Discussion

The horse is in poor shape: he is head shy, he has epistaxis and you suspect guttural pouch mycosis. You need to endoscope his upper airway so you fetch your 1 metre rigid endoscope with its unreliable power connection and face the task of introducing it into the nostril of this difficult horse without breaking the endoscope, causing more damage to the horse or sustaining a personal injury. Unpredictable tranquilisers aren't much help. Perhaps you achieve your goal but the light connection fails. The vet in 1965 would have sighed in disbelief when told this could be done with a flexible instrument showing a high definition image on a TV screen with the horse reliably tranquilised. What about your private life? You are married with 3 small children and though your wife would like to work she is expected to handle the practice out of hours telephone calls for you. She can't leave the house all weekend because portable phones don't exist and communication with you depends on her telephoning properties you are visiting to intercept you, or chancing that you will call in from a phone box. She is also probably trying to feed the children and field more telephone calls simultaneously. She would have wept in disbelief at the concept of mobile phones.
These examples illustrate some aspects of the effect of technological developments and there have probably been more changes associated with new technology since I qualified in 1968 than in any other period in the history of the profession. Graduates of the last 20 years may not appreciate that many facilities they take for granted and expect to be available just didn't exist in the sixties. Some developments relate to management changes that affect our way of life and how we run our practices, but most relate to technology that has transformed the diagnosis and treatment of our patients. There is a third strand that has also had impact on how we treat horses: the introduction of scientific journals such as Equine Veterinary Journal has offered opportunity and encouragement to perform and publish research and alongside this we have developed a more critical attitude to our clinical work.

Handwritten ledgers and accounts have been replaced by press button computer administration systems and the communications revolution has utterly changed the administration of the vet's day. Change brings its problems. As one of the first equine practices to computerise we experienced the tribulations involved in embracing new technology which at one time ground our practice administration to a halt (7 months behind with the monthly bills!). It was some years before its benefits, now so obvious and all embracing, seemed worthwhile to us. In 2012 the advantages of computerised practice management and the use of the internet are axiomatic.
Forty years ago the diagnostic armoury we now expect to use scarcely existed. Ultrasonography, fibreoptic endoscopy, scintigraphy, magnetic resonance imaging, computed tomography were mostly unavailable to the veterinary profession. Veterinary practice has to be commercially successful and many of us have not shied away from investing in these expensive technologies. There is always the temptation to use them because clients are impressed or because they bring business, and of course using them pays for them; however, we do have a responsibility to evaluate them critically, not only to validate their findings but also to ensure that using them rather than not using them has benefits for the patient.
Although many veterinary surgeons were very skilled at manual assessment of the mare's genital tract, it was still fraught with inaccuracies. Apart from being a spectacular revelation to practitioners, the introduction of ultrasonography in the 1970s gave us diagnostic abilities that have transformed the management of breeding mares. It remains a major diagnostic tool in stud practice where its value is proven. The evaluation of soft tissue injuries, especially the more subtle tendon injuries, was at best imprecise and diagnostic ultrasound was soon applied. Increasing sophistication of the machines has allowed more detailed diagnosis and measurement of tendon and other soft tissue injuries not possible previously. The ultrasonographic anatomy of many regions of the body has been established but artefact still confuses even experienced ultrasonographers so caveats remain. Validation of diagnosis in the absence of post mortem evidence (soft tissue stifle lesions for example) is still a problem that may take some years to elucidate and we should continue to question the images we see.

The fibreoptic revolution has changed imaging in equine medicine from almost no visualisation of body cavities into a visually satisfying experience. How rewarding it is to show the client the lesion in those once mysterious spaces such as the upper airway, bladder or stomach. In 2012 there is hardly an equine cavity that has not been examined endoscopically and the value of fibreoptic endoscopy is self evident.
Don Attenburrow, a practitioner from Exeter with a taste for research and an inquisitorial nature which we should all wish to emulate, was the pioneer of equine scintigraphy in the UK. We were his first disciples in the late 1970s in using a hand-held probe he devised in the physics laboratory at Exeter University. Standardisation of readings was a major difficulty, much improved when about 15 years later Rob Pilsworth devised a recording system linked to a computer programme. Gamma cameras have followed and are practically standard equipment in UK equine hospitals. The potential overuse of scintigraphy in equine practice is under scrutiny, especially by insurance companies, and this is a good example of the importance of clinical research to refine our deployment of a diagnostic tool.

Magnetic resonance imaging in terms of its physics, as well as the expertise needed to acquire images and interpret them, is in another league beyond scintigraphy and the rush by practices to board the bandwagon without adequate training has jeopardised its reputation. Standing low-field units have improved and are proving to be a useful tool for distal limb lesions. In the right hands they have been shown to compare well enough with the high-field magnet where their advantage of use in the standing horse outweighs their disadvantage of less detailed image quality. Validation of findings is even more critical than with scintigraphy and there is a fitting quote from the Irish Prime Minister evaluating progress after the credit crisis: "much done, more to do!"

In the surgical field fibreoptics enabled the development of minimally invasive surgery, another exciting and dramatic development at the time. In the early 1980s we operated through direct viewing which was an uncomfortable and tiring procedure. When monitors were introduced hand-eye coordination had to be relearned but they allowed the development of a great range of more sophisticated procedures. Arthroscopy is now embedded in the surgical repertoire and is indisputably the treatment of choice for many conditions. The kudos attached to arthroscopy may drive the ambitious surgeon to attempt procedures beyond his or her capabilities, possibly to the detriment of the patient, and we have a responsibility to look at our outcomes. There is a need for a proper comparison of outcomes between endoscopic and open surgery for procedures where there is doubt, and for individual surgeons to show that their results meet the expected standards.
A laparoscopy was in fact performed in the 19th century using an open flame as a light source but real progress wasn't made until fibreoptics and powerful light sources were developed. Those of us performing laparoscopy in the 1980s had little guidance and progress was slow at first. Though one of the most difficult surgical skills to acquire, it has found a place as a diagnostic tool and as the received treatment for ovariectomy and cryptorchidectomy to name two. For some human laparoscopists in the 1960s ambition overtook competence; we should avoid this situation by ensuring that we learn the skills required and properly establish that each laparoscopic procedure does have advantages over open surgery.
In 40 years clinical practice has become a different being. The clinical examination is still its backbone but we hope that the lot of the horse has been improved by the diagnostic and surgical repertoire new technologies have given us. Our responsibility is to educate ourselves in their use and to evaluate their outcomes, and what better quote encapsulates the latter than Lord Kelvin's famous comment "To measure is to know".