The Surgeon’s Religion
SINCE THE PERSONAL ESSAY has become quite outmoded since the days of Charles Lamb, William Hazlitt, and Robert Louis Stevenson, my situation is precarious. Now, for the first time in its thirty-five years, the Texas Surgical Society has decreed that its president shall deliver an address. There were no instructions as to form or content. A scientific discussion was unwanted. A personal, perhaps philosophical account of a surgeon’s religion seemed to be desired.
Let us consider what impels us to choose our calling, what spurs us on to excel in it. What makes us proud of it and happy to spend our lives as it votaries and how we develop the personal and professional qualities that make us most useful in it. The diversity of individual experiences is infinite but there must be a common core of basic thoughts and impulses. How many of this group remember their first ideas on choosing the surgeon’s life?
I well recall when I was a fifteen-year-old boy in a little west Texas town – one Sunday afternoon a Mexican murdered a Mexican woman. A ranger who had just returned from a deer hunt shot him through the upper left arm as the murderer raised his rifle to shoot at him. The soft-nosed rifle bullet almost tore his arm off. I was one of a crowd of boys who followed him to the jail. Only two doctors were available that afternoon. I heard one say that they needed some help badly. With more gall than sense I asked him if he would let me help him, and he said he would. On the kitchen table in a jail, with a very awkward but intensely interested young assistant, he amputated an arm. I even remember how he teased me about not taking off a ring when I started to scrub. From that day I had no other thought about how I wanted to spend my life. The man who gave me this inspiration has been a highly respected and useful practitioner to this day and is here as my guest tonight. I would like to pay personal tribute to Dr. J. S. Anderson of Brady.
This early conviction and fixed purpose was fortunate as far as my own peace of mind was concerned and though I have had, like all of you, many disappointments and regrets, not a day or an hour has been a time of doubt or misgiving about the way of life I had chosen. This has been an incalculable privilege for which I am grateful.
When from our viewpoint a boy is fortunate and intelligent enough to wish to be a surgeon and finds when he is started in his hospital training that he in not too awkward to master the basic mechanical skill required and begins to think about his future development and to observe the men he works with who are mature and consciously and subconsciously make an appraisal of their abilities and skills and weigh their attitudes and characters, he begins to deliberately attempt, first to be an individual in his own right , in a new and wonderful world and to try to imitate and cultivate within himself the qualities of the surgeons he considers great.
In his early months, as second or third assistant, he closely watches every move of his preceptors; how they handle knives, scissors, and hemostats and decorates the head of the simple iron bedstead in his monastically severe internes’ quarters with thousands of knots in catgut left-overs wheedled from the operating room supervisor who has seen such eagerness before and is glad to keep the flame alive. Then he begins to have some insight into what is being done and why. At this stage he is apt to be severely critical until he begins to acquire a little understanding. He is certain that most problems are simple and ought to be quickly and correctly solved and some of the errors he sees seem to him senseless and needless until he progresses to a little responsibility. By the time he is a resident, he has learned that sometimes the solution is not so clear-cut when it is up to him to work it out. Before long, he begins to believe that fellow ex-resident with Dr. McNealy of Hannibal Missouri, Mark Twain, was right when he said about his father that the old man seemed a lot smarter to him when he was twenty-five than when he was eighteen.
If he is fortunately adept and naturally gifted by the time he is well along in his residency he has mastered and put into his subconscious the mechanics of surgery which, though relatively simple, are never really acquired by some men. Until he has done this and does not have to think consciously about these matters, he is in the position of the bewildered centipede about which Foster Kennedy quoted a poem to this Society many years ago in San Antonio:
The centipede was happy quite
Until a toad in fun
Said “Pray, which foot comes after which?”
Which worked her mind to such a pitch,
She lay distracted in the ditch,
Considering how to run.
If he is to grow into a master surgeon he must not only begin the accumulation of a great store of scientific knowledge, early learn and assiduously cultivate gentleness and care in handling tissues, and, most of all, to learn to see the salient points in a patient’s history and physical findings, correctly size up a situation, create a concept of what must be done and get at doing it with the greatest directness and simplicity possible. Stone walls do not a prison make nor fancy instruments and gadgets a surgeon. One of the greatest surgeons I ever worked with once when a suture nurse asked him what he wanted, said, “A knife and a piece of string.” I have seen Dr. McNealy work on several occasions, and one of his former residents who is a guest here tonight told me he could do a thyroidectomy, for example, with less fuss and forceps by two-thirds than most men. This is possible only because of a long and exacting study of anatomy, getting in trouble a few times and learning the hard way how to stay out of it, proper recognition of structures and tissue planes and appreciation of the fantastic distortion of normal relations that numerous pathological states can bring about.
The poet Wordsworth once wrote about the literal-minded person:
The primrose by the river’s brim
A simple primrose was to him
And it was nothing more.
The possession of imagination is a rare asset in diagnosis and a young man who has been given it by nature and has not had it crushed and discourage by his traditional rigid exact scientific training id fortunate indeed. He will in his salad days when he is green in judgment doubtless put forth some ideas that may provoke well-deserved caustic comment from his elders but youth is the flowering time of ideas and opinions and he should cherish and nourish his imagination as far as he is able all thought life though he will gradually learn that while honest opinions are usually worthy of respect they must not be confused with facts.
During his eager, busy, and happy resident days he deals with ward patients, has all he can do, grows in grace and stature, and within limits is like Alexander Selkirk, “monarch of all he surveys.” Then suddenly it is at an end. Thomas Paine, when he wrote the line “These are the times that try men’s souls,” might well have been thinking of the young man just out of training and beginning practice.
In the exasperating tedium of idleness the thought “To rust unburnished not to shine in use” recurs. Here is truly the formative period of his professional life. “One ship sails East and another West though the selfsame breezes blow.” Here is the rare chance to begin the habit of wide and voracious Journal reading which, once established, will probably never be given up. Here is the opportunity to begin a habit of writing, utilizing some of the material from his recent resident days or a good case report from his early practice.
The you man, conscious of ability and hungry for surgical work will early be offered operations of doubtful legitimacy and may tempted by seeing a few surgeons in action who, if he knows his Lewis Carroll, will remind him of the little crocodile.
How doth the little crocodile,
Improve his shining tale
And pour the waters of the Nile
On every golden scale.
How cheerfully he seems to grin,
How neatly spreads his claws,
And welcomes little fishes in
With gently smiling jaws.
He will be besought by psychicly distraught females with pains in their abdomens and ovaries whose husbands and former doctors don’t understand them and will undoubtedly make a few first scars or add one more to a collection of several before he realizes, if I may paraphrase holy writ without irreverence, that the fear of the neurotic’s abdomen is the beginning of surgical wisdom.
Some such experiences every young man must have for himself but if he is right thinking he will profit by them and gradually realize that, people being what they are, he will have to spend a good deal of this time talking them out of operations which for one reason or another they think they want or need but which he know in his heart cannot benefit them.
He should become aware of the stigmata of the patient who wants to be operated on and is “out of bounds” surgically. This attitude does not at first promote a rapid building of a surgical practice but it builds very surely a good name with patients and fellow doctors, a good conscience in our young man and ultimately, if his ability and energy justify it, a high professional standing.
The surgeon works with perishable material. Michelangelo’s David the Parthenon, and Leonardo’s Mona Lisa have endured and been admired for centuries. The most brilliant surgical triumph like the scriptural grass is cut down and withered by the passage of a little time but personal satisfaction can endure only for a lifetime and it is hard to imagine anything more soul-satisfying than saving the first baby for two fond young parents by a simple Rammstedt operation, or in the middle of the night seeing the laboring man father of a large family with a strangulated hernia vomiting feces and recalling the lines of Sir Thomas Brown in “ A letter to friend,” “In the king’s forest the trees that are to be cut down the woodsman first marks with a broad arrow,” recognizing the broad arrow on the poor man’s forehead, rescuing him and returning him to his family in a few days. Though what we do for people is soon gone, a few surgeons, if they are fortunate and gifted, may contribute basic original ideas and techniques that make them justly honored by their contemporaries and successors but most of us can only aspire to useful active workaday lives.
That all of us will have many failures and make many mistakes is self-evident. I think I have had more mental anguish over errors in judgment than anything else. I vividly recall nearly twenty-five years ago a poor, gentle trusting negro woman with a huge pelvic abscess that in a moment of mental aberration I opened above and realized at once she would die of peritonitis, which she promptly did, and that I could have saved her with a simple colpotomy.
We can recall such examples of tragic errors but we should be our own severest critics and if we ever sense that we are becoming complacent about our daily efforts, unless we take ourselves in hand, we are surely on the down grade. If it were not that, after a proper period in sackcloth and ashes, nature had given us the power to forget, we would hardly be able to carry on. It is our solemn obligation to see that our mistakes are of the head and not of the heart and to try to steadily sharpen our thinking powers and season our judgment.
A wise old doctor in my younger days when I was impelled to do some desperate operation which probably could lead to little good for the patient, used to say, “Son, let them do their own dying.” It was sound advice then and still is to a degree, but, of course, all of us well know we can undertake many things now with comparative safety that were forbidding risks fifteen years ago. I think no surgeon should lack the courage to do anything desperate that he believes in his heart offers a reasonable hope of salvaging a patient from intolerable suffering or perhaps restoring him to a happy and useful state.
We will all be confronted with the consideration of extremely radical efforts to control or cure malignant neoplasms. First a surgeon should ask himself if he is competent to undertake such a procedure. Then, after frank discussion, he must try to decide if the patient can hope to be even tolerably content with his mutilated state, such operations as pelvic evisceration with ureteral transplants and a wet colostomy for advanced carcinoma of the cervix, resection of a massive stomach or colon lesion with a liver full of tumor or hemipelvectomy for a melanoma of the sole of the foot are examples of what I mean.
These decisions are hard and two men of equal ability and sincerity may feel differently about them. I think we should tell the patient what we think and why and if the patient wishes I and we believe it should be done we should go ahead fearlessly. Here, as in every situation in life, there is no substitute for integrity and if we quibble or cut corners with ourselves in our own thinking we are not the men we ought to be.
The demands on the modern surgeon who aspires to be conversant with the whole field of surgical knowledge are overwhelming and if he yields himself to the will-o’-the-wisp of pursuing this end to the total exclusion of other interest like the poor German scholar pedant who devoted a lifetime to the study of the use and construction of one word an on his deathbed voiced the regret that he had not confined himself to the dative case, some of the qualities of graces that make a personality interesting and stimulating and which add charm and zest to living are bound to atrophy.
Mr. James Parton, a biographer of one of our greatest Americans, Thomas Jefferson, said that Mr. Jefferson at thirty-two, only months before he wrote the Declaration of Independence, could calculate an eclipse, survey an estate, tie an artery, plan an edifice, try a cause, break a horse, dance a minuet , and play a violin. Mr. Churchill, whom I regard as the greatest man of our times, has been a journalist, polo player, solider, naval administrator, scholar, historian, painter, dauntless prime minister, and the most stirring orator I ever listened to.
Certainly none of us can become a Thomas Jefferson or a Winston Churchill. But if, in addition to a steady and compelling interest in the progress of knowledge in the fields of our daily efforts, we remember that such great qualities as we may hope to develop in ourselves are more likely to bud and flourish if we seek out and maintain a wide interest in general knowledge and the people and event about us and become, if we can, in the words of the mighty Ulysses “part of all that I have met,” we will have much fuller lives an be better able to give our patient that “something else” beyond skilled and competent professional service that lift up people in distress when they are in dire need of support. My old professor, William Lyon Phelps, once said, “The happiest man is the man who has the most interesting thoughts.”
Every child has the amazing quality of wonder. If in maturity we can maintain a daily wonder at the collateral circulation of the stomach, that a fine catgut strand tears easily through a muscle that can lift hundreds of pounds, at the earth history apparent in the exposed rocks with even an amateur knowledge of geology, of the way a serpent on a rock, the way of a man with a maid or the red giant Antares and Betelgeuse in the constellation of the Scorpion and Orion, we have within ourselves a wellspring of interest and pleasure.
Certainly, I have no thought of assuming a “stuffed shirt” attitude and lecturing you on what you should be. I will never attain, nor will you, all the qualities of character we may severally think desirable but as a man thinketh in his heart, so is he. There is a natural reticence, quite normal I think, in discussing our personal feelings about our innermost thoughts and ideals. Mr. Kipling, speaking of quite a different set of circumstances, said, “These be things a man would hide as a general rule from an innocent bride.” But this is a very special occasion, the first of it kind this Society has ever had, and I feel it can do us no harm to pause and consider a little the fundamental principles we ought to live by, certainly without ostentatiously flaunting them elsewhere, perhaps rarely mentioning them publicly again even in a gathering of like-minded men such as this.
The surgeon is a man apart. He deals with precious though perishable material. His responsibility at times is crushing. He is confronted with many unexpected problems that tax his wisdom to the uttermost, and he can only hope to solve some of them correctly by accumulating a deep store of knowledge from experience and reading. All too frequently he knows at a glance that he is helpless. Too often he must make a decision that is without recourse. His simplest laparotomy carries the hidden threat of fatal embolus. Some of his tragedies, particularly if he feels they are of his own making, leave him desolate. But if he has the courage he ought to have to be worthy of our calling when he meets disaster, he will recall the words of Johnny Armstrong in the old Scotch ballad talking to his company of soldiers, “Fight on, my lads, I’m wounded but not slain, I’ll lay me down and bleed awhile and then I’ll rise and fight again.” He should not be morbid or self-centered about his possible troubles.
After all, living is a very dangerous business and very few of us get out of it alive. No man worth his salt is too much concerned about himself. He should be cheerful and resourceful and the rare words of the late Colonel John W. Thomason, speaking of the fighting preacher from Brenham, Praxiteles Swan, of Civil War fame, “Humble before God and brash in all other relations.”
If a surgeon is first a doctor and offers his people in trouble the support, encouragement, and solace a good doctor should give, if he tried to live so that he may hope that the line, “Integer vitae scelerisque purus”, may fit him, if he is diligent and persistent in his efforts to improve himself and the first to realizes limitations and errors, if he never fails to face up to the responsibility that is and should be his, if he is eager to help the younger men about him and pass on whatever sound ideas he may have, if he is tolerant and understanding of his brother surgeons’ shortcomings as he hopes they are of his, if he has fierce and instinctive personal and professional integrity, and is humbly grateful in his own way to his Creator for whatever talents for usefulness may have been give him, I think he may hope to come to the end of the road serene, proud and happy to have spent his life as a surgeon.