I like good strong words that mean something… - Louisa May Alcott
My resident and I are in the OR, struggling to remove a large, recurrent cancer from the neck. The patient's prior surgery and radiation therapy have left a dense field of scar tissue. It is slow going and frustrating. The landmarks are missing. Each move is arduous. Bleeding obscures the anatomy.
“Watch out,” I tell her. “The jugular vein is buried somewhere in that scar.”
“Yeah,” she responds. A bit later, she notes, “Look at this nerve! It’s completely stuck on the side of the mass.”
We work steadily but know the case will be long and tedious. Small dissection here. Small snip there. Pushing with a piece of gauze makes little headway. “Pull harder on that retractor,” I tell the student. We go slowly, knowing that the cancer needs to come out but we want to save as much of the normal tissue as possible. One step at a time.
Then suddenly, in an area just beyond where the prior surgery was performed, the tissues open up and we get our first clear view of the jugular vein. The vein is dark blue--just like in the textbooks--and we can see eddies in the blood as it flows from the brain back to the heart. I grip the cancer and pull it one way while firmly tugging the neck tissues and vein the other. The resident slides an instrument between the mass and the vessel, then carefully snips between the two. The cut releases a very dense scar band and, almost magically, the space between the mass and the vein opens up. The vein is now easily visible and, to our delight, is not invaded by the cancer. Tension lifts and the next moves become clear. The cancer is mobile now, finally free of the scar tissue that had been holding it solidly in place.
"Wow!" I say. "We made more progress with that one cut than we had accomplished in the last hour."
The resident nods. “That was a real blow for freedom.”
“A blow for freedom," I repeat. "Yes, indeed.”
In our operating room, the expression, “a blow for freedom,” is relatively common parlance although I cannot remember hearing it outside of the hospital. I found a reference to a “blow for freedom” against slavery in an issue of the Congressional Globe of 1864. A 1941 Time magazine article about making uniforms and supplies for soldiers was titled, “National Defense: A Blow for Freedom.” A 2000 history of the 6th US Colored Infantry in the Civil War is titled Strike the Blow for Freedom. A 2004 Guardian report that Guantánamo Bay prisoners would be allowed to challenge their detentions was titled, “A Blow for Freedom.” There are other references to "blow for freedom" on the Internet, but they are not frequent.
What the Internet tells me, though, is that the expression usually implies some sort of an attack. This fits with one dictionary definition of blow as “a powerful or heavy stroke with the fist or a weapon.” Blow, in this context, is a term of violence.
That does not surprise me. Although, as surgeons, we are proud of our finesse, we understand that what we do is, at its core, a violent act. Finesse gets you only so far. Often, only an aggressive action drives a procedure forward. The resident and I carry on, more quickly now thanks to the moment when her cut opened up the surgical planes. After a few more moves, the neck tissues release the mass completely. The case will soon be over and be considered a success. Surgery is, by nature, a violent act, isn't it? A mentor once told me, “Sometimes, what we do is as close to assault and battery as you can get without being arrested.” There is something captivating about how our work in the operating room requires us to identify and attack problems in order to resolve them. Over the course of most cancer procedures, there are moments of brute force, thrust and parry, bloodletting, and destruction. Thank goodness for anesthesia. We pull off our gowns and snap off our gloves. As the patient's cart is rolled to the Recovery Room, I get on the computer. "Let's review at the scans for the next patient," I say. We will have another opportunity to strike a blow for freedom.
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A previous version of this essay was published in my blog, Reflections in a Head Mirror in 2017.
The OR is such a strange place. A blow for freedom said at the time when the struggle has been so slow and intense. Sometimes a small breakthrough, but the freeing up of tumor from “innocent tissue” not only feels relieving to the surgeons, but also signifies a success for the patient. They are asleep, and will never hear those words, but we feel the positive emotion of getting close to the goal… helping the patient in a difficult situation. Truly a blow for freedom for the patient too.
Sometimes it takes a student's reaction to surgery to make you take a step back and think in some ways it's barbaric, but we get so caught up in the moment and the momentum or lack thereof. It's one of the few times that I can say I stay in the present moment with utter focus, almost like mediation.