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called. Fitz concluded that what the sur-geon found at operation a large area of inflamed bowel and
widespread pus in the abdominal cavity had resulted from an initial, small infec-tion in the appendix. By
describing "appendicitis," he created, in effect, a new disease.
The new disease was not readily accepted by the medical profession. Nor was Fitz's assertion that
proper treatment required operation before rupture, instead of afterward. Today the idea of "operative
intervention" is commonplace, but in Fitz's day surgery was generally the last resort, not the first.
Even after his clinical description of appendici-tis was accepted, the surgical treatment remained a
matter of dispute. In many hospitals, appendec-tomy was considered a bizarre procedure of
ques-tionable value. In 1897, when Harvey Gushing was a house officer at Johns Hopkins (after having
in-terned at MGH and having seen several appendec-
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tomies performed), he diagnosed appendicitis in himself. He had great difficulty convincing his col-leagues
to operate; both Halsted and Osier advised against it. Finally, however, the surgeons gave in and agreed to
do the procedure. Gushing did all the rest: he admitted himself to the hospital, performed the admission
physical examination on himself, di-agrammed the abdominal findings, wrote his own pre-operative and
post-operative orders. It was said that he would have performed the operation him-self as well, had he been
able to devise a way to do so.
In the next few years, appendicitis became not only an acceptable but a fashionable disease; in 1902, it
was diagnosed in King Edward VII of En-gland, who was operated on for the condition. This signaled the
onset of a great vogue for diagnosis and surgical treatment of appendicitis.
As a reasonably safe, reasonably simple abdom-inal operation, it encouraged surgeons to be more daring
in exploring this body cavity. Their encour-agement was not without its drawbacks, however: surgeons
were so enthusiastic that nearly every bellyache was likely to receive an operation, and there sprang up a
vogue for removal of ovaries and tubes in women, along with the appendix. The end result of this was the
institution of quality-control checks on surgical procedures, through the "tissue committees" headed by
pathologists.
Dr. Francis D. Moore has said: "[Fitz] was a student of pathology telling the surgeons to do more
operations. . . . How ironical it was that
within thirty years it was to be the pathologists who applied the brakes to a surgical profession that was
running wild with the operation for ap-pendicitis."
Remembering Mr. O'Connor's case, it may be well to go into some of the differences, and some
misconceptions, regarding the relationship of sur-geons and internists. The two groups have never been too
congenial. Traditionally, physicians have considered themselves more intellectual than sur-geons.
Descendants of Hippocrates, they look down upon surgeons as descendants of barbers. Surgeons, on the
other hand, see themselves as action-oriented and regard internists as procrastina-tors, unwilling and unable
to take action.
Temperamentally and philosophically, the two groups are at loggerheads. At mealtimes in the doctors'
dining room, medical and surgical house officers can be heard berating each other about the care their
respective patients have received. The surgeons say that an internist will sit hapless by the bedside and
watch a patient die; the internists say that the surgeon will cut anything that moves. Most of this talk
represents a time-honored outlet for black humor, but there is a long history of gen-uine conflict.
Dr. Paul S. Russell quotes the surgeon Sir Heneage Ogilvie in a most revealing passage:
A surgeon conducting a difficult case is like the skipper of an ocean-going yacht. He knows the port he
must make but he cannot foresee the
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course of the journey.... The physician's task is more comparable to that of the golfer.... If he judges the
direction and the wind right, esti-mates each lie correctly, finds the right club for each shot and uses it
successfully, he will get an eagle or a birdie. If he makes a mistake he will make a poor score but he will
get there in the end. The ground will not split beneath his feet, the game will not change suddenly from
golf to bullfighting.
That was written in 1948. Six hundred years earlier, the French surgeon Henri de Mondeville set down
his reasons for considering surgery supe-rior to medicine:
Surgery is undoubtedly superior to medicine for the following reasons: 1. Surgery cures more complicated
maladies, toward which medicine is helpless. 2. Surgery cures diseases that cannot be cured by any other
means, not by themselves, not by nature, nor by medicine. Medicine indeed never cures a disease so
evidently that one could say that the cure is due to medicine. 3. The do-ings of surgery are visible and
manifest, while those of medicine are hidden, which is very for-tunate for physicians. If they have made a
mis-take, it is not apparent, and if they kill the patient, it will not be done openly. But if the surgeon
commits an error ... this is seen by everybody present and cannot be attributed to nature nor to the
constitution of the patient.
For hundreds of years, surgeons have been bet-ter paid than physicians. Internists will not be sur-prised
to know how ancient is the surgeon's concern with fees. In medieval times, Mondeville was
preoccupied with the matter:
The surgeon who wants to treat his patient prop-erly must settle the matter of fee first of all. If he is not
assured of his fee, he cannot concen-trate on the case. He will examine superficially, and will find
excuses and delays, but if he has received his fee, things are different. . .. The surgeon must have five
things in mind: first, his fee; second, to avoid gossip; third, to operate cautiously; fourth, the malady; fifth,
the strength of the sick man. The surgeon must not be fooled by external appearance. Wealthy people
when they go to see a surgeon dress in poor clothes, or, if they are richly dressed, will tell stories in order
to reduce the surgeon's salary.. . . I have never found a man rich enough, or rather, honest enough to pay
what he promised without being compelled to do so.
On the other hand, enthusiasm for operation is not an ancient vice of surgery, but a quite modern one. It
was heralded by the development of anes-thesia and antisepsis, both less than one hundred fifty years old.
Operative restraint is still newer, a consequence of quality-control checks that are less than forty years old.
Mr. O'Connor was in the hands of the surgeons
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for two weeks. He was not operated upon; there was insufficient evidence of surgically treatable disease
and therefore he received essentially med-ical treatment on the surgical wards. This is a far cry from the
days when an MGH surgical chief resident told his staff (perhaps apocryphally): "Ev-ery person has at
least three surgical diseases. All you have to do is find them." And it is a far cry from the days when the
medical residents could accurately claim that surgeons didn't know how to read an
electrocardiogram and furthermore didn't care. In fact, there is a great deal of evidence that surgery
and internal medicine are merging. It is a process that has taken several centuries, but today the
cardiologists and cardiac surgeons work hand in hand, as do the immunologists and transplant surgeons;
the tumor chemotherapists and the tumor surgeons; one need only look at the number of sur-gical house
officers at the MGH who have done basic research in biochemistry and molecular biol-ogy to recognize
the trend.
Bertrand Russell once said that we describe the world in mathematical terms because we are not
clever enough to describe it in any more profound way. Similarly, surgeons and internists have come to
see that surgery and medicine have the common goal of altering the functional status of tissues within the
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