Richard Smith: The history of surgery—my contribution

Richard SmithIn his book “Adolf Hitler: my part in his downfall,” Spike Milligan modestly suggested that his part had been small. My contribution to the history of surgery is even smaller and much more ignominious, but I’m prompted to tell the tale by the Royal College of Surgeons of Edinburgh deciding to make me a fellow. Goodness knows why this ancient and venerable college decided to do such a thing, but the motivation cannot have been my surgical prowess. Readers will, I’m sure, agree if they ever get to the end of this sad story.

My surgical prehistory

Surgery may have ruined my career. At the age of seven I was set to play the Archangel Gabriel in the Southwark Park Infant School nativity play. I was to climb in a long white sheet onto several desks and be the apex of a huge pyramid of children. I had high hopes and a dream of a career on the stage. A tonsillectomy intervened. I can still remember the smell of rubber as the anaesthetist shoved the mask over my nose and mouth. Almost half of my generation lost their tonsils in the butchery of the 50s. And what for?

My father had a worse experience. His father took him on the tram to have his tonsils removed. As he was wheeled back from theatre his mouth filled with blood. He spat it out. “You dirty boy,” said the nurse as she slapped his face.
But next it was cream buns. As a schoolboy in London I was an enthusiast for the Christmas lectures put on by institutions across the city. The one at the Royal College of Surgeons was breathtaking. The surgeons displayed their full pomp, marching nine deep in their red robes behind a mace. Then a quick Mickey Mouse film and up to the museum for tea. It was fabulous eating cream buns and looking at chunks of liver and babies with two heads in bottles.

Surgery as an erotic experience

My experiences with surgery as a medical student began positively when I discovered that it could be intensely erotic. It was the first time that I ever scrubbed. A famous professor was operating, and he was desperately slow. We students were required to strip naked, shower, and put on greens with nothing underneath. (At the time this was believed to reduce infection.)

I’d wrongly imagined that surgery would be exciting, but there were perhaps 20 of us stood in rows around the professor and the tiny red gash that was absorbing all his attention. I could see less than from the back row of the Palladium, and nothing was happening anyway. My attention wandered, and I began to look around. The student nurses were doing the same. I could see only their eyes, and that’s all they could see of me. Consciousness of my near nakedness and of theirs, I kept exchanging sly glances with them. It was like eye sex. And wholly anonymous. No words, promises, or personality defects to mess everything up.

Surgery and stupidity
That first day was the end of my positive associations with surgery. My main association is with stupidity. As a student I was in an outpatient clinic with a professor of orthopaedics who was famous for his short temper and ability to humiliate students. He asked me to examine a patient’s hand. There seemed to be something wrong with the ring finger of the right hand. I turned the patient’s hand over to examine the other side and in my confusion began to examine the index finger. “That’s odd, “ I said, “It seems to be fine on this side.” The professor gasped. He was too astonished to be angry. For a moment he perhaps thought that I was teasing him, but then he saw that he was dealing with new depths of stupidity. He simply asked the next student to take over.

Three years later I was working in a casualty department in a New Zealand hospital. Before I started the job I had never put in a single stitch into skin nor done any other procedures. Jet lagged and horribly aware of my gross deficiencies, I’d spent the morning before I started sitting on the toilet at 4 am reading “The Casualty Officer’s Handbook.” The culture was to muddle though pretending that you knew what you were doing. It would have been unthinkable to turn up and say: “Actually I’ve no experience of most of what I will be required to do in casualty, and I think it would be a good idea for the patients and me if I received thorough on the job training before I attempt anything on my own. In particular I think I should be trained full in resuscitation.” They’d have thought I was crazy.
One day a patient arrived with his ear torn almost in half. The surgical registrar wasn’t available so I thought I’d have a go. I did what I thought was an excellent job. I put about five big stitches through his ear from one side to the other. It was all over in five minutes. In retrospect this is a bit like trying to put on an amputated finger by putting in three big stitches from one side of the finger to the other—marginally better perhaps than using sellotape. Somehow I’d entirely forgotten that the ear has several different tissue layers. When the surgical registrar finally came and took over it took him three hours to do a proper job, repairing the ear layer by layer.

Almost as stupid was my attempt at treating a patient with a bleeding nose. I had no idea what to do. “Put ribbon up his nose,” said the nurse as she handed me everything I needed. Part of the equipment was an eye mirror and a light. I’d never used such a mirror, but I remembered the cartoons in Punch where the doctors all seemed to wear them. In my memory the mirror stood upright in the centre of the doctor’s forehead. So that’s how I wore it as I started on my work. (This story may need some explanation for anybody as clueless as me. You are supposed to put the mirror over your eye and look through a hole in the middle.) I twisted myself into bizarre contortions as I tried to shine the light up the patient’s nose, but I found it impossible to get the light in the right place and be able to insert the ribbon. The nurse was so amazed by my stupidity that she couldn’t find the words to put me right.

A ghastly moment that turned out well was when I began a conversation with the father of a boy whose forehead I was stitching. “What do you do?” I asked.
“I’m a doctor.”
“What sort?”
“A surgeon.”
“Oh. What sort of surgeon?”
“A paediatric surgeon.”
“Oh oh. Do you want to do this?”
“No. I’ll watch.”
Somehow I staggered through.

Twenty years later I had a similar conversation, only this time I was under the knife. I was having a vasectomy. The surgeon, who did 20 vasectomies a day five days a week, had already cut my right vas when he asked me what I did.
“I’m a sort of journalist.”
“What sort?”
“A medical journalist.”
“Oh. Where do you work?”
“At the BMJ.”
“What exactly do you do there?”
“I’m the editor.”

Suddenly the surgeon began to sweat. It had taken him two minutes to find and cut one vas. He now took 20 minutes to find the second. “Oh God,” he said, “I suppose I’m going to read about this in next week’s journal.”

Going solo

I did only one proper operation on my own. It was a circumcision. It simply never occurred to the consultant that anybody could not do a circumcision. Even I thought I could. I’d simply grab the foreskin and snip it off. What could be simpler? Unfortunately I failed to cut the foreskin evenly, and then the damn thing began to bleed. I sweated and put in stitches almost at random. It was so awful I honestly can’t remember how it ended. Did someone rescue me? Or did I simply improvise?

Sometimes I wake screaming in the night to think of the consequences for that boy. His first sexual encounters must have begun some 15 years later. Were they a disaster? Probably. They usually are. But were they even worse than that? Has he entered a seminary? May God and the Royal College of Surgeons of Edinburgh forgive me. I knew not what I did.

Observing surgeons

My only contribution to surgery that might possibly be useful is my observations of surgeons at work. My first thought—and you can see why I would think this—is that surgeons have a magical, almost childlike way of thinking. “There is something rotten in there. I’ll cut the patient open and cut the rottenness out. Then we can all go home for tea.” Sometimes surgery is that simple, and how gratifying when it is. But mostly it isn’t.

My next observation is that surgeons are most happy when operating. All the rest of their life is an anticlimax. I remember as a house surgeon calling in the consultant late one night because we had a patient with a dissecting aneurysm. I was apologetic, but the surgeon was ecstatic. We operated until four in the morning, and I’d never seen him jollier. The only time his happiness clouded was when I told him that I’d never seen him happier. “Nonsense,” he snapped. But he cheered up immediately when the wound filled with blood.

My final observation is that second assistants—my usual role—are nothing but emotional lightning conductors. They serve no other useful purpose. I’d stand in theatre hanging onto the retractor, and the surgeon would make polite banter.
“Married are you, Richard?”
“Good idea. The only point I can see in being married is that it saves you having to find somebody to go on holiday with.” (A genuine quote from a surgeon from my past.)
“Do you have horses?”
“No. I live in a flat.”
“Good chap. Super weather, isn’t it?”
And so it went until he cut something he shouldn’t have. “Bloody hell. Will you pull on that retractor, Smith? You are a bloody fool. Don’t you know anything about surgery? For God’s sake, pull harder.”

In relation to the physical aspects of the operation I was superfluous. The surgeon and his assistant did everything of consequence. I just stood there. But I was useful for being patronised and blamed. It would have been trickier to do either with the first assistant, who was expected to grow up to be a proper surgeon. They knew that I would grow up to be something useless—like an editor.

Competing interest: This article was first published years ago in what I think was called the Dumfries and Galloway Gazette, but I’m conceited enough to think that it might amuse the handful of people who don’t regularly read the Gazette.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.