A Surgeon's Valedictory

PERSPECTIVES IN BIOLOGY AND MEDICINE Volume 37 ¦ Number 2 ¦ Winter 1994 A SURGEON'S VALEDICTORY SHERWIN B. NULAND* A year has passed since I walked out of an operating room for the last time. After a career of three decades in a large universitycommunity hospital, preceded by six years of training in general surgery , the time had come to pass the burden and the pleasure into younger hands. General surgeons love to operate; general surgeons (at least general surgeons of my generation) love to sit at a bedside, or some other quiet place, and puzzle out a complex problem in diagnosis and therapy; general surgeons love clinical conferences and rounds, where they can match wits with their most agile colleagues; general surgeons are among the most vigorous and outspoken participants in the hurly-burly of hospital politics, and they love the corridors of power. I was by no means an exception to any of those characterizations. I have been, in fact, the whole package writ large. And yet, I don't for a moment miss the surgical life that has brought me so much fulfillment since I first discovered it almost forty years ago. As so often happens over the course of a long career, the field that was such an endless source of gratification when it first beckoned has become something else. The something else nonetheless had until recently seemed so much the natural progression of the original that its very evolution continued to provide immense satisfaction. No matter the new discoveries and innovations in technique, the values and viewpoints ofthe specialty did not change in any basic way during most ofmy professional lifetime. The Weltanschauung with which general surgeons envisioned pathophysiology and treatment remained steady and certain. A little personal history is in order here. In 1953, I was a third-year medical student determined to pursue a career in internal medicine, when I was one day taken in hand by an imaginative surgical resident who introduced me to an unanticipated aesthetic in his specialty. The *Address: P. O. Box 6356, Hamden, Connecticut 06517.© 1994 by The University of Chicago. All rights reserved. 003 1-5982/94/3702-086 1$0 1 .00 Perspectives in Biology and Medicine, 37, 2 ¦ Winter 1994 159 secrets of disease and the body's wondrous skill at restoring itself, I was made to realize, are discoverable less by words than by the visual and tactile elements that exist within human curiosity. From this perspective, a surgeon's uniquely cultivated skills could be seen as a way to reveal and express the beauty to be found through his mind's engagement with sickness and healing. Tissue teaches more than text, pathophysiology more than the printed page. Touching and seeing open the most direct paths to the surgeon's mind. I soon came to view surgeons as expeditors of nature's response to disease. An inflamed organ is removed, an obstruction is bypassed, excessive hormone levels are reduced, a cancerous region is swept clean of tumor-bearing tissue; surgeons are agents of the process by which an offending force may be sufficiently held at bay to aid physiology in its natural tendency to restore health. Surgery is the distilled essence of W. H. Auden's perceptive précis of all medicine: "Healing," said the poet, "is not a science, but the intuitive art of wooing Nature." For the wooing to take place, it is necessary not only to make an accurate diagnosis, but actually to visualize in one's mind a pathological process in all its multicolored, palpable, tangible reality. To predict the image of the territory I would enter—this became the ultimate diagnostic aim, just as the correction of disharmony is the ultimate goal of the operation. To me, surgery was a form of artistry, and the surgeon the personification of the art of medicine. There was in this clinical epiphany the kind of exhilaration that Percy Shelley must have been feeling when at twenty-four, the same age at which I began my surgical internship, he wrote his "Hymn to Intellectual Beauty." The poem now took on a new meaning for me, and I even heard an authentic note in two...