Category: Grander Rounds

Grander RoundsThe Lord Thy Surgeon

Death: A Gateway to…

An aneurysm ruptures as an 85 y/o woman talks on the phone with her only relative, a niece, 150 miles away. She dies hours later in my Emergency Room. A 40 y/o woman and her 6 y/o child have their passenger side destroyed by a driver running a stoplight. They never make it from the scene.

At times, it seems as though I am (we are) surrounded by death. I joke with my staff and residents to ease the tension, “All of us are dying. Some of us just get moved to the front of the line.” Death is experienced by all of us. Sometimes we look in. Sometimes we endure the loss. Sometimes, we are up. All of us deal with it differently. We all fear the unknown.

My wife worries about something happening to me. Finishing my will seems morbid and is difficult to complete. Though important, I know that when the will is “executed” I will be dead. It is a plan for what I hope won’t happen, at least not any time soon. My parents are essentially my oldest relatives. One by one, my grandparents departed.

“I’m ready to meet my Jesus.” A few nights ago, I prayed with a patient for the first time in a long time. The words proceeded from my mouth jumbled and awkward. It was short and not so eloquent. “Watch over this child of God. Comfort her in her pain. Bring Mrs. H to be with you,” was the gist of it. I had just diagnosed Mrs. H with pancreatic cancer at age 89. She had been trying to get a CT scan for the past several weeks with insurance not approving it because certain tests had not been ordered yet. She showed up in the ED with worsening pain and looking for answers with her daughter. She seemed otherwise content but desiring to know why she continued to have persistent abdominal pain. A CT scan a few hours after her arrival delivered to me the answer, “Pancreatic mass concerning for pancreatic adenocarcinoma with severe dilation of the pancreatic duct.” This diagnosis hits me like a train. As we have been told in medical school and on our surgical rotations, “Don’t mess with the pancreas!” (Using slightly more colorful language typically.) I knew that this was likely a terminal diagnosis. For a 30 or 40 year old, it might be a diagnosis of struggle and a year or two of intense pain before the inevitable death. Or if extra lucky, a longer course with the constant fear of return of the cancer of the “Whipple procedure” (which again is one of the most intense surgeries one can have.) In the face of death, this 89 year old didn’t ask about surgery or how long she had to live or what chemo she could have. She didn’t even ask for more pain medication. After I had explained to her daughters about the mass, she succinctly said, “I’m ready to meet my Jesus.”

I’ve met death many times in my emergency room. Some people fear it fiercely and others, like the 89 y/o woman above, seem relieved. For the Christian, death is a departure. Physical death is the body releasing the soul to be with God. The early church fathers viewed death not as the endpoint but as the beginning. Paul states, “For I am already being poured out as an offering, and the time for me to depart is at hand. I have competed well; I have finished the race; I have kept the faith! Finally the crown of righteousness is reserved for me. The Lord, the righteous Judge, will award it to me in that day – and not to me only, but also to all who have set their affection on his appearing.” 2 Tim 4:6-8

Nearly 50 executed in a nightclub. Dozens shot in a theater. Schools seem unsafe. This year freshmen in high school will learn about 9/11 as history. I feel old(er).

For the atheist, death is “the end.” It is nothingness. What does the atheist have to say at your suffering and dying? Is death (and this life) not absurdity and meaningless? “I’m glad it’s you and not me.”

As Christians, do we not have a different outlook? What have we “to fear”? Christ conquered death. For the Christian, spiritual death is put to death by Christ. Spiritual death comes from the fall.   Christ, who knew no sin, took on the likeness of sinful flesh and was sinless. Hosea and Paul exclaim, “Where, O death, is your victory? Where, O death, is your sting?” 1 Cor 15:55

Our favorite comedians die of overdoses. 5000 abortions happen every day in America. Every day. A prominent and influential Christian writer is diagnosed with advanced stomach cancer. A 28 y/o is on hospice, dying of ovarian cancer. A toddler dies of methamphetamine overdose after he puts a filter paper in his mouth in a rat infested basement while his mother gets a pop with her boyfriend at the local gas station. At times, it seems like death is on every corner and takes the most innocent.

In my emergency room, there is no shortage of those suffering and dying. In some senses, we only prolong the inevitable. I think it would be a grim profession if this was all we did. There is hope. The only place I know of this hope is in Jesus. We fell away from God when we transgressed His Law. Only one command existed at the beginning, “Do not eat of the tree of the knowledge of good and evil or you will surely die.” We did. It has been separation ever since.   Spiritual death reigns over us. The consequence is physical death. HOWEVER, God gave His only Son. Christ died that we should LIVE. Death is not the end. Christ resurrected from the dead. Death is a gateway to eternity with God for all who believe in Jesus. Jesus is the Way, the Truth, and the Life. John 14:6

For the Christian, death is not to be feared. Death is a reunion with God. We will shed off this body of death and live with Him in eternity. This life is only the beginning. As Paul states, “For to me, living is Christ and dying is gain. Now if I am to go on living in the body, this will mean productive work for me, yet I don’t know which I prefer: I feel torn between the two, because I have a desire to depart and be with Christ, which is better by far, but it is more vital for your sake that I remain in the body.” Phil 1:22-24

The word “depart” is just like a ship leaving harbor. The journey is just beginning. May we have confidence that Christ paid the price that we may be united with Him. Christ is our forerunner. He has conquered death. We have nothing to fear about death. As my 89 y/o sister said, “I’m ready to meet my Jesus.”

Grander RoundsThe Lord Thy Surgeon

Where has the doctor-patient relationship gone?

“We used to treat patients. Now, we treat computers.”  Such is some of the frustration facing the 21st century doctor today.  In 2014, implementation of Electronic Health Records was mandated across the board in healthcare facilities in the United States.  This was done with the goodwilled hope that quality and efficiency would improve. Legible and easily transferable records would ultimately help the patient and decrease costs. Unfortunately, these systems have increased costs everywhere. Doctors are now less efficient because of tedious interfaces and the necessity of documenting unnecessary information.

One thing that has improved: monitoring… Now CMS can monitor doctors’ performance, and on the basis of what they’re [not] doing or documenting [in]correctly, decide their compensation.  It takes coders on both sides to determine the right codes to describe what the doctor did in order to bill correctly.  Entire degrees have been created just to become a medical coder.  What happened to the good ol’ days of seeing your doctor and just paying him what you could afford for your visit? Perhaps you could have bartered a goat or a chicken with your doctor.  Honestly, I can’t even tell you exactly what it costs to come see the doctor.  At our hospital, we have a 24 hour nurse (probably more than one) that is there just to determine whether your admission is “observation” status or “full admission” status.  Their daily job is to review the status of a patient’s admission because the hospital may be partially paid or forfeit payment if it is listed incorrectly. Have we really come so far that our job as healthcare workers is to make sure that we collect enough costs and document thoroughly so that we can keep our jobs?  I’m not against collecting money for services but it seems like we’ve lost the heart of what medicine is: The doctor-patient relationship.

Obstacles, barriers, curtains, walls.  These are what we have set between our doctors and the patient.  We have so many middlemen in the temple of healing now.  What occurred to me this week is that men are great at setting up barriers.  Our new emergency department (about 5 years old now) went to completely private rooms. There are 2 doors to enter the ED waiting area, 1 door to get to the back area of the ED, 1 door to get into the patient room, 1 door to get into the inner core of the ED pod, and 1 door still that can separate the doctor “fishbowl” from the inner core.  6 doors separate the doctor from the patient outside the hospital.  The suffering patient can be physically separated from the healer.  It is easy to see how, to the doctor, the patient could become just a name on a list in the computer, sitting in a room down the hall.  Even while in the room, the computer’s information may dominate the words coming out of the patient’s mouth or sound of their lungs in the stethoscope.  Is not being a doctor more than processing the data in a computer?  Why are politicians, bureaucrats, administrators, coders, and everybody else telling the doctor and the patient what their relationship should be? Yes, clinical decision aids are helpful in computers. Yes, legible data that is easily transmittable is good.  But have we forgotten what was basic to the healer-healed relationship?

I think the same is true in our spiritual lives.  We have forgotten the Doctor-patient relationship.  We have set up barriers to our worship and praise.  We have set up barriers in our relationship with God.  We do not want to be naked before our Creator.  We put doors between God and our transgressions.  We put gowns over our iniquities.  We put traditions and religiousness in place of intimacy.  But isn’t orthodoxy a good thing? The priests, pastors and congregation can then monitor our holiness!?… Is this the kind of relationship our Creator wants?

At first, it was from a distance. It was for our own good. The temple of Israel had regulations. God’s holiness was separated from us because He could not identify with our sinfulness.  Sin was utterly sinful and God completely Holy. To approach Him, certain steps had to be taken.  The entire book of Leviticus is filled with the regulations for worship in the temple.  Wash here, purify there, separate here, slay there, pour blood here, sanctify there.  Most importantly, separate the holy from that which is stained.  Keep them apart! In fact, “holy” means “set apart” or “to be sanctified.” How could He Who was Holiness identify with a fallen creation?  How could He possibly have a relationship with us?…It is because HE TORE DOWN THE BARRIER!

In Christ, God tore the curtain between man and Himself! (Mark 15:38, Luke 23:45, Matthew 27:51) God came in the flesh and suffered with us! He had compassion on us. Compassion is made of two words. “com-” or “con-” or “co-” prefixes meaning “together/with” and “pathos” meaning suffering.  “Path-ology” is the department we send diseased tissue.  It is “the study of suffering.”  It is He Who identified with our suffering. He suffered WITH us. He knew what the pain felt like. He was tempted in the same ways.  As Hebrews states, “For we do not have a high priest incapable of sympathizing with our weaknesses, but one who has been tempted in every way just as we are, yet without sin. Therefore let us confidently approach the throne of grace to receive mercy and find grace whenever we need help.” (Heb 4:15-16) Jesus was offered as the perfect offering to God so that we could have relationship with Him!  (Heb 9:11-25) This is the meaning of the communion.  It is the Thanksgiving offering. It is the Passover.  It is togetherness with Him.

Why do we set up these barriers? Why do we make excuses? Why do we not just turn to Him in our time of need? Why do we make everything a complicated procedure? Faith and trust is what He is looking for.  As Habakkuk says, “My righteous one will live by faith.” (Hab 2:4) And to David He said, “if My people who are called by My name will humble themselves, and pray and seek My face, and turn from their wicked ways, then I will hear from heaven, and will forgive their sin and heal their land.” (2 Chr 7:14) In Hebrews it says, “But without faith it is impossible to please Him, for he who comes to God must believe that He is, and that He is a rewarder of those who diligently seek Him.” (Heb 10:6) And to Micah He says, “He has showed you, O man, what is good. And what does the LORD require of you? To act justly and to love mercy and to walk humbly with your God.” (Mic 6:8) Should we not walk closer with Him?

John explains our relationship with Him well. “Now this is the gospel message we have heard from Him and announce to you: God is light, and in Him there is no darkness at all. If we say we have fellowship with Him and yet keep on walking in the darkness, we are lying and not practicing the truth. But if we walk in the light as He Himself is in the light, we have fellowship with one another and the blood of Jesus His Son cleanses us from all sin. If we say we do not bear the guilt of sin, we are deceiving ourselves and the truth is not in us. But if we confess our sins, He is faithful and righteous, forgiving us our sins and cleansing us from all unrighteousness. If we say we have not sinned, we make Him a liar and His word is not in us. (My little children, I am writing these things to you so that you may not sin.) But if anyone does sin, we have an Advocate with the Father, Jesus Christ the righteous One, and He Himself is the atoning sacrifice for our sins, and not only for our sins but also for the whole world.” (1 John 1:5-2:2)

Why do we continually set up barriers between the doctor and the patient? Why do we set up barriers between the Lord thy Surgeon and ourselves? A doctor must take a history and do a physical examination.  It requires talking with and touching the patient.  As doctors, we use light to see where the problem is.  It is hard to see exactly what the disease is without being in the room.  I cannot tell you if you need stitches if you don’t show me your laceration. So why is it we do not want to come into His light to show Him where our problem is? Our sin is painful. We are ashamed of it. It is the part of us that is ugly and deformed.  But the Surgeon has the healing we need if this sin is exposed to Him. He provides the sin covering in the blood of Christ  He provides the healing in the body of Christ.

Computers and technology are not bad. Orthodoxy is not bad.  The temple was not bad.  The temple was complicated.  So, let us (as doctors) get back to listening to the patient and examining them and identifying the problem. Let us stop treating computers and and go back treating to the patient. As patients, let us seek a doctor that listens to our problem and examines our iniquities. As patients, let us seek the Surgeon in prayer and seek His Word.  Let us seek the intimacy that He wants.  Let us go by boldly to the throne of grace. (Heb 4:16) Let us restore the Doctor-patient relationship by communion with Him.  It was God Himself Who established Doctor-patient relationship when He tore the veil on Calvary. (Mat 27:51)  It is God who is our Healer. He is the Lord thy Surgeon.

 

Grander RoundsThe Lord Thy Surgeon

Can You Trust Your Doctor?

A patient rolls into the Emergency Department in cardiac arrest. The techs are doing compressions and hooking the patient to the monitors. The nurses are scrambling to put in an IV. Resident doctors are working to intubate the patient. Notes are being scribbled down about what has been done so far as the paramedics give a report amongst the commotion. I stand at the foot of the bed, watching over the action of the organized chaos. Five minutes later, I’m forming a relationship with family members. “Did he have any advanced directives? What medical problems does he have? Has he been ill? What happened? Is this what he would want?” In the crunch, forming trust with family members of a sick loved one may be one of the most difficult tasks an ER doctor can face. But why do they trust me? We just met. Are all doctors trustworthy? Can you trust YOUR doctor?

I don’t mean to call into question the relationship with the doctors that you see but why do we trust them? In the age of more specialization, we hardly know our doctors and they hardly know us. A question that I have heard dozens of times from Dr. Gene Scott sermons lingers in my mind. “What do you want from your spouse or loved ones? (Trust or performance?)” Doctors are human just like anyone else. Mistakes will be made. I think most would say that they could forgive a mistake if they knew that their doctor had good intentions for them. One could want perfect performance (an impossibility) but one really wants to be able to trust their doctor.

The Hippocratic oath made the king and the peasant equal. The healer had sworn an oath to the gods of healing to be a servant to the patient. He would consult and advise in the best interest of those who came to him. Why did the oath become so popular through the years? Because it formed a foundation for trust in the healer. The gods or God bound the healer. The healer was accountable to them.

Perhaps instead, when you are sick, you go to a healer that was paid off by a family member or acquaintance…“(quietly) You know doctor, if so-and-so dies, there may be a new Mercedes or a nice big check in your pocket.” Or perhaps worse, they want you to live… in a vegetative state for as long as possible… If you’re an atheist, cheating to get ahead is really not prohibited by evolution theory. Enjoying the most resources and outperforming others while here is your goal. I’m not exactly sure how an atheist could rationally be a moral doctor. Nor do I know how you could rationally trust one. However, a doctor submitted to God has a basis for your trust. His integrity is guarded by the One from whom integrity comes.

When we are talking about “trust”, we are really talking about “faith.” Dr. Scott always described faith as “Action, based upon Belief, sustained by Confidence.” This is the “ABC’s of faith.” It is not just a “mental ascent to.” One can “believe” that a parachute will catch you but until you strap in, jump out of the plane, and literally “hang the body” or “faith” (verb) in the parachute, you do not have “faith.” The Hebrew words of the Old Testament for “faith” are words that mean “run to the speaker” or “lean on a staff” or “get under the shelter.” Faith is action and trusting.

Again, Who will guard the integrity of the doctor except the One who is trustworthy Himself? God keeps His Word. He is trustworthy. In the garden, God said to Adam and Eve, “You may eat freely from any tree of the orchard but you must not eat from the tree of the knowledge of good and evil, for when you eat of it you will surely die.” (Gen 2:16-17) Then the devil comes along and says, “Surely, you will not die, for God knows that when you eat of it your eyes will be open and you will be divine beings who know good and evil.” (Gen 3:4-5)

Two things to think about: 1. Everywhere was life and God was speaking about death. After the fall, everywhere is death and God is speaking about life. 2. Adam and Eve only knew life and living in it. They had no idea what death or evil was.

Ultimately, this comes down to whose word will you place your trust in? Is God’s Word trustworthy? Or the serpent’s? Now, Adam and Eve fell short of God’s expectation to have relationship with Him. They broke the covenant with God. Now some may ask, “Why can’t God just forgive their sin and change His mind? Perhaps God says, ‘Well, you couldn’t do without eating from that tree, but I will change my mind, if you only don’t go into those waters, you won’t die.’” The problem with this is that how would we be secure in knowing that God wouldn’t change His mind again even if we attained such a mark. If God said, “If you eat of this tree, you will surely die,” but then didn’t follow through on the death delivered, how would be secure in the opposite? If one might meet the mark, how would we know that we had attained life? Perhaps God might say, “I changed my mind…if you do this other thing…then you will live.” No security could be obtained.

But this is where God’s greatest gift comes. He provides a substitute for the death we deserve. He provides the sacrifice in Christ. Christ identifies Himself with us. He comes in the flesh and dies for us. As Paul says, “Now if we died with Christ, we believe that we will also live with him. We know that since Christ has been raised from the dead, he is never going to die again; death no longer has mastery over him. For the death he died, he died to sin once for all, but the life he lives, he lives to God. So you too consider yourselves dead to sin, but alive to God in Christ Jesus.” (Rom 6:8-11)

God keeps His Word. He is trustworthy. God is the Judge. If a physician knows that judgment that is higher than any earthly judge is watching over, a doctor must maintain his integrity. And if a doctor falls short, God will keep those who trust in Him.

The original Hippocratic oath starts, “I swear by Apollo, Physician and Aesclepius, Hygeia and Panacea and all the gods and goddesses, making them my witness, that I will fulfill according to my ability and judgment, this oath and this covenant:” At the time in Greek culture, these were the gods of healing. The oath has been modified over the years to just “God.” To the Christian, this is the God of the Bible. God is the One who will keep the physician accountable.

It is amazing how much forethought the original oath had. The original oath has: 1.God as the witness 2. Guarding the art of medicine with purity and holiness, 3. Teaching the art to others 4. Not giving an abortive or suicidal remedy 5. Keeping the sick from harm and injustice 6. Healing for the benefit of the patient 7. Keeping the treatment confidential 8. Honor and happiness for fulfilling the covenant, and the opposite for transgressing it. (Read the entire original oath here.)

I do not know how patients and family members so readily trust me in moments of such great distress. Perhaps, it is my calming voice or sense of security I give them. Unfortunately, I only wish that I had all the answers to their questions or that I could always say that everything will be okay. Everything is not always okay. I don’t have all the answers and rarely do I have a perfect answer.

I think that each of us grasp for security in our times of distress. We will trust almost anything or anyone. God is truly the only One who is trustworthy in our times of trouble. He is our Shelter. He is our Staff to lean on. He is the Speaker of the Word. He is our Healer. He is the Lord thy Surgeon. (Exodus 15:26)

Can you trust your doctor? Hopefully, you can… with God as their Witness.

But, I know that you will always be able to trust the One who is Truth. (John 14:6-7) His Word is reliable and His Word is secure. (Psa 119:89, Psa 119:60, 1 Pet 1:25, Psa 147)

Grander RoundsThe Lord Thy Surgeon

Life Unworthy to be Lived – To Heal or Kill?

Some of the men in my bible study group, “Grander Rounds”, will remember that I started it with: “Why does human life matter?” It seemed like a straightforward question. My desire to finally start the group stirred again by the undercover Planned Parenthood videos in 2015 that were released by the Center for Medical Progress. Whether or not the videos are real or not, I do not want to debate but the questions that they raise are very thought provoking.

In the U.S. and around the world, body parts and organs cannot be sold. Now, legally one can charge for services related to delivery or procurement, but not for the organs themselves. (I.e. you cannot sell your kidney or even your blood.) But what about parts of aborted dead fetuses? For research? Is it not a good thing for humanity and may perhaps save several people some day? Many compared the Holocaust to the abortion situation that happens everyday in the world. Doctors are at the center of both. But what was the mentality of the Nazi doctor? How did those “healers” stray so far to killing millions of Jews?

To answer my questions, I purchased two books on the Nazi Doctors; The Nazi Doctors by Robert Jay Lifton and Doctors from Hell by Vivien Spitz. I read Ms. Spitz’s book first which was the easier of the two. Ms. Spitz was one of the court reporters on the medical trials at Nuremburg and Dr. Lifton interviewed several of the doctors for several years of his life.

Immediately apparent was that most of the doctors were not strongly ideological with regards to extermination of the Jewish people. A few people at the top like Himmler, Mengele and others pressed the rest who were mostly compliant. A couple decades earlier, the Eugenics movement started in the U.S. Compulsory sterilization and immigration restriction tried to find legal ground but eventually failed. Hitler, however picked up the movement with the purpose to improve the German people and to rid disease within the German people. Bad science with wrong ideas about “Aryan origin” and poor understanding of genetics led eventually to a legal declaration of noble purpose for the German people. Wouldn’t the German people be better off if the disease and weak genes were eliminated?

Who were the first ones that were killed? They were individuals that I think most doctors today would agree are poorly interactive with their environment. Colloquially, some people call these individuals “vegetables.” Schizophrenics and other mentally affected patients or “idiots, imbiciles, and epileptics” were also included. These people were deemed as being Lebensunwertes Leben, or “Lives unworthy to be lived.” The doctors saw the suffering of these people in homes and institutions and some were classified as “useless eaters.” In some sense, the doctors considered these people already dead. It was for them, a humane act to kill these people to free up food for others and to keep them from suffering longer. For the schizophrenic and epileptic, it was helpful to society to keep those bad genes from continuing by forced sterilization. The “preservation” of the race was at hand. However, it was a reversal of “healing” and “killing.” They were “killing” to “heal” the society.

The reversal provided that any unwanted or undesirable group of people found themselves scheduled to be discarded. But aren’t doctors supposed to “do no harm?” As Fritz Klein, a Nazi doctor, put it regarding the Hippocratic Oath and what was happening, “Of course I am a doctor and I want to preserve life. And out of respect for human life, I would remove a gangrenous appendix from a diseased body. The Jew is the gangrenous appendix in the body of mankind.” A legal justification for the execution of 6 million Jews had been found.

Now, where are we today?   4000-5000 fetuses are voluntarily aborted in the U.S. alone, each day. Now I specify voluntarily aborted because medically speaking, an abortion is any time the uterus does not carry a fetus to a viable state and is lost. We call this colloquially “a miscarriage” when it happens by accident or due to some problem in development. When it is done by choice, we call it “an abortion.”

Words over time develop new semantics and “abortion” carries a lot of emotion in our society. One of the more immediate recognitions of the Nazi community was that shooting the individuals that were chosen for “mercy deaths” gave uneasiness to the soldiers that had to carry out the act. It became necessary to separate and reduce any guilt of the executioner and the judge(s). The person to be executed had to be “less than human” or a “defective human.” A system was created slowly and a series of judges determined who was eligible to have a mercy death such that not one doctor/person/judge/executioner was responsible for the death. The executioners were convinced slowly that these individuals were “less than human” and that the individual’s fate had already been determined by a series of judges. The executioners were separated from the actual execution. Rather than having to look directly at the victims, the victims were put in chambers and gas was instilled. Healthier working Jews were forced to remove and burn the bodies. At the end of the day, it was no “one” person’s fault and of course, these Jews were “less than human.”

We now come to the crux of the modern abortion issue. Are these fetuses human? Is a fetus “a person”? What is required to be a “person”? Scientifically, we know that a fertilized embryo has everything it needs to become an individual human being. A fertilized embryo developing in a uterus has even the correct conditions set for living. The embryo is genetically independent of the carrier mother. This embryo that is not deprived of its developing environment will continue to grow into an adult as its DNA instructs its cellular machinery to do. When does this embryo/fetus become a person? Conception? 12 weeks? 24 weeks (viability)? At birth? If someone murders a pregnant woman, the suspect is charged with a double murder as the developing infant is considered killed as well.

A child may be born struggling in an environment or to a parent without many resources. Are not some of our greatest leaders from meager beginnings? Has the next hero been executed before exiting the womb?

Why does it require a doctor to carry out these abortions? Are not these men and women that swore an oath to “do no harm?” A non-doctor could easily perform the abortion procedures. Where will it lead us as doctors and patients if the Hippocratic oath is eroded away?

My bible study started and purposed itself in answering these difficult questions of life. How can secularism or science answer these questions and more? Medicine is a “moral” activity. Science tells us what “is” but it cannot tell us what “should” or “ought” to be done. Science can tell us how big the cancer is or what the CD4 count is but it cannot tell us what is “good” or “bad” or what one “should” do. “Should” and “ought” are moral issues. If medicine is a moral activity, what “should” we do when it comes to abortion and medicine?

I believe the answer to these problems centers around two major questions. Does all human life have value? Can you trust your doctor?

We will begin to explore these questions in more detail in the next volume of The Lord Thy Surgeon.