by Jerry
In the case of our own patient, the outcome, I am pleased to report, was bounteous; this was especially gratifying in the light of our guarded prognostications. I was not alone in the skepticism with which I approached the operation, for the tissues and regenerative capacity of an old man are not those of a youngster. During the surgery, when I noticed the friability and general degree of degeneration of his organs, my thoughts were inclined rather pessimistically. I remember wondering, as Dr Cochise severed the humeral head from the glenoid fossa, inadvertantly crushing a quantity of porotic and fragile bone, if our scrupulous planning had not, perhaps, been a waste of effort, that the fruits of our labor would not be commensurate with our toil. Even now, with the benefit of hindsight, I remain astonished at our degree of success. As much as it is a credit, I believe, to the work of our surgical team, it is, perhaps more so, a tribute to the resilience and fundamental vitality of the human body.
After releasing the dermal layer as described, I proceeded to detach the muscles. The adipose tissue, so slippery and difficult to manipulate, would be removed chemically, thus saving valuable time. As I have mentioned, the risk of hemorrhage—and its threat to Mr Reagan’s life—had been eliminated, but because of the resultant interruption of circulation we were faced with the real possibility of massive tissue necrosis. For this reason we were required to move most expeditiously.
With sweeping, but well guided, strokes of the scalpel I transected the ligamentous origins of Pectoralis Major and Minor, and Serratus Anterior. I located their points of insertion on the scrapula and humerus and severed them as well, indicating to Ms Narciso that we would need the technician responsible for the muscles. She replied that he had already been summoned by Dr Ng, and I took that moment to peer in his vicinity.
He and Dr Cochise had been working rapidly, already having completed the spiraling circumferential incisions from groin to toe, thus allowing, in a fashion similar to the peeling of an orange, the removal in toto of the dermal sheath of the leg. The anterior femoral and pelvic musculature had been exposed, and I could see the Sartorius and at least two of the Quadriceps heads dangling. This was good work and I nodded appreciatively, then turned my attention to the abdominal wall.
In terms of time the abdominal muscles presented less of a problem than the thoracic ones, for there were no ribs to contend with. In addition, as long as I was careful not to puncture the viscera, I could enter the peritoneum almost recklessly. I took my scalpel and thrust it upon the xiphoid, near what laymen call the solar plexus, and started the long and penetrating incision down the linea alba, past the umbilicus, to the symphysis pubis. With one hand I lifted the margin of the wound, and with the other delicately sliced the peritoneal membrane. I reflected all the abdominal muscles, the Rectus and Transversus Abdominis, the Obliquus Intemus and Externus, and detached them from their bony insertions. Grasping the peritoneum with a long-toothed forceps and peeling it back, I placed two large towel clips in the overlying muscle mass, and then, as an iceman would pick up a block of ice, lifted it above the table, passing it into the hands of the waiting technician. Another was there for the thoracic musculature, and once these were cleared from the table, I turned to the abdominal contents themselves.
Let me interject a note as to the status of our patient at that time. As deeply as I become involved in the techniques and mechanics of any surgery, I am always, with another part of my mind, aware of the human being who lies at the mercy of the knife. At this juncture in our operation I noticed, by the flaccidity in the muscles on the other half of the abdomen, that the patient was perhaps too deeply relaxed. Always there is a tension in the muscles, and this must be mollified sufficiently to allow the surgeon to operate without undue resistance, but not so much that it endangers the life of the patient. In this case I noted little, if any, resistance, and I asked Dr Guevara to reduce slightly the rate of infusion of the relaxant. This affected all the muscles, including, of course, the diaphragm and those of the larynx, and Mr Reagan took the opportunity to attempt to vocalize. Being intubated, he was in no position to do so, yet somehow managed to produce a keening sound that unnerved us all. His face, as reported by Dr Guevara, became constricted in a horrible rictus, and his eyes seemed to convulse in their sockets. Clearly, he was in excruciating pain, and my heart flew to him as to a valiant soldier.
The agony, I am certain, was not simply corporeal; surely there was a psychological aspect to it, perhaps a psychosis, as he thought upon the systematic dissection and dismemberment of his manifest self. To me, I know it would have been unbearable, and once again I was humbled by his courage and fortitude. And yet there was still so much left to do; neither empathy nor despair were distractions we could afford. Accordingly, I asked Dr Guevara to increase the infusion rate in order to still Mr Reagan’s cries, and this achieved, I returned my concentration to the table.
By pre-arrangement Dr Biko now moved to the opposite side of the patient and began to duplicate there what I had just finished on mine. The sole modification was that he began on the belly wall and proceeded in a cephalad direction, so that by the time I had extirpated the contents of one half of the abdomen, the other would be exposed and ready. With alacrity I began the evisceration.
It would be tedious to chronicle step by step the various dissections, ligations, and severances; these are detailed in a separate monograph, whose reference can be found in the bibliography. Suffice it to say that I identified the organs and proceeded with the resections as we had planned. Once freeing the stomach, I was able to remove the spleen and pancreas without much delay; because of their combined mass, the liver and gall bladder required more time but eventually came out quite nicely. I reflected the proximal small and large intestines downward in order to lay bare the deeper recesses of the upper abdominal cavity and to have access to the kidneys and adrenals. I treated gland and organ as a unit, removing each pair together, transecting the ureters high, near the renal pelvices. The big abdominal vessles, vena cava and aorta, were now exposed, and I had to withstand the urge to include them in my dissection. We had previously agreed that this part of the procedure would be assumed by Dr Biko, who is as skilled and renowned a vascular surgeon as I am an abdomino-thoracic one, and though they lay temptingly now within my reach, I resisted the lure and turned to accomplish the extirpation of the alimentary tract.
We did not, as many had urged, remove the cavitous segment of the digestive apparatus as a whole. After consultation with our technical staff we determined that it would be more practical—successful—if we proceeded segmentally. Thus, we divided the tract into three parts: stomach, including the esophageal segment just distal to the diaphragm; small intestine, from pylorus to ileo-cecal valve; and colon, from cecum to anus. These were dutifully resected and sent to the holding banks, where they await future purpose and need.
As I harvested the internal abdominal musculature, the Psoas, Iliacus, Quadratus Lumborum, I let my mind wander for a few moments. We were nearing the end of the operation, and I felt the luxury of certain philosophical meditations. I thought about the people of the world, the hungry, the cold, those without shelter or goods to meet the exigencies of daily life. What are our responsibilities to them, we the educated, the skilled, the possessors? It is said, and I believe, that no man stands above any other; what then can one person do for the many? Listen, I suppose. Change.
I have found in my profession, as I am certain exists in all others, that to not adapt is to become obsolete. There are many I have known, many of my colleagues, who, unwilling or unable to grapple with innovation, have gone the way of the penny. Tenacity, in some an admirable quality, is no substitute for the ability to change, for what in one age might be considered tenacious in another would most certainly be called cowardly. I thought upon our patient, whose fortunes had so altered since the years of my training, and considered further the question of justice. Could an act of great altruism, albeit forced and involuntary, balance a generation of infamy? How does the dedica
tion of one’s own body to the masses weigh upon the scales of sin and repentance?
My brow furrowed, for these questions were far more difficult to me than the operation itself, and had it not been for Ms Narciso, who spoke up in a timely voice, I might have broken the sterile field by wiping with my own hand the perspiration on my forehead.
“Shall we move to the pelvis, Doctor?” she said, breaking my reverie.
“Yes,” I countered, turning momentarily from the table to recover, while a nurse mopped the moist skin of my face.
The bladder, of course, had been decompressed by the catheter that had been passed prior to surgery, and once I pierced the floor of the peritoneum, it lay beneath my blade like a flat and flaccid tire. I severed it quickly, taking care to include the prostate, seminal vesicles, ureters, and membranous urethra in the resection. A technician carried these to an intermediate room, where a surgeon was standing by to separate the structures before they were taken to their respective tanks. What remained was to take the penis, which was relatively simple, and testes, which required more care so as not to disrupt the delicate tumica that surrounded them. This done, I straightened my back for perhaps the first time since we began and assessed our progress.
When one becomes so engrossed in a task, so keyed and focused that huge chunks of time pass unaware, it is a jarring feeling, akin to waking from a vivid and lifelike dream, to return to reality. I have felt this frequently during surgeries, but never as I did this time. Hours had passed, personnel had changed, perhaps even the moon outside had risen, in a span that for me was marked in moments. I looked for Drs Ng and Cochise and was informed that they had left the surgical suite some time ago; I recalled this only dimly, but when I looked to their work was pleased to find that it had been performed most adequately. All limbs were gone, and the glenoid fossae, where the shoulders had been de-articulated, were sealed as we had discussed. Across from me Dr Biko was just completing the abdominal vascular work. I nodded to myself, and using an interior approach, detached the muscles of the lumbar spine, then asked for the bone saw.
We transected the spinal cord between the second and third lumbar vertebrae, thus preserving the major portion of. attachments of the diaphragm. This, of course, was vital, if, as we had planned, Mr Reagan was to retain the ability to respire. It is well-known that those who leave surgery still attached to the respirator, which surely would have been the case if we had been sloppy in this last part of the operation, do poorly thereafter, often dying in the immediate post-operative period. In this case especially, such an outcome would have been particularly heinous, for it would have deprived this brave man of the fate and rewards most deservedly his.
I am nearing the conclusion of our report, and it must be obvious that I have failed to include each and every nerve, ligament, muscle, and vessel that we removed; if it seems a critical error, I can only say that it is a purposeful one, intended to improve the readability of this document. Hopefully, I have made it more accessible to the lay that exist outside the cloister of our medical world, but those who crave more detailed information I refer to the Archives of Ablative Technique, vol. 113, number 6, pp. 67-104, or, indeed, to any comprehensive atlas of anatomy.
We sealed the chest wall and sub-diaphragmatic area with a synthetic polymer (XRO 137, by Dow) that is thin but surprisingly durable and impervious to bacterial invasion. We did a towel count to make certain that none were inadvertently left inside the patient, though at that point there was little of him that could escape our attention, then Dr Guevara inserted the jugular catheter that would be used for nourishment and medication. Dr Biko fashioned a neat little fistula from the right external carotid artery, which, because we had taken the kidneys, would be used for dialysis. These completed, we did a final blood gas and vital sign check, each of which was acceptable, and I stepped back from the table.
“Thank you all very much,” I said, and turned to Mr Reagan as I peeled back my gloves. He was beginning to recover from the drug-induced paralysis, and his face seemed to recoil from mine as I bent toward him. I have seen this before in surgery, where the strange apparel, the hooded and masked faces, often cause fright in a patient. It is especially common in the immediate post-operative period, when unusual bodily sensations and a frequently marked mental disorientation play such large roles. I was therefore not alarmed to see our patient’s features contort as I drew near.
“It is over,” I said gently, keeping my words simple and clear. “It went well. We will take the tube from your mouth, but don’t try to talk. Your throat will be quite sore for awhile, and it will hurt.”
I placed a hand on his cheek, which felt clammy even though the skin was flushed, and Dr Guevara withdrew the tube. By that time the muscle relaxant had worn off completely, and Mr Reagan responded superbly by beginning to breathe on his own immediately. Shortly thereafter, he began to shriek.
There are some surgeons I know, and many other physicians, who believe in some arcane manner in the strengthening properties of pain. They assert that it fortifies the organism, steeling it, as it were, to the insults of disease. Earlier, I mentioned the positive association between pain and tissue survival, but this obtains solely with respect to ablative surgery. It has not been demonstrated under myriad other circumstances, and this despite literally hundreds of studies to prove it so. The only possible conclusion, the only scientific one, is that pain, apart from its value as a mechanism of warning, has none of those attributes the algophilists ascribe to it. In my mind these practitioners are reprehensible moralists and should be barred from those specialties, such as surgery, where the problem is ubiquitous.
Needless to say, as soon as Mr Reagan began to cry, I ordered a potent and long-lasting analgesic. For the first time since we began his face quieted and his eyes closed, and though I never questioned him on it, I like to think that his dreams were sweet and proud at what he, one man, had been able to offer thousands.
Save for the appendix, this is the whole of my report. Once again I apologize for omissions and refer the interested reader to the ample bibliography. We have demonstrated, I believe, the viability of extensive tissue ablation and its value in providing substrate for inductive and variant mitotics. Although it is an arduous undertaking, I believe it holds promise for selected patients in the future.
Appendix
As of the writing of this document, the following items and respective quantities have been produced by our regeneration systems:
Item
Source
Quantity
Oil, refined
Testes: seminiferous tubules
3761 liters
Perfumes and scents
Same
162 grams
Meat, including patties, filets, and ground round
Muscles
13,318 kilograms
Storage jugs
Bladder
2732
Balls, inflatable (recreational use)
Same
325
Cord, multi-purposed
Ligaments
1.2 kilometers
Roofing material, e.g. for tents; flexible siding
Skin: full thickness
3.6 sq. kilometers
Prophylactics
Skin: stratum granulosum
18,763 cartons of 10 each
Various enzymes, medications, hormones
Pancreas Adrenal Glands Hepatic Tissue
272 grams
Flexible struts and housing supports
Bone
453 sq. meters
The vast majority of these have been distributed, principally to countries of the third world, but also to impoverished areas of our own nation. A follow-up study to update our data and provide a geographical breakdown by item will be conducted within the year.
BEACHWORLD
Stephen King
FedShip ASN/29 fell out of the sky and crashed. After a while two men slipped from its cloven skull like brains. They walked a lit
tle way and then stood, helmets beneath their arms, and looked at where they had finished up.
It was a beach in no need of an ocean—it was its own ocean, a sculpted sea of sand, a black-and-white-snapshot sea frozen forever in troughs and crests and more troughs and crests.
Dunes.
Shallow ones, steep ones, smooth ones, corrugated ones. Knife-crested dunes, plane-crested dunes, irregularly crested dunes that resembled dunes piled on dunes—dune-dominoes.
Dunes. But no ocean.
The valleys which were the troughs between these dunes snaked in mazy black rat-runs. If one looked at those twisting lines long enough, they might seem to spell words—black words hovering over the white dunes.
“Fuck,” Shapiro said.
“Bend over,” Rand said.
Shapiro started to spit, then thought better of it. Looking at all that sand made him think better of it. This was not the time to go wasting moisture, perhaps. Half-buried in the sand, ASN/29 didn’t look like a dying bird anymore; it looked like a gourd that had broken open and disclosed rot inside. There had been a fire. The starboard fuel-pods had all exploded.
“Too bad about Grimes,” Shapiro said.
“Yeah.” Rand’s eyes were still roaming the sand sea, out to the limiting line of the horizon and then coming back again.
It was too bad about Grimes. Grimes was dead. Grimes was now nothing but large chunks and small chunks in the aft storage compartment. Shapiro had looked in and thought: It looks like God decided to eat Grimes, found out he didn’t taste good, and sicked him up again. That had been too much for Shapiro’s own stomach. That, and the sight of Grimes’s teeth scattered across the floor of the storage compartment.
Shapiro now waited for Rand to say something intelligent, but Rand was quiet. Rand’s eyes tracked over the dunes, traced the clockspring windings of the deep troughs between.