Mr David Hamilton
SMJ 2006 51(1): 8-12
Summary
The Scottish Medical Journal has been published for half a century and its pages reveal not only the steady changes in Scottish medical care and careers, but also reflect the attitudes of the times. The journal has survived a number of crises. Recent changes, both at the journal and in Scottish politics, leave it well placed for an expanded and important place in Scottish medicine.
The Scottish Medical Journal appeared in 1956 from a merger between two long-established journals - the Edinburgh Medical Journal (founded 1805) and the almost equally long-lived Glasgow Medical Journal (established 1828). In detail, the events were more complex. After inception, the GMJ had a rocky first two decades and in Edinburgh there was a short-lived Scottish Medical and Surgical Journal which ran from 1897. Moreover,at the time of the apparent merger in 1956, the Edinburgh Medical Journal had ceased publication in the previous year.
With the new arrangement, there was also fusion of the previous publishers, namely the Royal Medico-Chirurgical Society of Glasgow, the Medico-Chirurgical Society of Edinburgh and the Edinburgh Obstetrical Society, the latter withdrawing in 1971. The Scottish Society for Experimental Medicine added its support in 1961. The new combined 1956 Board of Management (co-chaired by physicians Thomas (‘Tom’) Anderson, professor of public health in Glasgow and Rae Gilchrist, the Edinburgh cardiologist) put forward the laudable aim of ‘better co-operation between the medical schools in the Northern Kingdom.’ Anderson remained chairman until 1973, and the longest serving member of the joint Board was James Innes, the Edinburgh physician, who was active until 1980.
The
real agenda for the SMJ was probably different, namely that whereas in a former day the
two journals had carried many long and important articles from authors in the
two cities, other journals with international circulations were now favoured by
Scottish medical authors. Another
change was that formerly, the three societies were active academic bodies, often
meeting every two weeks, and important papers with new material went straight to
the two journals. Habits were
changing and researchers instead favoured the growing number of national or
international academic societies, encouraged by the lowering cost and increased
speed of travel. Lastly, the NHS
was only eight years old when the journal emerged, and there were calls for
change, with national plans and reports being sent north to the St Andrews House
administration of the NHS in Scotland. A
single journal might give a collective response and substitute for separate
Glasgow and Edinburgh views.
The New Journal
Figure 2
Alexander Brown, first editor of the Scottish Medical Journal, had charge of medical wards in Glasgow's Southern General Hospital and then move to be a ward chief the Royal Infirmary. He contributed to the literature on haematology and made important observations at the war-time MRC Burns Unit at the Royal Infirmary.
The first issue of the new Scottish Medical Journal emerged in January 1956 and was thereafter was published monthly until 1970. It usually had 50 pages at that time, but was to appear less often and to be smaller later. This monthly appearance allowed the journal to be topical both in the article content and also editorially. The first editor of the SMJ was the physician Alexander Brown of the Southern General Hospital, Glasgow, who had been editor of the GMJ to that point. The subsequent editors, shown in Table 1, all came from Glasgow. Contributions from Glasgow predominated in the early years of the SMJ, and perhaps the previous closure of the Edinburgh journal affected the balance of support from the two cities.
The
SMJ’s
typography was advanced for its day and in particular the layout of the
references was admired. The reader
now smiles at the practice in these innocent times, when there was no need to
disclaim conflicts of interest and the authors were so well-known that their
institutions were not named. The
papers often had a single, or perhaps, two authors.
Fifty years later the average was four, with greater numbers of authors
in many contributions. In the early
SMJ patients were easily recognisable from frontal photographs or
from investigations and charts. Also to be seen in a different light later was
the routine raiding of the post-mortem room for normal tissues for study.
The
Early Years
In
the first years of the journal, a feature was the solid contributions by
established consultants, perhaps not yet diverted by committee work or
administration, local or distant. Nor
was there much private work to take them away from reading or writing.
There was also a now-forgotten incentive for this scholarly effort by the
NHS consultants, namely that the ‘unit chief’ posts still existed and young
consultants always aimed for this desirable high-profile promotion, and the wait
could be long. The academic departments were also confident and productive,
and there was pride that senior lecturers were streaming out from Scotland,
notably from Glasgow, to English chairs, notably of surgery, medicine and
pathology, and. England was seen as
being locked in a pre-scientific Dark Ages obsessed with private practice, and
centred on out-dated small, free-standing medical schools. There was pride in the unique Scottish arrangement of medical
faculties existing within the universities, and integrated with the local health
board, giving both academic links and a huge patient population and many
teachers.
The
Contents
There was the familiar mix usual in a medical journal of editorials, original articles, occasional advertisements, short case reports, books reviews (uniformly laudatory) and the SMJ had regular reports of the meetings of the societies sponsoring the journal. This was a vestigial but necessary reminder of the days when Lister or Liston would present their new data at the frequent meetings of these societies and would have a large and critical audience. The SMJ benefited from those giving the named lectures at the two Colleges since they were asked to publish them in the journal and this rapid publication was doubtless an attraction.
The
journal reveals an optimistic profession who considered that scientific medicine
was delivering. A hospital building
programme was coming, and new thinking in medical education was being debated,
after encouragement by the General Medical Council in 1957.
There were lengthy articles on educational methods, one of the best being
Charles Illingworth’s critique of the medical course’s tedious first three
years of basic science teaching, particularly the first year:
The
trouble starts with the preclinical year, when boys and girls fresh from school
discover that ‘science’ means no exciting introduction, at the hands of
eminent professors, to the intriguing mysteries of chromosomes, electronics and
the chemistry of life, but dull pack drill on the amoeba, the dogfish and the
elementary mechanisms of the inclined plane.
Illingworth, Regius Professor of Surgery at the Western Infirmary at the time, was a distinguished and prolific contributor to the SMJ and all his views read well today. His many invited lectures, written up in crisp prose, not without humour, were handed over promptly to the editor.
In the first years the hope for major contributions to the journal from the Scottish medical schools was realised. Authoritative research articles and reviews of therapy were a feature and reflect some strong points of Scottish medicine. Perhaps the most celebrated, and certainly most cited, article was one in 19xx on ‘Myasthenia gravis: A new hypothesis’ from John Simpson, the neurologist, then in Edinburgh and soon moving to Glasgow. This heralded the revolutionary insights into auto-immune disease.
The
pages of the early SMJ at the time show a heavy bias towards hospital medicine, and
this was an all-male world which took a patronising attitude to general
practice. The GP’s complaint at
their exclusion from the hospitals under the NHS was noted but the matter taken
no further.
The
Late 1950s
The monthly editorials could be robust at this time. The Medical Research Council was attacked for neglecting Scotland, and even the Royal Faculty and Colleges did not escape a rebuke, since in July 1959 the SMJ noted that:
The medical corporations have come to depend so much on revenues derived from examinations: the treadmill has become a mint and we are in danger of reaching the absurd position when foreign doctors are coming to Britain merely to acquire a diploma and some of the magic letters such as FRCS. By perpetuating this nonsense we are loosing caste among the truly learned bodies of the civilised world.
There
were some causes for professional unease, often, as always, over ‘professional
freedom.’ In mid-1958 the editor could regret that, for the first, but not the
last time, that
today there is scarcely a man of eminence in the profession who is not finding his work impaired by the need to prepare drafts on this or the other subject.
Nor
did the apparently progressive idea of a central organisation to collect cancer
statistics please the editor in mid-1959. It
would, he opined:
issue circulars, memoranda, and instructions to appoint committees and regional co-ordinating bodies and planning officers and all the familiar claptrap of bureaucratic medicine… There was talk of a ‘Cancer Service’ with a ‘Standing Cancer Committee’ and ‘Regional Cancer Control Officer’ There was to be a Registration Bureau… Fortunately financial stringency and sheer inertia combined to delay its inception.
Nor
did the early growth of administrative control in the hospital meet approval.
A politician had to tell the troops what was coming.
In 1962 Lord Craigton, the Secretary of State’s minister for health,
speaking in Glasgow at the Biennial Dinner of the Royal Faculty (as it was),
recalled that the limited remit of hospital management before the War was
to provide
an
efficient, heated, clean, wholesome sickhouse, equipped with the necessary
furniture and fittings for the reception of patients; and to provide the
necessary medicine and food.
You
may feel, as I do, that today these concepts are as remote as the language in
which they are expressed.
Many
of his listeners did not feel as he did. Many
dining that night were happy to leave management in charge of only housing the
sick.
But
otherwise there was general contentment with the NHS, which meant contentment
with the hospital service, and its salaries and overall funding.
The only improvement the journal could suggest for the NHS was in care of
the elderly and Glasgow had its activists. In March 1957 the journal pointed out
that
many
clinicians feel that of recent years, much more than in the good old days before
1948, their wards often become ‘cluttered up’ with old people.
Expansion
of the ‘geriatric’ services was to follow.
The
journal took historical articles but whereas there was a noticeably patriotic
editorial stance and obvious Scottish self-confidence at the time, the
historical content is puzzling. To
the SMJ, medical history seemed to
mean the life and works of English physicians notably Harvey, Sydenham and
Heberden who were praised by dull, derivative contributions from secondary
sources. A possible explanation is
that Scotland was looking forward, not backwards at the time: nostalgia was to
come later.
Some
topics of the time are listed in Table
2.
The
Journal in the 1960s
The
use of the artificial kidney was precariously established and Kenneth Lowe in
Dundee thought ‘it would produce marginal improvement in the medical
management of acute renal failure’ and that one machine per 5million
population would suffice. Tuberculosis was still about.
New diseases appeared, and the hunt for argentaffinomas and
pheochromocytomas was on, much to the distress of the stretched biochemists, and
an old disease, rickets, returned in 1961.
A new thought was that in ‘barren marriages, the husband might be
examined.’ A book on healthy living was praised by the reviewer because ‘the
author does not avoid the question of pre-marital sex.’
In
clinical work the dogma that arterial disease below the inguinal ligament was
not suitable for surgery was being challenged and in 1964 it was noted that the
invention of a ‘balloon-ended catheter by Fogarty’ the previous year had
promise. In the treatment of duodenal ulcer the journal opined that
the old simple stomach by-pass was at least safe, and doctors
might
themselves take a chance with gastro-enterostomy while reserving vagotomy and
gastrectomy for treatment of a possible recurrence.
Richard
Doll’s Fleming Lecture at the Glasgow College on his studies of the various
regimens for gastric ulcer revealed the power of the use of randomisation in
medical research and the SMJ commented
that in future
it
will be increasingly difficult to get published, uncontrolled observations based
on mere assertion…’
Hospital
infection caught the eye of the infectious disease specialists looking for new
roles. Tom Anderson in 1961 wrote
that
since
the 1930s surgeons and obstetricians have passed through a period when they have
been free of their ancient curse of infection….
During this happy phase when antibiotics rapidly abolished the main agent
they [surgeons and obstetricians] have developed a resistance to the recognition
of infection as strong as the antibiotic resistance.
The
issue of hospital infection did rise in priority thereafter. ‘Too often there
is only one wash-basin and one towel at the end of the ward’ complained the
journal. In 1968 the first heroin
addicts were encountered in Glasgow and described as a novelty in the journal.
They were incomers who suffered from withdrawal through lack of supplies
in the city.
Debates
on Administration in the 1960s
The Wright Report of 1964 proposed more consultant posts for Scotland and tidied up junior staffing with proposed simple forms of rotational training. The old part-time consultant appointments to an number of hospitals were to go. Interestingly, research sessions for all consultants was suggested and welcomed in the academic mood of the times.
In
1964 the journal praised the conferring of the titular title of professor to
some staff at Glasgow University and Dr A.S. Douglas at the Royal Infirmary was
the first to be elevated. The
journal considered this to be ‘an enlightened outlook of the University
Court.’
Illingworth
was again ahead of time in 1966 for what he called ‘Continued Medial
Education.’ He also wanted the
‘unit chief’ system abolished and consultants given equal rights.
In 1964 he attacked the ‘lamentable’ and accepted need for young
surgeons to sit the fellowship of all three surgical Colleges.
This verdict was generally accepted later, and the round-Britain tour
ceased.
The
Farquharson-Lang Report in 1966 on administrative structures of Boards and
hospitals is now celebrated for its proposal that Chief Executive Officer posts
should be established in the hospitals and Boards.
This radical departure was not implemented at the time, but the SMJ shows that there was enthusiasm for it and after request for
comments, there was remarkable support from the profession.
Instead the post of medical superintendent went out and the community
physicians came in.
Some
other issues of the 1960s are shown in Table
2.
The
Journal in the 1970s
In
1970, publication of the journal was handed over to E and S Livingstone, but in
spite of now carrying quite a number of advertisements, the SMJ
had to cut back. Rising costs of
production and distribution resulting from inflation meant a change from monthly
to bi-monthly the total pages in the year were shrunk by half. Something had gone, not only from the change in size.
The lack of monthly appearance meant a loss of immediacy.
Some
symposia were arranged, often devoted to a single new drug, and were largely
paid for by the pharmaceutical company involved, which caused no ethical
distress at the time. Initiatives
included publishing selected abstracts from the proceedings of the Scottish
Society Experimental Medicine and a ‘Postgraduate Section’ and MCQs appeared
briefly in 1970.
Inflation
was also causing problems with doctors, dentist’s and nurses pay.
Entry into Europe meant that comparisons of health care methods and
allocations were appearing, and the UK’s spending of 4.8 % of the GNP compared
unfavourably with Italy’s 6.0%. These
hard times meant that value for money was to be sought.
Thomas Taylor, a lecturer in medicine at the Glasgow Royal Infirmary,
warned in 1975 that consultants’ performance might soon be studied and that
‘the face of clinical medicine in the next decade is likely to change
radically. The freedom of the
individual is likely to be increasingly curtailed.’
The Journal in the 1980s
From
1984, production of the journal was taken over by Durrant Publications in
Pencaitland, with sponsorship from MCP Pharmaceutical.
In 1988 the long-standing small page format, unaltered from 1828, was
changed to the larger A4 format common to most journals and this had more
impact. But the total of only 167
pages for that year, even with a reduction in type size, gave a further
reduction in content and this was needed for continuing financial constraints.
To assist the journal, the Aberdeen Medico-Chirurgical Society joined the
other societies supporting the journal from earlier times and a number of other
organisations also assisted later in that decade.
Charles
Forbes continued as editor in spite of moving from Glasgow to the chair of
medicine in Dundee in 1987 and he was to steer the SMJ over twenty years in all,
and through its most difficult times.
Figure 4
Charles Forbes, long serving editor of the Scottish Medical Journal from 1978-2002. He was Senior Lecturer in Medicine at Glasgow Royal Infirmary before moving to be Professor of Medicine at Dundee University.
The Journal in the 1990s and early 2000s
Figure 5
The new cover in 2003
Boehringer
Mannheim UK took over as sponsor in 1990, and Astra Zeneca and Roche assisted
later. Publication by Durrant changed in 1996 to Hermiston
Publications run by Dr Ian McKee in Edinburgh, though Durrant took over again in
2001. The journal’s perilous finances forced it to shrink again and in the
mid-1990s some issues hardly exceeded 30 pages. A
serious problem followed abrupt withdrawal of major sponsorship in 2002, and in
response the journal had to cut back from bi-monthly to became a quarterly
publication.
But printing costs were falling and with new outside assistance the crisis was averted, Charles Forbes then handed over after two distinguished decades as editor. Guy Fletcher took over and with the internet now offering new opportunities, an electronic form of the journal was made available. Finances allowed the possible size of the journal to rise, and submissions were increasing, perhaps affected by the closure of the long-running and worthy Health Bulletin produced from St Andrews House.
Robert
Carachi was appointed editor in 2004 and with the sponsoring societies rising to
eight, Glasgow’s Royal College of Physicians and Surgeons promised major
support for the journal for three years, and became the publisher in 2006.
The journal had a makeover in 2003, gaining a new cover design and the
typeface and layout inside now followed the style of the Glasgow College’s
elegant Bulletin, which closed in
2005.
Figure 6 The cover of the journal in 2005
The
Future
The founders of the SMJ felt that its first obligation was to Scotland, and that any international impact would be bonus. This obligation to Scotland is now greater after devolution of control of health care to the Scottish Parliament. Financial support is assured in the medium term and the journal has survived into a new era where health care is a matter for the Scots within the constraints of allocated budget. The London-based journals, though interested, no longer have an obligation to report on the nuances of the separate NHSScotland, and these differences are growing. Other nations and even federal states within other nations have viable and observant journals serving the needs of those working in health care. Much is happening. The way ahead for the Scottish Medical Journal is wide open.
