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PUBLISH OR PERISH
HONORED G U E S T S ADDRESS
PUBLISH OR PERISH N. R. Barrett*
London,
England
. . . a small drop of ink, falling like dew upon a thought, produces that which makes thousands, perhaps millions, think. Byron
T
centuries ago, Baltasar Gracian, a Spanish Jesuit, wrote a book of aphorisms called The Art of Worldly Wisdom, and here is a piece of his advice: HREE
Know the measure of your luck.
When your president invited me to give this lecture I realized at once that he had mistaken me for somebody else; but recognizing my luck I accepted before he could change his mind. The next time I opened my Gracian I found this: Beware of entering to All too large a gap.
It was too late. Here I am. Mr. President, I appreciate the friendship of your gesture. I know that this Society stands in the van of International Surgery and that famous men have stood in this place before me. You have paid me a compliment—the nicest I have ever had. And so it is with trepidation lest I waste your time, but with a most sincere conviction of the importance of my subject, that I shall discuss the writing of surgical papers. A dry topic, perhaps, and one that stands forgotten behind the advancing frontiers of thoracic surgery. My qualification to venture along this thorny path is not that I can write good prose where others fail: it is that, as editor of a surgical journal, I see manuscripts and have opinions about them. A critic is entitled to comment upon the work of others without claiming to be their peer. Indeed, it is strange that throughout the ages little men have criticized giants and, even stranger, that their criticisms have sometimes been constructive. It is my experience that many surgical manuscripts are badly written and Honored Guest's Address: Presented at the Forty-second Annual Meeting of the Ameri can Association for Thoracic Surgery a t St. Louis, Mo., April 16-18, 1962. Address: St. Thomas' Hospital, London, England. •Editor of Thorax. 167
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that, in consequence, they do not do justice to the facts they contain. This is an old complaint. In 1904, Professor Bryan wrote a letter to the Journal Nature. Here is a part of his text: I have before me a number of mathematical papers which contain no indication whatever of what the authors are driving at.
An editor has two duties: to assess the scientific merit of the paper he has been asked to publish, and to make certain that the author has expressed himself clearly. I shall comment upon the belief that surgeons must publish or perish, and I shall talk about clarity in scientific writing. I shall try to persuade you that to achieve clarity surgeons must cultivate some literary values. Election to this Society, or to any position of surgical importance, is in fluenced by the number of papers a man has written: no papers, no hope of election, no future! At least that would be the prospect for all but a Martin Luther prepared to nail a broadsheet of heresy to the door of orthodox surgical opinion. Nevertheless, I suspect that most of you deplore this obligation, not only because it is a doubtful test of a man's surgical ability; but, because, in later life, you resent having to grind out an article every few months. As things stand it is difficult to see any alternative to this but I think there are signs that this way of spreading technical knowledge is changing. In 1939, Professor Bernals stated that there were 35,000 scientific journals. This spate of publications was inadequate then to deal with all the articles that were sub mitted; and many that were printed were, in fact, buried. Since then medical research has increased, and the situation is almost beyond control. Nobody can keep abreast of the current literature. A writer in the literary supplement of The Times had this to say: In every profession, in every branch of scholarship, it is becoming harder to keep pace with current developments. Nor is this just because so many actual discoveries are being made. The fragmentation of knowledge itself leads to overlapping and duplication, to scattering of the relevant material through an ever widen ing range of publications; as t h e horizons close in there is more and more pointless research. Keeping up with the real advances is only part of the problem. Trying to identify them at all in the vast wastes of words and effort: that is what takes the time. . . . The young scholar, pressed to publish ' o r i g i n a l ' work, may think he is doing so when the ground has already been covered; he may be thicken ing the word-jungle to no purpose. And there are many other indications that even if the flow of new discoveries in other fields is less than in science the problem is still the same. For the scholar in the humanities cannot afford to treat his prede cessors as superseded. He has to keep up with the present and the past.
It is possible that surgical journals, as we know them today, may cease to exist. All new papers may have to be sent to a central editing service where the information they contain would be microfilmed and fed into electronic computers by experts. New facts would be correlated with existing knowledge and the cur rent position of any subject would be quickly available. A few journals of the digest type might survive, and subscribers would receive official abstracts on advances at regular intervals. Such a system would save surgeons the pleasures of claiming priorities, and it would clear the air! So far medical men have
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contributed nothing to the solution of these problems; but industry is fully aware that memory is fallible, and that time is wasted in redundant work. If the ways in which information is spread abroad change, it may be possible for us to kill the dragon called "Publish or Perish"; supposing always that we should want to do so. The onus for this execution will not rest with editors because their duty is to publish as much as they can of the material submitted to them. The only thing they can do is to remind you all, as often as an oc casion arises, that your duty is not only to yourself but to truth, to readers all over the world, and to patients. They can plead that you should only write when you have a strong urge to do so, when you have something important to communicate to others, and, above all, when you have plenty of time to do the job properly. For these reasons you must not expect editors to kill this dragon for you. The only way in which they might help is to reject most of the papers that are sent to them, and this is an unpleasant thing to ask them to do. Most editors send unsatisfactory manuscripts back with polite notes of encouragement and this is especially the case when the author is a young graduate. Here is a rejec tion slip sent by a Chinese mandarin. We have read your manuscript with boundless delight. If we were to publish your paper it would be impossible for us to publish any work of lower standard. And as it is unthinkable that, within the next thousand years, we shall see its equal we are, to our great regret, compelled to return your divine composition, and to beg you a thousand times to overlook our short sight and timidity.
Some feel that the present necessity to publish as much as possible is a good competitive stimulus. They point out that writing papers is a part of every surgeon's training as well as an advertisement that pays dividends. It ensures that every bit of information is available somewhere. Famous surgeons of the past have written, and nobody has suggested that they were wrong to do so. The argument that there are good men who publish nothing does not impress those who believe that these silent practitioners are benefiting from circum stances they neither create nor maintain. The young man who gets several papers published marks himself out as capable and willing to do more than the minimum imposed by necessity; he develops his ability to refine facts and he learns to marshal ideas. So runs the argument. It is particularly in the education of surgeons that I doubt the propriety of expecting young men to write papers when they have nothing important to write about. A man at the beginning of his career has no experience of his own to draw upon; his sources of information are the library, the record room, or the laboratory. None of these is satisfying to everybody; but if a young man wants to write they are his inspirations. So it comes about that, to publish and not to perish, young men must work in a laboratory. Clinical studies are regarded as scientifically inferior stuff. The elite gaze upon beads of light that dance monotonously across a screen—■ and are gone. I do not disagree with the view that surgeons should have practical experi ence in the discipline of modern science. They must be taught how science can
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be equated to the everyday work of a doctor and they must learn to measure and to assess their achievements. But I object to this period of apprenticeship being used as an excuse to write papers. Men who enter a laboratory are, at first, observers in a place that is strange to them, and the papers they write are not suitable for international publication. I know that many manuscripts, sub mitted by a team of workers, carry the cachet of an established scientist; but I prefer a paper written by a single authority. A cynical Englishman once said about immature scientific papers: To copy from one book is cheating.
To copy from.two books is EESEAECH.
John Gibbon—your president for 1961—spoke about educating young thoracic surgeons. He recognized that some able students have no aptitude for research, and that it is a waste of their time to do this work. He said that they would be filtered off from the main stream into teaching and clinical studies. For him the road to the top had been through research. That was the gateway through which he, and you, entered into this important Society. But the idea that research in a laboratory is the fire that tempers surgeons and that he who lacks this 'discipline will be banished to obscurity seems to me to be too rigid. If we all lived a great deal longer it would still be impossible to extend the compass of our learning to include all knowledge. Nobody can study every facet that throws light upon our work, and while one is forging ahead profitably in a laboratory, another, who is not gifted in this type of work, is wasting his time. In my travels I have been fascinated to study the behavior as well as the technical skill of surgeons working in different countries. I have noted that the men who are most esteemed by their colleagues are international in outlook and in education; they are interchangeable, clinic for clinic, country for country. They are men of the world, and they have wisdom. I believe that most of them were born with the gifts that have raised them above their contemporaries, because it is doubtful if a scientific education alone could have carried this re ward. Apart from these great men there is the host of lesser lights who lack this vital touch. They are often splendid technical performers but their educa tion has been circumscribed. Surgery needs the individual and the combined contributions of clinicians and technicians, scientists and leaders, scholars and men of the world; and who among us can measure up to these heights? And, since the learning of those who could contribute usefully to the advancing front of science is so wide, we must expect a variety of roads to the top. Whatever curriculum we arrange, some men, ploughing their own furrows, will make their mark. They are our benefactors because they remind us that excellence cannot be cast in a mold. I have suggested that too many papers that are unworthy of publication are being written, and important information is often swamped; that young men driven to publish or perish find their inspiration in laboratories and write many of these immature works; that some surgeons are out of place in a laboratory and would benefit from the study of other subjects. It is conceivable that the humanities may be as valuable, as a training ground, as animal physiology.
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My life as a surgeon, as well as my experience as an editor, has convinced me that we should know much more about the humanities—and in particular the arts—than we do. There would, of course, be no early dividends for any young graduate who forsook the laboratory and used the time to study literature. He would probably be regarded as an eccentric heretic who had taken leave of his senses; but who can tell—he might acquire a taste for scholarship and on that account he might even be able to help his scientific colleagues in later life. But no young surgeon will dare to deviate from an official course if he knows that he is drawing a bow at a venture. Appointments boards would have to be prepared to weigh scholarship against a pile of research papers. The inability of some eminent scientists to express themselves in writing, and to explain their discoveries to others, has become obvious as the complexity of their work has increased. Some experts in medical education, such as Pickering, have lamented that language has become a lost tool of learning; and others, in lighter vein, have devised jokes to ridicule the inarticulate men of science. Here is a story to this end: "When a physicist visited a well-known research institution, and was asked to write his name in the visitors' book, he drew two crosses. When asked what these marks meant he said, '' The Second is my P h . D . " A reason for suggesting that a knowledge of the arts and, in particular, of the fine literature, might be valuable to those who aspire to the practice of surgery is this. None of us spends all his days in the operating theaters. The older we get the more time we devote to the personal problems of our patients, and to management of surgical affairs. To do this effectively we need wisdom, and an acute sense of values; we must also be able to communicate our ideas accurately and simply to others. Those critics who are most qualified to speak have told us that the arts are not only the supreme form of communication but they are the foremost teachers of values. No commerce with science or technology alone will teach a man who lacks a natural sense of values the things that really matter. If he has not got this gift then he may acquire some part of it by studying the arts, and particularly by reading the works of the great men who have left their opinions for our benefit. A sense of values is another name for wisdom, and to acquire this wisdom some leisure is necessary; leisure to watch the world, to contemplate opposing opinions, and learn how to discuss affairs in a civilized way; leisure to cultivate a balanced sense of values. Richards has this to say about values: The Arts are our storehouse of recorded values. They spring from and perpetuate hours in the lives of exceptional people, when their control and command of experi ence is at its highest, hours when the varying possibilities of existence are most clearly seen and the different activities which may arise are most exquisitely reconciled, hours when habitual narrowness of interests or confused bewilder ment are replaced by an intricately wrought composure.
You may think that time spent in acquiring a modicum of wisdom and a sense of values would be wasted in this mechanistic age. You may argue that the bare facts of a scientific idea carry their own message, however clumsily that
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message may be presented; and you may be convinced that to study the humani ties, in the vague hope of writing better prose or of becoming a more erudite surgeon, is a luxury that does not concern you. But you should know that in formed opinion would not accept such views. The arts educate people by example. They not only enlarge a man's range of expression and experience, but they teach him to analyze complex and unusual situations. Everybody knows the feeling of freedom, of relief, and of increased competence and sanity that follows any reading in which more than usual order and coherence has been given to our responses. We seem to feel that our command of life, our insight into it and our discrimination of its possibilities, is enhanced, even for situations having little or nothing to do with the subject of the reading. (Eichards)
The foremost intellects in every age have made it clear that the education that the arts offer is not easily obtainable in other studies. Critics, from Aristotle onwards, have stated that wisdom, clarity of thought and purpose, and scholarship that are the fruits of learning are indispensable to the best practice of every profession; they are not relevant to the arts alone. The material upon which a beginner may work is everywhere accessible in abundance; no special tutors or personal teaching is necessary. Indeed the surgeon who comes home, tired and confused by the problems that beset him, has but to take a good book from his shelf, and read. The tale that unfolds reveals the folly, the weakness, the strength, and the goodness of the actors. I t teaches by imperceptible ex ample and ordered criticism. There is nothing new in the suggestion that some surgeons might benefit from a study of the humanities. In mediaeval times, theology, medicine, and the law were regarded as the superior faculties in all the important universities, and each was approached through the arts. As time has passed, medicine has joined forces with the new faculty of science, and in so doing, it has lost contact with the arts. The new alliance between surgery and science has been valuable to surgeons because it has taught them to be critical of their achievements. But the price has been heavy; scholarship has almost been thrown away, and some deplore this for its own sake and because surgery can never be truly scientific. Patients are not test tubes. The suggestions I have made may be trivial when measured against the need to provide education and medical care throughout the world. Concern about " v a l u e s " and "wisdom" are luxuries that can wait; but in the more enlightened countries these attributes should be examined now. Surgery has become an inanimate technical scramble; let us not forget the human side of our calling. I am aware that these ideas may be somewhat nebulous, and that they will be unacceptable to some of you because they savor of things that are outmoded; they draw upon the past. I answer such critics by asking them to read the opinions of men such as Whitehead, mathematician and philosopher. Listen to this:
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What we should aim at producing is men who possess both culture and expert knowl edge. Their expert knowledge will give them the ground to start from, and their culture will lead them as deep as philosophy and as high as art.
Whitehead also wrote: Mastery of knowledge, which is wisdom, is the most intimate freedom obtainable. The ancients saw clearly—more clearly than we do—the necessity for dominating knowledge by wisdom.
And so I submit that surgeons will be unwise to abandon the arts. The enlightened men in both faculties will always be aware of what goes on in the other camp; but it is our duty to bridge the gap for those who are wholly com mitted to science. In the remarks that I have made so far you may think that I have been unduly critical of young surgeons working in laboratories. But the papers they submit for publication are no worse than the average. I have singled this group out because, being young and amenable to reason, they can be saved from blindly copying the majority. Two factors have been interwoven in this talk; the laboratory as an inspiration, and the urge to write. In fact, some of the worst papers that an editor sees are submitted by very senior men; it can be embarrassing to turn them down. But I feel no responsi bility for the reputations of my contemporaries; to me they often seem to be in corrigible. The remarks that follow concern the ways in which surgical papers may be composed. This is a large topic and only the general principles will be men tioned ; books have been written about the details. As I am convinced that you will all continue to write papers, I commend to your attention a small book, first published in 1904, by Sir Clifford Albutt who was Regius Professor of Physics at Cambridge University. He was described in these words by a correspondent in the Lancet, "My interest in the clinical thermometer goes back to 1920 when I first beheld its inventor, Sir Clifford Albutt. He was then a septuagenarian but still rode his tricycle through Cam bridge. He was always immaculately dressed in his morning coat, grey waist coat, striped trousers, spats, white gloves and Homberg hat.'' This is the man whose book you should read. It is called Notes on the Composition of Scientific Papers, and it is one of the first on this subject. Since 1904 a number of more elaborate works have appeared but none excels these notes. The moment you choose and the circumstances under which you take up your pen to write have an important bearing upon what you can produce. Who can doubt that a subject about which you have, consciously and subconsciously, been thinking for some time will have more to offer the reader than one written without previous thought. Richards, commenting upon the quality of the work that an artist produces when his mind is functioning at its best, said: As a chemist's balance to a grocer's scales, so is the mind in the imaginative mo ment to the mind engaged in ordinary intercourse or practical affairs.
It is useless to sit down late at night, or when you are tired, and hope to
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produce anything of value to others. And if you stop to think whether you should write at all, here is what Professor Bryan says about that: If a paper [for the Royal Society] is of any value, the author must 'ipso facto' know more about the subject-matter than anyone else. If he does not, he is not the proper man to write the paper.
This standard may be a little high for you and for me! You may like to know that the first American to write a medical paper was Thomas Thatcher, minister of the Old South Church in Boston, and the date was 1677 (Blumgart, 1961). Its title was " A brief guide in the Small Pox and Measles.'' He started an avalanche. Surgical papers, like works of prose, should have a beginning, a middle section, and a conclusion; all are vital to the balance of the whole, and the purpose of each is different. The beginning should state the problem, carry the reader to the root of the matter, and indicate the style in which the whole will be set; the middle part should offer a contribution toward the solution of the subject; and the conclusion should present the picture in the light of the writer's ideas. Many of the papers sent to me begin with a brief review of the literature. This is unsatisfactory because there is nothing original here; the information has been copied verbatim from the last paper the author read. Men who have written reviews for important journals realize that the task is more onerous than to record a list of names and dates; it is to allot to each the merit it deserves. Nor is it desirable to begin by decrying the existing state of knowledge, for this suggests that the author is about to set things right; a hope that is seldom ful filled. Remember this: We should be aware of the hollowness of our knowledge and the solidity of our ignorance. (Albutt)
The opening words can be so difficult to choose that it may be wise to defer writing them until the main theme has been written. I have found instruction and amusement in looking at the way great works of literature are introduced. The first words often define the subject; in addition they may date the story, set the style, and indicate whether the work that follows is fact, fiction, or in the realms of the imagination. John Bunyan begins The Pilgrim's Progress like this: As I walked through the wilderness of this world I lighted upon a certain place where was a Denn; and I laid me down in that place to sleep; and as I slept I dreamed a dream.
But for me there is one special book in which the opening words are beyond compare; I mean The Stones of Venice by Ruskin. I would like to think that some of you would read the first page of this book immediately before you begin to write your next surgical paper. The effect will not be to deter you; but rather to give you encouragement and example. A surgeon may not be able to emulate the masters of prose with any more success than an amateur can challenge a champion; but with practice and ap-
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plication he can transform his performance from bad to acceptable. And the fact that his material is technical rather than artistic is not a cause for despair. The complexity of his subject must be as a stimulus to simplify the text. The author who composed the Book of Genesis had a complicated story to tell; but his technique was simple. In the beginning God created the Heaven and the Earth.
A surgeon who sits down to write is like Christian in The Pilgrim's Progress. Enemies stand everywhere around him. He comes at first to the Forest of Technical Jargon and this is so dense that he may be overwhelmed, because he knows that the function of language is to convey meaning. This is what Christie had to say about people who coin and use unnecessary technical words " . . . . all professions suffer from people who use long words to increase their sense of importance. And the worst of it is that they are so successful." The French critic was right when he said, '' Nothing is so persuasive to men of little intelligence as what they do not understand.'' The temptation to write ten words where one would have been enough is difficult to repress. It springs from the mistaken idea that size and quality go hand in hand. One of the duties of an efficient editor is to prune wordy pas sages; and he does this to protect his readers. No editor likes rewriting other men's papers—to do so is a drudgery, because authors are allergic to a blue pencil. Many regard their prose as impeccable and are deeply insulted if it is cut. But an editor often has no alternative; he must fulfill the obligations of his position. How would you react to a paper that starts like this 1 " I wish to present a series of between two and four rodents of the species mus vulgaris suffering from amblyopia ex anopsia.'' My urge is to cross this out and to write: "This paper is about three blind mice." Christie gives a beautiful example of using too many words. I recall a pamphlet in which the author wished to make the excellent point that a boy will work better at a subject if he likes it: His words were, ' The urge towards creative ideation in the adolescent is primarily volitional.' What a mouthful! Hun dreds of years earlier the same thing was said by a Tudor schoolmaster: Liberty kindleth love and love requireth no labour.
Most surgeons who write efficiently achieve the polish that distinguishes their work by repeated revision of the manuscripts—they cut out useless words, clear away sentences that are redundant or vague, and readjust the sequence of the argument. Older men are sometimes less industrious than their juniors in refining the essence of their papers and this may be because they believe that age has brought them special ability. As men grow older two circumstances develop that lead them to enhance the value of their own opinions. They be come progressively more addicted to making statements, and these pronounce ments often go unchallenged. The fact that they are unchallenged signifies polite tolerance for age, and not assent. Artists are not agreed about the extent to which a text should be revised. Some spend much time polishing and refining the details of their manuscripts; others rely upon spontaneity, and, if a passage or a book does not measure up to their standards, they scrap it and begin again. . This was the way that Stendahl
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worked. And it is recorded that, while Leonardo da Vinci spent 3 years im proving the details of the Mona Lisa, Michelangelo painted two hundred pictures. But surgeons are not setting out to write gems of English prose; they only hope to make their work clear to others. Nevertheless they can learn from the great writers, who have set standards by which they should measure their own use of words—both in respect of clarity of expression and competence of style. In the past, surgeons have not been sufficiently jealous of their reputations as educated men; they have been satisfied to see their names in print—any print. Nobody can tell us exactly how to write our papers because there is no ac cepted standard of excellence. But ideas that are badly expressed are not only deadening to any who want to learn; they can be dangerous if they are misunderstood. How a page has been written lias often been a matter of life and death. Misread orders on the battlefield have sent thousands to unnecessary destruction. Their readings of a page of Scripture have led as many to the stake. Written words are dangerous things. (Bichards)
The writings of surgeons may be less momentous than those of the masters of prose; but they are not absolved on that account from creating confusion. Words that have definite meanings are the most appropriate for surgical papers. By contrast the masters of English prose often prefer words that are ambiguous. This does not mean that they are confused; it means that they put a great deal more into the text than is apparent at first sight. This enables scholars to derive various experiences from words that have different shades of meaning; and for this reason there are libraries filled with books about literary criticism. Here are two sentences that illustrate these points. Blessed are the meek for they shall inherit the earth.
In this particular context the words "blessed," "meek," "inherit," and " e a r t h " have many interpretations, and wise men continue to sift the varieties of their meanings. By contrast, the words of Ambroise Pare, written in despair of his ignorance as to how wounds healed, are like arrows that fly to their mark. I dressed the wounds: God cured the patients.
After reading good prose for some years a person becomes his own critic and there is much satisfaction in it; for you will begin to appreciate the subtleties, the innumerable inflections of meaning, and the competence of the writing. You will understand that there are certain rules that the student should stand by, until he has learnt the skill to deviate from them. These rules have been expressed in the preface of Fowler's book, The King's English. Prefer Prefer Prefer Prefer
the familiar word to the far-fetched, the concrete word to the abstract, the simple word to circumlocution, the short word to the long.
The style most suited to the composition of scientific papers is tightly knit factual prose. If a person has not thought about this he may assume that his arguments will be misunderstood unless every point is amplified in the fullest
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way. This is a fallacy because a well-composed, concise paper rivets the at tention of everybody who needs the information it contains. Moreover, there is a special fascination in things written once, clearly and simply. People remem ber the points in such a paper and they often quote them accurately. The economic style has an honored place in all creative arts. Consider the skill of a Chinese painter who can draw a particular sparrow in two lines, or create a pattern of bamboos with a few strokes of a brush. There are no ir relevant details in such work; there is nothing a critic could strike out. The effect is specific to the painter, and beautiful to those who see the picture. Southey gave us this advice: If you would be pungent, be brief; for it is with words as with sunbeams—the more they are condensed the deeper they burn.
Factual prose frightens those who believe that it will be dull to read, be cause it is said to lack the personality of the writer. But this need not be true. If you will read Oscar Wilde's essay, The Soul of Man under Socialism, you will be convinced that nobody but Wilde could have written this. I t sparkles with ideas that are typical of the man and it touches surely upon a host of contro versial matters. A way to appreciate the merit of this writing and the difficulty of emulating it is to try an experiment. Take and read a passage, such as Portia's plea to Shylock in The Merchant of Venice, study the content for some moments and then write the passage out in your own words. To cover the same range of ideas you will probably use twice as many words as there are in the original; and your meaning will not be as precise. On a less lofty plane, but no less admirable in its achievement, is a paper written in 1814 by Abraham Colles of Dublin. It concerned a special type of fracture dislocation at the wrist and it was written 80 years before Roentgen discovered x-rays. He described the anatomy and the mechanics of the injury, the facts of the deformity and impaction, the ease of reduction, the difficulty of fixation, a method of treatment and an assessment of the prognosis. It was simple and complete. I t comprised 1,528 words. Nowadays there is a tendency to pepper papers with diagrams, tables, xray studies, photographs, statistics, and other obstructions; the more bits and pieces an author can get accepted, the better he thinks his paper. But many readers, dismayed by the complexity of the text, do not read it for this very reason. Nine out of ten of the obstructions to consecutive reading that are sub mitted to me are unnecessary. Statistics are another problem that every editor faces. I believe it was Florence Nightingale who first introduced the medical profession to these weapons. After her return from the Crimea she lay for 50 years, almost con tinuously, upon a bed of sickness and she occupied herself in writing innumer able letters to people in India. Using the statistical information accumulated in this way she proved that more British soldiers died in their barracks than were killed fighting. The War Office was defeated by this onslaught, and the Royal Army Medical Corps was reorganized under her instructions.
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The use, and abuse, of statistics has become a science that affects surgeons and their patients. To be valid, numbers must be checked by a statistician and, since a paper is not respectable unless it carries this hallmark, we bow to the statistician. Some clinicians, as well as some editors, hold out against statistics, because they have known circumstances in which figures refute experience; situ ations in which they dictate treatments that may be scientifically accurate but humanly stupid. The editor of a journal finds himself in a dilemma when he receives a paper that has a statistical basis. He knows that accurate, properly assessed statistics are solid evidence. He also knows that nearly all the statistics in the papers he receives have been improperly assessed, and hence may be dangerous because some doctor will base his actions upon them. My purpose in mentioning these obstructions to reading is to plead that surgical writers might relegate everything that intereferes with consecutive thought to an appendix at the end of a paper. Some journals already adopt this policy; it seems to me to be a step in the right direction. I have an extravagance to inflict upon you. Every editor has been deceived by the author who submits a paper that has already been published elsewhere, or that has been slightly rehashed to get it into print again. I object strongly to this trick, and it comes in several guises. Some years ago, an ancient tablet is said to have been excavated by a group of archaeologists in Brittany. When the dirt had been cleared off the inscription, this was what they found: Le morse et le menuisier se promenaient la main dans la main, ils pleuraient forte amerement de voir tant de sable . . .
The motif of this paper has been to suggest that surgeons in their headlong surge toward science have lost something. I have tried to persuade you that some familiarity with the humanities, and particularly with fine literature, would be beneficial to us. We have assumed too quickly that writing papers is essential to the training and the success of all who aspire to high surgical office and we have forgotten that other things might produce men who could help us onward in our little world of surgery. Let us take note that scholars in every age have said that any man who studies fine literature will learn by example and by precept to appre ciate the niceties of life. He will be guided to a fuller understanding of every thing that happens to him; and, if he acquires wisdom, as well he may, he will direct those who rely upon him with sense and discrimination. I hope that more of us will look back over our shoulders at the gap widening between surgery and the arts. Let us bridge that gap before it deepens to a canyon. We are still well placed to do this because we are educated men who work with our hands and our brains. We have some of the attributes of creative artists and we should be proud and not scornful of them. And now I stand down from this high place. I thank you all for entrusting me with your valuable time. I shall always remember the honor you have done me. I am convinced . . . that fine writing is, next to fine doing, the top thing in the world. . . . (John Keats. Letter to John Hamilton Reynolds, Aug. 25, 1819.)
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BIBLIOGRAPHY
Albutt, T. C : Notes on the Composition of Scientific Papers, London, 1940, The Macmillan Company. Barrett, N. R.: American Heart Surgery: An Address given before the Cleveland Area Heart Society in December, 1958. Bernal, J . D.: The Social Function of Science, London, 1939, George Routledge & Sons, Ltd., pp. 117, 292. Blumgart, H. L.: Class Day Speech, " A Point in T i m e , " Harvard, May 27, 1961. Brown, L.: Nature, 193: 724, 1962. Christie, J . T.: Opening of Session Address, 1950-1951, University College Hospital, London. Fowler, H. W.: The Kings English, ed. 3, London, 1931, Clarendon Press. Gibbon, J . G.: Presidential Address: The Road Ahead for Thoracic Surgery, J. THORACIC SURG. 42: 141,
1961.
Hubble, D.: Medicine in I t s Setting, Lancet 1: 1359-1362, 1960. Keynes, G.: The Apologie and Treatise of Ambroise Pare, London, 1951, Falcon Educational Books. The Lancet: Publication but How? May 6, 1961; Not for the Record, March 24, 1962; Peripatetic Correspondent, March 14, 1959. The Literary Supplement in The Times, Friday, March 23, 1962. Pickering G.: Language: The Lost Tool of Learning in Medicine and Science, Lancet 2 : 115-119, 1961. Richards, I. A.: Principles of Literary Criticism, New York, 1938, Kegan P a u l ; How to Read a Page, New York, 1943, Kegan Paul. Roberts, F . : Good English for Medical Writers, London, 1960, Heinemann Medical Books. Snow, C. P . : The Two Cultures and the Scientific Revolution, Rede Lecture, London, 1959. Whitehead, A. N . : The Aims of Education, London, 1947, Williams and Norgate, Ltd. Wilde, O.: The Soul of Man Under Socialism, London, 1891, The Fortnightly Review.
PUBLISH OR PERISH N. R. Barrett*
London,
England
. . . a small drop of ink, falling like dew upon a thought, produces that which makes thousands, perhaps millions, think. Byron
T
centuries ago, Baltasar Gracian, a Spanish Jesuit, wrote a book of aphorisms called The Art of Worldly Wisdom, and here is a piece of his advice: HREE
Know the measure of your luck.
When your president invited me to give this lecture I realized at once that he had mistaken me for somebody else; but recognizing my luck I accepted before he could change his mind. The next time I opened my Gracian I found this: Beware of entering to All too large a gap.
It was too late. Here I am. Mr. President, I appreciate the friendship of your gesture. I know that this Society stands in the van of International Surgery and that famous men have stood in this place before me. You have paid me a compliment—the nicest I have ever had. And so it is with trepidation lest I waste your time, but with a most sincere conviction of the importance of my subject, that I shall discuss the writing of surgical papers. A dry topic, perhaps, and one that stands forgotten behind the advancing frontiers of thoracic surgery. My qualification to venture along this thorny path is not that I can write good prose where others fail: it is that, as editor of a surgical journal, I see manuscripts and have opinions about them. A critic is entitled to comment upon the work of others without claiming to be their peer. Indeed, it is strange that throughout the ages little men have criticized giants and, even stranger, that their criticisms have sometimes been constructive. It is my experience that many surgical manuscripts are badly written and Honored Guest's Address: Presented at the Forty-second Annual Meeting of the Ameri can Association for Thoracic Surgery a t St. Louis, Mo., April 16-18, 1962. Address: St. Thomas' Hospital, London, England. •Editor of Thorax. 167
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that, in consequence, they do not do justice to the facts they contain. This is an old complaint. In 1904, Professor Bryan wrote a letter to the Journal Nature. Here is a part of his text: I have before me a number of mathematical papers which contain no indication whatever of what the authors are driving at.
An editor has two duties: to assess the scientific merit of the paper he has been asked to publish, and to make certain that the author has expressed himself clearly. I shall comment upon the belief that surgeons must publish or perish, and I shall talk about clarity in scientific writing. I shall try to persuade you that to achieve clarity surgeons must cultivate some literary values. Election to this Society, or to any position of surgical importance, is in fluenced by the number of papers a man has written: no papers, no hope of election, no future! At least that would be the prospect for all but a Martin Luther prepared to nail a broadsheet of heresy to the door of orthodox surgical opinion. Nevertheless, I suspect that most of you deplore this obligation, not only because it is a doubtful test of a man's surgical ability; but, because, in later life, you resent having to grind out an article every few months. As things stand it is difficult to see any alternative to this but I think there are signs that this way of spreading technical knowledge is changing. In 1939, Professor Bernals stated that there were 35,000 scientific journals. This spate of publications was inadequate then to deal with all the articles that were sub mitted; and many that were printed were, in fact, buried. Since then medical research has increased, and the situation is almost beyond control. Nobody can keep abreast of the current literature. A writer in the literary supplement of The Times had this to say: In every profession, in every branch of scholarship, it is becoming harder to keep pace with current developments. Nor is this just because so many actual discoveries are being made. The fragmentation of knowledge itself leads to overlapping and duplication, to scattering of the relevant material through an ever widen ing range of publications; as t h e horizons close in there is more and more pointless research. Keeping up with the real advances is only part of the problem. Trying to identify them at all in the vast wastes of words and effort: that is what takes the time. . . . The young scholar, pressed to publish ' o r i g i n a l ' work, may think he is doing so when the ground has already been covered; he may be thicken ing the word-jungle to no purpose. And there are many other indications that even if the flow of new discoveries in other fields is less than in science the problem is still the same. For the scholar in the humanities cannot afford to treat his prede cessors as superseded. He has to keep up with the present and the past.
It is possible that surgical journals, as we know them today, may cease to exist. All new papers may have to be sent to a central editing service where the information they contain would be microfilmed and fed into electronic computers by experts. New facts would be correlated with existing knowledge and the cur rent position of any subject would be quickly available. A few journals of the digest type might survive, and subscribers would receive official abstracts on advances at regular intervals. Such a system would save surgeons the pleasures of claiming priorities, and it would clear the air! So far medical men have
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contributed nothing to the solution of these problems; but industry is fully aware that memory is fallible, and that time is wasted in redundant work. If the ways in which information is spread abroad change, it may be possible for us to kill the dragon called "Publish or Perish"; supposing always that we should want to do so. The onus for this execution will not rest with editors because their duty is to publish as much as they can of the material submitted to them. The only thing they can do is to remind you all, as often as an oc casion arises, that your duty is not only to yourself but to truth, to readers all over the world, and to patients. They can plead that you should only write when you have a strong urge to do so, when you have something important to communicate to others, and, above all, when you have plenty of time to do the job properly. For these reasons you must not expect editors to kill this dragon for you. The only way in which they might help is to reject most of the papers that are sent to them, and this is an unpleasant thing to ask them to do. Most editors send unsatisfactory manuscripts back with polite notes of encouragement and this is especially the case when the author is a young graduate. Here is a rejec tion slip sent by a Chinese mandarin. We have read your manuscript with boundless delight. If we were to publish your paper it would be impossible for us to publish any work of lower standard. And as it is unthinkable that, within the next thousand years, we shall see its equal we are, to our great regret, compelled to return your divine composition, and to beg you a thousand times to overlook our short sight and timidity.
Some feel that the present necessity to publish as much as possible is a good competitive stimulus. They point out that writing papers is a part of every surgeon's training as well as an advertisement that pays dividends. It ensures that every bit of information is available somewhere. Famous surgeons of the past have written, and nobody has suggested that they were wrong to do so. The argument that there are good men who publish nothing does not impress those who believe that these silent practitioners are benefiting from circum stances they neither create nor maintain. The young man who gets several papers published marks himself out as capable and willing to do more than the minimum imposed by necessity; he develops his ability to refine facts and he learns to marshal ideas. So runs the argument. It is particularly in the education of surgeons that I doubt the propriety of expecting young men to write papers when they have nothing important to write about. A man at the beginning of his career has no experience of his own to draw upon; his sources of information are the library, the record room, or the laboratory. None of these is satisfying to everybody; but if a young man wants to write they are his inspirations. So it comes about that, to publish and not to perish, young men must work in a laboratory. Clinical studies are regarded as scientifically inferior stuff. The elite gaze upon beads of light that dance monotonously across a screen—■ and are gone. I do not disagree with the view that surgeons should have practical experi ence in the discipline of modern science. They must be taught how science can
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be equated to the everyday work of a doctor and they must learn to measure and to assess their achievements. But I object to this period of apprenticeship being used as an excuse to write papers. Men who enter a laboratory are, at first, observers in a place that is strange to them, and the papers they write are not suitable for international publication. I know that many manuscripts, sub mitted by a team of workers, carry the cachet of an established scientist; but I prefer a paper written by a single authority. A cynical Englishman once said about immature scientific papers: To copy from one book is cheating.
To copy from.two books is EESEAECH.
John Gibbon—your president for 1961—spoke about educating young thoracic surgeons. He recognized that some able students have no aptitude for research, and that it is a waste of their time to do this work. He said that they would be filtered off from the main stream into teaching and clinical studies. For him the road to the top had been through research. That was the gateway through which he, and you, entered into this important Society. But the idea that research in a laboratory is the fire that tempers surgeons and that he who lacks this 'discipline will be banished to obscurity seems to me to be too rigid. If we all lived a great deal longer it would still be impossible to extend the compass of our learning to include all knowledge. Nobody can study every facet that throws light upon our work, and while one is forging ahead profitably in a laboratory, another, who is not gifted in this type of work, is wasting his time. In my travels I have been fascinated to study the behavior as well as the technical skill of surgeons working in different countries. I have noted that the men who are most esteemed by their colleagues are international in outlook and in education; they are interchangeable, clinic for clinic, country for country. They are men of the world, and they have wisdom. I believe that most of them were born with the gifts that have raised them above their contemporaries, because it is doubtful if a scientific education alone could have carried this re ward. Apart from these great men there is the host of lesser lights who lack this vital touch. They are often splendid technical performers but their educa tion has been circumscribed. Surgery needs the individual and the combined contributions of clinicians and technicians, scientists and leaders, scholars and men of the world; and who among us can measure up to these heights? And, since the learning of those who could contribute usefully to the advancing front of science is so wide, we must expect a variety of roads to the top. Whatever curriculum we arrange, some men, ploughing their own furrows, will make their mark. They are our benefactors because they remind us that excellence cannot be cast in a mold. I have suggested that too many papers that are unworthy of publication are being written, and important information is often swamped; that young men driven to publish or perish find their inspiration in laboratories and write many of these immature works; that some surgeons are out of place in a laboratory and would benefit from the study of other subjects. It is conceivable that the humanities may be as valuable, as a training ground, as animal physiology.
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My life as a surgeon, as well as my experience as an editor, has convinced me that we should know much more about the humanities—and in particular the arts—than we do. There would, of course, be no early dividends for any young graduate who forsook the laboratory and used the time to study literature. He would probably be regarded as an eccentric heretic who had taken leave of his senses; but who can tell—he might acquire a taste for scholarship and on that account he might even be able to help his scientific colleagues in later life. But no young surgeon will dare to deviate from an official course if he knows that he is drawing a bow at a venture. Appointments boards would have to be prepared to weigh scholarship against a pile of research papers. The inability of some eminent scientists to express themselves in writing, and to explain their discoveries to others, has become obvious as the complexity of their work has increased. Some experts in medical education, such as Pickering, have lamented that language has become a lost tool of learning; and others, in lighter vein, have devised jokes to ridicule the inarticulate men of science. Here is a story to this end: "When a physicist visited a well-known research institution, and was asked to write his name in the visitors' book, he drew two crosses. When asked what these marks meant he said, '' The Second is my P h . D . " A reason for suggesting that a knowledge of the arts and, in particular, of the fine literature, might be valuable to those who aspire to the practice of surgery is this. None of us spends all his days in the operating theaters. The older we get the more time we devote to the personal problems of our patients, and to management of surgical affairs. To do this effectively we need wisdom, and an acute sense of values; we must also be able to communicate our ideas accurately and simply to others. Those critics who are most qualified to speak have told us that the arts are not only the supreme form of communication but they are the foremost teachers of values. No commerce with science or technology alone will teach a man who lacks a natural sense of values the things that really matter. If he has not got this gift then he may acquire some part of it by studying the arts, and particularly by reading the works of the great men who have left their opinions for our benefit. A sense of values is another name for wisdom, and to acquire this wisdom some leisure is necessary; leisure to watch the world, to contemplate opposing opinions, and learn how to discuss affairs in a civilized way; leisure to cultivate a balanced sense of values. Richards has this to say about values: The Arts are our storehouse of recorded values. They spring from and perpetuate hours in the lives of exceptional people, when their control and command of experi ence is at its highest, hours when the varying possibilities of existence are most clearly seen and the different activities which may arise are most exquisitely reconciled, hours when habitual narrowness of interests or confused bewilder ment are replaced by an intricately wrought composure.
You may think that time spent in acquiring a modicum of wisdom and a sense of values would be wasted in this mechanistic age. You may argue that the bare facts of a scientific idea carry their own message, however clumsily that
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message may be presented; and you may be convinced that to study the humani ties, in the vague hope of writing better prose or of becoming a more erudite surgeon, is a luxury that does not concern you. But you should know that in formed opinion would not accept such views. The arts educate people by example. They not only enlarge a man's range of expression and experience, but they teach him to analyze complex and unusual situations. Everybody knows the feeling of freedom, of relief, and of increased competence and sanity that follows any reading in which more than usual order and coherence has been given to our responses. We seem to feel that our command of life, our insight into it and our discrimination of its possibilities, is enhanced, even for situations having little or nothing to do with the subject of the reading. (Eichards)
The foremost intellects in every age have made it clear that the education that the arts offer is not easily obtainable in other studies. Critics, from Aristotle onwards, have stated that wisdom, clarity of thought and purpose, and scholarship that are the fruits of learning are indispensable to the best practice of every profession; they are not relevant to the arts alone. The material upon which a beginner may work is everywhere accessible in abundance; no special tutors or personal teaching is necessary. Indeed the surgeon who comes home, tired and confused by the problems that beset him, has but to take a good book from his shelf, and read. The tale that unfolds reveals the folly, the weakness, the strength, and the goodness of the actors. I t teaches by imperceptible ex ample and ordered criticism. There is nothing new in the suggestion that some surgeons might benefit from a study of the humanities. In mediaeval times, theology, medicine, and the law were regarded as the superior faculties in all the important universities, and each was approached through the arts. As time has passed, medicine has joined forces with the new faculty of science, and in so doing, it has lost contact with the arts. The new alliance between surgery and science has been valuable to surgeons because it has taught them to be critical of their achievements. But the price has been heavy; scholarship has almost been thrown away, and some deplore this for its own sake and because surgery can never be truly scientific. Patients are not test tubes. The suggestions I have made may be trivial when measured against the need to provide education and medical care throughout the world. Concern about " v a l u e s " and "wisdom" are luxuries that can wait; but in the more enlightened countries these attributes should be examined now. Surgery has become an inanimate technical scramble; let us not forget the human side of our calling. I am aware that these ideas may be somewhat nebulous, and that they will be unacceptable to some of you because they savor of things that are outmoded; they draw upon the past. I answer such critics by asking them to read the opinions of men such as Whitehead, mathematician and philosopher. Listen to this:
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What we should aim at producing is men who possess both culture and expert knowl edge. Their expert knowledge will give them the ground to start from, and their culture will lead them as deep as philosophy and as high as art.
Whitehead also wrote: Mastery of knowledge, which is wisdom, is the most intimate freedom obtainable. The ancients saw clearly—more clearly than we do—the necessity for dominating knowledge by wisdom.
And so I submit that surgeons will be unwise to abandon the arts. The enlightened men in both faculties will always be aware of what goes on in the other camp; but it is our duty to bridge the gap for those who are wholly com mitted to science. In the remarks that I have made so far you may think that I have been unduly critical of young surgeons working in laboratories. But the papers they submit for publication are no worse than the average. I have singled this group out because, being young and amenable to reason, they can be saved from blindly copying the majority. Two factors have been interwoven in this talk; the laboratory as an inspiration, and the urge to write. In fact, some of the worst papers that an editor sees are submitted by very senior men; it can be embarrassing to turn them down. But I feel no responsi bility for the reputations of my contemporaries; to me they often seem to be in corrigible. The remarks that follow concern the ways in which surgical papers may be composed. This is a large topic and only the general principles will be men tioned ; books have been written about the details. As I am convinced that you will all continue to write papers, I commend to your attention a small book, first published in 1904, by Sir Clifford Albutt who was Regius Professor of Physics at Cambridge University. He was described in these words by a correspondent in the Lancet, "My interest in the clinical thermometer goes back to 1920 when I first beheld its inventor, Sir Clifford Albutt. He was then a septuagenarian but still rode his tricycle through Cam bridge. He was always immaculately dressed in his morning coat, grey waist coat, striped trousers, spats, white gloves and Homberg hat.'' This is the man whose book you should read. It is called Notes on the Composition of Scientific Papers, and it is one of the first on this subject. Since 1904 a number of more elaborate works have appeared but none excels these notes. The moment you choose and the circumstances under which you take up your pen to write have an important bearing upon what you can produce. Who can doubt that a subject about which you have, consciously and subconsciously, been thinking for some time will have more to offer the reader than one written without previous thought. Richards, commenting upon the quality of the work that an artist produces when his mind is functioning at its best, said: As a chemist's balance to a grocer's scales, so is the mind in the imaginative mo ment to the mind engaged in ordinary intercourse or practical affairs.
It is useless to sit down late at night, or when you are tired, and hope to
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produce anything of value to others. And if you stop to think whether you should write at all, here is what Professor Bryan says about that: If a paper [for the Royal Society] is of any value, the author must 'ipso facto' know more about the subject-matter than anyone else. If he does not, he is not the proper man to write the paper.
This standard may be a little high for you and for me! You may like to know that the first American to write a medical paper was Thomas Thatcher, minister of the Old South Church in Boston, and the date was 1677 (Blumgart, 1961). Its title was " A brief guide in the Small Pox and Measles.'' He started an avalanche. Surgical papers, like works of prose, should have a beginning, a middle section, and a conclusion; all are vital to the balance of the whole, and the purpose of each is different. The beginning should state the problem, carry the reader to the root of the matter, and indicate the style in which the whole will be set; the middle part should offer a contribution toward the solution of the subject; and the conclusion should present the picture in the light of the writer's ideas. Many of the papers sent to me begin with a brief review of the literature. This is unsatisfactory because there is nothing original here; the information has been copied verbatim from the last paper the author read. Men who have written reviews for important journals realize that the task is more onerous than to record a list of names and dates; it is to allot to each the merit it deserves. Nor is it desirable to begin by decrying the existing state of knowledge, for this suggests that the author is about to set things right; a hope that is seldom ful filled. Remember this: We should be aware of the hollowness of our knowledge and the solidity of our ignorance. (Albutt)
The opening words can be so difficult to choose that it may be wise to defer writing them until the main theme has been written. I have found instruction and amusement in looking at the way great works of literature are introduced. The first words often define the subject; in addition they may date the story, set the style, and indicate whether the work that follows is fact, fiction, or in the realms of the imagination. John Bunyan begins The Pilgrim's Progress like this: As I walked through the wilderness of this world I lighted upon a certain place where was a Denn; and I laid me down in that place to sleep; and as I slept I dreamed a dream.
But for me there is one special book in which the opening words are beyond compare; I mean The Stones of Venice by Ruskin. I would like to think that some of you would read the first page of this book immediately before you begin to write your next surgical paper. The effect will not be to deter you; but rather to give you encouragement and example. A surgeon may not be able to emulate the masters of prose with any more success than an amateur can challenge a champion; but with practice and ap-
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plication he can transform his performance from bad to acceptable. And the fact that his material is technical rather than artistic is not a cause for despair. The complexity of his subject must be as a stimulus to simplify the text. The author who composed the Book of Genesis had a complicated story to tell; but his technique was simple. In the beginning God created the Heaven and the Earth.
A surgeon who sits down to write is like Christian in The Pilgrim's Progress. Enemies stand everywhere around him. He comes at first to the Forest of Technical Jargon and this is so dense that he may be overwhelmed, because he knows that the function of language is to convey meaning. This is what Christie had to say about people who coin and use unnecessary technical words " . . . . all professions suffer from people who use long words to increase their sense of importance. And the worst of it is that they are so successful." The French critic was right when he said, '' Nothing is so persuasive to men of little intelligence as what they do not understand.'' The temptation to write ten words where one would have been enough is difficult to repress. It springs from the mistaken idea that size and quality go hand in hand. One of the duties of an efficient editor is to prune wordy pas sages; and he does this to protect his readers. No editor likes rewriting other men's papers—to do so is a drudgery, because authors are allergic to a blue pencil. Many regard their prose as impeccable and are deeply insulted if it is cut. But an editor often has no alternative; he must fulfill the obligations of his position. How would you react to a paper that starts like this 1 " I wish to present a series of between two and four rodents of the species mus vulgaris suffering from amblyopia ex anopsia.'' My urge is to cross this out and to write: "This paper is about three blind mice." Christie gives a beautiful example of using too many words. I recall a pamphlet in which the author wished to make the excellent point that a boy will work better at a subject if he likes it: His words were, ' The urge towards creative ideation in the adolescent is primarily volitional.' What a mouthful! Hun dreds of years earlier the same thing was said by a Tudor schoolmaster: Liberty kindleth love and love requireth no labour.
Most surgeons who write efficiently achieve the polish that distinguishes their work by repeated revision of the manuscripts—they cut out useless words, clear away sentences that are redundant or vague, and readjust the sequence of the argument. Older men are sometimes less industrious than their juniors in refining the essence of their papers and this may be because they believe that age has brought them special ability. As men grow older two circumstances develop that lead them to enhance the value of their own opinions. They be come progressively more addicted to making statements, and these pronounce ments often go unchallenged. The fact that they are unchallenged signifies polite tolerance for age, and not assent. Artists are not agreed about the extent to which a text should be revised. Some spend much time polishing and refining the details of their manuscripts; others rely upon spontaneity, and, if a passage or a book does not measure up to their standards, they scrap it and begin again. . This was the way that Stendahl
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worked. And it is recorded that, while Leonardo da Vinci spent 3 years im proving the details of the Mona Lisa, Michelangelo painted two hundred pictures. But surgeons are not setting out to write gems of English prose; they only hope to make their work clear to others. Nevertheless they can learn from the great writers, who have set standards by which they should measure their own use of words—both in respect of clarity of expression and competence of style. In the past, surgeons have not been sufficiently jealous of their reputations as educated men; they have been satisfied to see their names in print—any print. Nobody can tell us exactly how to write our papers because there is no ac cepted standard of excellence. But ideas that are badly expressed are not only deadening to any who want to learn; they can be dangerous if they are misunderstood. How a page has been written lias often been a matter of life and death. Misread orders on the battlefield have sent thousands to unnecessary destruction. Their readings of a page of Scripture have led as many to the stake. Written words are dangerous things. (Bichards)
The writings of surgeons may be less momentous than those of the masters of prose; but they are not absolved on that account from creating confusion. Words that have definite meanings are the most appropriate for surgical papers. By contrast the masters of English prose often prefer words that are ambiguous. This does not mean that they are confused; it means that they put a great deal more into the text than is apparent at first sight. This enables scholars to derive various experiences from words that have different shades of meaning; and for this reason there are libraries filled with books about literary criticism. Here are two sentences that illustrate these points. Blessed are the meek for they shall inherit the earth.
In this particular context the words "blessed," "meek," "inherit," and " e a r t h " have many interpretations, and wise men continue to sift the varieties of their meanings. By contrast, the words of Ambroise Pare, written in despair of his ignorance as to how wounds healed, are like arrows that fly to their mark. I dressed the wounds: God cured the patients.
After reading good prose for some years a person becomes his own critic and there is much satisfaction in it; for you will begin to appreciate the subtleties, the innumerable inflections of meaning, and the competence of the writing. You will understand that there are certain rules that the student should stand by, until he has learnt the skill to deviate from them. These rules have been expressed in the preface of Fowler's book, The King's English. Prefer Prefer Prefer Prefer
the familiar word to the far-fetched, the concrete word to the abstract, the simple word to circumlocution, the short word to the long.
The style most suited to the composition of scientific papers is tightly knit factual prose. If a person has not thought about this he may assume that his arguments will be misunderstood unless every point is amplified in the fullest
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way. This is a fallacy because a well-composed, concise paper rivets the at tention of everybody who needs the information it contains. Moreover, there is a special fascination in things written once, clearly and simply. People remem ber the points in such a paper and they often quote them accurately. The economic style has an honored place in all creative arts. Consider the skill of a Chinese painter who can draw a particular sparrow in two lines, or create a pattern of bamboos with a few strokes of a brush. There are no ir relevant details in such work; there is nothing a critic could strike out. The effect is specific to the painter, and beautiful to those who see the picture. Southey gave us this advice: If you would be pungent, be brief; for it is with words as with sunbeams—the more they are condensed the deeper they burn.
Factual prose frightens those who believe that it will be dull to read, be cause it is said to lack the personality of the writer. But this need not be true. If you will read Oscar Wilde's essay, The Soul of Man under Socialism, you will be convinced that nobody but Wilde could have written this. I t sparkles with ideas that are typical of the man and it touches surely upon a host of contro versial matters. A way to appreciate the merit of this writing and the difficulty of emulating it is to try an experiment. Take and read a passage, such as Portia's plea to Shylock in The Merchant of Venice, study the content for some moments and then write the passage out in your own words. To cover the same range of ideas you will probably use twice as many words as there are in the original; and your meaning will not be as precise. On a less lofty plane, but no less admirable in its achievement, is a paper written in 1814 by Abraham Colles of Dublin. It concerned a special type of fracture dislocation at the wrist and it was written 80 years before Roentgen discovered x-rays. He described the anatomy and the mechanics of the injury, the facts of the deformity and impaction, the ease of reduction, the difficulty of fixation, a method of treatment and an assessment of the prognosis. It was simple and complete. I t comprised 1,528 words. Nowadays there is a tendency to pepper papers with diagrams, tables, xray studies, photographs, statistics, and other obstructions; the more bits and pieces an author can get accepted, the better he thinks his paper. But many readers, dismayed by the complexity of the text, do not read it for this very reason. Nine out of ten of the obstructions to consecutive reading that are sub mitted to me are unnecessary. Statistics are another problem that every editor faces. I believe it was Florence Nightingale who first introduced the medical profession to these weapons. After her return from the Crimea she lay for 50 years, almost con tinuously, upon a bed of sickness and she occupied herself in writing innumer able letters to people in India. Using the statistical information accumulated in this way she proved that more British soldiers died in their barracks than were killed fighting. The War Office was defeated by this onslaught, and the Royal Army Medical Corps was reorganized under her instructions.
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The use, and abuse, of statistics has become a science that affects surgeons and their patients. To be valid, numbers must be checked by a statistician and, since a paper is not respectable unless it carries this hallmark, we bow to the statistician. Some clinicians, as well as some editors, hold out against statistics, because they have known circumstances in which figures refute experience; situ ations in which they dictate treatments that may be scientifically accurate but humanly stupid. The editor of a journal finds himself in a dilemma when he receives a paper that has a statistical basis. He knows that accurate, properly assessed statistics are solid evidence. He also knows that nearly all the statistics in the papers he receives have been improperly assessed, and hence may be dangerous because some doctor will base his actions upon them. My purpose in mentioning these obstructions to reading is to plead that surgical writers might relegate everything that intereferes with consecutive thought to an appendix at the end of a paper. Some journals already adopt this policy; it seems to me to be a step in the right direction. I have an extravagance to inflict upon you. Every editor has been deceived by the author who submits a paper that has already been published elsewhere, or that has been slightly rehashed to get it into print again. I object strongly to this trick, and it comes in several guises. Some years ago, an ancient tablet is said to have been excavated by a group of archaeologists in Brittany. When the dirt had been cleared off the inscription, this was what they found: Le morse et le menuisier se promenaient la main dans la main, ils pleuraient forte amerement de voir tant de sable . . .
The motif of this paper has been to suggest that surgeons in their headlong surge toward science have lost something. I have tried to persuade you that some familiarity with the humanities, and particularly with fine literature, would be beneficial to us. We have assumed too quickly that writing papers is essential to the training and the success of all who aspire to high surgical office and we have forgotten that other things might produce men who could help us onward in our little world of surgery. Let us take note that scholars in every age have said that any man who studies fine literature will learn by example and by precept to appre ciate the niceties of life. He will be guided to a fuller understanding of every thing that happens to him; and, if he acquires wisdom, as well he may, he will direct those who rely upon him with sense and discrimination. I hope that more of us will look back over our shoulders at the gap widening between surgery and the arts. Let us bridge that gap before it deepens to a canyon. We are still well placed to do this because we are educated men who work with our hands and our brains. We have some of the attributes of creative artists and we should be proud and not scornful of them. And now I stand down from this high place. I thank you all for entrusting me with your valuable time. I shall always remember the honor you have done me. I am convinced . . . that fine writing is, next to fine doing, the top thing in the world. . . . (John Keats. Letter to John Hamilton Reynolds, Aug. 25, 1819.)
Vol. 44, No. 2 August, 1962
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BIBLIOGRAPHY
Albutt, T. C : Notes on the Composition of Scientific Papers, London, 1940, The Macmillan Company. Barrett, N. R.: American Heart Surgery: An Address given before the Cleveland Area Heart Society in December, 1958. Bernal, J . D.: The Social Function of Science, London, 1939, George Routledge & Sons, Ltd., pp. 117, 292. Blumgart, H. L.: Class Day Speech, " A Point in T i m e , " Harvard, May 27, 1961. Brown, L.: Nature, 193: 724, 1962. Christie, J . T.: Opening of Session Address, 1950-1951, University College Hospital, London. Fowler, H. W.: The Kings English, ed. 3, London, 1931, Clarendon Press. Gibbon, J . G.: Presidential Address: The Road Ahead for Thoracic Surgery, J. THORACIC SURG. 42: 141,
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Hubble, D.: Medicine in I t s Setting, Lancet 1: 1359-1362, 1960. Keynes, G.: The Apologie and Treatise of Ambroise Pare, London, 1951, Falcon Educational Books. The Lancet: Publication but How? May 6, 1961; Not for the Record, March 24, 1962; Peripatetic Correspondent, March 14, 1959. The Literary Supplement in The Times, Friday, March 23, 1962. Pickering G.: Language: The Lost Tool of Learning in Medicine and Science, Lancet 2 : 115-119, 1961. Richards, I. A.: Principles of Literary Criticism, New York, 1938, Kegan P a u l ; How to Read a Page, New York, 1943, Kegan Paul. Roberts, F . : Good English for Medical Writers, London, 1960, Heinemann Medical Books. Snow, C. P . : The Two Cultures and the Scientific Revolution, Rede Lecture, London, 1959. Whitehead, A. N . : The Aims of Education, London, 1947, Williams and Norgate, Ltd. Wilde, O.: The Soul of Man Under Socialism, London, 1891, The Fortnightly Review.