Aphorisms are part of the fabric of surgery. They comprise the great range of quotes, sayings, adages and pithy statements of principle that remain indelibly in the memory from student days and the years of surgical training. The mature surgeon distils a favourite small collection to dispense, and rejoices in hearing new or unfamiliar aphorisms that strike a chord of truth or cynicism. Many surgeons create one or two of their own, and just a few surgeons leave a rich legacy of aphorisms for future generations.
Very old aphorisms survive in books but seldom in everyday speech because much of the appeal of an aphorism is clever use of words in a contemporary sense. Nevertheless some are as relevant now they were in ancient times; Hippocrates (460–377 BC) observed that ‘In acute diseases, coldness of the extremities is bad’. This is an example of most typical kinds of surgical aphorism that trainees remember and which guide good practice. ‘Never let the sun set on undrained pus’, ‘Skin is the best dressing’, ‘Lose a leg rather than a life’, ‘If you don't put your finger in, you will put your foot in it’ and ‘It is easier to stay out of trouble than to get out of it’ are all sayings that are likely to endure.
Some statements of principle are more facetious. ‘Arterial spasm is spelled clot’ is one for vascular trainees, whereas ‘You have to ligate the artery if the tip of the diathermy fits in the end’ is a fair rule for all. Some observations on the human body and the diseases surgeons deal with fall into this category, such as ‘God put the pancreas at the back of the abdomen because he did not want surgeons messing with it’ and ‘Varicose veins are the result of an improper selection of grandparents’.
Much has changed in the 100 years since the BJS was first published. The aphorism ‘The human body is the only machine for which there are no spare parts’ is manifestly no longer true, whereas the exhortations ‘Never let the skin stand between you and a diagnosis’ and ‘It is safer to look and see than to wait and see’ have fallen into disuse with the capabilities of modern imaging. Despite his great prescience, Lord Moynihan (1865–1936), first Chairman of the Journal, stated ‘The craft of surgery has in truth nearly reached its limit in respect of both range and safety’. We are so accustomed now to continual development of technology and techniques that we accept more readily ‘The only thing that is permanent is change’ and ‘If you don't like the way surgery is practised today, just wait a while – it will change’. Any surgeon who doubts this should perhaps ‘Visit the Mecca that produced you: you'll be surprised that what you consider holy grail has become anachronistic’.
The drivers of progress and change have been the fact that ‘The first attribute of a surgeon is an insatiable curiosity’ and research: ‘But why think? Why not try the experiment?’ (John Hunter, 1728–1993). Some advances are the result of flashes of insight – ‘Discovery is seeing what everyone else has seen and thinking what nobody else has thought’ (and do remember ‘The more original a discovery, the more obvious it seems afterwards’) – but dogged persistence and hard work have been more common features of research leading to new information and change in surgery.
The recent emphasis on research as a career requirement and the pressure to publish bring to mind a diversity of aphorisms. Among these are: ‘An experiment is reproducible until another laboratory tries to repeat it’, ‘A record of data is useful: it indicates you've been working’, ‘Only God can make a random selection’ and ‘If things were left to chance, they'd be better’. Cynicism about statistics has helped to drive the modern demand for really good and appropriate analysis of data. ‘Skill in manipulating numbers is a talent, not evidence of divine guidance’, ‘An experiment may be considered successful if no more than half of the data need to be discarded to obtain correspondence with your theory’ and ‘Statistics will prove anything, even the truth’ are examples. On a related note: ‘The plural of anecdote is not data’.
Getting good data into the public domain is important for any new procedure because ‘The first report of any new operation is rarely unfavourable’. It is important to know when new developments do not work well: ‘No experiment is ever a complete failure. It can always be used as a bad example’.
Describing the results of scientific and clinical work in writing is a challenge for some surgeons. ‘It is amazing to note that the same hand that is direct and neat with a scalpel becomes paralytic or dyskinetic with a pen’ and ‘The meaning of this paper is hidden by the way it was written’ are testament to this, whereas for many ‘The ultimate inspiration is the deadline’. Presenting work at surgical meetings deserves comment. ‘One cannot be brief about a subject unless one knows it well’ and, on a rather different theme, ‘Aim at a ratio of operative cases to meetings of greater than one’.
Much of the shift of emphasis in surgical practice in recent times has been towards less invasive treatment. Wise surgeons have always recognized the advantages of trying to avoid operations that might do more harm than good: ‘It is less important to invent new operations than to find ways and means to avoid surgery’ and ‘Not all that is technically feasible is in the patient's best interest’. The aphorism ‘Most men die of their remedies, not their diseases’ still has an element of truth, but ‘The most difficult thing to do is nothing’ and ‘The mere withholding of an operation is not a virtue in itself’.
‘Most medical students are attracted to surgery … They know nothing of the haunting anxieties, the keen disappointments, the baffling perplexities, the dread responsibilities and the numerous self-reproaches’. The road for surgical trainees has never been an easy one: ‘Everything in surgery is complicated until one learns to do it well: then it is easy’. So much of surgery is an apprenticeship and the restrictions on trainees from working similar hours to their ambitious friends in other professions, in many parts of the world, has done them few favours: ‘The only bad thing about being on call every other night is that you miss half of the educational opportunities’. How much operating needs to be done at night is a controversial issue, coloured by the observations that ‘It is a curious but well-known fact that many who are taken with abdominal pain in the daytime endure till evening before they feel compelled to send for a doctor’ and ‘Everything gets worse at night’. Experience, supported by a sound foundation of knowledge, is the basis of surgical training, but the important quality of wisdom is more elusive: ‘From experience we should derive wisdom: but in surgery experience is never finished and wisdom is never complete’.
Of all the principles that should guide a surgeon, consideration for the patient is paramount. ‘You can't always be clever, but you can always be kind’ and ‘The quality of survival is as much the surgeon's responsibility as the fact of survival’ should be part of the ethos of all surgeons. Interventions that surgeons consider (or used to consider) routine should not be used thoughtlessly. ‘Every surgeon should have a gastric tube passed through his nose for 24 hours’ is a reminder of this. More generally, we are so used to hospital life that it is easy to forget that ‘Looking out of a hospital window is different from looking out of any other. Somehow you do not see outside’. The idea of early discharge is often considered to be a recent one, but Charles Mayo (1869–1935) advocated ‘The sooner the patient can be removed from the depressing influence of general hospital life the more rapid their convalescence’.
Surgeons have needed to become increasingly adept in management and politics. Useful lessons include ‘Don't fight battles you can't win’, ‘Charm is a way of getting the answer Yes without having asked any clear question’ and (especially with the march of specialization) ‘Never have anything taken from you that you could give away with magnanimity beforehand’.
A couple of aphorisms that I would like to include are ‘You can take your work seriously but take yourself less so’ and ‘Character is doing the right thing when no one is watching’. Perhaps these shine a light on me – ‘Show me your favourite aphorism and I will tell you who you are’ – so I will finish with an aphorism from my father (a radiologist and the first in our family to enter medicine): ‘The greatest rewards as a doctor are the respect of your colleagues and the respect of your patients’.