Surgeons themselves tend to be almost complacent about the studies, largely because postoperative infection is no longer a major problem. In fact, the most common early, immediate, direct cause of death from surgery is not the operation but the anesthesia.

  One wonders why this was not always so, especially in view of early methods for administering ether, by use of a cone-shaped sponge. J. C. Warren recalls that during the Civil War period:

  These men, many of whom had become inured both to fighting and to a free use of alcohol, were not favorable subjects for the administration of ether, and I have still a vivid recollection of my efforts as a student and a house pupil at the hospital [1865-6] to etherize these patients. "Going under ether" in those days was no trifling ordeal and often was suggestive of the scrimmage of a football team rather than the quiet decorum which should surround the operating table. No preliminary treatment was thought necessary, except possibly to avoid the use of food for a certain time previous to the adminstration. Patients came practically as they were to the operating table and had to take their chances. They were usually etherized at the top of the staircase on a little chair outside the operating theater, as there was no room existing for this purpose at the time. In the struggle which ensued, I can recall often being forced against the bannisters with nothing but a thin rail to protect me from a fall down three flights. But however powerful the patient might be, the man behind the sponge came out victorious and the panting subject was carried triumphantly into the operating room by the house pupil and attendant.

  Although the method of induction was primitive, it was not very dangerous. Profound anesthesia was difficult to accomplish and serious complications, Warren says, "were not commonly encountered."

  Thus in a sense surgery has come a full circle, from the time when anesthesia opened new horizons to the time when anesthesia provides a serious hazard to operation. It is the kind of ironic twist that one frequently encounters in medical history.

  A classic example of the full circle is the story of appendicitis. This is a very old disease-Egyptian mummies have been found who died of it-but it was never accurately described until 1886.

  During most of the nineteenth century, surgeons were well aware of diseases which produced pain and pus in the right lower quadrant of the abdomen. Some attempts were even made to operate for the condition, by draining the abscess. But results were not encouraging and in 1874 the English surgeon Sir John Erickson said that the abdomen was "forever shut from the intrusion of the wise and humane surgeon." Note that pain was not a consideration here-surgical anesthesia was nearly thirty years old. Rather it was the fact that pus collections in the abdomen were not understood and did not appear to be helped by surgical intervention.

  Twelve years later, an MGH pathologist named Reginald H. Fitz, who had traveled in Europe and studied under the great German pathologist Rudolf Virchow, published the results of an intensive study of 466 cases of "typhlitis" and "perityphlitic abscess," as the disease processes were then rather vaguely called. Fitz concluded that what the surgeon found at operation-a large area of inflamed bowel and widespread pus in the abdominal cavity-had resulted from an initial, small infection 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 appendicitis was accepted, the surgical treatment remained a matter of dispute. In many hospitals, appendectomy was considered a bizarre procedure of questionable value. In 1897, when Harvey Gushing was a house officer at Johns Hopkins (after having interned at MGH and having seen several appendectomies performed), he diagnosed appendicitis in himself. He had great difficulty convincing his colleagues 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, diagrammed the abdominal findings, wrote his own pre-operative and post-operative orders. It was said that he would have performed the operation himself 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 England, 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 abdominal operation, it encouraged surgeons to be more daring in exploring this body cavity. Their encouragement 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 appendicitis."

  Remembering Mr. O'Connor's case, it may be well to go into some of the differences, and some misconceptions, regarding the relationship of surgeons and internists. The two groups have never been too congenial. Traditionally, physicians have considered themselves more intellectual than surgeons. 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 genuine 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 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, estimates 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 superior 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 doings of surgery are visible and manifest, while those of medicine are hidden, which is very fortunate for physicians. If they have made a mistake, 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 better paid than physicians. Internists will not be surprised 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 properly must settle the matter of fee first of all. If he is not assured of his fee, he cannot concentrate 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 anesthesia 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 for two weeks. He was not operated upon; there was insufficient evidence of surgically treatable disease and therefore he received essentially medical treatment on the surgical wards. This is a far cry from the days when an MGH surgical chief resident told his staff (perhaps apocryphally): "Every 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 surgical house officers at the MGH who have done basic research in biochemistry and molecular biology 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 body. However, altering tissues with a knife is a relatively crude way of going about things; the finest surgeons are always the most reluctant to operate.

  This is not to say that the scalpel will become a museum piece in our lifetime. Far from it. As surgery moves from a business of excision to a business of repair and implantation, it will be ever more important to the conduct of medicine. But the trend toward cooperation with internists, rather than competition with them, is likely to be extended as time goes on.

  Indeed, the dramatics of the operating room have obscured the fact that most of the advances in surgery have taken place in terms of pre-operative and post-operative care. Modern surgery is immensely more complex than it was a century ago, but this complexity has more to do with electrolyte balances than with ligature points.

  One can argue that in the last twenty years surgical advance has been largely dependent on para-surgical innovation, more involved with what goes on outside the operating room than with what goes on inside it. The paradoxical effect of this has been to increase the range and variety of services directed toward the operating rooms. Vast areas of the hospital are now given over to support and maintenance of a heavy surgical schedule, involving more than 16,000 operations a year. Two clear examples are Central Supply and the Blood Bank.

  "Central Supply" consists of a single large room located one floor above the operating rooms. As its name implies, it serves as the central supply room for the hundreds of sterilized articles required for the operating rooms, as well as the other floors, of the hospital. All sterilization is done here; forty-three people are employed to keep the room in operation around the clock, seven days a week. Its operating budget is more than $600,000 a year.

  Excluding operating instruments, Central Supply stocks nearly 500 separate items. These include 44 kinds of Foley catheters, 29 kinds of drains, 10 kinds of needles, 15 kinds of sponges, and 55 kinds of "sets"-prepackaged collections of equipment used in carrying out special procedures. They range from alcohol nerve-block sets to arterial-oxygen sets to liver-biopsy sets to suture sets and venous-pressure sets. Each set is handed out, used, returned for re-sterilization and repackaging, and handed out again.

  Altogether, Central Supply hands out 12,000 items a day, or nearly 4.5 million items a year. The work of Central Supply has been increasing markedly in recent years. For example:

  1966 27,000 37,000 485,000

  1968 38,000 61,000 1,208,000

  Hospital Use Dressing sets Suture sets Thermometers

  These are real figures, in the sense that they do not represent absorption of work previously done by some other area in the last two years, but rather a simple increased demand by the hospital for these items.

  It should be stated at once that Central Supply does not handle all the items now required by medical technology. For instance, the ten kinds of needles it carries do not include needles for routine intramuscular and intravenous use; these are purchased presterilized and are thrown away after use. Rather, Central Supply stocks intracardiac needles, spinal needles, sternal puncture needles, ventricular needles, and other similarly specialized nondis-posable apparatus.

  The question of whether Central Supply should be doing as much as it does is the subject of debate. The cost of everything used in the hospital has grown so enormously that even the simplest details of patient care have undergone renewed scrutiny-revealing them, suddenly, as not so simple. Consider the Great Thermometer Controversy.

  Thermometers were first used clinically in 1890, when they were delicate gadgets a foot long, but they are now a staple of modern care, and the largest item of business for Central Supply, which hands out between 3,000 and 4,000 thermometers a day. The MGH employs a method of reprocessing thermometers-unclean thermometers are returned to Central Supply, washed, sterilized, spun dry, and repackaged for use again.

  The hospital recently commissioned a cost analysis of thermometer systems, which concluded that the average patient had 2.5 thermometer readings a day, and a total of 32 readings during an average admission of 13 days. Within this framework, three possible systems were examined: the reusable thermometer; a disposable probe used in conjunction with a portable sensing unit; and a personal-thermometer system in which each patient is given his own thermometer at admission, and keeps it at his bedside throughout his stay.

  The conclusions on cost per year were as follows:

  Reprocessable, reusable $30,113.00

  Probe and sensing unit $49,786.00

  Personal thermometer $13,250.00

  This does not tell the full story, however. There are some complicating factors. First, the present MGH system is inefficient. Central Supply does not get back all the thermometers it gives out; in 1968, it spent $30,000 to replace lost thermometers, thus effectively doubling the cost of the present system. Second, the probe and sensing unit has an important front-end cost, namely the sensing units, which cost $190 each. Amortization has not been figured into the above accounting. Neither has nursing time been assessed-and the sensing units, unlike regular thermometers, are virtually instantaneous.

  The situation is further confused by fear that a personal-thermometer system may not provide adequate patient safeguards. Some have envisioned a situation in which a tuberculous patient is moved to a different room, and a new patient put in his place, with the thermometer inadvertently remaining at his bedside, to be popped into the mouth of the unsuspecting new admission. The example is farfetched, but certainly any new system deserves close scrutiny to assess its reliability and safety.

  The upshot of all this is that it is difficult to be certain what is the best, safest, and cheapest way to take a patient's temperature. The problems in determining cost for this relatively simple matter are magnified many times when one attempts to unravel the cost of a radiological unit or a chemistry laboratory. Given the vagaries of accounting methods, and the uncertainty of reliability with different systems, it becomes extraordinarily difficult to decide which costs are justified and which are not.

  The controversy rages on, but on balance the cost advantages are too great, and the potential for danger too little, to permit the hospital to disregard the personal-thermometer system. Converting to this system would save the hospital only five hun-dredths of one per cent of its annual budget. But one can see how a series of similar minor cost changes could ultimately affect total hospitaliza-tion cost.

  The Blood Bank is another large and expensive facility. The MGH now has what is believed to be the largest single hospital blood bank and transfusion service in the world. Located on two floors of the Gray Building, it accounts for one fifth of all the blood used in the state of Massachusetts. The great majority of the blood goes to surgical patients, with a large proportion going to open-heart cases. At times as much as a third of all hospital blood has gone to the cardiac surgical service. This massive consumption, in turn, is largely the consequence of the heart-lung machines, which require large amounts of blood to "prime" the pump.

  Although the size of the Blood Bank is closely related to the increasing demand of cardiac surgery, its growth preceded the development of open-heart techniques. The MGH Blood Bank was begun in 1942, under the part-time direction of Dr. Lamar Soutter. The hospital, skeptical of the need for such a thing, contributed $5,000 in equipment and a basement room in one of the buildings. Soutter recalls that "in the beginning everything went wrong [but] the effort paid off with unexpected rapidity. In November of 1942 the Hospital was flooded with victims of the Cocoanut Grove [fire] disaster. The Bank had more than enough plasma to give the patients adequate care. This single episode swept away the last of the opposition to the Bank and it became firmly established as a necessary part of the Hospital."