The Anatomy of Deception

by Lawrence Goldstone

  “Johnny, the nurses will be coming around with medicine. It isn’t going to taste very good, but it’s going to help you get better very quickly. The nurses are very nice women and I don’t want you to give them any trouble about taking it. Then, they are going to give you a nice meal and I expect you to eat it without a fuss. All right?”

  The boy agreed quite willingly and we moved on to the next bed, which was occupied by a scrawny girl with sunken eyes and stringy blond hair, no more than twelve. She had been here for over a week with a nontubercular pulmonary illness. “Well, Annie.” The Professor smiled, pulling up a chair next to the bed while the rest of us gathered around. He took her hand and patted it softly. “How are you feeling today?”

  “A little better today, Doctor.” The rasp from her lungs was audible with each breath.

  “Doctor?” he scolded gently. “Didn’t I tell you to call me Willie?”

  A strained smile played across the girl’s pallid face. Her teeth, even at such a young age, were stained and rotting. “Willie,” she whispered.

  The Professor nodded. “That’s better.” Again he removed his stethoscope. “Now I’m going to auscultate … you remember … it means I’m going to listen to your breathing.” The Professor listened to her lungs.

  “Well, that certainly sounds better,” he said to her after he was done. “In fact, I’d like some of these other doctors to listen also. Would that be all right?”

  Annie smiled and nodded. The Professor had made her feel proud, part of the process instead of the subject of it. We took turns listening, the grate in her lungs roaring like surf in our ears. She was not in the least improved. As Simpson placed the stethoscope’s diaphragm against the girl’s protruding ribs, I saw moistness in her eyes and realized that my colleague was fighting for control. I then remembered that she was always stiffer and quieter in the children’s ward. I surmised that despite her protestations, not having children of her own had not left her inured to maternal instincts.

  When the examination was complete, the Professor reached down and smoothed the girl’s hair. “Well, Annie,” he said, “we have to move along and examine some other children who are really sick. I’ll be back tomorrow. Will you wait for me?”

  “Oh, yes, Willie.” Her eyes had brightened and she seemed genuinely happy. But her tomorrows were not to be many.

  As we moved away, one of the students, a boy of about twenty named Naughton, began to ask a question while we were still in earshot of the girl’s bed. The Professor spun and faced him with a glare that closed Naughton’s mouth like a bear trap. Particulars of a case were never discussed when a patient could overhear. In this case, particularly, there was little that needed to be said.

  After rounds, the Professor asked me to join him for a moment. As we walked down the corridor, unexpectedly he asked, “Do you have any notion of where Turk is this morning?”

  I said I did not, although I did not look him in the eye.

  “Excuse me for embarrassing you,” he said, “but when a physician who has not made a misstep in two years arrives at work appearing as you do, it is not difficult to diagnose the cause … or the means of transmission.”

  I admitted that I had been out with Turk, but added that he had dropped me at my rooms and I knew nothing of his whereabouts since then.

  “What sort of fellow is Turk?” he asked.

  “He is of extremely high ability,” I replied, assuming that the Professor was reassessing Turk’s fitness to be on staff.

  “But?”

  It was difficult to know where disloyalty to Turk ended and disloyalty to the Professor began. “His upbringing has left him angry and embittered,” I answered. “I hope it does not cause him to squander his talent.”

  “Yes, I agree,” the Professor replied. “Do you like him … personally, I mean?”

  “Whenever I begin to like him, he does something to bring me up short. But he is difficult to dislike as well.”

  “Yes,” mused the Professor. “Quite so.” Then he brightened and placed his hand on my shoulder. “There’s something else, Ephraim. If you are free tomorrow evening, I would like you to accompany me to a dinner. It is at the Benedicts’ on Rittenhouse Square. Formal, I’m afraid. Starched collar, tight vest, and all. Are you up for it?”

  “I would be glad to,” I said.

  “It is not strictly a social affair,” the Professor noted. “Carroll, how abreast are you with the doings in Baltimore?”

  He was speaking, of course, of the new hospital and plans for a medical school funded by an extraordinary endowment by the Quaker Johns Hopkins. Hopkins had amassed a fortune in dry goods and railroads and died childless in 1873, leaving seven million dollars to create the most modern medical facility in the world.

  “I know,” I replied, “that the hospital will finally open after years of delays but the medical school is still not as yet complete. There are those who doubt it ever will be.”

  “Oh, it will be, it will be. And when it is, it will be the envy of the nation. During that weekend I was absent last month, I traveled to Baltimore. Briefly put, I was solicited by the Hopkins board to accept the position of Physician in Chief at the hospital. It would, I was not displeased to learn, pay five times what I earn here. I was also offered the Professorship of Theory and Practice of Medicine when the medical school opens.”

  “That’s wonderful,” I exulted. For a moment, an echo of Turk’s cynical prediction that the Professor would leave Philadelphia for money alone rang in my ears. I quickly dismissed it. Advancement in any profession was remunerated, and the acceptance of higher pay was not necessarily evidence of greed. “Congratulations,” I said. “There is no one who deserves it more.”

  “Thank you.” The Professor seemed genuinely touched at my enthusiasm. “The offer was supposed to have remained private, but, doctors, I fear, are more uncontrollable gossips than spinsters. News of my visit has reached the board at the hospital here.”

  “Has your position in Philadelphia been compromised?”

  “I suppose not,” he replied, “although it did result in this dinner. Old Benedict—he’s head of the trustees—has asked for an opportunity to persuade me to remain in Philadelphia.” The Professor reached up and tugged at the dip of flesh under his chin. “It is all quite flattering, actually.” Then he smiled and clapped his hands together. “But that brings us to you. If I accept the offer, I would like you to come with me to Baltimore as Assistant Head of Clinical Medicine. The position would apply not just to the hospital, but eventually to the medical school as well. Initially, you will receive two thousand dollars per annum, although I’m certain that you can at least double that with private patients.”

  I stared at the Professor, feeling my lower jaw moving but with no sound emerging. Finally, I managed, “Dr. Osler … I … am …” No more words came.

  The Professor laughed, one loud cannon shot. “Well, Carroll, I believe I have for once struck you dumb. You look quite exceptional. Well, you’ve earned it. I knew you were a special sort the first day I saw you at rounds two years ago, and nothing has since persuaded me otherwise. You are professional, thorough, curious, and a fine doctor. As to your age, I suppose you know that for my first teaching assignment, I was younger than you are now.”

  I did know. At McGill University in Canada, Dr. Osler had been granted a teaching position at twenty-three. His students dubbed him “The Baby Professor.”

  “And besides,” he went on, “children of the backwoods such as ourselves need to stick together, eh?”

  Although the Professor enjoyed stressing the bond of our rural upbringings, he was hardly a rustic. The Osler family had eventually settled in a wilderness town in northern Canada, it was true, but the Professor’s father, Featherstone Lake Osler, had been the original choice to sail on the Beagle as ship’s naturalist, a post that went to Charles Darwin only when the elder Osler declined. Though the Professor’s father had then entered the ministry and been posted to Bond H
ead, Ontario, William Osler had been surrounded by books and learning during his entire childhood.

  My boyhood, by contrast, had been dominated by a decidedly different set of stimuli. The fetid smell of our farmhouse still lingered in my nostrils, unwashed bodies mixed with the waft of cheap stew and even cheaper liquor. Yelling, tears, and the soft moans of my mother were never far away. I would continue to send money home so long as I was able, but I had not and would not return to Marietta. With four thousand dollars per year, I could finally make certain that no one in my family could have further cause to accuse me of ingratitude.

  “Still,” he continued somberly, “it will be difficult to leave … I have made so many friends.” Then he brightened once more. “But as much as I prize my colleagues here, the Hopkins staff will be truly extraordinary. Welch, as you may know, will be running the show … brilliant pathologist. Lafleur, whom I taught in Canada, will arrive shortly. Halsted is already there.”

  “Halsted?” I asked.

  The Professor’s face turned dark, an instantaneous eclipse. “And why not Halsted?” he bristled. “He is the finest surgeon in America, probably the world.”

  I was stunned by the Professor’s change in demeanor at my query. “Why, yes, Dr. Osler,” I sputtered, “I’m sure you are correct, but I thought that he …”

  “Yes, I know what you thought,” the Professor replied. “‘Drug addict.’ You and everyone else.”

  “I didn’t mean—”

  “Of course you didn’t,” he snapped, though his irritation seemed directed no longer at me, but to an audience not present. “Halsted has been unfairly maligned for the better part of a decade. To think that a man of his genius has been reduced to … Well, it’s not important now. Do you know that at this moment, he is perfecting a new surgical suture that will be largely subcutaneous and cause almost no tissue trauma and minimal scarring?”

  Before I could respond, the Professor continued, more willing to expound on the prejudices foisted on a colleague than those foisted on him. “Halsted has pioneered one brilliant surgical advance after another. Just months ago, he had aseptic gloves fabricated by the Goodyear Company. Rubberized gloves are a huge step, Carroll. They promise to all but eliminate surgical infection.”

  “I had heard that surgeons in New York were beginning to use gloves,” I said, “but I didn’t know Halsted had pioneered them.”

  “It was typical,” the Professor fulminated. “One of his nurses was experiencing sensitivity to the carbolic soap with which everyone—or at least almost everyone—now washes before surgery to try to achieve some level of asepsis. To eliminate the need for caustic material to touch the skin, he had the gloves fabricated. They can be rendered truly aseptic. Thousands of lives will be saved each year.”

  Dr. Osler took a step forward and actually placed an index finger on my chest. I was stunned. I had never known him to make physical contact in anger.

  “Doctor, I would protect William Halsted as I would protect a treasure,” he told me, almost in a growl. “The good he will do over what I hope will be a long life, the lives he will save, the suffering he will prevent … do you really desire that medical science deny itself a man such as this?”

  “No,” I replied, still not daring in my astonishment to move. “I suppose not.”

  “No supposing about it,” he grunted. Then, like a kettle removed from a flame, he stepped back and emitted a deep sigh. “This is a simple issue that pits the prejudice of ignorance against the enlightenment of knowledge. Nothing could be clearer. I confess, Carroll, I cannot understand the way some people think.” Dr. Osler withdrew his watch. “We’ll just have time. Come with me, Doctor.”

  The Professor turned on his heel and headed back the way we had come. He took the far staircase to the first floor and emerged across the hall from the operating theater. He opened the door and bade me to enter.

  “Burleigh will be clearing an abscessed bowel,” he said with disgust. “You’ve never seen Burleigh at work before, have you? I believe you will find it enlightening.”

  Wilberforce Burleigh was perhaps the Professor’s most impassioned critic on the staff. He was in his sixties, had been a surgeon for forty years, and thought that medicine was just fine as it was. Burleigh’s eyes narrowed at our arrival and he glared at us as we strode up to the gallery, muttering to himself. I could distinctly make out the words “spying on me.”

  A moment after we had been seated, the patient was wheeled in, and Burleigh turned to the task at hand. An emaciated, sandy-haired man of about forty lay on the table, covered up to his chin with a sheet, his terrified eyes flitting about and his lower jaw quivering. The surgeon took no notice.

  Burleigh was from the “flashing hands” school of surgery—everything the man did was based on speed. Quick work was not mere affectation. In traditional surgery, bleeding was only minimally controlled, usually with pads and pressure, and as a result more surgical patients died from shock than from their primary illness. What hemostasis did exist was achieved by other flashing hands, often eight or nine sets of them, belonging to the army of assistants that most surgeons employed in the effort to have every task attended to immediately. I’d heard that a wag at Yale called this process “nine women trying to have a baby in one month.”

  Recently, the development of mosquito clamps—small, scissor-shaped hemostats—allowed for more effective clamping of blood vessels. With bleeding controlled, the surgeon could work more slowly and carefully, but not every surgeon cared to slow his pace. Burleigh was notorious for continuing to place a premium on speed. He never tired of recounting that in 1846, during the first successful use of ether in surgery, Robert Liston had amputated a leg in mid-thigh in twenty-six seconds, or of bragging that he, Burleigh, had once performed eighteen operations in a single day. Fewer and fewer of that ilk were left, however, as almost every surgeon entering the field now followed the lead of the man who had invented mosquito clamps specifically to staunch blood flow during surgery—William Stewart Halsted.

  Ten assistants stood at the table dressed in hospital uniform instead of gowns, while Burleigh remained in street clothes. Corrigan, the bulldog, who was not trusted to do more than take notes in the Dead House, was to the surgeon’s immediate left, meaning that he was chief assistant. The Professor rolled his eyes at the sight.

  Burleigh signaled another assistant and the ether cone was placed over the patient’s face. As the drug was poured, Burleigh faced the gallery, which contained about twenty students in addition to ourselves, and announced, “Today, I will be treating a patient with acute diverticulitis, removing a suspected abscess from the sigmoid colon and then resecting the bowel.” He smiled, parting an extremely full beard. “Please watch carefully. I don’t wait for stragglers.”

  After the patient had been poked with a long needle to ensure that the ether had rendered him senseless, Burleigh removed a case in fine Turkish leather from his coat. I recognized it at once as the deluxe Tiemann & Company Patent Catch Pocket surgical set, advertised in their catalog at thirty-three dollars, the most expensive kit on the market. At eighteen surgeries per day, I surmised, Burleigh could well afford it. He opened the case, set it on a table behind him, and removed the large scalpel. Standing over the patient with what seemed almost malevolence, Burleigh lowered the scalpel to just above the abdomen, nodded to an assistant to note the time, and then cut.

  Flashing hands was no understatement. Burleigh made a swift paramedian incision on the left abdominal wall, about two inches from midline, beginning just under the rib cage and ending five inches below the umbilicus, cutting in one motion through the skin, subcutaneous fat—minimal due to the patient’s physique—and the anterior rectus sheath. As he spread these aside, four of his assistants dove in with pads. Burleigh then called for a retractor, cut the rectus muscle itself, and placed the retractor laterally, instructing a fifth assistant to hold it still. The entire process was completed in seconds.

  I glanced at the Pro
fessor, but he gave no sign anything was amiss. A paramedian incision was the correct choice—the rectus muscle is not divided, the incisions in the anterior and posterior rectus sheath are separated by muscle, and incisional hernia is less likely—but the length of Burleigh’s cut was far too long. It would be much harder to close, chance of secondary infection greatly increased, and control of the organs inside the peritoneum would be difficult.

  By the time I returned my gaze to the table, two assistants were frantically applying pressure to the larger vessels, while another sponged away fluids. Burleigh should here have switched to the small scalpel for a finer cut, but instead, in the interest of speed, he used the same large instrument to incise the posterior rectus sheath, transversalis fascia, and peritoneum. When he encountered the epigastric vessels, a geyser of blood shot out of the patient, spattering everyone on the right side of the table. Corrigan grabbed a hemostat and tried to clamp the artery, but with blood obscuring the cut end, it took him at least ten seconds to achieve the result. All the while, Burleigh was snarling, “Get that closed, damn you!”

  The rule in surgery, with so many crowded around the table, was “no talking except the big man.” Burleigh was particularly loud and abusive. As soon as Corrigan had placed the clamp, Burleigh screamed for another. The disorganization in the efforts of the team was palpable.

  When finally the bleeding was sufficiently controlled so that Burleigh could see, he began to incise the peritoneum to access the colon itself. Suddenly, the patient began to squirm on the table. Burleigh screamed once more, this time to increase the ether. If the patient’s diaphragm began to move, the bowel could bubble and, especially with this huge an incision, it might force sections of intestine out through the opening and into Burleigh’s face.

  The patient once more lay still as the additional ether began to take. Burleigh proceeded to the target. Still furious, he yelled, “Hold that still, you fool!” The eyes on the assistant holding the right angle retractor went wide, and he struggled to remain perfectly motionless. Burleigh began his inspection of the colon, performing the task as rapidly as possible. He found the diverticular abscess that he expected almost immediately, but there was no way of knowing what, if anything, he missed.