After learning about Dr. Robert Goldwyn’s death, I pulled out his book “The Operative Note: Collected Editorials” to reread (published in August 1992). I’d like to share a few with you over the next weeks/months.
The first is entitled “Surgeon”
On a recent trip to Hawaii, I learned that in the Polynesian dialect spoken there, the word for surgeon is kauka oki: doctor (kauka) who cuts (oki). While some of us surgeons might resent such a graphic, “cut and dry” definition, we cannot deny its verity. No matter how we may slice it, a surgeon is a doctor who makes incisions. In fact, the origin of the word surgery is Greek, from cheir, meaning “hand,” and ergon, meaning “work.” That surgeons work with their hands did not always bring honor. Centuries ago, one recalls that those who cut on others, with their permission, generally held a lower status than those who eschewed the knife.
At the bottom were the barbers, and slightly above them, the surgeons. In England in 1462, the Guild of Barbers became the Company of Barbers, and under Henry VIII, the Barber Company was united with the smaller Guild of Surgeons to form the United Barber-Surgeon Company. In commenting on Henry VIII’s role in this episode, Garrison cites the painting by the younger Holbein, the court painter: “Henry VIII—huge, bluff, and disdainful—in the act of handing the statute to Vicary [Thomas Vicary, First Master of the United Barber-Surgeon Company], in company with fourteen other surgeons on their knees before the monarch, who does not condescend even to look at them.”1 Perhaps Henry was irate at having to leave his dinner table and his newest wife.
The metamorphosis from the lowly barber to the glamorized surgeon has been long. I am sure that Henry VIII did not envision the consequences of his royal decree. The seesaw of history is marvelous as long as you are on the upswing. The rise of the surgeon did not erase the schism (in fact, it may have intensified it) between the so-called thinkers and the doers. This enmity, although lamentable, is centuries old. some, however, such as Lanfranchi of Milan (the first to describe concussion of the brain and to distinguish between cancer and hypertrophy of the female breast), did rise above the petty, professional fray. In his Chirurgia Magna, completed in 1296, he wrote:
- Why, in God’s name, in our days, is there such a great difference between the physician and the surgeon? The physicians have abandoned operative procedures to the laity, either, as some say, because they disdain to operate with their hands, or rather, as I think, because they do not know how to perform operations. Indeed, this abuse is so inveterate that the common people look upon it as impossible for the same person to understand both surgery and medicine. It ought, however, to be understood that no one can be a good physician who has no idea of surgical operations and that a surgeon is nothing if ignorant of medicine. In a word, one must be familiar with both departments of Medicine. 2
We do accept the fact today that the best surgeon is one who knows not only how to operate, but when not to. Harvey Cushing, about the time that he became the first Surgeon-In-Chief of the Peter Bent Brigham Hospital, Boston, said in his letter to his counterpart in medicine, Henry Christian: “I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work.” 3
Cushing, of course, did have hands, good ones, and more important, a superior brain, which he used prodigiously. His remark was a hyperbole that reflected his correct view of surgery; it must grow from research and basic sciences and from its application to clinical problems. Surgery, despite the awe it now has (for those who doubt this, see the afternoon “soaps”), represents a failure of nonoperative medicine. Who would not want to take a pill rather than undergo an operation for cholecystitis, breast cancer, or benign prostatic hypertrophy if the results were the same? Would not genetic engineering by medication to prevent facial clefts be preferable to repairing them, no matter how meticulous and innovative the surgeon? The thought that a capsule could safely enlarge or reduce breasts or salve could eliminate Dupuytren’s contracture or a prominent dorsal hump may seem too fanciful even for the most imaginative, yet landing a man on the moon and retrieving him without mishap has long been a fait accompli. However, since medical Shangri-La is many years hence, we heirs of Pare will be continuing our manual ministrations, our barbers’ burden.
1. Garrison, F.H. An Introduction into the History of Medicine with Medical Chronology. Suggestions for Study and Bibliographic Data, 4th Ed. Philadelphia: Saunders, 1929; reprinted in 1960. Pp. 238-240.
2. Lanfranchi of Milan. In M.B. Strauss (Ed.), Familiar Medical Quotations. Boston: Little, Brown, 1968. P. 583.
3. Fulton, J.F. Harvey Cushing: A Biography. Springfield, Ill.: Charles C. Thomas, 1946. P. 352.