Five Patients - Crichton Michael. Страница 18

Although the method of induction was primitive, it was not very dangerous. Profound anesthesia was difficult to accomplish and serious complications, Warren says, "were not commonly encountered."

Thus in a sense surgery has come a full circle, from the time when anesthesia opened new horizons to the time when anesthesia provides a serious hazard to operation. It is the kind of ironic twist that one frequently encounters in medical history.

A classic example of the full circle is the story of appendicitis. This is a very old disease-Egyptian mummies have been found who died of it-but it was never accurately described until 1886.

During most of the nineteenth century, surgeons were well aware of diseases which produced pain and pus in the right lower quadrant of the abdomen. Some attempts were even made to operate for the condition, by draining the abscess. But results were not encouraging and in 1874 the English surgeon Sir John Erickson said that the abdomen was "forever shut from the intrusion of the wise and humane surgeon." Note that pain was not a consideration here-surgical anesthesia was nearly thirty years old. Rather it was the fact that pus collections in the abdomen were not understood and did not appear to be helped by surgical intervention.

Twelve years later, an MGH pathologist named Reginald H. Fitz, who had traveled in Europe and studied under the great German pathologist Rudolf Virchow, published the results of an intensive study of 466 cases of "typhlitis" and "perityphlitic abscess," as the disease processes were then rather vaguely called. Fitz concluded that what the surgeon found at operation-a large area of inflamed bowel and widespread pus in the abdominal cavity-had resulted from an initial, small infection in the appendix. By describing "appendicitis," he created, in effect, a new disease.

The new disease was not readily accepted by the medical profession. Nor was Fitz's assertion that proper treatment required operation before rupture, instead of afterward. Today the idea of "operative intervention" is commonplace, but in Fitz's day surgery was generally the last resort, not the first.

Even after his clinical description of appendicitis was accepted, the surgical treatment remained a matter of dispute. In many hospitals, appendectomy was considered a bizarre procedure of questionable value. In 1897, when Harvey Gushing was a house officer at Johns Hopkins (after having interned at MGH and having seen several appendectomies performed), he diagnosed appendicitis in himself. He had great difficulty convincing his colleagues to operate; both Halsted and Osier advised against it. Finally, however, the surgeons gave in and agreed to do the procedure. Gushing did all the rest: he admitted himself to the hospital, performed the admission physical examination on himself, diagrammed the abdominal findings, wrote his own pre-operative and post-operative orders. It was said that he would have performed the operation himself as well, had he been able to devise a way to do so.

In the next few years, appendicitis became not only an acceptable but a fashionable disease; in 1902, it was diagnosed in King Edward VII of England, who was operated on for the condition. This signaled the onset of a great vogue for diagnosis and surgical treatment of appendicitis.

As a reasonably safe, reasonably simple abdominal operation, it encouraged surgeons to be more daring in exploring this body cavity. Their encouragement was not without its drawbacks, however: surgeons were so enthusiastic that nearly every bellyache was likely to receive an operation, and there sprang up a vogue for removal of ovaries and tubes in women, along with the appendix. The end result of this was the institution of quality-control checks on surgical procedures, through the "tissue committees" headed by pathologists.

Dr. Francis D. Moore has said: "[Fitz] was a student of pathology telling the surgeons to do more operations… How ironical it was that within thirty years it was to be the pathologists who applied the brakes to a surgical profession that was running wild with the operation for appendicitis."

Remembering Mr. O'Connor's case, it may be well to go into some of the differences, and some misconceptions, regarding the relationship of surgeons and internists. The two groups have never been too congenial. Traditionally, physicians have considered themselves more intellectual than surgeons. Descendants of Hippocrates, they look down upon surgeons as descendants of barbers. Surgeons, on the other hand, see themselves as action-oriented and regard internists as procrastina-tors, unwilling and unable to take action.

Temperamentally and philosophically, the two groups are at loggerheads. At mealtimes in the doctors' dining room, medical and surgical house officers can be heard berating each other about the care their respective patients have received. The surgeons say that an internist will sit hapless by the bedside and watch a patient die; the internists say that the surgeon will cut anything that moves. Most of this talk represents a time-honored outlet for black humor, but there is a long history of genuine conflict.

Dr. Paul S. Russell quotes the surgeon Sir Heneage Ogilvie in a most revealing passage:

A surgeon conducting a difficult case is like the skipper of an ocean-going yacht. He knows the port he must make but he cannot foresee the course of the journey… The physician's task is more comparable to that of the golfer… If he judges the direction and the wind right, estimates each lie correctly, finds the right club for each shot and uses it successfully, he will get an eagle or a birdie. If he makes a mistake he will make a poor score but he will get there in the end. The ground will not split beneath his feet, the game will not change suddenly from golf to bullfighting.

That was written in 1948. Six hundred years earlier, the French surgeon Henri de Mondeville set down his reasons for considering surgery superior to medicine:

Surgery is undoubtedly superior to medicine for the following reasons: 1. Surgery cures more complicated maladies, toward which medicine is helpless. 2. Surgery cures diseases that cannot be cured by any other means, not by themselves, not by nature, nor by medicine. Medicine indeed never cures a disease so evidently that one could say that the cure is due to medicine. 3. The doings of surgery are visible and manifest, while those of medicine are hidden, which is very fortunate for physicians. If they have made a mistake, it is not apparent, and if they kill the patient, it will not be done openly. But if the surgeon commits an error… this is seen by everybody present and cannot be attributed to nature nor to the constitution of the patient.

For hundreds of years, surgeons have been better paid than physicians. Internists will not be surprised to know how ancient is the surgeon's concern with fees. In medieval times, Mondeville was preoccupied with the matter:

The surgeon who wants to treat his patient properly must settle the matter of fee first of all. If he is not assured of his fee, he cannot concentrate on the case. He will examine superficially, and will find excuses and delays, but if he has received his fee, things are different.… The surgeon must have five things in mind: first, his fee; second, to avoid gossip; third, to operate cautiously; fourth, the malady; fifth, the strength of the sick man. The surgeon must not be fooled by external appearance. Wealthy people when they go to see a surgeon dress in poor clothes, or, if they are richly dressed, will tell stories in order to reduce the surgeon's salary… I have never found a man rich enough, or rather, honest enough to pay what he promised without being compelled to do so.

On the other hand, enthusiasm for operation is not an ancient vice of surgery, but a quite modern one. It was heralded by the development of anesthesia and antisepsis, both less than one hundred fifty years old. Operative restraint is still newer, a consequence of quality-control checks that are less than forty years old.

Mr. O'Connor was in the hands of the surgeons for two weeks. He was not operated upon; there was insufficient evidence of surgically treatable disease and therefore he received essentially medical treatment on the surgical wards. This is a far cry from the days when an MGH surgical chief resident told his staff (perhaps apocryphally): "Every person has at least three surgical diseases. All you have to do is find them." And it is a far cry from the days when the medical residents could accurately claim that surgeons didn't know how to read an electrocardiogram-and furthermore didn't care. In fact, there is a great deal of evidence that surgery and internal medicine are merging. It is a process that has taken several centuries, but today the cardiologists and cardiac surgeons work hand in hand, as do the immunologists and transplant surgeons; the tumor chemotherapists and the tumor surgeons; one need only look at the number of surgical house officers at the MGH who have done basic research in biochemistry and molecular biology to recognize the trend.

Bertrand Russell once said that we describe the world in mathematical terms because we are not clever enough to describe it in any more profound way. Similarly, surgeons and internists have come to see that surgery and medicine have the common goal of altering the functional status of tissues within the body. However, altering tissues with a knife is a relatively crude way of going about things; the finest surgeons are always the most reluctant to operate.

This is not to say that the scalpel will become a museum piece in our lifetime. Far from it. As surgery moves from a business of excision to a business of repair and implantation, it will be ever more important to the conduct of medicine. But the trend toward cooperation with internists, rather than competition with them, is likely to be extended as time goes on.

Indeed, the dramatics of the operating room have obscured the fact that most of the advances in surgery have taken place in terms of pre-operative and post-operative care. Modern surgery is immensely more complex than it was a century ago, but this complexity has more to do with electrolyte balances than with ligature points.

One can argue that in the last twenty years surgical advance has been largely dependent on para-surgical innovation, more involved with what goes on outside the operating room than with what goes on inside it. The paradoxical effect of this has been to increase the range and variety of services directed toward the operating rooms. Vast areas of the hospital are now given over to support and maintenance of a heavy surgical schedule, involving more than 16,000 operations a year. Two clear examples are Central Supply and the Blood Bank.