PORTRAIT OF A SURGEON.

H. S. CARTER, M.D., D.P.H.

He spoke of himself as '

a physician doomed to the practice of surgery concentrating in that significant phrase a summary of his life-long labour

infuse an exquisite mastery of a craft with the beauty of art and to vitalise it with the spirit of physiological research. He used surgery as a scientific probe to elucidate, by the exploration of the pathology of the living/ some of the physical ills that afflict mankind. He has been

Ascribed as the greatest surgical figure of the first half of the twentieth century, and the creator of a tradition. He survives in the best known Modern medical dictionary as the eponymous author of an outmoded test f?r hour-glass stomach by the administration separately of the component Parts of a seidlitz powder. Fame is fleeting in a civilization that endeavours

exceed the speed of sound. tjod by god goes out, discrowned and unanomted.'

Inhere are however other memorials of Berkeley Moynihan than an e*itry jn an American dictionary. Early in life he realised the aesthetic ^?Ppeal of a dramatic destiny and lost no time and spared no work in

producing himself to the times in which he lived, for most opportunely arose when all was prepared and ripe for a great stride forward in

Sl^ery : when from being a dreaded and dangerous fringe on the body of >S1C- surgery was about to begin its development into the safe scientific

Pr?cedure it is today.

Background and early life.

lo ^ginnings are soon told. Born in Malta in 1865 he came of a ^ne ?f soldiers. Five Moynihan brothers from Tipperary fell in

des ^a^P^aciue^' that Pyrrhic victory which even Marlborough Scribed as '

a very murdering battle.' They may have followed Patrick

Wa S

'

?eese '

w^? sought adventure in England's continental s" father won one of Queen Victoria's first V.Cs. at the storming

^.^le ^edan in 1855, was commissioned from the ranks, but unfortunately 'rh 0UnS ?f Malta fever when the future surgeon was two years old.

SOj^ -^ish blood of his paternal ancestors was however tinctured with ^

e ^nghsh and Scottish contributions, which may have accounted for

to Versatility and for the whipcord strands with which his nature was

le i etlec^" blood of his soldier forebears probably made him the

er anc^ nian of action he undoubtedly was, but the family history

flo "? accounts ^or his genius, which must have been the cumulative

^ of gifts long hidden in obscurity. Perhaps he acquired tenacity s?me strengthening which made for fixity of purpose?for he always

243

Ui GLASGOW MEDICAL JOURNAL

knew where he was going and what he wanted?from the discipline of Christ's Hospital, that half-monastic and half-military academy in which he received most of his early education. He intended to follow his line

and become a soldier, but with some Irish quixotry and to please his mother, turned to medicine which he studied at Leeds. Soon after he

qualified in 1887 the Fates took a hand and the surgeon was born. In

Leeds he stayed, and from that focus-point radiated the world-wide fame of his triumph and success.

He began work at a time when the Listerian deductions from Pasteur's work were developing into their logical outcome. The carbolic spray was

hardly defunct, and von Bergmann had only recently given us steam sterilization and was busy formulating the aseptic technique and intro-

ducing marble or tile-walled operating theatres. Moynihan was fortunate in his day and school for Leeds had a colourful tradition in surgery which included three generations of Heys, Pridgin Teale the elder, Samuel

Smith, and Nunneley. The last-named opposed Listerism, but his views were repudiated by Teale on behalf of his colleagues. There was a lot of

muddle-headed thinking at this time. Moynihan afterwards said that

Pridgin Teale the second assured him that Leeds Infirmary was the first

hospital in England to practise Listerism. Spencer Wells had been a

student there and it possessed as surgeons T. R. Jessop, afterwards

Moynihan's father-in-law, A. F. McGill, nephew of Sir Wm. Fergusson, C. G. Wheelhouse, Pridgin Teale the younger and Mayo-Robson. Wheel- house it was who with others in the winter of 1846-7, and in the dissecting

room of all places, first tried out anaesthesia in Leeds by inhaling

sulphuric ether from sponges. Fortunately there were no casualties-

White coats were scarce in Moynihan's earliest days and he used to tell

of his master, Mayo-Robson, ordering himself a nice new operating coat

of soft tweed which covered him from his neck to below his knees.

Moynihan was Mayo-Robson's house-surgeon in 1887-8, but before this stimulating experience he helped McGill as resident assistant with what he ever afterwards claimed was the first transvesical prostatectomy- Some portion of the gland had been removed as a growth causing obstruction. It proved to be adenomatous, and this provoked McG$ into enquiring why the prostate could not always be removed when

ft

projected into the bladder. Moynihan was fond of relating that in 18*$

McGill showed at a medical meeting a row of old men each holding 011

his knees a glass jar containing his prostate. From McGill and Mayo-Robson, he was accustomed to say he leart^

the rudiments of surgery. McGill he regarded as a genius and acknoW-

ledged great indebtedness to him. Mayo-Robson he thought must raI1^

with the very greatest surgeons of all time.

Moynihan began private practice in 1893 and was associated with

T. R. Jessop who was one of the last of the all-round specialists, and a

Portrait of A surgeon?carter 245

most competent surgeon. Thus he stood in ideal relationship with the old and new schools of surgery, and from now onwards knew with the

certainty of an artist what he was fighting for, and with the superb confidence and self-assurance he always showed, proceeded steadily to pursue his aims. He had already, with Osier, realised that the master- Word in medicine is Work. In the next ten or twelve years he published ?ver ninety papers and three or four books, which include the major part of his contributions to surgery proper, though there was much more to follow in the period of his maturity, emphasizing his methods and

spreading his doctrine.

Moynihan as surgeon.

Moynihan began early to acquire the perfection of technique, delicacy ?f manipulation and respect for the living tissues which he strove later like a crusader to introduce into surgical practice. There is evidence of

this in his early writings. He realised also the surgical dividends which

painstaking care of the patient pays. As he was to reiterate frequently and forcefully

'

the patient must be made safe for surgery as surgery is made safe for the patient.' For him the patient was always the most

important person in his operating theatres. He cherished the patient's

Well-being before and after operation and sought to convey the lesson. He had a natural gift in an unusual degree which enabled him to inspire patients with confidence and a feeling of safety, This magnetic power of his personality increased as he grew older so that even unresponsive or more knowledgeable people felt the tonic effect of contact with him.

From the wider field of general surgery covered in his early practice he soon gravitated to abdominal surgery chiefly, no doubt under Mayo-

Robson's influence. A glance at the subjects of his papers confirms this,

was soon fervently interested in the surgery of appendicitis, of gall- bladder disease, internal hernias, pancreatic disease and of affections of the stomach and intestines. He must have learnt much from Mayo-

Robson, that pioneer of abdominal surgery, and quickly found his

attention increasingly focussed on that area which Osier called the

abdominal area of romance '

where the head of the pancreas lies folded

1Ji the arms of the duodenum.'

Out of his correlation of the signs and symptoms of disease with

conditions revealed at operations he elaborated his classical work on

duodenal ulcer, gall-bladder disease, appendix infection, pancreatic disease and the mimicries of malignant disease of the large intestine,

ihese studies bore fruit in many addresses and papers, in books written

collaboration with Mayo-Robson and in one or two books of his own. In 1903 he first visited America and laid the foundation of life-long

association and friendship with American surgeons. Indeed he started a

to-and-fro transatlantic surgical traffic which was something new and

246 GLASGOW MEDICAL JOURNAL

which brought into closer association the surgery of old and new worlds. Osier, whom he much admired, playfully called him

'

Carnifex Maximus.'

Moynihan liked Americans and they liked him. He returned with new

ideas which he applied to his own practice. From Halstead, one of the

big four at Johns Hopkins, he received a present of rubber gloves and believed he was the first surgeon in Europe to use them. They were a

great improvement on the cotton gloves suggested by Mikulicz, but it is told that at first he had much difficulty in putting them on. This year saw in Leeds the first complete theatre outfits of white operating suits, caps, masks and gloves. Gordon-Taylor says that Moynihan had to

stand some chaff at first, being known as the '

pyloric pierrot.' These labours and adventures of" his first period culminated in 1905 m

his best known book, Abdominal Operations, which he shrewdly published in America where it was received with acclamation. It reached its fourth

edition in 1926 and still bears reading for the lucidity and the concise

descriptions of his own methods.

Pressing forward continuously, striving for that complete perfection which Cicero said was unattainable, he was led by his great experience to propound in 1907 his doctrine of

'

the pathology of the living.' It has

been claimed for him that he coined the phrase, but as Rolleston pointed out, Allbutt used it in 1903 in a paper on blood-pressure. Moynihan however made it peculiarly his own, emphasizing the knowledge gained by observation of pathological conditions in the living tissues disclosed at operations before there was radical alteration or destruction by disease, as contrasted with the pathology found at the necropsy. The

increasing safety of abdominal section procured by meticulous technique made this possible, for more organs than those receiving immediate attention could be explored, and signs and symptoms could be correlated with findings in the living body. Looking into the abdomen enabled the

construction of a pathology that could be related to these. He also spoke of a

'

histology of the living '

in relation to the development of malignant changes in gastric ulcer. Today, of course, looking and seeing into most cavities is comparatively easy and biopsy common practice. But once

it was not so. Moynihan's work was imbued with the spirit of sanity that informed Greek medicine.

Most great surgeons are credited with having been the first to perform some dramatic intervention, and Moynihan was no exception. He is

said to have been the first British surgeon to excise an aneurysm of the

subclavian artery, to employ blood-transfusion using a direct transfusion cannula, to perform a total gastrectomy successfully, and the first to

operate on a chronic duodenal ulcer (1900). He remembered Hunter's

injunction, '

try it.' If he was careful, he was bold, though he recognised increasingly the implications of lister's work.

'

Every surgical operation is an experiment in bacteriology,' he wrote.

PORTRAIT OP A SURGEON?CARTER 247

Those of us who have seen Moynihan operating at the height of his powers are not likely to forget the experience. Braithwaite and K. R. I1 lint have paid tribute to his precision and mastery. Moynihan himself described the ritual of a surgical operation as he conceived it.

'

Surgery after all is an affair of the Spirit,' he said ; and again,

'

The body of man is the plastic material in which an artist works, and no art is worthy ?f such a medium unless it has in it something of a sacrament.' Braith-

waite emphasized the quietness pervading his theatres. It is true there vvas never any brouhaha such as one has occasionally heard elsewhere, f?r surgeons are supposed to be temperamental. There was never

engendered to the patient's detriment a pervading irritability that some surgeons have been known to provoke, though I once saw him lay down Jnefficient scalpels and murmur sadly,

'

excellent fruit knives, Mr. ,

excellent fruit knives.' The atmosphere was charged with his powerful Personality, and when he was closely engaged his capable hands seemed

times to move and handle instruments of their own volition, smoothly and unhurriedly as though independent of the mind behind them, which vvas nevertheless supremely conscious of their effortless superiority. On a drowsy afternoon in the hot theatre when, in the wound surrounded by ?reen towels, there could be seen perhaps the edge of the liver, the green tip of the gall-bladder and a knuckle of intestine, looking for all the World like some exotic dessert on a Victorian fruit-plate, an imaginative ^an might have conjured up the grave face of Lister looking on approv- ingly or the wraith of John Hunter enviously taking note of the pathology ?f the living. But he would awake to the consciousness of having watched Workmanlike perfection such that Murphy of Chicago was once moved t? say was worth coming all the way from America to see.

As Wilkie of Edinburgh put it, it was this '

refining of surgery which by Precept and example Moynihan sought at all times to promote which

an enduring contribution which will stand for ever.'

Moynihan liked to quote old Thomas Fuller's three requisites for a Surgeon's practice,

'

an eagle's eye, a woman's hand and a lion's heart' ; aild he would add,

'

never a lion's claws and the heart of a sheep.' He ever advocated gentleness of manipulation. All rough surgery was ailathema to him. He said

'

Surgery of the "

brilliant "

kind is a

desecration. Such art finds its scope in tricks with cards, in juggling with billiard balls '

Although he used the instruments best fitted for their tasks, many Modified by himself, he had little use for mechanical retractors. Sensitive

^ngers were required to do the work, and no unnecessary trauma was Permitted. He strove like Halstead for perfect haemostasis, and paid Patient attention to details. '

Success in surgery, as in all affairs of life

depends very largely upon the observance of details.'

24$ GLASGOW MEDICAL JOURNAL

Such was his concern for perfection that he was probably never

completely satisfied with an operation. His constant advocation of the

very highest ideals is proof of this. He himself had no second-best in

surgery, and was devoted down to the last stitch?and the extra stitch, which he said, helped him to sleep at night.

He wrote of the surgeon, '

a life is entrusted to his hands. It is for

him to safeguard it.' Even in 1926, he was saying '

there is today, too much bad surgery.' He would probably repeat it now.

After the first world-war in which he had an active part in various consultative capacities, and wrote on various aspects of traumatic

surgery, he took of necessity, as he became famous, more interest in affairs social and administrative, but he still continued speaking to his text, the betterment of surgery. In his various orations he did honour

to the twin gods in his Valhalla, John Hunter and Iyister. But ever he

returned with evangelizing zeal to the theme nearest his heart, the

improvement of the surgical craft, its beautification as an art and the

extension of its usefulness by attention to physiological principles. '

Biology is the interstitial tissue of surgery,' he said. He strongly influenced the surgical practice of his generation by bringing surgeons together and by the lasting passion of his constant crusade for better and safer surgery. He devoted all his enormous energy to this, and used to say he was never tired, though he admitted that sometimes virtue went out of him. At the end of his life he could write that it had all been

great fun.

Moynihan as teacher.

It has been said that Clifford Allbutt entered the lecture room like

Moses descending from the Mount. He certainly looked like an immaculate

major prophet and exuded an aura of patriarchal scholarship. Moynihan's entry was different. He was not a scholar as Osier and Allbutt were,

nor did he look it. His tall athletic figure with the pale, handsome face and rust-coloured hair, strode in,

'

in form and movement how express and admirable,' radiating utter capability and supreme assurance. Then

he would lean against the table and talk. In his earlier years he must have been a teacher after the student's own heart, for Braithwaite used to

declaim to his students a long list of the foreign bodies to be found l*1

the knee joint, which he had learnt from Moynihan years before, and which included such things as the

'

additamentary bones of Adams,' whatever

they are. Moynihan had a prodigious memory, a great love of eponymous objects and curling phrases, and as great a liking for pithy sayings and

epigrammatic utterances as the student has for lists. His writings are

littered with them, and so were his addresses and lectures. Later in his

career he might have said with Montaigne (whose Essais was one of his

books) '

I do not teach, I only tell.' And how well he told ! The hour of

PORTRAIT OF A SURGEON?CARTER 249

his clinical lecture passed like a flash, as his mellifluous voice made the dry bones of his subject leap to life in the smooth continuous flow of perfect sentences, sprinkled with allusions and with the great names of his predecessors and contemporaries. All Leeds men soon learned that Wolfler at the suggestion of Nicoladoni, performed the first gastro- enterostomy in Billroth's clinic in Vienna in 1881. He liked to paint in the historical background. Then in due course we were told, speaking of appendix dyspepsia,

'

the commonest site of gastric ulcer is in the right iliac fossa,' or to emphasize the importance of the early diagnosis of duodenal ulcer,

'

haemorrhage is no more a sign of duodenal ulcer than a ruptured perineum is a sign of pregnancy.' A little later he told us that Kocher was the greatest surgeon in the world (this was in 1916). He

refrained from conjecture-as to the second greatest. Crile he said was

a great disturber of intellectual traffic.' On occasion he did not disdain a histrionic opening, and when he began

'

I was reading Hippocrates this morning

'

we felt sure for a moment, that it must have been in the

?riginal Ionic dialect. Few surgeons' lectures can have had more charm than Moynihan's. He gave us the facts embedded in a coloured tissue of Surgical word-painting.

At the bedside it was much the same sort of good talk. He threw the mantle of his personality over the patient and put him at ease. He

examined him carefully, and it was a lesson in gentle diagnostic efficiency to see him palpate an abdomen, his sensitive hand and fingers moving, 0r so it seemed, as though they were part of the living abdominal wall.

did not, like many, drive the student to incoherence and reduce his

imperfect notes to tatters. Instead he would say of the patient, '

Tell

about him,' and after the student's stumbling description, would himself cover the subject as only he could, with more epigrammatic Sayings and up-to-date allusions. So we learnt that he approved Murphy's dictum in appendicitis,

'

get in quick, and get out quicker. One day, in lighter mood, advising that gastroenterostomy might be

d?ne if there was time and the patient's condition permitted, he told us, After all, what is gastroenterostomy but twenty minutes, two needles

and a bit of string.' He talked of other cases in illustration, relating his

^xperiences. He would speak of the practice of his contemporaries, ^ ace wen, Rutherford Morrison, Stiles ; and of the Americans, Crile,

^

e Mayos, Murphy, Gushing. If he asked who Syme was, he expected ? be told that he was leister's father-in-law, but I doubt if he ever got at answer. The corrollary to this question was obvious to those who

ttew. It was all thouroughly delightful, if not the best preparation for e academic examination as the average student saw it. But for the

ri?ht man he was a brilliant clinical teacher. It is said that Moynihan never founded a school; that when he died

ere Was no one to wear his mantle, There may be some truth in this,

250 GLASGOW MEDICAL JOURNAL

but he certainly trained some very efficient surgeons in his own line of

work, and his reforming influence spread into countless operating theatres. As for his mantle, perhaps he never had anyone near him of sufficient calibre to carry it, for it needed more than mere excellence in surgery.

Moynihan as orator and writer. Moynihan enjoyed speaking and had an inborn gift of eloquence.

Careful preparation, a prodigious memory and complete self-assurance were aided by a magnetic voice, polished diction and great felicity of

expression. He was fluency itself and has been rated as the greatest medical orator since Sir James Paget and compared favourably with the fifth Earl of Rosebery. He had few gestures but could, as he did in

America, raise great enthusiasm. His magnificent development of his

gift no doubt surprised himself. As a writer he could say what he wanted lucidly in flexible English

of delightful though disciplined phraseology. He was a phrase-maker and word-painter and most of his work has a literary patina uncommon in scientific writings. His more important productions are finished

examples of the literary art, rounded and polished. His historical and

laudatory orations which were written for delivery showed his excellence in vivid portraiture and critical appreciation. Though he published a

great deal, whether he equalled Osier and Albutt at their best is a matter of opinion. His field was much narrower and he lacked the breadth of

historical outlook which was theirs ; but he was often most stimulating-

Moynihan as leader. The great leader shows the way to others and commands acceptance

of his views. Moynihan did this. In his time he played many parts. His life stretched over a period of great change in surgical ideas, of which he had a cool far-sighted comprehension. He managed his reconnaisance like a good soldier, and with keen perception and ceaseless industry did a good deal to blaze the trail, He was formidable, dominating, possessed ,

by a perpetual enthusiasm such that men readily took a lead from ofle who made them believe that their own work was so worthy and s?

important. He succeeded in changing the intellectual outlook on surgery and was able to infect others with the spirit of progress and reform which

they carried to their own hospitals. And yet he was no innovator. #e

was an assiduous collector of all that was best which he wove into a

tapestry for men to admire and reproduce if they could. One of hlS

favourite quotations was Montaigne's '

I have gathered a posy of othef men's flowers and nothing but the thread that binds them is mine oWfl- The thread he spun was strong and the binding firm.

Much of his work as a crusader for better surgery was done through his association with such projects as the travelling Chirurgical Clu^'

PORTRAIT OF A SURGEON?CARTER 251

now specifically carrying his name ; with the later-formed Association of

Surgeons ; through his pioneer work for and long connection with the British Journal of Surgery, and through his frequent visits to America, where he was much appreciated and where he was given a great ovation during the war in 1917. As a surgical ambassador he was a brilliant success.

He sought to bring surgeons together in a clubbable way for the

interchange of views and experiences and to facilitate the diffusion of surgical knowledge among the brotherhood of the craft, all with the

Purpose of raising the dignity of surgery, improving its technique, and

increasing the humanity of its outlook. In all this Moynihan was very successful for he had great charm of manner and was not to be put off

by '

non-cooperators' or lukewarm doubters. He could overcome

obstacles, and get things done.

Moynihan was knighted in 1912, became a baronet in 1922 and was elevated to the peerage in 1929. Lord Moynihan of Leeds was the first

surgical peer since Lister, and he appreciated the honour. He had

founded a dynasty. He was President of the Royal College of Surgeons of England for

six years from 1926 and here his administrative power backed by his

compelling personality bore fruit in the creation by the College of

facilities for surgical research, something which had always been near

^oynihan's heart. He had often asked the physiologists to come out into the field and leave their test-tubes. Perhaps he did not fully appreciate pure science.

So his dynamic personality and the shrewdness with which he used bis gifts carried him to the heights, though there were one or two honours be coveted unavailingly.

In the last analysis of personality all great men have flaws and

Moynihan was no exception. There were chinks in his armour. He was

a great man, and a master-surgeon of uncommon prescience. Lesser men

Said he was proud, ambitious, aloof. He had heroic qualities but much ?f his power and success stemmed from the peerless quality of his work.

his time he was the greatest abdominal surgeon in the world. His

VVas a complex character, a mixture of soldier and man of affairs as well as surgeon. He may have appeared austere at times but there was a streak of Puck in him, and he could be very kind.

Moynihan died in 1936 and a resting place in Westminster Abbey Was offered for him, where he would have lain with his heroes John hunter and Uster. The offer was declined for sufficient reasons, but it

dlustrated the truth of what Voltaire said at Newton's funeral, that it ^vas one of the glories of England that she is able to recognise the

Supreme merits of a King among men,'

252 GLASGOW MEDICAL JOURNAL

REFERENCES.

Most of Moynihan's papers and addresses are to be found in the Brit. med. J. and the Lancet from 1896 to 1932. Some of these were collected : The Pathology of the Living and other Essays (1910) ; Essays on Surgical Subjects (1921) ; Addresses on

Surgical Subjects (1928). London and Philadelphia : Saunders.

Bateman, D. (1940). Berkeley Moynihan : Surgeon. London : Macmillan

Gordon-Taylor, G. (1940). Univ. Leeds med. Mag. 10 : 3, 127

Gordon-Taylor, G. (1940). Lancet. 2 : 537

Groves, E. W. Hey (1840). Brit. med. J. 1 : 601, 649

Rolleston, Sir Humphry (1929). Life of Sir Clifford Allbutt. London : Macmillan

University of Leeds med. Mag. (1937). 1:1. This is a Moynihan memorial number and contains appreciations by Wilkie, Win. Mayo, Braithwaite, Mr, E. R. Flint and others.