TSS Blackburn 8-10 September 2022
2022 will be remembered in perpetuity. We were at an organ recital, part of the Alan Green lecture by our Blackburn host Andrew Evans, when we learnt that the Queen had died that afternoon. Our visit was unique on other accounts too – we stayed at possibly the most lavish hotel we had ever enjoyed, our dinner under a Michelin chef was on its premises, the outstanding programme was of a high academic standard, and the Alan Green lecture was a unique combination of talent and exposition. The 29 who attended the meeting – in whole or part – included our President Linda de Cossart and Secretary Graham Sunderland; a further five attended the business meeting on Zoom (also used in Milan).
PROFESSIONAL PROGRAMME
Friday 9 September 2022 – The Royal Blackburn Hospital
Leaving the hotel as close to 7.45 am as our waiter-service breakfast permitted, we reached the Royal Blackburn Hospital within 40 minutes for our academic meeting in the huge amphitheatre with its twin projection and tin roof (the heavy rain at one point was almost deafening). Technician Tom Whittaker was ever on hand for IT. We were joined by Rachel Hargest and Asha Senapati.
Medical Director Jaward Hussain welcomed us, informing us that robotic and vascular surgery were available on-site amongst the 44 departments of the Royal Blackburn Teaching Hospital. Burnley General Hospital provided maternity, neonatal and orthopaedic services, with a third hospital completing the Trust. He was proud of the liaison of his hospital with community and support services.
Our President Linda de Cossart gave an illustrated overview of the origin and role of the Travelling Surgical Society, founded in 1924 at the instigation of Sir Berkeley (later Lord) Moynihan of Leeds, the first provincial surgeon to be PRCS. During WW1 British surgeons on the Western Front (at Beauval, for instance) smarted at the gibe of being ’the best amateur surgeons in the world’ and resolved to learn from their Continental counterparts, visiting Holland first, in 1925. They watched their peers at work in the operating theatre, and our fifty or so members (thirty in active practice and several in the military) have visited over thirty countries, travelling in Europe then the wider world.
Over the past century the world has seen enormous changes in surgery and medicine, and the TSS has kept up by learning from our peers and predecessors as well as sharing our own experience with more junior surgeons whom we encourage with the Price Thomas Fellowships and the Residents’ Prize presentations. Our president extolled the ethos of visiting other centres, and thanked our host Andrew Evans for this current visit to Blackburn.
Session One on perioperative care was chaired by consultant anaesthetist Matt Turner who introduced Anton Krige, of South African extraction, whose comprehensive review of Preoperative Risk Prediction more than justified his roles as Honorary Professor, University of Lancashire School of Medicine, Consultant in Intensive Care and Anaesthetics, and Perioperative Medicine Lead. He recommended prehabilitation (see later) and intra-operative monitoring. His profusion of acronyms and a fast delivery encouraged critical attention.
First he emphasised that the goals of risk prediction hinged on reducing the specific risks of the disease and of the surgery and he listed these under SDM/IDM1. Patients do badly because of impaired physiological response, inadequate cardiopulmonary reserve (assessed as MET2 or VO2, resting and peak) or inappropriate medical intervention.
Subjective assessment of capacity included stair climbing (2 flights/44 steps) or walking for 4 blocks/600 metres with a pVO2 of 14- 21(4-6 METs). ADLs3 with a DASI4 <34 may increase the risk of cardiac complications. CPET variables underestimate risk. Objective techniques can include spirometry and ECHO cardiograms and (whether resting, on exercise, or dobutamine stressed), a 6 minute walk test (10 metres+), and the incremental shuttle test. He predicted the future would include MCA5, assessment of strength and frailty, ergometric assessment and epigenetic markers.
Joel Lambert (Year 7 surgical trainee) defined Prehabilitation as that part of the continuum of care tailored to any individual cancer patient and consisting of healthcare strategies (such as supervised exercise, nutrition and psychosocial support) intended to optimise a patient’s physical and emotional wellbeing prior to a stressful event such as cancer surgery. This intention to increase functional capacity has been studied around the world in trials he reported from Canada, Italy, the Netherlands, Spain and the UK. Successful prehabilitation may have anti-inflammatory effects and modulate the tumour micro-environment by inhibiting pro-inflammatory cytokines, reducing weight and stress as well as improving general lifestyle. He concluded that regular exercise (which needed to be carefully defined) with improved fitness can reduce complication rates, especially wound infection, and perhaps shorten hospital stay with a better response to later treatment. ‘Living well after cancer’ is the aim.
ERAS guidance was extended by Manchester anaesthetist John Moore who decried ‘the massive gap between GP and hospital care’6. He said the decision to operate was made by the MDT7, subject to chatting with the patient usingtechniques imbued in healthcare workers at ‘Surgery School’. He stressed the role of the support services and data collection, and confirmed that DrEaMing8 , prehabilitation and psychosocial support improved functional capacity and outcomes. He recommended reassessment a year after surgery, and digital prehabilitation using wearable devices (such as a FitBit, Oura ring, Wittings ScanWatch) which communicate with patients’ smartphones.
The multimodal stress-minimising approach of ERAS and allied projects reduces morbidity, improves recovery and shortens length of stay (LOS) after major surgery and can improve long term outcomes; it can now encompass at least twenty components. Exercise can also be considered cancer therapy, increasing stress hormones and lactate, activating CD8 lymphocytes, increasing tumour perfusion and thereby oxygenation, permitting resident macrophages to polarise to anti-tumour M1 phenotypes and improving tumour infiltration by natural killer cells. Greater Manchester has 80 gyms and 14 evaluation centres, facilitating the delivery of the Prehab4 cancer programme which has already been evaluated in 130 patients. Plans are in hand to deliver this over the next few years, though Dr Moore said it needs real-world data regarding sleep, activity levels, vital signs, HRV9 and symptoms, being pursued through the EMBRaCE study10 of patients with lung or colorectal cancer, and those undergoing Car-T cell therapy11.
Anton Krige took the podium again, this time reviewing analgesia for major abdominal surgery. ERAS recovery pathways had become more complex and compliance was reducing. The DrEaM bundle prioritised early drinking, eating and mobilising: the literature suggested this was associated with a 3 day reduction in length of hospital stay after a variety of surgical procedures. As to the analgesics to facilitate this, Professor Krige recommended minimising systemic opiates in favour of paracetamol +/- NSAIDs, gabapentinoids, ketamine, i/v lidocaine infusion and possibly dexamethasone, clonidine and magnesium.
Regional anaesthesia could involve spinal opiates, thoracic epidurals (though discussion thereof could make patients anxious), thoracic paravertebral blocks, quadratus lumborum blocks, TAP12 blocks, rectus sheath catheters and continuous wound infusion. His comprehensive review of the relevant literature concluded that spinal opiate analgesia was best for minimally invasive abdominal procedures and open transverse incisions (with a lidocaine infusion), whereas midline incisions warranted spinal opiates and rectus sheath
catheterisation with continuous wound infusion. Epidurals should be reserved for selected cases.
The next presentation was ’virtual’, being a recorded closely-considered commentary with illustrative slides by Professor Dan Conway of Manchester University on the earlier prediction of the deteriorating patient by pre- operatively triaging patients at risk, considering enhanced care (halfway between a surgical ward and a high dependency unit, facilitating monitoring), minimising the inflammatory response through enhanced recovery, and the use of wearable technology to monitor mobility and identify complications earlier. The following is a more detailed version of his presentation.
He began with a quote from ‘Franny’ Moore and observed that over 300 million operations were performed around the world annually before Covid struck – a rise of 25% within a decade – of whom 8 million will die.
In the UK, 8 million procedures are undertaken annually with a 30-day post-procedure mortality of 1.1%, rising to 1.8% at 60-days. For high risk patients staying overnight, the 90-day mortality is 2.8%. A third of all deaths occur within 90 days of any major procedure but many of these are due to underlying disease.
Globally, a study of 474 hospitals indicated that 17% of operated patients developed complications with reduced long term survival. 11% sustained a single complication but 5% had two or more: long term problems often result.
He said the physiological impact of surgery begins with afferent nerve stimulation of the sympathetic nervous system producing stress hormones, particularly cortisol, with metabolic consequences due to mitochondrial dysfunction, a deficit of ATP, catabolism and oxygen debt. IL-6 and CRP rose proportionate to stress. Hyper-inflammation was induced which appears counter-productive though he quoted the palaeontologist and science writer Stephen Gould that “There has been no biological change in humans in 40,000- 50,000 years”. Modern contributory factors include the scale of surgical injury and the fact older people are less healthy.
He discussed how the perioperative scenario might be influenced, risks anticipated and early signs of deterioration detected. He recommended targeting high risk patients, monitoring the sympathetic nervous system, protecting cardio-pulmonary function and seeking early signs of renal failure that might cause loss of nephrons. Potential if controversial measures are goal-directed therapies and improved gas exchange by CPAP13 and high flow O2, as stimulated by experience in the Covid pandemic. Enhanced recovery can minimize an inappropriate inflammatory response.
As the patient goes to the operating room and anesthesia is induced trauma is suffered and convalescence begins
Francis D Moore 1953
Session Two examined treatment options for rectal lesions.
Judith Salaman made an impassioned plea for less stringent endoscopy guidelines around rectal polyps, currently putting heavy burdens on the colonoscopy service causing out-sourcing and lack of adequate follow-up. She decried the 2-week ’suspected cancer’ wait as not evidence-based, and criticised the pressure forced on the service when small polyps were detected at colonoscopy. Clear evidence-based guidelines were needed: she cited cases where patients with many hundreds of polyps not being followed up adequately.
Colorectal surgeon Michael Gill reported good result from TEMS14 confirming the value of performing this in specialist units. His talk was subtitled ‘Organ Preservation’, a witty ambiguity acknowledging our host’s talent and musicalappreciation, acknowledged with a photo of the UK’s oldest organ (in St Botolph’s church in London) saying that the world’s oldest playable one is in the fortified Basilica of St Valère in Sion, Switzerland, with 12 pipes dating back to 1435. Birmingham Town Hall’s organ was unveiled in 1934, boasts 6000 pipes (some 32’ high), and matches the most powerful organs around the world.
The instrument for TEMS is also little changed (since its introduction by Bue in the 1980s) and can reach up to 20 cm from the anal verge for benign lesions. For malignancy it can permit diagnostic biopsy, therapeutic treatment (for those not fit for major surgery) and management of T1 tumours up to 3-4 cm in diameter, below the peritoneal reflection, as he illustrated on video. The (low) risk of local recurrence does not preclude excisional diagnostic biopsy followed by total mesorectal excision (TME) for adverse histopathology.
He reported in detail a Dutch study and several trials including GRECCAR2 and CARTS, determining from the latter that complete pathological response rates vary between 4-49% for T1-T3 tumours and dependent on size and location ‘organ preservation’ is possible in two-thirds of patients though there is still a high risk of low anterior resection syndrome (50%) with TEMS. He concluded by referring to the STAR-TREC study (discussed online in the BMJ as below):
Transanal Endoscopic MicroSurgery
Adnam Sheikh’s comprehensive overview of robotics concluded that the robot in the pelvis offered particular benefits in the management of low rectal cancer. The five year survival had improved from zero to 60% between 1900 and 2000, with Miles’s ‘ introduction of the abdomino-perineal excision (1910) and the total mesorectal excision promoted by Bill Heald in 1982. The CLASICC 2007 trial showed laparoscopic resection of colorectal malignancy was on a par with the open operation on outcome measures, except for rectal cancer. Quoting results from the CLASICC, CART, ACOSOG and COREAN trials he said subset analysis revealed a high conversion rate and worse outcome in the low rectal cancer group, with more margin positivity because the view was limited and two- dimensional whereas the robot could offer 3D views and better oncological clearance with easier anastomosis and neural preservation. He demonstrated elegant robotic dissection for rectal cancer and for endometriosis on video.
Difficult to establish, the first such robotic case in the East Lancashire Healthcare Trust was undertaken in May 2017. The ROLARR trial (Randomised to compare Laparoscopic And Robot assisted Resection), published that year, showed no statistical difference in the usual outcome measures, but subset analysis revealed that compared with open or simple laparoscopic operations the robot was helpful in the obese and in men, with reduced conversion rates and fewer stomas. Data from 130 patients studied between 2014-2017 showed robotic procedures reduced length of stay, conversion rates and blood loss, with earlier return of gut function and improved circumferential resection margins. The results were published on 19 April 2021.
Developments in ‘Watch or Wait’ was an analysis by PhD student and colo- rectal surgeon Kat Parmar (currently researching with MRI at the Christie Holt Institute) of the surgical management of the regrowth of localized rectal cancers after short course radiotherapy (operating within a week) or when this is left eight weeks or more (long course). What should we do with patients who achieve a complete clinical response after radiotherapy? Do we need to operate, or can we ‘watch and wait?’ She concluded that it was not proven which was better despite several trials and said a three-way study would be justified. Such treatment needed to be validated against the gold standard of surgical total mesorectal excision first described by Professor Bill Heald in 1982.
A twenty-minute sandwich lunch from twelve heavily laden platters (then fruit and/or yoghourt) saw us back in the Learning Centre Auditorium for TSS Prize Presentations by five senior surgical trainees (STs) working with BRIDGES, the Blackburn Research Innovation Development group in GEneral Surgery.
1. Joel Lambert (ST7) presented the role of prehabilitation in major cancer resections: our experience from the SPECS trial (Standard versus Prehabilitation in patients undergoing Elective hepatopancreatobiliary and colorectal Cancer Surgery). The researchers measured VO2peak at the anaerobic threshold of 1.5 – 2 ml/kg/min and interleukin-6 levels following exercise. Secondary outcomes included DEXA body composition ratios, complications, length of stay, 90-day mortality, quality of life scores and hand grip strength. He emphasised that the exercise needed to be carefully defined. The patients were aged 18-85 of either sex with a radiological and/or tissue diagnosis of cancer undergoing elective surgery with intent to cure and had to have access to digital technology (mobile phone, tablet or computer) and be willing to participate in supervised exercise, All participants were fitted with an accelerometer to measure habitual and active exercise.
The Prehab intervention group underwent 40 minutes of aerobic and strengthening exercises including a five minute warm up, 20 minutes of activity at 60-70% VO2 max followed by a five minute cool down. They also had nutrition supervised by a dietitian, including Forceval multivitamin supplementation. The standard care group of controls got routine advice from the Cancer Care Team of East Lancashire Hospital Trust. The intervention group had statistically significant improvement in VO2 peak but their anaerobic threshold remained unchanged. However, individual responses in VO2 peak and anaerobic threshold suggested wide variability of metabolic responses for which a mechanism might be uncovered by studying secretomes16 and muscle gene expression.
2. Hassan Ahmed (ST5) wondered. ‘Does a minimally invasive approach in liver resection reduce incisional hernia? From a retrospective study’. Reich et al (1991) had reported a 22% incidence of incisional hernia after laparoscopic liver resection (for various pathologies) over a 22 month period. He said there was a dearth of data from a good laparoscopic sample size in a comparative UK cohort of single pathology, justifying his retrospective single centre review covering the period 2011-2018.
Elective records (from PACS17, clinical portals and GPs) of incisional herniation proven on CT scan (with secondary endpoints death or end of follow-up) in a review of 247 patients undergoing live resection followed up for 41 months (+/- 29 months) had an overall survival of 90%, 82% 65% and 42% at 1,2,3 and 5 years respectively. Mean hospital stay was 9 days (+/- 7). In 48 patients (whose demographics and clinical data he presented) the incidence of incisional hernia was 10, 15 and 19% at 1,2 and 3 years leading him to conclude that the incidence of hernia was the same after a laparoscopic procedure as had been reported from Asia for laparoscopic colorectal resection.
3. Abdul Shuguba (MD student) asked ‘should all surgery be robot assisted? citing the local experience with the MURALS study18 and the familiar benefits of small incisions, less pain, reduced blood loss, decreased catabolic response, shortened hospital stay, and quick recovery. However, he also asked ‘what about the surgeon?’ and the possible physical and mental consequences for him or her, particularly on muscular movement and cognitive demands.
16 A secretome is any molecule secreted from mesenchymal stem cells, with a variety of biological activities mainly acting on blood vessels. They include vimentin, galectins, integrin and collagens. 17 Picture Archiving Communications System used to store images and reports electronically
18 Manchester University Robotic And Laparoscopy Surgery
Using EMG to assess bicipital and back muscular activation and EEG for alpha brain activity in eighteen male surgeons undertaking 26 laparoscopic and 28 robotic procedures, he concluded there was less back muscle activity during robotic surgery (the surgeon being seated), particularly when holding rather than moving instruments but there were greater demands on attention. Perhaps a ‘warm-up’ was needed to protect against musculoskeletal injury, and mental visualisation might ‘allow surgeons to switch off’.
4. Donna Shrestha (PhD student) explored health inequalities in patients undergoing complex abdominal wall reconstruction, first drawing on three published reviews which identified three possible problems: presentation delayed to the GP, late or non-referral to a hernia specialist, or an inadequate procedure (reflecting the training and experience of the surgeon) leading to increased recurrence rates, length of stay and surgical morbidity. A multicentre retrospective cohort study was initiated of adults (aged 18 years or older) with a complex primary ventral hernia or an incisional hernia with a defect of 10 cm or greater and a previous repair, needing component separation, adhesiolysis or flap reconstruction and undergoing any type of repair, from 2012 onwards with at least two years subsequent follow up. Patients with parastomal herniae were excluded. The primary outcome was recurrence, with standard secondary outcomes (complications and length of stay in critical care and in hospital).
Regression and statistical analysis (Chi-squared or Mann-Whitney) was performed on 88 patients managed by three surgeons at two sites, to date. Five patients had primary herniae and 83 were incisional. She presented pie charts of the type of repair (a third were by bilateral posterior approaches) and of the original surgical incision (three quarters were midline). The results indicated a higher incidence amongst patients with a high (level 9 or 10) index of multiple deprivation (IMD)19. The intention is to review 300 patients with regression modelling (of the relationship between one or more independent variables).
5. Zaibun Khan (ST5 in Gynaecology) asked Are general surgeons really ‘better’ than gynaecologists? comparing laparoscopic skills acquisition in O&G and general surgeon (GS) trainees, who differ in the length and structure of their training programmes though the CCT20 requirements for fundamental laparoscopic skills (FLS) are comparable. 67% of O&G trainees felt unprepared for their certificate of completion, and not all senior O&G trainees could manage an ectopic pregnancy laparoscopically whereas 67% of general surgery applicants for CCT had achieved the logbook requirement. FLS in general surgery and O&G trainees (ST3/4/5) were investigated by comparing the musculo- skeletal and cognitive demands during laparoscopic tasks, and by comparing the level of laparoscopic ability expected by experienced consultants.
Part 1 was a nationwide survey of trainees and consultants in both specialties.
19 These indices use measures of deprivation for small areas across England, based on seven different domains, or facets, of deprivation, relating to • Income • Employment • Education, Skills and Training • Health and Disability• Crime • Barriers to Housing and Services • Living Environment
20 Certificate of Completion of Training
Part 2 was a study in which North-West trainees (24 O&G; 23 GS) performed four simulated laparoscopic tasks, each three times, on a laparoscopic skills training and testing (LASST) model. In the first task, the time taken to find 14 targets with a 30o camera was measured. Hand-eye coordination was then tested by the time taken to transfer 6 cylinders to pins on a LASST model. This was followed by testing the time taken to stick 6 pins into six discs. Finally, the trainees had to create 4 interrupted knotted sutures within fifteen minutes: the number of sutures and knots were counted and suturing quality was assessed. Finally, in eleven O&G and ten general surgery candidates, cognition and musculoskeletal activity were assessed using an EEG and EMG respectively.
Results indicate that general surgeon trainees were faster than the O&G trainees and there was no effect of experience except on suturing. The results of the nationwide survey (the Part 1 study) could be downloaded from a QR code21. It was suggested that perhaps general surgeons attend theatre more frequently than O&G trainees, but all data has yet to be validated and approved.
Following tea or coffee we reconvened to hear that the winner was Abdul Shuguba who would receive a cheque from our President. All presenters had kept within time (7 minutes) and answered questions well.
Trainee Elisha Ogbodo (a Nigerian Igbo who has worked in Cork) then gave a 20 minute overview of the options for Minimally Invasive Treatments for Benign Prostatic Hypertrophy, clearly presented with excellent illustrations. He concluded that TURP was still the gold standard despite the need for an inpatient stay and its potential risks (erectile dysfunction, incontinence and retrograde ejaculation). He discussed MIST, HOLEP, the Urolift (which can preclude future MRI or even TUR), Rezum, 532 nm green light laser, embolisation of the prostatic artery, aquablation, and the temporarily implanted Nitinol device. His talk is archived should further details be wanted.
Retired TSS urologist Peter Guy then advised us that taking someone in can change lives, illustrating this with his personal experience over Ukrainian refugees. There were fascinating insights. Two weeks before the Russian ‘special operation’ in Ukraine on 24 February 2022 it was clear that this would indeed be an invasion because medical ‘chatter’ revealed that Russian field hospitals were stockpiling blood (which is expensive, has a short life-span and is never taken on an exercise, which is what Putin claimed the military build-up was engaged in).
Peter‘s experience of the Bosnian conflict and the media reporting of Russian involvement in Syria indicated there would be a massive refugee crisis in Europe, even before the Ukrainian invasion. Experience from past conflicts indicated the likelihood that artillery and missiles would be fired at land-based targets, and this conflict would be between two artillery giants. If this was to be a proxy war using Western weapons and compromising Ukrainian lives, the West could at least look after the wives and families of Ukrainian soldiers.
Peter and Jane Guy’s experience of finding and housing a Ukrainian family was recounted. The extent of the refugee crisis became apparent by mid-March and a profusion of internet based sites tried to match families with potential hosts across Europe. The UK government created ‘Homes for Ukraine’ – a registration system suggesting London was a potential place of refuge – but some websites were little better than computer dating agencies in matching individual refugee requirements with what was offered by potential hosts. Peter preferred a direct email or WhatsApp conversation for better mutual understanding before deciding compatibility. He therefore accessed a Facebook-based site on which open comments were left by Ukrainians to whom he could reply privately via Messenger, giving them the opportunity to ignore him or respond positively.
Lyudmyla’s post popped up. When the Russians took the nuclear power station across the river Dnieper, within striking distance of Zaporizhzhia, their home town, Lyudmyla’s husband was keen his wife and daughter Mariia should leave. Lyudmyla was born in 1976 to ordinary working people in the Soviet Union. She was married in 1998 and the next year graduated in accounting and auditing. Their son Vladimir was born that year, and Mariia was born in 2012. The family worked hard, bought a large plot of land and built their dream house, moving in during 2019 at the start of the Covid outbreak. That apart, their lives were good until 24th February when the days of terror began: no schooling, livelihoods lost, a curfew and blackouts, sleep was interrupted by trips to the bomb shelter, and the family went to bed fully dressed. There were Russian atrocities elsewhere, and a mass exodus. Trains were packed and roads were jammed with traffic. On 16th April a Russian rocket exploded near their home; the blast broke doors and windows and cracked ceilings. Luckily the rocket had missed the house itself.
Pressed by her husband to leave, Lyudmyla posted on Facebook and within two minutes Peter had messaged her. They corresponded every day. By the end of April permission was received for her and Mariia to come to the UK.
Peter, by contrast, had found the application process staggeringly inefficient, bureaucratic and complicated but it eventually yielded. Recognition was mutual on arrival but Jane, having learnt Ukrainian on Duo Lingo, found their new guests were Russian-speakers who knew no English! Thankfully the Guy’s i-phones were loaded with ‘Say Hi’, a fantastic App offering instant and nearly fluent conversational Russian – their sole means of conversation for the first six weeks!
Over that period, hosting a refugee seemed a full-time job involving Wiltshire Council representatives, level 3 CRB checks, bank accounts to be opened, National Insurance and NHS numbers applied for, and registration with doctor’ssurgeries completed. British Resident Permits were needed. The benefit system had to be contended with – the Guys became overnight experts. Then they were directed to a Job Centre in distant Poole rather than nearby Salisbury; a heated exchange had this remedied, but not so the bus pass. There was a run on local school placements but suddenly the offer of a music scholarship came out of the blue from a private school, and unexpected offers also popped up everywhere from generous individuals and organisations.
Lyudmyla and her nine-year-old daughter Mariia were even more bright and cultured than anticipated. The daily school run was accompanied by Classic FM, almost all composers were identified, and in mathematics Mariia was light years ahead of her contemporaries although her English was limited. Her piano lessons were conducted by WhatsApp online from Zaporizhzhia, yet she was equally happy with a screwdriver and taking items to bits. ‘Pet therapy’ evolved as mother and daughter made friends with the Guys’ cocker spaniel Freddie, which comforted them in distress and quickly seemed to understand Russian!
A local Sponsors’ WhatsApp group shared information between existing and new host-volunteers, facilitating shortcuts and proving a forum for all manner of assistance and activities for incoming refugees: free English language lessons, IT and art therapy, bicycle and clothing procurement, bread making, access to swimming pools and transport. There were even offers by local organisations of children’s activities in the summer holidays. Life remains difficult for the refugees, a heterogeneous group from different socio-economic backgrounds with varying exposure to the horrors of the Russian invasion. Each family has different needs, and some from Western Ukraine especially have found it very isolating and think of returning home despite the risks, often because of difficulty mastering the English language. They are living with the constant threat of death for loved ones back home, and an uncertain future. Nonetheless, the community of hosts of which the Guys were part has found it an almost universally positive experience even thinking that his refugee guests have, in their own way in Peter’s words ‘brought more to our party than we have to theirs, and we are truly thankful for their presence in our household’.
He ended with a military adage: Time spent in recce is seldom wasted. Be careful whom you select to live with under the same roof as yourselves. The meeting closed by 4.30 pm and after a ‘hospital group photo’ we returned to our hotel for our formal evening, held there.
SOCIAL PROGRAMME
Thursday 8 September 2022 – Arrival; Visit to Queen Street Mill; Alan Green
lecture with organ recital; supper at Holmes cottage (the Evans’s home)
Most came by car, though the intended rail strike did not materialise. Our large, lavish rooms at Northcote (‘A Stafford Collection Hotel’) are worth a brief mention: king sized double beds, wet-room style shower, bath and twin sinks, few other guests, gloved22 dining service, exquisite food (the haddock with egg at breakfast was hidden under a cloud of frothed milk)…… and a printed schedule for our visit awaiting us in our room (one for the Archives?).
A seated lunch (of warm mushroom soup with Tarragon Oil, and sandwiches with discretionary forks) was enjoyed before we boarded the Hodder Executive luxury coach with personalised number plate and jovial driver John who cheerfully informed us that seat belts were compulsory by law, and promptly drove through a red light. He took us safely past many sandstone dwellings (two up, two down?) reminiscent of Lancashire’s industrial past, to Harle Syke in Briercliffe, Burnley. Here the Queen Street Mill is the last surviving 19th century steam powered weaving mill in the world.
In the early 19th century the British textile industry used traditional fibres, namely wool and flax (for linen), both of which could be found in Lancashire. As raw cotton imports increased, mechanisation began to displace handloom weavers and the textile industry reached its zenith just before the First World War, with 100,000 power looms in the Burnley area alone. In the Queen Street Mill the bobbins only enabled plain cloth (‘stripes’) to be weaved from cotton.
Guides Lizzie and Jane showed us how delicate raw cotton strands were treated, the final woven product – calico – leaving the mill in bales packed high on carts drawn by two horses which were only retired in the 1970s. This harsh working life (with no pension or healthcare, despite innumerable risks) afforded women the opportunity to earn as much as men at a time when the school leaving age was thirteen. The mill was built in 1874 at a cost of £20K (several million intoday’s money) raised from £5 shares in the middle of the Industrial Revolution.
The Grade 1 listed building offered illuminating insights into a period which lined some pockets well and provided local employment, but carried a heavy toll on the health of many, the industrial processes being dangerous, accident prone and noisy, causing deafness and sometimes chest diseases including tuberculosis. A family working in the weaving mill could earn 100 shillings (£5) a week when a traditional loom-weaver might only make ten pence. Costs had to be cut after the First World War and again after the Second: in the 1950s a 3-shift system was introduced followed by a compensation scheme as looms were scrapped.
On arrival we entered a sunken outbuilding with its two huge boilers fed –until recently – with coal shovelled into the open maw of one and the hopper of the second, tiring work conducted from 6 am to 6 pm, with the boilers kept alight overnight. The steam would pass into the main building to power the 500-600 horsepower engine ‘Peace’ whose piston drove an 8-foot centrifugal flywheel of which the axle ran the length of the mill, revolving at 68 rpm. Off it came pulleys that ran all the machinery. We learnt about cheeses, pirn winding and drawing in, and the serious risk of eye loss from errant shuttles. We visited the weaving shed with its 308 Lancashire looms, and commiserated that the enthusiast maintaining the piston engine had just retired.
We may or may not have appreciated the roles of Grinders, Overlookers, Drawers, Tacklers, Stubbers and Rovers or known the function of bobbins, creels, and beamers let alone yuticks, or even needed to use the Women’s Necessary (with instant dismissal if you were male). Warp and weft we were now familiar with – the two basic components used in weaving to turn thread or yarn into fabric. The lengthwise (aka longitudinal) warp yarns are held stationary under tension on a frame (the loom) while the transverse weft is drawn and inserted over and under the warp. A single thread of the weft crossing the warp is called a pick. Inventions during the 18th century that spurred the Industrial Revolution included the ‘picking stick’ and the ‘flying shuttle’ (John Kay, 1733) speeding up the production of cloth. The power loom patented by Edmund Cartwright in 1785 allowed sixty picks per minute.
Back at the hotel we had just enough time to prepare for the evening, our Executive coach taking us to St Leonard’s church in Balderstone and Mellor, a visit with yet another TSS coach incident: the lane to the church was blocked by a Range Rover which eventually retreated into a drive, allowing us to pass.
At the church Andrew Evans delivered the Alan Green lecture in unique style, combining musical appreciation and composition with talent and enlightenment as he switched between addressing us and demonstrating the church organ, built by the famous organ builder Henry Willett (1820-1910) who was responsible for the ones in Winchester and the Albert Hall, and who installed the St Paul’s Cathedral organ in 1870. This one in the church was tucked away, surrounded on three sides by stone, and used a wind chest (no longer worked by a small boy!). Organs, Andrew told us, attempt to mimic all instruments of the orchestra, and he illustrated simulation of the clarinet and flute with organ pieces. Organsprovide a ‘flat steady tone’ unlike most instruments which mimic the human voice, so he introduced the tremulant to us with Bach’s Air on a G string.
Next came Procol Harum’s ‘A Whiter Shade of Pale’ from 1967 which Andrew played on a nearby piano, evoking memories of Jacques Loussier and also that Hamlet cigar advert. He then explained Fugues as resembling a family mealtime at which the father repeated his message, his wife made the same point and the children’s responses were counter-fugues. He said he had never known Alan Green but offered ‘Alan Green Imagined’, an organ piece which he constructed using the letters of Alan’s name to produce notes combined in a harmony which he played. It was talented, clever and elegantly explained. It entranced us, and Andrew challenges you to solve his Motif message in Appendix 2 (page 19).
By virtue of smartphones during this event we learned of the death earlier that afternoon of Her Majesty Queen Elizabeth ll. Andrew announced this and played the National Anthem. We stood in respectful silence. The coach then took thesomewhat sombre group to the Evans’s home (surely Holmes ‘Cottage’ is a misnomer?) and raised our spirits on their patio with white wine (Cotes de Gascogne). Piano music drifted through the open bi-fold doors as we looked across the Evans’s ten acres and were soothed by the gentle trickling of their patio fountain (not to mention the exquisite canapés of sweet potato falafel and chicken and tarragon arancini23) under a blue sky gently turning to dusk.
Moving inside, we sat at three long tables in the high-vaulted library cum dining room (a former barn) with minstrels’ gallery, though neither minstrels nor pianist – no longer present – would have been heard above the hubbub of discussion. The pre-ordered starter of salmon or Guinea fowl, main course of beef bourguinon or local Goosnargh duck, and dessert (pannacotta or pear and apple crumble tart) were served with a Chardonnay or Sicilian U Passimiento.
This gourmet’s delight of an evening, served by polished staff from Breda Murphy’s Restaurant, was rounded off with tea, coffee and a vote of thanks by our President. Back at the hotel most retired to their rooms to see the life of the late Queen reviewed and revered on television.
Friday 9 September 2022 – Partners’ Bowland Tour; Annual dinner (at the Northcote hotel)
The eleven ladies had a free morning (whilst James Thomson enjoyed lunch in the centre of Blackburn, visiting its cathedral and admiring its stained glass) before being collected by their guide Katie and bus driver Karen.
Katie Wilson started her Bowland and Bay Artisan Foodie Adventures in 2021. She guides guests from the Fells and nearby coastline around the Forest of Bowland, an Area of Outstanding Natural Beauty, mixing a history of the region with ancient legends and wonderful food stories about local artisans who use local produce to provide amazing cheeses, ice creams from local herds, boutique breweries, and gin distilleries using fragrant botanicals. There are also top chef platters at fine country inns. The TSS ladies were regaled by Katie with stories of highwaymen and of Norse culture whilst they were being driven through the lush countryside of the Ribble valley past Longridge Fell, Dunsop Bridge, the Forest of Bowland itself, Ribchester, and Clitheroe. They stopped at Mrs Kirkham’s Farm Shop, developed during the pandemic lockdown to supplant the shutdown of deliveries to the hospitality industry. Here are produced award winning cheeses, bread and pastries, and pickles, all using local ingredients.
The lunch venue was a smart restaurant in the recently renovated Ye Horns Inn which served a taster menu of Tempura cod, chicken liver pâté, lightly crumbed Scotch Egg and falafel arancini accompanied by tasty chunky chips.
Soon they were on their way again, to the Wild Fox Distillery where four shots of differently-flavoured gin were tasted, produced using products foraged from the fields and hedgerows around the farm. Each visitor received a mini-bottle (5 cl, no less, no more) of Ivy’s Signature London Dry gin (Farm to Bottle ‘Copper pot distilled, Lancashire spirited’ and 40% ABV24) though there was also Blushing Vixen, the naturally cloudy Twelve Bore, or It’s a Rum Do (aged in seasoned oak for a year, allegedly the nation’s first). They then visited a beautifully perfumed candle outlet which also sold luxury goods. Before returning home there was time for tea and cakes in the Bowland Food Hall at Holmes Mill in Clitheroe, with more from the very best of Lancashire’s food and drink producers. Then it was back on the bus, returning to the hotel by 4 pm.
At 6.45 pm, all met formally dressed for the traditional TSS group photos. These were taken by our host Andrew Evans (at some personal risk, standing on a small wall) and by helpful hotel staff outside the Louis Roederer rooms (named for the link of the hotel with the Méthode Traditionnelle). Passing indoors, we had a champagne reception, courtesy of a legacy from Pat Stephens in memory of her late husband, the surgeon Major-General Robert Stephens, both TSS members. Photos from our May visit to Milan were displayed on a television screen.
We moved through for a magnificent Michelin-starred dinner in the company of our ten guests, preceded by a welcome from our President Linda de Cossart, two minutes’ silent reflection about our late Monarch, then the TSS Grace.
The meal for 37 (at four tables) was, in a word, magnificent – an imaginative creation of little-recognised components (each carefully explained by a gloved attendant, once our attention was caught) combining nouvelle cuisine with a wondrously subtle combination of flavours, and of course excellent wine. The menu (see Appendix) certainly needed explanation for most of us, and was a tribute to the Michelin starred chef Lisa Goodwin-Allen who had signed its cover.
The Queen’s death precluding any Loyal Toast, our host Andrew Evans addressed us, gently deriding the southern view – proposed by J B Priestley in his 1934 book ‘English Journey’ – that it’s Grim up North (as sung by The Jam in 1991). It clearly isn’t. Andrew was applauded for his recitation of northern towns. George Osborne’s Northern Powerhouse metaphor was being superseded by levelling up, rays of light and the focus on Blackburn. Non-members were invited to stand and toast the TSS – our visit symbolic of levelling up – and they happily obliged. For organisation Andrew awarded our Secretary 98 points out of 100 (two deducted for late submission of his meal preferences), praised the visit as a learning opportunity for working together and regaled us with the time when he was staying in southern Spain: the house help justified taking her evening off saying “Not to worry, another maid will interfere on my behalf”.
Andrew thanked his wife Kathy, all the speakers, the Northcote staff, those at the Education Centre of the hospital, and the coach company, ending with “Now to drink my red wine!” Our President Linda de Cossart thanked Andrew and Graham for all they had done, presented Kathy with flowers and there was a little something for Andrew. We then drank a Toast to ‘The Duke of Lancaster’.
This enchanting evening extended much later than usual, the last carriages leaving around midnight. For the TSS it was a very short walk to their rooms, safe in the knowledge that by contrast with that morning’s early start the morrow’s business was set back an hour, for a 9 am AGM.
Saturday 10 September 2022 – AGM; Visit to Stonyhurst College’s Museum and some Hot Holy Ladies with much stitching; departure
The AGM (with seven on Zoom too) concluded that Cork be explored as the potential venue for Spring 2023. Plans for Guernsey (7-9 September 2023) were in hand. Promotion of the aims of the TSS and its future were discussed (it might still have one beyond its 2024 centenary). The website would be re-jigged. There were two potential new members. The accounts were healthy.
The fifteen of us who visited Stonyhurst College, with its impressive Grade 1 frontage, were surprised at the circuitous approach to the site’s obligatory rear entrance which we reached by 11.30 am, receiving our ‘Visitor’ badges at Reception where we were met by our two guides for the morning, former teachers Jacquie and Anne. Saturday being a ‘working’ day we passed uniformed students of either sex and various haircuts in the endless corridor, past rooms such as ‘Games Master’ – or was it Master of Games? – with its relaxed occupants, and studious youngsters at their computers while others made their way to the hockey and rugby pitches (there was even an inflatable ‘indoor’ tennis court). We paused briefly in the ‘Do’ library to admire artefacts relating to achievements by College pupils and alumni, including a giant silk cloak, somewhat resembling a carpet, said to have once been worn by Henry Vlll. Why the ‘Do’ Library? This was apparently because each College success was once celebrated here by a ’do’.
Stonyhurst College has four main libraries: the Arundell, the Bay, the Square and the More: the More Library (dedicated to Sir Thomas More whose cap we could see in the Arundell library) is the main one for students while the others, the ‘House Libraries’, contain many artefacts from the Society of Jesus and English Catholicism. The Arundell Library content was presented in 1837 by Everard, 11th Baron Arundell of Wardour, and is not only a typical early country-house library transposed from Wardour Castle but also has a notable collection of 250 incunabula, medieval manuscripts and volumes of Jacobite interest, particularly Mary Tudor’s Book of Hours which may have been given by Mary, Queen of Scots, to her chaplain on the scaffold and will be mentioned again. There is a copy of the Chronicles of Jean Froissart, captured at the Battle of Agincourt in 1415, a First Folio of Shakespeare and ownership of the 7th- century Stonyhurst Gospel of St John (now loaned to the British Library).
Here upstairs in the Arundell Library our guides Anne and Jacquie introduced the formidable Curator Dr Jan Graffius, whose twenty years in post gave her authority over her mementoes, whether weird or wonderful but all fascinating. It seemed appropriate that Dr Graffius had contributed to the BBC’s ‘A History of the World in 100 Objects’. She shepherded us into a smaller room where we watched a twenty minute video (viewable on the internet) produced by Dr Graffius about Helena Wintour (1600-1668), the orphaned daughter of a proscribed traitor. She survived her close connections with the Gunpowder plotters and embroidered fabulous garments for secret Catholics, for which the penalty was death if discovered. The talented and learned Helena never married, but lived a long and fruitful life dedicating her legacy to the cause of Catholicism.
Stonyhurst’s most famous pupils, Arthur Conan Doyle and Gerald Manley Hopkins, were celebrated with some contemporaneous letters, and there was a newspaper cutting from the Sun (then a worthy broadsheet) about Queen Victoria’s Jubilee and another about the visit of Queen Mary (who sought
The Book of Hours for her personal collection, a request declined by the Vatican). Incidentally, Arthur Doyle had classmates whose surnames might sound familiar: Patrick Sherlock, Arthur Watson and the Moriarty twins. The Dark Walk in the College garden provided the setting for Sir Charles Baskerville’s fatal meeting with the famous ghostly hound. Dr Graffius denied that Doyle was expelled for opening an umbrella during a sermon by a phlegm-spewing chaplain (“a myth”).
First editions held here include Thomas Paine’s (1791) The Rights of Man Being an Answer to Mr Burke’s Attack on the French Revolution, A Defence27 of the Constitutions…of the United States by John Adams (1787), Contrasts by A WPugin (1836), The Hunting of the Snark by Lewis Carroll (1876), Prometheus by Robert Bridges (1887) given to Gerard Manley Hopkins, and Death of the Moth and other Essays by Virginia Wolf (1942).
We saw the skull of Cardinal Morton. Items apparently not on public view included numerous blood-soaked garments from Jesuits martyred in Japan, ropes used to quarter St Edmund Campion SJ, hair of St Francis Xavier SJ, and a thorn said to be from Jesus’s crown of thorns at his crucifixion.
Stonyhurst College now has students of any or no denomination, and was founded in Tudor times when Catholicism was not merely frowned upon but vigorously discouraged and persecuted. To practise it was to risk exposure and martyrdom, but its clerics and supporters persisted with the help of Catholic women who adapted and embroidered their own clothing to make religious vestments (‘chasubles’) with which to celebrate communion secretly. Those exposing them received a bounty of £300 (an enormous sum in those days) and were entitled to half the assets recovered from the victims.
The phrase ‘Hot Holy Ladies’ was first used as a sarcastic insult in 1602, aimed at an impressive group of strong-minded female supporters of the Jesuit Catholic mission. The Hot Holy Ladies exhibition examines the lives, circles and works of a selection of those influential and educated Catholic women who carried out remarkable acts of creativity and subversion in the early Tudor pre-Reformation period until the era of Catholic Emancipation under King George IV. The displays, open to the public since 8th July 2022, included five surviving contemporaneous chasubles, together with a sparkling one created with glorious sequins in 1961 to commemorate this Tudor period which was characterised by high-profile historical figures who shaped policy and national events, down to less well- known individuals who pursued extraordinary acts of religious defiance and cultural creativity in the shadows. Their stories are revealed through a remarkable array of artefacts, manuscripts and relics which we marvelled at and were allowed to photograph.
Our visit to the upstairs Museum was booked for an hour but was extended in true TSS fashion to 90 minutes, still not seemingly long enough. As we were leaving, Dr Graffius proudly demonstrated a circular silver container, never opened, containing Oculus dexter, the right eye reputedly secured from a Jesuit martyr after his execution (many had been hung drawn and quartered). The bony remnants of a distinguished hand and many other relics brought home much history and the harshness – for Catholics at least – of Tudor times. Anyone wishing to know more can search the internet for Hot Holy Ladies28 which is on the Stonyhurst College website. Our visit ended by one o’clock at Reception’s solitary toilet, and we dispersed home (once we found the exit drive) after one of the best home meetings ever.
Blackburn attendees
Stephen Chadwick and Margaret Linda de Cossart (President) Andrew Evans and Kathryn Peter Guy and Jane
Dimitri Hadjiminas and Kathryn Rachel Hargest
Joe Horner and Pamela
Rob Kiff and Carol Makins
Tim Lane
Simon Mellor and Alex
Barry Powell and Jill
Asha Senapati
Graham Sunderland and Anne (Honorary Secretary)
James Thomson and Kate (Past Secretary and Past President) David Ward
Mark Watkins and Janet
Tim Williams and Gail (Editor; Past President)
Appendix 1 – the Northcote menu
Tim Williams
Appendix 2 – The Alan Green motif
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(Andrew Evans)