In 1994 I wrote a novel, called The Blue Afternoon, that was about a surgeon. I suspect the usual jumble of motivations was immediately on offer to explain why I decided to write such a novel: I was living next door to a surgeon I’d come to know a bit; I was the son of a doctor; a member of my family had recently undergone a serious operation – but I now think the basic reason was more fundamental. I believe I was looking for the answer to a question – a question that stimulates all non-medical fascination about surgery – namely: what is it like to “pick up a knife and make an incision into living human flesh?”
These words come from the first paragraph on page one of my novel where the narrator asks her father, a surgeon, to try to distil that defining feature of the profession. In the novel the surgeon then proffers a scalpel – and his forearm – and asks his daughter to make a small cut into it so she can see what it’s like: “Sometimes it’s like a knife through clay or modelling wax,” he says, “Some days it’s like cutting into cold blancmange or cold raw chicken.”
This may sound plausible but in fact I was making an educated guess. At the time I was writing and researching the novel, nearly 25 years ago – pre-Google, of course – it was surprisingly difficult to find first-person accounts of surgery by surgeons. There were plenty of text books and the usual biographies of eminent, titled surgeons, and a few soldier surgeons had written up their field-hospital memoirs (I found one from the Mesopotamian front in the first world war, Surgery on Trestles by Robert Campbell Begg and another from the Falklands war, Rick Jolly’s tremendous The Red and Green Life Machine), but there was a real paucity of authentic, well-written, first-person surgical experience available. But not any more. If I were writing The Blue Afternoon today I would have what amounts to a significant subgenre of autobiography to explore – surgeons’ tales have proliferated in the last few years and, perhaps for the first time in the short history of modern surgery, we now have many voices offering the answers to the mystifying aspects of the profession.
Consequently, I’m an avid consumer of these surgical/medical autobiographies but I can hardly keep pace. The earliest of the books I will refer to, Atul Gawande’s Complications, was published in 2003 – three other books by Gawande have appeared since. Gabriel Weston’s Direct Red (a rare woman’s voice from the coal face) arrived in 2009; Do No Harm by Henry Marsh, This Living and Immortal Thing by Austin Duffy and Fragile Lives by Stephen Westaby were all published in the last two years, and Thomas Morris’s The Matter of the Heart – a history of cardiac surgery rather than an autobiography – is imminent. Admissions, Marsh’s swift follow-up to Do No Harm, is out this week.
The trickle has become something of a flood; the drip something of a serious arterial haemorrhage. It’s as if, in the early 21st century, the profession of surgeon has suddenly found its collective voice and surgeons feel the need to express and explain themselves, to lift the lid on this most fraught and perilous world, the world of the operating theatre, where matters of life and death are part of the diurnal round and where the corporeal – that unique sense of ourselves – achieves a special, palpable prominence.
Very unusually, perhaps – though serendipitously – I can count four internationally renowned surgeons in my circle of friends: two ophthalmic surgeons, a reconstructive plastic surgeon and a colorectal surgeon. I thought that, given this new autobiographical outpouring from the profession, it might be intriguing to see what the writer surgeons had in common – if they shared a philosophy, an overview of the job they did – and what a practising surgeon might reflect on his calling when this new literary light is being shone on his world.
Brendan Moran is a world-famous colorectal surgeon, or a “cancer surgeon”, as he more straightforwardly terms it. He has been a practising surgeon for more than 30 years, and has completed well over 2,000 major operations. Colorectal cancers are known as below-the-belt cancers and usually involve significant surgical procedures. Atul Gawande succinctly describes what is the norm in this field: “We made a fast, deep slash down the middle of his abdomen, from his rib cage to his pubis. We grabbed retractors and pulled him open.” Here is Gabriel Weston: “We cut the woman open from breastbone to pubis and cleared her gut out with one deep sweep.”
At this point the faint-hearted reader reels away, eyes watering, wondering how anyone can do this as a matter of course on a near-daily basis and remain a happy, functioning human being. Brendan Moran is very aware of the perceived abnormality of the profession, to those who’ve never been inside an operating theatre. “Surgery is legalised assault, from one point of view,” he says: just as you can’t make an omelette without breaking eggs, you can’t be a surgeon without cutting people open with sharp knives. But my fundamental question – what is it actually like to do this thing? – is one that all the surgeons seem to find a bit baffling.
Stephen Westaby describes watching a failed heart operation, when he was a young doctor. Despite the surgical team’s every effort, the patient died on the table – gallons of blood everywhere – and while there is a great deal of empathy, Westaby never once mentions any feelings of nausea, shock or recoil. For the non-surgeon, I would claim, the sight of a dead human being, supine, spatchcocked, heart removed, would be a life-changing horror. The fact is that for surgeons the interior of the human body – its glossy organs, its swelling fluids, its lurid blood – becomes a very normal, unremarkable sight, an everyday arena of activity, very quickly losing its freight of torrid emotion and associated gag reflex. I put this to Moran and he admits to never having felt squeamish. Maybe this is the crucial first requirement: the squeamish factor.
Quite a number of writers of fiction have been doctors – Chekhov and Somerset Maugham come instantly to mind but you could also mention Conan Doyle, Bulgakov, William Carlos Williams and numerous others. JG Ballard spent two years training to be a doctor and had this to say about the dissecting room: “The cadavers, greenish-yellow with formaldehyde, lay naked on their backs, their skins covered with scars and contusions, and seemed barely human, as if they had just been taken down from a Grünewald Crucifixion. Several students in my group dropped out, unable to cope with the sight of their first dead bodies … I still think that my two years of anatomy were among the most important of my life, and helped to frame a large part of my imagination.”
Moran confirms that this prior exposure to the lifeless human corpse is a key test of inherent squeamishness and sorts out the potential surgeons from the swooners and fainters. “But then I grew up on a farm,” he says, “and you see all sorts of blood and guts on a farm.” He is the son of a farmer from County Clare, Ireland. Initially he wanted to be a vet, and duly signed up to veterinary college in Dublin, but before he started quickly shifted to study medicine in University College, Cork, and then to surgery. Why surgery? I ask. “I wanted to do something with my hands,” he says simply, then reminds me of the etymology of “surgeon”. Originally from the Greek kheirourgia, from kheir – “hand” – and ergon – “work”. Surgery: hand-work.
The celebrated surgeon Frederick Treves (1853-1923) – best known for his connection with the “Elephant Man”, Joseph Merrick – said that a good surgeon needed “a lace-maker’s fingers and a seaman’s grip”. Gabriel Weston recalls a surgeon who was “impressively quick with his hands, his hobby is motocross bike racing; his reputation and strength impressively linked to alacrity”. The robust, tactile, sheerly physical nature of the job is part of the allure, I suspect.
Treves was also famous for operating on Edward VII’s appendix just before the coronation in 1902 – a very risky operation in those days. Lord Lister, no less, also attended. Treves didn’t remove the appendix – he drained the corrupted abscess and the king luckily recovered. Intriguingly, one could claim Treves as possibly the earliest precursor of these modern writer-surgeons. Two years before he operated on Edward VII, Treves’s daughter, Hetty, aged 18, fell ill with abdominal pains. But Treves, for various perverse reasons, refused to diagnose her condition as appendicitis. And yet Treves was then the British – if not the world – authority on appendicitis. Hetty’s symptoms duly worsened and she became gravely ill yet still Treves hesitated. Finally he decided to operate but by then it was too late – Hetty had full-fledged peritonitis – and she tragically died, in great distress.
One can imagine Treves’s huge grief. He turned to fiction in an attempt to exorcise his guilt and wrote a short story in 1923 called “The Idol with Hands of Clay”. In the story the arrogant young surgeon figure (who performs an appendectomy on his wife who subsequently dies) looks at himself in the mirror: “It was not himself he saw: it was a murderer with the mark of Cain upon his brow.” The tone of the story – its doubt, its recriminations – chimes closely with these modern surgeon-memoirs. There is no vainglory, no triumphalism, no excuses; instead we are presented with a brutally honest, heartfelt confession of human error.
Moran recalls that his first operation, aged 23, was also an appendectomy. “It was often thought a good training op for young surgeons,” he says with a smile. Does he remember that moment, I ask, when scalpel bit into flesh? “Oh, yes,” he says. “Real blood flowed.”
Little did he know then, he continues, that cancers of the appendix would become his area of expertise and would make his global reputation. One of the major operations he performs (he had done two in the week before I met him) is to treat a rare cancer of the appendix, pseudomyxoma peritonei, that can involve not just removing the tumour but also stripping out the lining of the abdomen and other organs and then washing the abdominal cavity with a heated solution (40 degrees) of chemotherapy drugs. “Very major surgery,” as Moran describes it.
However, the biggest and most complicated operation he has performed (as part of a team) was a massive bowel transplant, only the fourth that had ever been done, that involved removing – and then replacing from a donor – the stomach, small bowel, large bowel, pancreas, spleen and the abdominal wall, including the muscles and skin of the midriff. The non-surgeon’s mind boggles incredulously once again. The operation took 23 hours. And the patient survived and survives.
Moran draws me a small Venn diagram of three overlapping circles labelled “knowledge”, “skill” and “experience”. The sector in the middle where all the circles overlap is “the place you want to be”, he says, then points to the “experience” circle. “But that’s the vital one. Surgeons don’t have magic powers,” he insists. “Decisions are more important than incisions.” You can have all the medical knowledge in the world and all the dexterity but it doesn’t add up to the years of actual operating.
Gawande writes: “Medicine is a strange and in many ways a disturbing business, the stakes are high, the liberties taken are tremendous. We drug people … we lay them unconscious and open their bodies to the world. We do so out of an abiding confidence in our know-how as a profession. What you find when you get in close, however … is how messy, uncertain and also surprising medicine turns out to be.”
Henry Marsh would concur. He operated on a tumour in a young woman’s spinal cord. The procedure was uneventful and seemed to go well but: “She awoke from the operation paralysed down the right side of her body. I had probably tried to take out too much of the tumour. I must have been too sure of myself. Insufficiently fearful.”
It’s a telling point. Moran would agree: “It’s clear that the older and wiser you become as a surgeon there can be a ‘loss of nerve’ – an awareness of risk – and consequently as a surgeon you become more risk averse. Surgeons start to do only what’s required but they may not be doing the patient any favours.” He tells me of a routine operation he once did to remove a tumour of the appendix. He opened the patient up and immediately saw, to his complete surprise, that the man’s bladder was also severely cancerous. He wasn’t “authorised” to remove the man’s bladder but he made the decision to do so, however difficult. By removing the man’s bladder he reckons he saved him from an agonising death and he survived for six more years. “I didn’t save his life, I prolonged it. That’s what surgeons do – they prolong life.”
So, how would you define a “bad” surgeon, I ask him? – apart from the rare psychopath or a sinister, scalpel-happy mutilator (such as the breast surgeon charged and found guilty) who might have crept in to the profession. All serious professionals, in whatever metier, can recognise the fraud or the foolhardy, the inept and the incompetent.
Moran thinks before answering. “Overconfidence,” he says. “Arrogance. Those surgeons who live long lives with short memories.”
It’s clear that a lifetime of surgery takes its own particular toll. Being “insufficiently fearful” at the bravura, superconfident beginning of your career is replaced, as time passes, by a growing, knowingly fearful appreciation of the risks involved and of the defining role of chance. Moran quotes, word perfectly, the eminent French surgeon René Leriche who wrote in his book, La Philosophie de la Chirurgie (1951), that: “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret where he must look for an explanation for his failures.”
Simon Westaby, at the end of his career of complex surgery, reflected: “I was good at it. Yet despite my best efforts, some patients took the fast track to heaven. How many, I don’t know. Like a bomber pilot, I didn’t dwell on death. It was more than three hundred, fewer than four hundred, I guess.”
It’s remarkably honest of him to admit this, and if there’s one shining virtue that characterises the writer surgeon it’s honesty, it seems to me. Here is Austin Duffy in his remarkable novel-memoir This Living and Immortal Thing: “I used to leave work in a similar state of blankness … In that job I took care of a lot of sick people, most of whom are dead now. I recall some of them very fondly but to be honest I have forgotten most of them.” And Marsh, at the apotheosis of his career, writes in Admissions: “Each time I scrub up, I am frightened. Why am I continuing to inflict this on myself, when I know I can abandon neurosurgery at any time? Part of me wants to run away, but I scrub up nonetheless … I sit on a stool and lean the back of my head against the wall. I keep my gloved hands in front of my chest with palms pressed together, as though I were praying – the pose of the surgeon, waiting to operate.” Despite the astonishing, near-unimaginable nature of their job, there is evidence from the books they are now writing that surgeons experience – as the glittering career progresses and the life-prolonging operations mount up – a growing sense of humility, a particular amalgam of wonder at what they do and modesty about their achievements.
Moran is no exception. After nearly four decades of being a surgeon, he talks eloquently of the “ghosts in every bed”, meaning the ones who didn’t make it, the ones who couldn’t be saved. Marsh writes about how, “knowing when not to operate is just as important as knowing when to operate, and is a more difficult skill to acquire”. Decisions not incisions, as Moran would put it. Marsh contemplates the difficulty of trying to find “a balance between the necessary detachment and compassion that a surgical career requires, a balance between hope and realism”.
It seems from these autobiographies and memoirs that the detrimental changes to this equation – detachment/compassion and hope/realism – are what make surgeons decide to stop the “complex” operating and move into more ancillary, less fraught aspects of the career. The stresses and strains begin to exact their dividend, thousands of operations down the line. Moran confides: “You begin to think not of the nine operations that went well but of the one where something went wrong.”
I ask Moran what being a surgeon all these years has taught him about human beings and the human condition. He thinks for a moment and then says: “A respect for human resilience. An acknowledgement of the survival urge that lies in us all.” It’s a quietly profound statement and, in a way, it unites all these recent accounts from the front line of the operating theatre.
The popular image of the surgeon as the egomaniacal maestro conductor figure dominating the orchestra that is the hospital he practises his arts in is both cliched and wrong. All these surgeons are aware that they pit their talent, their gifts – their knowledge, skill and experience – against something malign, elusive and finally uncontrollable: disease and injury. As ever, luck, good and bad, plays an unassailably prominent role in the way things turn out. And the longer the surgeons work, the more they realise that this truth pertains.
Given all these books appearing by this new generation of writer surgeons, I ask Moran if he has one of his own on the stocks. He has his fascinating stories to tell, after all. He’s pondering the idea, he says. It’s clear from reading these memoirs and talking to this thoughtful, humane man that the great surgeons are always, one way or another, haunted by “the ghosts in every bed” and, in the end, that would be a perfect collective title for everything they have to say about the extraordinary profession they share and the phenomenal life they lead.
Admissions: A Life in Brain Surgery by Henry Marsh published this week by Weidenfeld & Nicolson.
