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“In 1908, Tan Tock Seng Hospital being better staffed, the wards were for clinical purposes thrown open to the students of the medical school, who were not slow in availing themselves of the opportunities offered to improve their professional knowledge by attending the clinical demonstrations and the operating theatre, as well as assisting in the dressings and clerking in the wards. ....” 

“During 1909, classes have been conducted in all the subjects of the curriculum, including ophthalmology and lunacy. .... Dr D J Galloway was on leave during the end of the short session and part of the long session. His place was taken by Dr F W Moore, who also gave part of a course on ophthalmology at Tan Tock Seng Hospital. Major E M Pilcher, RAMC, FRCS, DSO, conducted classes in systematic, clinical and operative surgery. To him and to Dr Finlayson who superintend the work of the students in the wards of Tan Tock Seng Hospital, the school is much indebted for their thoroughness and enthusiasm in teaching clinical surgery and medicine respectively. These gentlemen in superintending the clinical work of the fourth and fifth years’ students at a critical stage in their training, have set them on right lines, and have taught them a thoroughness of method which will be of the greatest assistance and advantage to them in their future careers. To all the teachers, the school is deeply indebted for their ungrudging devotion to their duties, and in many cases, for sparing to the school, valuable time, which might otherwise have been given to private work. .... ” 

A good deal of surgical work was done during 1910 at Tan Tock Seng Hospital, the number of operations numbering 583 (including dental operations). It was reported that: 
“Splenectomy was performed here for the first time in any number. The indications for the operation were: (1) trauma, and (2) great enlargement due to chronic malaria accompanied by pain, weight and discomfort. The weight of the spleens removed was from 800 to 3,000 grammes. The results are being watched; whenever practicable, the convalescent patient is taken on as a coolie in the hospital; at present there are three so employed. 
Spinal anaesthesia was introduced during the last six months of the year. Twenty-eight operations were performed under this method. 

Iodine disinfection of the skin for both major and minor operations was also introduced. The method is simple, labour saving, and in every way more satisfactory than the older method. Stitch abscesses are of less frequent occurrence, and for emergency operations, the advantages are obvious. The 2% solution of iodine in rectified spirit has answered our purpose quite well. ....” 
 
In January 1909, Freer was appointed Senior Medical Officer, Selangor, and in February 1909, Keith succeeded him as Principal of the medical school, and Dr S M Livesey was appointed to succeed Keith as Physiologist and Assistant Pathologist. 
In 1911, it was reported that: 
“the standard of teaching is now on a higher scale than when the school was established and with the addition of a second assistant to the principal and a surgical lecturer, both shortly to be appointed, one hopes that improved results will gradually ensue.” 

Regarding the General Hospital, the report stated: 
“It is to be regretted that the majority of the house surgeons arrive with no knowledge of tropical diseases; this combined with unavoidable ignorance of native languages forms a serious hindrance to their work, and sometimes militates against the satisfactory treatment of patients, time which might profitably be spent in acquiring the latter being devoted to learning the former. There is an increasing amount of work in this hospital and a supernumerary medical officer has been detailed here for duty when available. A third house surgeon is being asked for. .... The senior students of the medical school have been of considerable assistance under the direction of the Principal in the microscopic diagnosis of malarial fevers and other minor laboratory work. ....” 

Dr Livesey, who had been appointed a medical officer in December 1907, obtained the Fellowship of the Royal College of Surgeons of Edinburgh when he was on leave in England in 1911, and he applied for the post of Professor of Surgery in August 1911. He was informed that the post of Professor of Surgery had not been established yet. He resigned from government service on 31st January 1912. 

During Livesey’s absence, Dr G B McHutchison did his work and also acted as Lecturer in Surgery during the short term. This subject was taken for five months in the long term by Dr J Gray, Resident Medical Officer, Tan Tock Seng Hospital, who in his turn went on leave at the end of November 1911. The constant changes in the lectureship in surgery had naturally had a detrimental effect on the students. 
Dr J Gray, who had been appointed a Medical Officer in March 1909 applied in 1912 to be Lecturer in Surgery. The Governor’s reply to the Secretary of State for the Colonies on 8th May 1912 will be quoted verbatim in full as it paints a vivid picture of the times, of the practice of surgery in the United Kingdom then, and of the difficulty in getting qualified staff for the colonies: 
“Sir, 
1. I have the honour to acknowledge the receipt of your despatch No 38 of the 15 February last, transmitting papers of an application from Dr J Gray for appointment as Lecturer in Surgery in the government medical school at Singapore. 
2.  I have for some time had under consideration the question of the desirability of obtaining for the general community of this colony the services of a rising surgeon of proved ability and skill. The need for such an appointment has been urged in the public press here and I find that the unofficial members of the legislative council are unanimous in considering that such an appointment should be made as early as possible. It is recognised that to obtain such a surgeon as is desired it would be necessary to offer a salary of £1,500 or possibly £2,000 per annum, with the right of consulting surgical practice. 
3.  If such a surgeon could be obtained, his duties would be those set out in the enclosed paper of particulars in which, it will be noted. It is stated that he would also be required to perform the duties of lecturer in surgery at the government medical school, receiving the existing honorarium of $500 per annum for this work in addition to his salary. 
4.  I have caused the committee of the medical school to be consulted and understand that it is their opinion that even a salary of £2,000 would be insufficient to obtain the services of such a surgeon as is desired. The principal civil medical officer is of a similar opinion and doubts whether any assistant surgeon of one of the London hospitals with an attached school would come to Singapore on that salary. He adds that it might suffice to attract an assistant surgeon from one of the provincial English, Scotch or Irish Schools, or, failing such a man, perhaps one holding a surgical registrarship at one of the big London hospitals with a surgeoncy or assistant surgeoncy at one of the smaller outlying hospitals, who had given up hope of ever getting on the permanent staff of his hospital or who could not afford to wait longer. 
5.  If you approve the proposed appointment, I would ask that Sir Patrick Manson be requested to confer with Dr McDowell with a view to obtaining the services of such a surgeon on a three years’ agreement in the first instance. 
6.  As it may prove impossible to obtain such a man or may at any rate take time to do so, I would, subject to your concurrence, propose to appoint Dr Gray temporarily as Surgeon to the General Hospital, Singapore, to take also surgical cases at Tan Tock Seng Hospital. He should be allowed consulting surgical practice and a horse allowance. His pay should be that of his substantive appointment but while acting in this post he should receive a duty allowance bringing his emoluments up to £725 per annum, ie the same as those of an officer drawing the initial salary of a senior medical officer, viz £600 plus £125 duty allowance. He would also perform the duties of lecturer in surgery at the school and receive the honorarium for that work. 
7.  If such a temporary appointment is made, a medical officer would have to be appointed to Tan Tock Seng Hospital at a salary of £300 rising to £420 with a duty allowance of £100 per annum. 

These temporary arrangements would involve extra provision of about £275 over the amount provided for the medical service in the current year’s estimate.” 
Arthur Young 
 
When Dr J Gray, who was the medical officer in charge of Tan Tock Seng Hospital, returned from leave on 7 June 1912, he took up temporarily the duties of the new post of surgeon to the Singapore hospitals. 
This newly-created post of surgeon (specialist) was offered to Dr G D Freer, but he declined. The governor then asked permission from the Secretary of State to make the offer to Dr E D Whittle, who was then a medical officer in Penang. (He had been appointed a medical officer in December 1909). 

In November 1912, the governor proposed the creation of a post of surgeon (specialist) for Penang. 

The Secretary of State instructed the governor in March 1913 to offer Dr Whittle the probationary appointment of surgeon (specialist). He was to sit for the FRCS examination when next on leave in England. Dr Whittle accepted the probationary appointment as Surgeon to the Singapore hospitals. 
In May 1913, the post of Surgeon, Penang hospitals, was offered to Dr J Gray. This appointment was approved by the Secretary of State in June 1913. Dr Gray was also to serve a probationary period of one year just as Dr Whittle. 

The principal civil medical officer in his 1913 annual report stated: 
“Surgeons 
During the year, effect was given to the proposed 
appointment of 3 officers as specialists in surgery and who should undertake no other duties. Dr Whittle was appointed surgeon to the General Hospital, Singapore, and Lecturer in Surgery to the Medical School; Dr Gray, Surgeon to the Penang hospitals; and Dr McVail, Surgeon to Tan Tock Seng Hospital. Already sufficient time has elapsed to make evident the wisdom of these appointments ....” 

Dr McVail was the medical officer in charge of Tan Tock Seng Hospital, and he officiated as surgeon, Tan Tock Seng Hospital, as the post had not yet been established. Dr Whittle was also appointed Visiting Surgeon to Tan Tock Seng Hospital. 

Work increased considerably. The specialist surgeons were also visiting surgeons to the Hospital for women (Kandang Kerbau). In 1913 they performed three major operations there: An ovariotomy by Dr McVail and a complete hysterectomy for uterine myomata and a removal of carcinoma breast by Dr Whittle. The operations were successful. 

A third post of surgeon (specialist) was created in 1914, and was offered to Dr C J Smith, FRCSE, in August 1914, as surgeon, Tan Tock Seng Hospital. He was transferred from the Federated Malay States Medical Service. 
In 1914, 1,853 operations were performed at Tan Tock Seng Hospital as compared with 1,443 in 1913 and 941 in 1912. It was found necessary to use the waiting room of the old theatre as a theatre for minor operations. It was reported that the new theatre then nearing completion would obviate this and allow all operations to be carried out in suitable surroundings. 

At the general hospital, in the first, second and third class wards (“patients in these wards include Europeans, Eurasians and better class Natives”), 261 operations were performed. Operations in the native wards numbered 861. At the women’s hospital (Kandang Kerbau), 78 major and minor operations were performed. 
At the medical school, the following were lecturers of surgical subjects: 

Surgical anatomy,               TD Kennedy, MB ChB 
  anatomy and osteology 
Surgery                            ED Whittle, MRCS (Engl) 
Clinical surgery                 ED Whittle, MRCS (Engl)   CJ Smith, FRCS (Edin) 
                                        JR McVail, MB ChB (Glas) 
Ophthalmology                 FW Moore, MD (Edin) 
 
and the principal reported: 
“The teaching of surgery and clinical surgery is now greatly improved by the establishment of a highly efficient permanent surgical staff”. 

There was an unpredicted effect of World War I on surgical practice in Singapore. Indian sepoys in Singapore mutinied in January 1915, and Dr Whittle, then senior surgeon, and his wife were among those killed. 
As the result of the vacancy caused by the death of Whittle, the principal civil medical officer recommended C J Smith, Surgeon, Tan Tock Seng Hospital, to be senior surgeon, and that there be a new appointee as surgeon at Tan Tock Seng Hospital. 

(To be continued)