CHAPTER II In the later eighties, I had about determined to make my (Part 1)

CHAPTER II In the later eighties, I had about determined to make my work exclusively surgical. Some of the leading surgeons in New York were asked their opinions of the plan. There was no surgeon in New York at that time who did not add a con- siderable amount of general medical practice to his work, and I was the first one in New York (probably in the whole coun- try) to determine to give up all general practice. Dr. Stimson told me that he had always considered surgery-exclusively to be an ideal sort of practice, but he did not dare to give up general practice in addition. Dr. McBumey said that some of the most interesting part of his work was with families who depended upon him, and that he doubted if any one could devote himself wholly to surgery. Dr. Bull said, "That would be very interesting, but you will have to get your bread and butter out of medical practice, taking such surgery as gradu- ally comes your way." Dr. Bryant said, "In my opinion you cannot gain the confidence of people sufficiently to get surgical cases unless you first secure their confidence through successful medical practice." Dr. Charles Phelps said, "It will be many years before your time could be filled with surgery. There will be some consultations with men of your own age, and they will also ask you to do some surgery, but they cannot have the class of practice that will furnish an income sufficient for your support." Dr. Fluhrer said, "I would like to devote 55 56 TO-MORROW'S TOPICS myself to surgery, but those of us who are engaged in that work are not fully occupied with it. The work is so divided that we are obliged to take general medical cases." While considering seriously this advice from men who stood among the first in authority, and gradually finding that my surgery, if properly studied, really filled all the time, particularly if experimental work were done, the idea of the desirability of doing nothing but surgical work continued to grow. A climax came one night when I had been up until four o'clock in the morning on a parturition case and had a difficult gall-bladder operation to do at nine o'clock in the morning. It was done rather badly and tediously. From that moment the decision was made never to take another medical case of any sort again. This was in the latter part of 1889. How times and customs have changed since then! Hundreds of men are now devoting themselves exclusively to surgery in its different branches, to the exclusion of all medical work. As late as 1889 at least, only one man apparently believed that it could be done. Had I cared for the financial part of the work or had there been a family to support it would not have been a safe procedure, but it made very little difference then whether my income were one thousand dollars a year, or fifty thousand a year. For that matter I have seldom cared since that lime about income in any personal bearing, because there is as much fun and work to be had upon three thousand dollars per year as upon thirty thousand per year. Hav- ing experienced both of these incomes, I feel competent to express an opinion. The desire for large income is a little vanity trick of nature's, which she plays upon us in order to keep us evoluting without regard for any discomfort to which we may be subjected in this matter. I have always looked Up into nature's face. laughed, and winked one eye at her. [ She made no response. We understood each other. Some- TO-MORROW'S TOPICS 57 times, for days at a time, my work would be at the Academy of Medicine Library, disregarding practice and being out of the office during office hours. It was my belief, — ^which was correct much of the time, — ^that nobody would come in. That was very wrong. A yoimg man should have a definite office hour, and always manage to be there, particularly during the very earliest days of practice. It is far more important then than in the later days, when people feel they are not sure to live unless they succeed in getting a certain doctor to look after them. In the early days of practice a number of friends in the profession in the smaller communities at a distance from New York would occasionally send for me. Trips requiring an entire day of time for a fee of perhaps twenty-five dollars beyond expenses, were often taken. Sometimes I did not even get that fee when cases had been cared for on the ground of their being interesting and valuable in the way of experience. At times it happened that even small fees were not collectable, and occasionally railway fares and expenses had to be paid out of a pocket that needed to be securely stitched at the bottom in order to prevent a single dime from slipping through. Young men with ready-made incomes buy easy chairs. In those days surgery was done chiefly by two different classes of men. Practically all of the pathological surgery was done by masters, who had given themselves opportunity of position in order to perfect themselves in operative work. The general practitioner confined himself to emergency cases, and to certain kinds of ordinary work not requiring the technic of an expert. Since that time we have entered a transition stage. Hundreds of small hospitals have been erected in various parts of the land, and this fact as a funda- mental general proposition stands for progress. Simul- taneously with this development of the small hospital, several traits of human nature came strongly into evidence. A certain 58 TO-MORROWS TOPICS prestige is popularly supposed to inhere in operative work, although this is a mistake belonging to the present crude stage of our cultural period. In response to this popular misconcep- tion at least one half of the men on the average hospital staff feel it incumbent upon them to obtain the eclat that goes with operative surgery. Two results follow. Here and there a man of great natural talent and mechanical ingenuity becomes ascendant and a valuable addition to the ranks of surgery, but most of the operators, reaching their limitations quickly, bring discredit upon surgery as a whole. My good friend the late Dr. Maurice H. Richardson said it was a misfortune that so many people recovered from surgical operations, no matter what was done to them. It is the morbidity rate, rather than the mortality rate, upon which we are to fix attention when a question of the present day abuse of surgery is under dis- cussion. The mora! side of the question seems to me to be this: Anyone who has passed State requirements may have a right to take up surgery, provided that he gives himself the best preliminary training within his power before attacking pocket books, knife in hand. His duty is, then, to devote him- self closely to the subject, with elimination of all other work as rapidly as it lies within his power to do so. and with no inten- tion of continuing to do other work in connection with surgery. Even this assumes that the question is to be worked out along lines of natural competition, but the state should take charge (to a far greater extent than it has done up to the present time. ■fae state should standardize the surgeon. The state is the ief sufferer from the present-day abuse of surgery, and if 3ie matter is really taken in hand in a modern way laws may : enacted which will require years of apprenticeship on the «rt of anyone who is to engage in operative work. The state till prescribe his course of study and of technical training. yCembers of the medical profession, like all other organic \ t m gica TO-MORROW'S TOPICS 59 objects when left to their own inclinations, follow the natural laws of competition, — with the pubHc as chief victim in this The chief victim, awakening to a realization of condi- tions, will probably place surgery again in the position which it occupied thirty years ago, in so far as it relates to individuals who are to do special work. No one can realize how much time, pains, mistakes, imag- ination, mental distress and money have gone into the making of an experienced surgeon. Part at least of these things are avoided by men who are now swarming into surgery for the reason that they have not been able to keep up-to-date in the course of the rapid evolution of internal medical practice. The men who have been "drifting into surgery" in shoals are the ones who lack the skill and knowledge requisite for doing new high-class medical work. The surgeon must not only learn at the outset of practice if he is really equipped by nature for becoming a surgeon, but he will be obliged to learn by self-analysis the particular sort of surgeon he is likely to become. Is his forte the dis- covery of basic problems and the formulation of principles? Then research work of philosophic character will engage the latent tenths of his brain capacity. Does his mechanical talent make him the skilled technician by nature? Then skilled tech- nician he will be in the end. Is he an essayist who makes critical analysis of surgical principles, as he notes their appli- cation to pathologic findings, and records his observations in the field of applied surgical science and art? Then he will be a publisher of contributions for the benefit of his colleagues. His mind may have scope sufficient in degree for comprehend- ing all of these features of surgery, but time limitation will confine him rather closely to the development of those natural personal talents which belong in some particular field of sur- gical work. If he has a generalizing type of mind and organ- 6o TO-MORROW'S TOPICS izing ability he may depend upon assistants to work out (under his direction) most of the features of a full surgical training, excepting those of skill and technic, which are peculiarly per- sonal matters. Is his interest one of pecuniary nature, and desire for fame? Then he will make neither forttme nor fame, for these are incidental to the recognition of his ability on the part of his peers. In the pecuniary interest class we find what might be called a rather unsatisfactory group of men who add surgery to general practice. Their hearts are not so much in the progress of surgery as in the economic progress of themselves. We find some very excellent sur- geons in this class, to be sure, because personal interest is a stimulant of primordial origin and no mean degree of power. I have asked perhaps fifty members of my class at the Medical School about medical conditions in their own towns. The reply has been almost a stereotyped one. "Everything is all wrong in our town. Almost every doctor thinks he is doing surgery but no one is devoting himself to the subject in such a way as to become properly trained and informed." I asked a clever surgeon in a city of about one hundred thousand inhabitants about the present conditions in his local- ity. He replied, "two or three of us who have taken the trouble to prepare ourselves for surgery have all that we can do, but that represents only a small part of the surgery that is being done in this town. By far the larger part of the operating is in the hands of men who don't know when to begin nor when to stop with a case." A breezy doctor all full of ideas came into the office one day to discuss some of the features of my clinic at the College, and his conversation ran something as follows: "Say, your work is all right, but you ought to see Joe Price of Phila- delphia. He uses fine silk for ligatures, and it will hold better than your catgut, beside being safer in many ways. His sue- TO-MORROW'S TOPICS 6i tion drainage is more dependable than the drains which you employ in abdominal work. He is a wonder ! He has had a run of more than fifty pyosalpinx operations without a death. When I get back home I am going to do a lot of this work — lots of cases of that sort in my part of the country that are neglected because no one has taken the trouble as I have to get out and run arotmd to see you men at work. I am going to get a hospital started in our town, because it makes things easier and better for patients and doctors." Some four or five years later we again met at a society meeting, and my friend was asked how he was getting on with his abdominal surgery. He looked surprised for a moment and then said: *'Oh, I am in pediatrics." My response was: "How is that? You told me of the inspiration of watching the operations of our Philadelphia friend and you were going to carry his ideas into your work." To this he replied : "Now, say, that fellow is a faker, and I am sure of it. Don't you believe for a minute that he had fifty pyosalpinx cases without a death. Why, it just can't be done! Look at all of the adhesions that interfere with doing the work, to say nothing of peritonitis. I tried three cases. In the first one I got into some kind of a bowel before I had hardly begun the operation. The next case turned out to be one of cancer, and you couldn't tell the difference before getting in and doing a lot of damage and no good. Think of having to tell the family! The third case was absolutely inoperable, but I opened the main abscesses and the patient got well in about a year. Whew! No sir! It's pediatrics for me, and I don't take any stock in these reports about fifty pyosalpinx cases without a death. It can't be done unless you select them to make a showing, because a good part of them are inoperable anyway on account of ad- hesions, and nothing is said in these reports about cancer and ovarian abscess and appendicitis and things like that turning 62 TO-MORROW'S TOPICS up, when the signs are all those of pyosalpinx before you begin." Men may unconsciously deceive themselves in regard lo their motives when engaged in general practice including surgery. One of my family-doctor friends who has a first rate natural gift for surgery said on one occasion: "1 do not do any surgical work excepting for those who cannot afford to employ experts." At another time, forgetting his first expres- sion of opinion, he said. "Surgical cases that I get here are about the only ones that bring in any ready cash." These two statements are somewhat conflicting. The man who made the conflicting statements is one of my ideals in the way of a high character with honest conviction. Under no circum- stances would he attempt to deceive or to mislead anyone else, yet he was deceiving himself, because the two motives had become inextricably mixed without his conscious knowl- edge, Ahhough he is a man of strong and competent will, the ties which bind him to his clientele in general practice are such that he has not quite sufficient will for severing these ties and devoting himself exclusively to surgery, which he would do exceedingly well. His generous and gentle ways and delicacy , of sensibility have endeared him to so many people that he I cannot think of breaking these ties. Under the circumstances n only do surgery "pretty well." Doing surgery "pretty does not suffice when human life and happiness are at mistake at the present time for men who are engaged medical work to attempt to do surgery, unless expert is not to be obtained. Surgeons who are engaged cial work exclusively never feel that they have Jiing like perfection. Human life and happiness direct connection with the degree of perfection d by a surgeon. Hardly a week passes that some TO-MORROW'S TOPICS 63 case does not appear in which I would like to try that case over again just once. Lord ! how we would like to "do some cases over again just once" ! Hardly a month passes that I do not keep somebody in bed too long because of some fault in technic or because of shock due to unnecessary time expended at the operation. A more expert operator would have done the work more quickly or efficiently. Sometimes a life is lost, or some permanent defect left which would have been avoided had I known just a little more. Some of my patients are not relieved as they would be were someone else in charge of their cases. One may divert his attention frpm surgery for purposes of recreation — that is desirable indeed — ^but for purposes of mingling thought of medical cases with thought of surgical cases — No ! One of my friends who does occasional surgical work along with general practice is not particularly talented in surgery, and never would do really fine work even though he were to devote himself wholly to the subject. He has built up a very good general practice because of his first rate general educa- tion, and because of a genuine sociability with people whom he holds in high regard. His ideas are almost wholly commercial in tendency, and he frankly admits it, and has told me that he ought to have gone into business instead of into a profes- sion. He never treats one of the poor without making him promise