 1815. Despite the secession in 1830 of Belgium, the Netherlands flourished under the House of Orange, adopting in 1848 a constitution based on the British system. It remained neutral during World War I, suffered economic difficulties during the Great Depression, and was occupied by the Germans during World War II, when many Jews were deported to concentration camps. Until World War II it was the third largest colonial power, controlling the Dutch East Indies, various West Indian islands, and Guyana in South America. The Japanese invaded the East Indian islands in 1942 and installed Sukarno in a puppet government for all Indonesia. In 1945 he declared independence and four years of bitter war followed before the Netherlands transferred sovereignty. Guyana received self-government as Surinam in 1954 and independence in 1975, but Curacao and other Antilles islands remained linked to the Netherlands. Following the long reign of Queen Wilhelmina (1890-1948) her daughter Juliana became Queen. She retired in 1980 and her daughter succeeded her as Queen Beatrix.
Since 1945 the Netherlands has been ruled by a succession of coalition governments, the seat of government being located at The Hague (Den Haag, literally the hedge). With a population of half a million, this is the third largest city in the Netherlands, and takes its name from a wooded former hunting reserve, on which there has been a royal palace since 1250. The Hague houses the International Court of Justice in the Palace of Peace, built in 1913. The Hague Convention of 1907 still supposedly underpins the conduct of international warfare, though terrorism has changed the nature of modern conflict.
Holland’s strong export-led economy suffered a recession in the early 1990s with an increase in unemployment. The Netherlands was a founder member of the European Community, and of NATO. It is a member of the OECD, the European Union and the Council of Europe. The currency used to be the guilder (= 100 cents) until the Netherlands joined the European Union and inherited the euro. As to religion, one third of the population is secular, just over a third claim to be Roman Catholic, and of the remainder most belong to the Dutch Reformed Church and similar groupings. The ethnic mix is liberal, native Netherlanders (accounting for more than 90% of the population) having welcomed Turks, Moroccans and Muslims, some of whom are reluctant to integrate culturally leading to the tensions which were most obvious in the brutal murder of Theo van Gogh in 2004 in Amsterdam by a 26-year-old man of joint Dutch and Moroccan nationality. This shocked a nation already shaken by the assassination in May 2002 of Pym Fortuyn, their populist right-wing anti-immigration politician.
Amsterdam has been called the greatest planned city of Northern Europe and is the capital city of the Netherlands. It was founded as a small fishing village at the mouth of the River Amstel where the sea was restrained by dykes and polders, and it expanded relentlessly to become the chief trading city of Northern Europe. Its trademark canals are lined by gabled houses dating back to an architectural heyday in the 16th and 17th centuries, by the end of which Amsterdam had becomes the heart of the Netherlands’ massive global empire. In the 18th century it was also a major financial centre, but became constrained under Napoleonic rule leading to a decline in Dutch fortunes. Industrialisation came late, but during the 20th century Amsterdam entered the mainstream of European life: Schiphol airport, completed in 1993, opened up Holland to the world, making its tulips, tourism and art accessible.
Rotterdam, too, is of world importance in several areas, including shipbuilding, engineering, oil refining, petrochemicals and electronics. The principal port of the Netherlands, it is one of the largest in the world. It lies at the junction of the Rotte and Nieuwe Maas rivers in the province of South Holland where the New Waterway of 1890 linked it with the Hook of Holland. Rotterdam was the birthplace of the humanist Erasmus, after whom its University was named in 1973.