by M. J. Cates
Before Frank Billings and I developed focal infection therapy fewer than 25% of patients improved enough to leave state asylums permanently—and even those were due entirely to spontaneous recovery.
All devitalized teeth, especially those with root canal fillings, should be extracted immediately. All progressive dentists support this view.
I’ve made mistakes. But all of them were cases of not going far enough. I hesitated, in the early days, to resect more than a foot or so of large intestine. This was far too conservative.
The modern operation is safe for the patient. The modern surgeon must make the patient safe for the operation.
If a patient has twelve infected teeth it is bad medicine to extract only eleven. You harm without benefit.
As Imogen was leaving, Bingham invited her to attend one of his surgeries. Excited by his own magnanimity, he became uncharacteristically animated and insistent. “No, you must come, Dr. Lang. I think it’s essential you see what we do here, don’t you? Besides which, I should very much value your comments and opinions.”
“I’m afraid surgery is a long way from any expertise I may possess.”
“Still. You must come and see. It’s what we do best here. It’s what we’re known for. You can’t go to New York and not see the Statue of Liberty.”
* * *
—
The Trenton State Hospital had three surgical service areas, two for women and one for men. Imogen had no need to ask why the discrepancy; it was clear from Bingham’s own writings. If removing tonsils, teeth, and lengths of colon didn’t work, it was a certainty that “the female organs” must be involved.
The operation she was to witness was a straightforward colectomy and anastomosis on a thirty-four-year-old patient named Penny Clark, who had a history of chronic schizophrenia. At Bingham’s invitation, Imogen waited, gloved and gowned, in the operating theatre where she could watch the nurses prepare. They were extremely efficient and capable. The room itself was a bright, sunny space with huge windows and three skylights. Overhead, a sky of electric blue was traversed by a procession of clouds as smooth as whipped cream. Sunlight flashed on the chrome of the instruments and caused the white sheets and gowns, even the white floor, to glow as if lit from within.
Shouting erupted in the outer area. A woman’s voice—distorted by toothlessness and no doubt a heavy bromide—yelled no, no, no over and over. It’s not fair! It’s not fair! Her words slowed, became more slurred, and then stopped altogether. She was wheeled into the operating theatre, dreamy and docile. Dr. Bingham followed, majestic in gown and mask, greeting everyone cheerily, his eyes merry above his mask.
“Have you all met Dr. Lang—our formidable and lovely colleague from Baltimore?”
They had.
“Dr. Lang is a protegé of Jonas Ganz himself, so we must all be on our toes.”
He walked round to the head of the operating table.
“Miss Clark? How are you this fine morning?”
The patient answered with difficulty that she was sad. Distorted by sedatives, it came out as s-s-s-ssad.
“And perhaps a little anxious, no? But I assure you that I have the finest surgical team on the East Coast in this room and we’ll be looking after you all the way.”
“No-o-o-o.”
Imogen assumed this was a patient under court committal and that the necessary consent had been signed by next of kin, because clearly this woman was here against her will.
“Not to worry. The procedure is simplicity itself, and one that I have employed many times with excellent outcomes. We’ll just be cutting out a bit of infected bowel and joining the two healthy pieces back together. Nothing simpler.”
He nodded to the anaesthetist, and the mask was lowered. The woman was now just a shape under sheets, the mask obscuring the last individualizing features. A few drops of chloral were administered, and when unconsciousness was certain, Bingham asked for a pulse. The anaesthetist already had a finger against the carotid vein. “Seventy-six.”
“Blood pressure?”
“One twenty-four over eighty.”
“Excellent. Part the draping please.” The nurse folded back the surgical drape to expose the woman’s abdomen. As Dr. Bingham turned back from his tray, scalpel in hand, the pale plain of her belly, tiny shadowed depression of navel in the centre, looked to Imogen the most vulnerable thing she had ever seen.
“This may be routine for the rest of you, but I’m going to give a running commentary for the benefit of our visitor. Dr. Lang, can you see all right?”
“Yes, thank you.”
“As you know, for an inguinal colectomy, incision is on the left and exactly the same as for an appendectomy on the right, meaning we split the muscles, à la McBurney, without dividing the fibres.”
A firm stroke, as with a pen nib, followed by the welling of scarlet ink. “No more than two inches is required. I’m taking a middle approach about two inches above the anterior superior spine at the ilium. There’s a slight risk of prolapse, but the fecal reservoir is preserved, avoiding the risk of incontinence.”
He clamped the bleeding at the edge of the wound, and swabbed the area.
“Note that the fibres of the external oblique muscles run parallel to the incision. You’ll see as I split the fibres lengthwise…” which he now did, ever so gently, “we expose the internal oblique. Clever Mother Nature, you observe, runs these underlying fibres at right angles to the external.”
He made a small incision, little more than a nick, and lengthened it with careful tearing. “Beautiful. Look at that. We’re now looking at the transversalis fascia and the peritoneum. Retractor, please.”
The retractor held the muscles apart, allowing Bingham to make a small incision in the peritoneum. Imogen winced. The peritoneum was the membrane that held the viscera in place, one layer being attached to the wall of the abdomen, the other folded around the entrails themselves. To pierce it was one of the most dangerous manoeuvres in medicine, with a high risk of infection. Peritonitis was excruciating, and nearly always fatal.
Bingham secured the cut edges with a pair of clips and inserted his forefinger into the opening.
“Seeking the sigmoid flexure…usually easy enough to find. Now hauling it to the surface.”
From out of the tiny opening he pulled some eight inches of pinkish-grey tubing.
“Now pulling on the upper end until no more bowel will come out, at the same time…tucking the lower sigmoid back inside. Excellent. We have a good length of colon here, but it’s crucial to pull the mesentery taut. We have to see the blood vessels.”
The mesentery was part of the peritoneum and was roughly to the colon what the placenta is to a fetus. Dr. Bingham glanced at Imogen. “All right so far?”
“Yes. Fine.”
She was struck by the change in Bingham. His eyes, framed between the surgical cap and mask, had lost their usual wounded look. Furtiveness replaced by calm. Instead of the hunted he was the hunter, on the trail of the focal infection that was driving this young woman (she was barely two years older than Imogen) into misery and madness. If that required him to yank out a loop of her guts and examine them on her belly, so be it. He was in his element here; he was in control. He would not be one of the countless psychiatrists defeated by the implacable mysteries of psychosis. If Imogen’s only experience of Rupert Bingham had been this operation, he would have enjoyed her complete confidence.
He bent low over the patient’s belly to examine the mesentery, then called for Pagenstecher. “It’s the heaviest thread. I always use it to fix the bowel in place, and the Hagedorn needle—you need that full curve.” He held it up for Imogen to see. He described what he was doing as he continued. “Holding the loop of gut in my left hand, we go down through all three muscles and the peritoneum, and leave about six inches of thread on top. Now I put it through the bloodless area of the mesentery I already selected. And up through the muscles and skin on the other side. Then back down through t
he wound and passing the needle through the same hole in the mesentery and—voilà—up through the wound. Tubing, please.”
The nurse handed him a three-inch section of clear tube. Bingham disengaged the needle, and placed the tubing on the abdomen under the thread. The nurse handed him a second piece and he did the same on the other side. “This is just to keep the thread from cutting into the skin,” he said, and tied off the suture. He looked across the patient at Imogen. “What do you think, Doctor?”
“It’s brilliant.”
“We stand on the shoulders of giants, Dr. Lang, giants—Moynihan and Paul to name just two. This stitch holds better than the usual strip of gauze wrapped around a glass rod and it doesn’t get in the way.” He spread the loop of gut with both hands. The mesentery was an intricate webbed fan of blood vessels. “Beautiful,” Bingham said. “She’s nice and trim. In obese patients the mesentery is a cloudy mess. Clamps please, Nurse.”
One by one, the nurse handed him four surgical clamps, which he attached to the gut in pairs forming a wedge shape. “Paquelin, if you please.”
The nurse handed him the knife of a cautery unit, the blade glowing dull red.
“It looks normal to me,” Imogen said. “I don’t see any growth or infection.”
“Ah, but I do. That pink tinge? It’s much pinker than normal. In a matter of weeks or months it would be flaming red. But even I can’t see it sometimes. That’s why we have one of the most advanced labs in the country. This woman’s colon is swarming with a staph infection, and the only thing to do is cut out as much of it as we can. The distal portions, luckily, are disease free, as they must be. Few rules are so binding on the surgeon, Dr. Lang, as the one prohibiting the resection of unhealthy tissue. You’ll notice I cut very slowly to prevent hemorrhage.”
A whiff of seared meat rose from the table as he cut through first one side of the loop, then the other. The nurse held out a chrome pan, and he placed in it—with a clang—the severed length of gut, two clamps still attached. Now the openings of the sectioned gut, even though squeezed by the two remaining clamps, lay fixed on the abdomen like twin gun barrels. Over the next hour Bingham clipped, ligated, cauterized, and stitched. When done, he washed the gut with bismuth and called for a Paul’s tube for drainage. He fixed this to the abdomen with a couple of stitches, packed the wound, and dressed it.
“I’m not going to close up now. Everything remains exterior for at least three days, sometimes as long as a week. We have to ensure that the stitches will hold even in the presence of digestion.”
“But isn’t that incredibly dangerous?” Imogen said—it wasn’t really a question.
“As you saw, our antiseptic measures border on the fanatical, and our mortality rate is no higher than anyone else’s. Yes, there are risks—internal bleeding, incisional hernia, leaking stitches—but the danger must be weighed against this woman’s prognosis: the risk of a negative surgical outcome versus the certainty of a lifetime on the ward. I love surgery, Dr. Lang, I adore surgery. Surgery—whatever else it may be—is an adventure of the spirit, a trial of one’s mettle, but I firmly believe there’s no enemy that can’t be conquered if a man’s heart is set on victory.”
* * *
—
From the operating room at Trenton State Hospital to her home on Dukeland Street, Baltimore, was only a half-day’s journey—not so far, in the grand scheme of things. In some ways, it was no distance at all, a mere step through a mirror, but in this mirror-world Imogen found herself trapped in a bad dream from which there was no waking. Carl’s contrition had soon mutated to anger and resentment, as if he were not the betrayer but the betrayed.
No doubt the atmosphere at work had changed for him. Jonas Ganz, Imogen was gratified to hear, was no longer cordial in his relations with Carl. Where before he had been friendly and interested, he was now merely civil. Invitations to have dinner at the chief’s house stopped cold. Ganz no longer popped into the psychology lab to pay his respects, although he did still stop by Imogen’s lab. Imogen thought this served Carl right, and he should have expected much worse for seducing a student.
Once having got over the initial shock, she had assumed that gradually her hurt would heal and their married life would resume its normal cheerful temper. She had withdrawn her demand that Carl dispose of the marriage bed he had sullied. They could not afford a new one, and Carl’s hours at the lab did not allow him the time it would take to build one. Imogen had wanted nothing more than to set fire to it, but she accepted that this was impossible and, swallowing her pride, once more slept in the same bed with her husband. If she had thought he would recognize this concession for the sacrifice it was, she was soon disillusioned. Where she had hoped for some semblance of gratitude, she was met with his turned back.
Carl behaved toward her with stiff correctness, nothing more; there was no warmth in his “good mornings” or “thank yous” beyond that between people who happen to work in the same building. No smiles. He never inquired about her progress with the Trenton study, and showed not a flicker of interest when she couldn’t help talking about events at the asylum. In contrast to his previous irrepressible chatter concerning his own work, he now came home humourless and mute. The only exception to this implacable cold—and it was an exception she valued highly—was in his attitude to Aubrey and Charlotte. He still played with the twins as eagerly, as joyfully as ever, listened to them attentively, and told them silly stories about a mischievous rat who disrupted his lab and wrote poems for him to find every morning. Still, Imogen could not watch these displays of love without pangs of abandonment. His coldness was so selective that it screamed, You, my dear, are not worth loving.
Her certainty that she had done nothing wrong began to waver. Perhaps she had failed him and was too self-centred to be aware of it. Perhaps it was sex. Perhaps he had been so unfulfilled that he was driven to look elsewhere for satisfaction. Now that Cynthia Bee was gone, he resented his wife for depriving him of his pleasure. Or it could be even simpler. No man or woman likes to be caught being his or her lowest self, and no one can be expected to thank you for shining a light on his lapses. Whatever the cause, Carl’s cold anger caused Imogen’s own love, already blighted by betrayal, to wither to its roots.
When the four of them were together as a family—at the market, in the park, at dinner—Imogen found it difficult to be loving even toward her children.
“Carl,” she said one night after the twins had gone to bed, “you are behaving toward me as if I’ve done something terrible. I don’t know why that should be, but I do need to know if you plan to continue this way.”
Carl was hidden behind a wall of newspaper. “I don’t know what you’re talking about,” he said, and noisily turned a page.
“Carl, look at me.”
He lowered his newspaper halfway.
“Carl, I’m trying to forgive you for what you did to me—to us and our family. I want to forgive you and for life to go back to normal. But I receive nothing from you except hostility and resentment.”
“Hostility and resentment. Sounds like normal married life to me.”
“It’s certainly not how we were before all this…”
“Before you abandoned us for Trenton.”
“I didn’t abandon anyone. I took a temporary job because we need the money and I need the publication. If you showed the slightest interest in my life, you’d know that what I’m doing is extremely worthwhile. When it’s published this study will ultimately save lives.”
“So being a good wife is beneath you, I suppose. No, no—Imogen Lang is far too grand to be a mere wife.”
“I’m not a mere anything. Neither are you. I’m a wife, a mother, and a psychiatrist—a working woman, yes. I was a working woman when you met me. You said many times I was just what you wanted, I was exactly right for you. You claimed to think women should work.”
“Women. Not mothers. You’re a mother, now, Imogen, a mother. It’s a full-time job.”
; “No, it’s not. The children are at school for half the day and asleep for ten hours at night and Myra looks after them for half days. There’s no reason I shouldn’t have a career, and certainly no reason to defend my career to you. We’ve been over all this. Why are you harping on it now?”
“Because I’m the one who has to be home with the twins. I’m a man, Imogen, a man—someone who goes out into the world and earns a living. That’s what men are for. I should not be called upon to be nanny and nursemaid and housekeeper—it’s menial labour, for God’s sake. I have more important things to do with my time. Unlike you, I’m not travelling around the country counting mad people.”
“Can you not hear yourself, Carl? Can you not hear what you are saying to me? One minute you’re accusing me—falsely—of deeming motherhood beneath me. The next minute you’re calling it manual labour and far below the likes of you.”
“Women have traditionally seen raising children as their main purpose in life.”
“Suddenly Carl Kromer is a traditionalist? Whatever happened to the free-thinking progressive I married? The man who insisted he saw the two of us—and our careers!—as equal. Suddenly I’m just obsessed with the worthless occupation of counting mad people, as if counting mad people can’t begin to compare with the importance of counting rats. You know what I’m studying and you know why it matters.”
“Some women find their children—yes, and even their husband—more important.”
“But you were reconciled to this! Carl, I was so relieved when you apologized and said you were wrong to object and I should absolutely go ahead and do the study. I thought to myself, ‘Yes, my man is the real thing—a husband who can treat me as an equal without feeling something has been stolen from him.’ Why, oh, why have you now reverted?”
“I only agreed to this ridiculous situation because we had Cynthia to look after the kids, Imogen. Well, you got your wish and now she’s gone, so I get to play babysitter.”