FrÍre Jacques, Dormez-Vous?
The Pleasures of Contemporary Surgery and WoodcraftClack... clack... clack... clack.. clack. clack-clack-clack. I am in a room with a man on a table whose pulse triggers a shock wave aimed at his right kidney. The man and I share this room with three others: a surgeon to explain the workings of the Dornier lithotripter; a radiographer to coordinate the imaging of the kidney; and an anaesthetist to ensure that the man is not uncomfortable.
The lithotripter is a device that enables kidney stones to be destroyed without cutting open the patient. This device approaches the man on the table from two directions. To his side is a treatment head that contains both an ultrasound imaging system and a spark plug. The spark plug provides the energy for shock waves that are sent through a water cushion to the offending calculus. And from above is a moveable arm that contains equipment for taking x-ray images of the stone. The ultrasound and x-ray images are relayed to a control panel a few metres away where they are inspected by the surgeon.
I am a writer in the crafts and I feel unprepared for this room -- as though I'd gone off to post a letter and strayed into a Turkish bath. Because sterilisation is unnecessary, I am free to walk into the operation without the rites of purification that prepare for the spectacle of surgery. The familiar props of the surgical theatre are absent: no green gowns, bright lights, sweaty foreheads, clamps or masks. The surgeon is free to offer me a practical account of his device.
The surgeon spoke on behalf of the $2m Dornier lithotripter (MPL 3000). Lithotomy used to be a messy business which left the patient with scars that which would take weeks to heal. Now, with the non-invasive method of the lithotripter, eighty percent of cases can be back to normal life within a day. The average stone requires about 2000 shocks before it is pulverised enough to pass easily through the urine. This kind of treatment is mild enough to require only a local anaesthetic, so the patient is awake during the whole process. You would be paranoid to take issue with such a device, though the surgeon did tell me a rumour -- denied by Dornier -- that the lithotripter developed out of military research (an attempt to disable tank crews by transmitting ultrasonic vibrations through the walls of the vehicle). It wasn't the surgeons account which provided uncertainty about the lithotripter, it was the background rhythm accompanying his voice.
While the surgeon was speaking for the lithotripter, his voice was accompanied by the steady rhythm of `clacks' -- shocks synchronised with the man's pulse. He explained that this alignment of body and machine is necessary to avoid heart complications. We turn to the console which shows the ultrasound image of the offending stone. It looks just so easy: the stone is clearly visible and a few buttons are all that's needed to aim the shocks. It seems more like a video game than the delicate exploration normally associated with surgery. But of course, this is only on the outside -- I don't see the diagnoses and the unexpected occurrences that require the surgeon's knowledge and experience.
I enquire about the progress of this treatment. While the surgeon speaks about the patient's condition, a strange thing happens: as the surgeon estimates the number of shocks still needed, the rhythm of the `clacks' increases. This seems to raise the tension in the room, but it goes without comment by those present, including myself. As our conversation turns to more general matters, the `clacks' return to their previous rhythm.
The surgeon reflects on the effect of the lithotripter on urological practice. Now that the machine is so commonly used, it is more difficult to train students in the traditional invasive method of lithotomy. As a well-seasoned urologist, he finds the old techniques are like `milking a cow', but future generations will not have his depth of experience in cutting for the stone. Before taking my leave, I ask if he has any hobbies. He replies wryly that he is a keen fly-fisherman, like many other urologists.
As I leave the room, I express my gratitude to the surgeon and his team for providing me with information about this innovation in medical practice. I feel a little uneasy that I had not been introduced to the man on the table and so did not bid him farewell with the others. Though conscious, the man was still not part of our conversation. It was this absence which perhaps made the increased rhythm of the `clacks' more poignant than it need be, as though it were a telegraphed message directed to me, the other non-medico in the room. It had the mystery normally associated with the Lacanian `Real': the thing-like presence that cannot be spoken of. The Real is a `umbilical cord' of consciousness which presents itself as an absence or uncanny repetition of meaning. Within a Lacanian turn of thought, therefore, it is the very exclusion of the patient from the conversation that enables his presence to be asserted in a way that ruptures the symbolic order. That `turn' gives a theoretical stamp to my unease, but I prefer to keep it within a more immediate realm -- to think about what the lithotripter means in terms of the surgeon's relationship to his or her medium: the man on the table.
FrÍre JacquesLet's go back a few centuries. The story goes that the Papal Edict of 1215 precluded monks from drawing blood, and therefore prohibited their practice of medicine. The monks looked for someone to whom they could pass on their special knowledge. Barbers were regular visitors to monasteries, catering for the monks' preference for smooth skin. Used to handling sharp instruments, the barbers were able to receive the monks' knowledge of such practices as bone-setting, tooth-drawing and cutting for the stone. Following this, surgery became discredited as a rogue's game; in the words of a 13th century writer, lithotomy was relegated to `barbers and low persons, rustics, idiots and imbeciles and, what is even worse, to base and presumptuous women who are not afraid to perform it'.
Thus lithotomists were often flamboyant figures who went from town to town, relieving sufferers of the offending stone. The most notorious of these was Jacques de Beaulieu. de Beaulieu apprenticed himself to an Italian roving surgeon; in 1690, he donned a monkish habit of his own design, took the name FrÍre Jacques, and entered France to ply his trade. His notoriety was partly due to his unreliability. In 1702, Marťchal de Lorges presented FrÍre Jacques with 22 patients to test the surgeon's skill before undergoing the operation himself: all were successful except the 23rd, his own. de Lorges death and many others led to FrÍre Jacques' expulsion from France. Despite this failure, Jacques radical technique of lateral incision was taken up in England by the famous surgeon William Cheselden, who was credited with performing the subtle operation in 45 seconds, with much greater success. This technique returned to Paris through the surgeon Morand who in 1730 sold tickets to those wishing to watch it performed at the Charitť. Eventually, surgery came under control of the Paris Faculty of Medicine and barbers found alternative business serving the new royal fashion for wigs.
I introduce this `dark history of surgery' because it uncovers an element unspoken for in the model of a modern surgeon as consultant. The image of a freelance lithotomist roaming the countryside with a breadknife seems better assigned to criminology than medicine. Many of the time would rather die of the stone than submit to the brutal methods of a roving surgeon. Since ancient times, the operation has involved a finger up the rectum to locate the stone which is then pushed towards a cut at the neck of the bladder. Attendants have been necessary to hold the patient down through this ordeal. Understandably, sufferers of the stone were renowned for their reluctance to submit to surgical treatment: `Their repugnance is sometimes carried so far as to cause them to shun the society of those whose conversation turns on the stone.'
It's difficult to conceive of submitting to the knife now without the guarantees of professionally qualified staff, anaesthetics and a hospital. The invention of the Dornier lithotripter seems a reason to feel blessed with living in the late 20th century. Yet has something been forgotten in this ascension to `virtual' surgery? Where is the mystery of `a surgeon's hands'? What seems cast away in medical technology is the carpentry side of surgery: the craftsperson's immediate engagement the medium of his or her practice. A surgical observer evokes this manual dimension of handiwork:
... the practice of operating appears to be a versatile craft. It resembles building or carpentry in the way bones are sawed, drilled, chiselled and screwed together; tailoring, where skin and tissue of different consistency are cut apart and sewn together; the work of sailors, when various knots are tied; and a butcher's trade, when muscles and innards are carved up.This allusion to handicrafts seems more than a little macabre. To reduce a person to the level of physical stuff conjures the gruesome scandals of cannibalism that inhabit the `dim dark past'. Yet this identification of surgery with carpentry has another function besides dark humour: it allows us to imagine what it is like to be the surgeon and makes available to us the satisfaction to be gained from the successful completion of a delicate operation. In case this seems too far fetched, let's examine a domain where such pleasures are not out of place.
WOODWORKStaying in Fitzroy, we move from St Vincent's Hospital to the Victorian College of Woodcraft. Here the visitor is invited to enjoy the pleasures of wood: the smooth touch of solid timber, the sturdy feel of a deft joint, the heady aroma of saw dust and the rich visual texture of the grain. Yet here too, the pleasures of manual labour are subject to technology.
Woodwork's equivalent to the lithotripter is the laser cutter. Laser cutting enables the shape of the wood to be determined by computer programming. The woodworker's hands are largely free then to concern themselves with problems of design. But when I approached the surgeon equivalent in this process, there was greater scepticism. A resident woodworker unfolded the limits of the laser in three layers. First layer: lasers are not appropriate to fine furniture work because they leave scorch marks on solid timber. But this is only a technical matter. There is also something about the grain of solid timber which makes a laser inappropriate. Second layer: the unpredictability of the grain requires the consciousness of a hand to be able to navigate its surface -- the knots, ripples, fiddleback and figurt that characterise the texture of solid timber. But there is more. Third layer: the woodworker explains that, given the tactile pleasure to be provided by fine furniture, the producer has to assure him or herself that it satisfies the hand. The limits of `virtual' woodwork are both practical and intrinsic: the woodworker's own pleasure in the wood is directly related to the value of the object produced. The laser cannot take pleasure in the wood.
Indeed, the impact of technology on woodcraft seems to increase the opportunities for manual dexterity. Hand-held tools such as drills and routers now free the woodworker from much that before required machining. When I asked the woodworker to show me something special that he had produced, he pointed to a delicate blackwood canteen (cutlery box). What seemed a point of pride for him in this piece was the `finish'. When I asked him what kind of tools provided the delicate finishing touches, he pulled out from his draw a collection of fine blades: surgeon's scalpels. Snap!
THE CRAFT OF SURGERYWhile the manual pleasures of the woodworker are relatively secure in the 1990s, the introduction of technologies such as the Dornier lithotripter seems to deprive surgeons of these kinds of satisfactions. Let's dwell awhile on the inappropriateness of this proposition.
The incorporation of the pleasure into the scheme of surgical practice seems highly dangerous. Pleasure is prey to the internal feelings of the surgeon, and therefore cannot insure the consistency required of such a responsible position. The identity of a surgeon seems to demand the surrender of individual feelings. Even a book titled The Surgeon's Craft takes pains to emphasise the absolute nature of `professional' devotion:
Surgery demands from its acolytes a submission which is not exceeded by any other branch of medicine; it requires a lifetime of devotion equal to that demanded of the servants of the Church... No man, no doctor, should ever engage in `a spot of surgery' as one might from time to time play `a spot of golf'. Surgery, even the apparently simple operation, is work for the professional.
This renunciation focuses on a conformity to medical ethics that is beyond individual whim. It is this in which we place our trust. Yet it is by necessity only one side of the story. As a conscious subject, the surgeon must register a level of experience of the theatre; and as subjects who are conscious before and, hopefully, after surgery, we are interested in the consciousness which takes control of our bodies. Within the internalised scheme of surgical identity arise stereotypes that play upon this imagining: the `gentle' paediatric surgeon; the `flamboyant' cardio-thoracic surgeon; the `brusque' orthopaedic surgeon, etc. Here the writer on surgical craft evokes the `pleasures' of the profession:
One will enjoy especially putting into practice the delicate techniques of tissue craft; another will be called to probe the unknown and woo the capricious mistress, research; yet another will take his greatest delight from the human contacts which he makes, and his life's happiness will derive from the gratitude of his patients, but each will sense something of these gracious gifts, and at the end, if he has followed the traditions of his craft, will be able to say, `this has been a life worthy of a man'.The `traditions of his craft' finally legitimises the `enjoyment', `probing', `wooing' and `delight' which entices the surgeon into the theatre. Though these are presented as the internal satisfactions of surgery, they find a place in its identity outside the profession: they are the imagined enjoyment of surgery, though not the less real for being imagined.
Even to surgeons themselves, the pleasure of watching good work was real. I spoke with an experienced urologist who acted as Executive Director for Surgical Affairs at the Royal College of Surgeons. He was quite adamant that it was capacity for judgment rather than physical dexterity that determined a surgeon's worth. Given the healing properties of human tissue, precision was not as important as it might be in other handicrafts. It was more important to know what procedure to execute -- the skill of execution could be largely taken for granted. Despite this opinion, he did admit that it was `beautiful to watch, sometimes, a good surgeon'. He attended particularly to the way certain surgeons could unwrap the layers of tissue leading to the relevant organ: for some surgeons `the tissues just seem to fall apart'. Now the allusion to handicraft did not seem so macabre: rather, it denoted an inner talent governed by a caring disposition. The surgical craftsperson attracts the admiration one feels for the kind of dexterity that goes beyond the bounds of simple practicality. Accolades such as `consumate ease' refer to a style that exceeds what is required to get the job done. Our identification shifts from the patient to the surgeon, from butchery to ballet.
It would be a mistake to position the `carpentry side' of surgery in an either/or evaluation: viz., either a remnant of pre-Enlightenment brutality or a benign mystery of surgical vocation. This opposition will remain indeterminate while surgery entails the surrender of one's body as a `thing' for another's handiwork. Whether it is brutal or benign will depend whether one stands with the surgeon or lies with the patient. To return to `stamp' of Lacanian theory, the craft of surgery is a floating signifier of unstable meaning which can only be fixed in a `quilting point' -- a signifier which is empty of meaning. What is the quilting point for the craft of surgery? I think I found it in the historical collection on display at the Royal College of Surgeons. It is a hand cast from the original of James Symes, a famous Edinburgh surgeon. The inscription reads:
The original in marble was made by Mr Brodie, sculptor, from a cast of Professor Syme's hand. It belonged to Dr John Brown, who gave it to Lord Lister in 1877. Lord Lister presented it to the Anatomical Museum of Edinburgh University in February 1905.
This is a copy made by permission of the late Professor Emeritus J.C. Brash, sometime professor of Anatomy at the University of Edinburgh.Thus the professional identity of surgery is passed down by hand through the generations. Unlike the woodworker, a surgeon cannot show me the proud result of his or her labour. The ideal product of surgery is after all invisible. Nonetheless, there has traditionally been a mystery that can be woven around the surgeon's hands. I would argue that this mystery evolves out of the contradictory nature of surgery: the hand is both a sophisticated instrument and a thing of flesh.
This is where the Dornier lithotripter poses a dilemma. The romance of technological progress supersedes the mystery of surgical vocation. To what kind of agency, in that case, do we render our bodies? In a room with a lithotripter, the surgeon acts more like a film director than a participant: he calls the shots rather than takes the inner journey. The surgeon hero -- and the dubious spirit of FrÍre Jacques -- has fallen asleep, just at the time when the man on the table has woken up. He appears to be in control, but this control is controlled by the machine. The uncanny `clack' of the lithotripter sounds a consciousness yet to be embodied.
This article was originally published in Arena Magazine, Feb 1993.