The two generals

After his much-vaunted oesophageal resections for cancer of the oesophagus, when the Parsi Professor would emerge from the OT to speak to the patient’s family, he would cinematically refer the matter upwards, to a Radically Benevolent God. For a man who was antipathetic to any superintending deity, this referral was never done shiftily or casually, but with the highest seriousness, almost as an act of faith. Posterior to it, Marx’s great throwaway line from the Critique of Hegel’s Philosophy of Right was thrown at us, the small congregation of surgical residents, as a sort of verbal annotation: ‘To call on them to give up their illusions about their condition is to call on them to give up a condition that requires illusions’. “But we do need to find out,” he’d often say, “if God can heal the oesophageal anastomosis.” Twice, midway through my term, he’d threatened to change the subject of my dissertation to ‘A Study of the Intercessory Effects of Prayers in Patients Undergoing Oesophageal Resection’.

As young residents in a mofussil hospital in Maharashtra, we could belong to one of two surgical units: the Parsi’s or the Maratha’s. We had no choice in the matter. We ended up spending two years in our respective parent unit and were decanted in the middle for a year to the other unit. The whole thing wasn’t quite fun and games: the work was very hard for very little, the conditions feudal, the atmosphere a meld of what you’d find in a debased communist State and a Victorian workhouse.

The Professors, Dickensian villains both, glowered at us perpetually and treated us like chattel. The Maratha was a leathery old curmudgeon who displayed the most coxcombical variant of vanity and conceitedness, and operated so imperiously that every time he took off his surgical gloves, it seemed he was going to announce he’d invaded Multan. The prospect of working in his unit was a lowering one as his residents never got a chance to operate. What they got, was a kind of spectatorial education. Intraoperatively, they served as tissue retractors to make way for His Majesty; postoperatively, they provided the ovation.

The Parsi, an illustrious savant in the groves of academe, was equally irascible most of the time and looked upon us as valets, but all that was fine for he actually allowed us to cut people up. It was in his unit that we got a whole lot of surgical action, which meant the chance to wander unaccompanied into abdominal and thoracic cavities amid their sundry viscera. He allowed us our first unchaperoned encounters with animate tissues. It was there that we plugged the hole between theory and praxis. Everybody wanted to be in the Parsi’s unit. He was the man we exalted. Almost as much for his fantastic swagger and pudendum-based expletives and all-round grouchiness as his surgical discourse. And, as might be expected, for giving us free rein.

But, it was during our time with the Maratha that most of us could feel the first stirrings of the artisan in us. We hated the man on a cellular level, but delighted in the consummately artisanal way in which he performed surgery. We wanted to do it just like that. The lecturers would be his first assistants and we were relegated to the position of being second and third assistants, watching those magnificent performances from the sidelines. Even his circumcisions (for pathologically adherent, non-retractile adult foreskins) were transcendent. It could be said he considered it a procedure for beautification. It was done with trigonometric solicitude, without any loss of blood, the penile breach closed with an impossible running subcuticular stitch.

We couldn’t do it, no matter how hard we tried. Our circumcisions in the Parsi’s unit produced fringes around the glans, like lacework or the ample necks of frilled lizards, even though we removed as much prepuce as was legislated by the Maratha. On excising haemorrhoids, we couldn’t get those three perfectly formed cloverleaf defects (with his tally of just three streaks of blood on a solitary gauze piece). Our haemorrhoidectomies tended to be blood-sodden campaigns.

It was actually a departmental audit that prepared us for what turned out to be an unfalsifiable conclusion — the Maratha was the better surgeon. Not just empirically, but measurably. We noticed significant differences between their outcomes for every parameter — postoperative morbidity, mortality and patient survival. The results for oesophageal surgery were: curative resection rates 40 per cent (Parsi) vs 76 per cent (Maratha), 30-day patient mortality 30 per cent vs 10 per cent, local recurrence 38 per cent vs 15 per cent, anastomotic leaks 25 per cent vs 10 per cent, and 10-year survival after curative resection was 20 per cent vs 63 per cent. Our own audit was carried out in the slipstream of a self-evident proposition that widely appeared in surgical journals then: the surgeon is to be considered an important variable that can influence patient outcome, particularly in cancer surgery. The foregrounding of this ancient bromide happened in the characteristic language of peer-reviewed journals. ‘The current data suggests that the surgeon is an important prognostic factor in the treatment of oesophageal cancer.’

Paradoxically, the results of our departmental audit were at variance with the other bit of inference being bandied about in these journals as gospel — the relation between case volume and outcome. That, somehow, quantity meant quality. The more you undertake, the better you get at it. Miller et al had analysed the Hamilton (Canada) regional oesophageal cancer registry (1989-1993), and found 22 per cent hospital mortality for surgeons performing fewer than six cases per year, compared with zero per cent for surgeons performing over six cases per year. In our hospital, the Parsi did more than twice as many oesophageal and pancreatic cases as the Maratha (whose score in an average year would not exceed six).

The two of them were true generalists. As general surgeons, there wasn’t a pathology that did not fall in their remit. Lung, oesophagus, pancreas, prostate, breasts, thyroid, thymus: they did everything and looked upon the loss of generality as the declension of the new generation. But the Parsi had always considered the oesophagus and pancreas his forte.

A major element of the Maratha’s personality had been his unslackening contempt for the Parsi. The Parsi believed in all seriousness that the Maratha, as an organism, had lower intelligence than his constituent parts. The results of the audit had absolutely no effect on him. His operative technique, with its equal mix of insouciance, flamboyance and caprice had become a habit.

The Maratha’s big-headedness grew even more. He thought the audit was the apotheosis of his career. His operative technique had never come across as a transferrable skill. Nor did he ever try any kind of transference.

I’m aware that the debt for my own surgical enlightenment must be split evenly between the two. Let it also be said that some of those oesophageal resections (imputed to the Parsi) were performed by residents. In the course of a few of them was begotten my own learning curve. When residents operate, the religious might make a case for intercessory prayers.

(Ambarish Satwik is a Delhi-based vascular surgeon and and the author of a rogue and deviant sexual history of the British Raj called Perineum: Nether Parts of the Empire)

>asatwik@gmail.com

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