The surgeon

by Wilfred Charles Heinz

  "Patient takes fluids well." . . . "Passing gas." . . . "Abdomen not distended." . . . "Patient complains of pain but refuses morphine as prescribed." . . . "Otherwise patient is extremely co-operative."

  "Good morning," he said to the nurse, when he walked into the room. "How's everything?"

  "I think we're doing pretty well," the nurse said, "except for some discomfort."

  "Do you want to take a break for a few minutes?"

  "All right, Doctor," the nurse said. "Thank you."

  "You're looking pretty well," he said to Grace Cowan. "How do you feel?"

  "Fair," she said.

  There were two arrangements of mixed flowers in vases on the bedside table. Lying open in front of them was a Bible.

  "How's the pain?" he said, taking her wrist and finding her pulse.

  "Terrible."

  "You know we can eliminate that."

  "I know."

  "What's this I hear about you refusing the medication I prescribed?"

  "If it's the morphine you're talking about, I don't want any."

  "It will not only take care of your pain but it will augment your recovery. Right now, because of the pain, you can't breathe as deeply as you should, and we want to get you breathing normally again as soon as we can."

  "I'll remember to breathe deeply," she said.

  "If it's addiction you're afraid of," he said, "you can ignore that possibility. There's no danger."

  "I'm not afraid of that. It has nothing to do with that."

  "Oh?" he said, stalling just to see what would happen.

  "Warren," she said, "my brother-in-law, told me yesterday afternoon that he had a talk with you."

  So that's it, he thought. So she's regarding this whole thing as a punishment visited upon her. So she's trying to eradicate her guilt with pain, or maybe I'm playing psychiatrist.

  'Yes," he said, "we did have a talk. He was very concerned about you."

  "You know that's not what I mean," she said. "Warren talks too much. I don't mean normally, but there was no need for him to bring that up at any time."

  "He felt a need, and I'm a doctor."

  "You know, my sister is really a very fine person. Warren and I have never wanted to hurt her."

  "I'm sure of that."

  "I guess you'd call it just one of those things," she said. "I guess what I'm really seeking now is absolution of my guilt."

  "I understand."

  "Have you ever read the Bible, Doctor?"

  "I was brought up on it."

  "I wasn't. It's new to me."

  "I hope you're finding something in it."

  "At least I'm trying," she said, and then: "How am I doing otherwise?"

  "Very well, actually. You're doing so well that, if I had a hundred cases just like you, I'd be famous."

  "It was cancer, wasn't it?"

  "Yes, but I got it all out."

  "Good."

  I don't know whether that "good" is because she welcomes the disease as a guilt purgative, he thought, or whether it's for the cure.

  "The growth was limited and confined," he said. "It hadn't spread, so we were able to get it all."

  "I'm glad to hear that report."

  "I'm glad to report it," he said. "Tomorrow morning we may be able to take that tube out. Later in the day we may let you up to walk to the bathroom, if you feel like it."

  "That would be appreciated."

  "Meanwhile," he said, "I want you to wiggle your toes once in a while, and occasionally bring your feet up and down."

  "That's for my circulation?"

  "Right, and I'm leaving that order for that medication if you change your mind about getting help for that pain."

  "I won't change my mind. You might not think it, knowing what you do now, but I'm really quite strong-willed."

  "I believe it."

  In the hall the nurse was walking up and down near the door.

  "Did you convince her to let me give her a hypo, Doctor?" she said.

  "No," he said. "She doesn't want it, and she'll be all right."

  "Honestly," the nurse said, "I don't understand some people, but I suppose it takes all kinds."

  "That's right."

  "Is it against her religion or something?"

  "No. I don't know what it is, but we'll go along the way she wants it. Dr. Robinson will be in to see her this afternoon. He may leave an order with your relief to give her ten milligrams of sodium luminal if she's too uncomfortable."

  "Honestly," the nurse said.

  At the nurses' station he asked the talker to check on Mrs. Louise Brower again. Then he took Grace Cowan's chart out of the rack and wrote in his comments on the progress report.

  How can that have gone on for twenty years, he was thinking, without her sister knowing? It seems impossible, but do you suppose she really doesn't know?

  "Mrs. Brower has just checked in, Doctor," the talker said.

  "Good," he said, looking at his watch. "Thank you."

  If I skip Lynn Cummings and Anthony Trusco, he thought, I've just got time for Bernard Waterman. They'll still be doing the tests on Lynn Cummings, anyway, so Rob can see her late this afternoon. Anthony Trusco is curing himself, so Rob can tell him the good news, and I've got just enough time for Bernard Waterman before I do Mrs. Louise Brower and, finally, Mr. Scheller. Finally they'll let me get to my Mr. Scheller.

  He put Grace Cowan's chart back and found Bernard Waterman's.

  IX

  "Oh?" he said, feigning surprise. "Am I in the right room?" The nurse was standing by the intravenous stand at the side of the bed, adjusting the tube from the bottle of glucose and saline that was hanging inverted from one of the arms of the stand. She turned, surprised, when she heard him, and then she smiled at his small joke.

  "That's right," she said. "This is the right room."

  "Then this must be Dr. Bernard Waterman," he said.

  "Hello," the boy said.

  Bernard Waterman was fifteen years old. How many times Dr. Matthew Carter had worked over him on an operating table in the last six years only the records would show. He had twice performed major surgery, the last time two days before, to remove strictures in Bernard Waterman's esophagus, the passage by which food moves from the mouth to the stomach. Between those two operations he had periodically passed into the esophagus, through a tube called an esophagoscope, small steel ovals affixed to slender steel rods, hoping by that means to keep the passage open. In those past six years Bernard Waterman had gone under anesthesia at least thirty times.

  "You know, Dr. Waterman," he said to the boy now, still trying to get a rise out of him, "I thought you'd be much older. I thought Dr. Bernard Waterman, the famous mathematician, would be about eighty years old, and have a long white beard."

  "Do I still have to have all these tubes in?" the boy said, looking back at him through his black-rimmed glasses.

  He was sitting up in bed. The intravenous tube ran to his right arm. The red rubber Levine tube that originated in his stomach and came out through his left nostril ran to the suction bottle beneath the bed. A third tube, draining the pleural cavity between his left lung and his chest wall, emerged from his left side and ran to another bottle on the floor.

  "You mean you don't like these tubes? They're doing a lot of good work for you."

  "When can you take them out?" the boy said.

  "Well," he said, "I think we can take this one in your nose out tomorrow."

  "When can you take the others out?"

  "Oh, in a couple of days or so. You see, we like to keep you anchored to those bottles so you don't get up and run up and down the hall. We don't want you disturbing the other patients."

  The boy just looked at him. His pale, thin, expressionless face did not change, and he said nothing.

  "Except for the tubes," he said to the boy now, "are they treating you all right?"

  "I guess so."

  "You don't have any other complaints?"

  "Nope." />
  "Then we've got to find something to do to make you mad. Do you know why?"

  "Nope."

  "When you get mad," he said, "we'll know you're feeling fine."

  I wonder, he had often thought over the past half-dozen years, if Bernard Waterman ever gets mad. It is a strange desire to see another, especially a child, in anger, but I cannot make him laugh. I have tried, and I cannot even make him smile. I will never, of course, purposely try to anger him but at least we would know, after everything that he has had to take over these years, that there is still a spark in him if, just once, he would flare up in anger.

  "So tell me something," he had said to Bernard Waterman the first day he had examined him. "What do you want to be when you grow up?"

  "I don't know," the boy, who was nine years old then, had said.

  "A baseball player? Would you like to be Ted williams or Mickey Mantle, or that pitcher in Milwaukee—Warren Spahn?"

  "Nope," the boy had said.

  "He used to be interested in baseball," the father had said. "I explained the batting averages to him once, and he used to work out the average of every player after every game."

  "That was when I was small," the boy said. "I don't do it any more."

  "He's going to be a mathematician," the father said.

  "Are you a mathematician, Mr. Waterman?"

  "Me?" the father said, smiling. "No. I'm in the wholesale hardware business, but I think Bernie might be a mathematician."

  "Maybe," the boy said, "but I haven't made up my mind yet."

  He had been a poor eater from birth. Because he had instinctively learned to chew his food well in order to swallow it, there was no reason at first to suspect that there was any abnormality in his esophagus. As swallowing became more difficult, however, it was apparent that there was something anatomically wrong, and the X-rays showed a stricture in the esophagus just above the point where it joins the stomach.

  "What do you think it is, Doctor?" the father had said.

  "I don't know. It's possible that it's tuberculosis of the lymph nodes. When the lymphatics become inflamed they contract and pull the nodes tight around the esophagus, like a napkin ring. Then a pocket forms above this stricture. When this pocket fills with food it overflows, in his sleep, into his lungs and that could account for the pneumonia and the chest colds he's had."

  "What can you do about it?"

  "We have to get that stricture out of there, so we'll remove that small section of the esophagus to clear the channel."

  "You can do that?"

  "Certainly. Although he hasn't been able to eat all the foods he needs and doesn't have any fat or much muscle on him he's otherwise healthy."

  "You know he's our only child, Doctor."

  "I know, and we'll cure him."

  The operation took two and a half hours. When he removed the stricture, however, he was also forced to remove the valvelike guardian mechanism where the esophagus enters the stomach. It is this muscle which, following the passage of food, closes and prevents the regurgitation of that food back up into the esophagus. Its removal meant that Bernard Waterman would never again be able to lie flat while sleeping. For the rest of his life he would sleep in a semi-reclining position.

  "But what caused his trouble, Doctor?" Bernard Waterman's father asked the day after the operation.

  "I don't know," he said. "It was nothing that we could see or feel when we took it out. Now we're waiting to hear what the Pathology Department finds when they put it under a microscope. We'll have their report by tomorrow."

  The pathology report was noncommittal. They could find no cause and merely described the abnormality as "inflammatory stricture." For two months, however, Bernard Waterman appeared to be cured. He was able to swallow solids and he started to take on a little weight. During the third month his difficulty began to reappear, and he became cautious and almost afraid to swallow. They reduced his diet from normal foods to baby foods, and brought him back to the hospital.

  "What did you find this time?" his father asked.

  "We found the stricture has re-formed."

  "Doctor," his mother said, "you're not going to have to operate on him again?"

  She was tall and thin and nervous, and it was obvious that when her son was in pain she was in pain, too.

  "No," he said. "Not at this point. We're going to make another try at finding the cause of this. Meanwhile, I'm doing something else to help him. While I had him under the anesthesia today I re-enlarged the opening, so he should be able to swallow quite well again."

  "You could do that?" the father said.

  "Yes. I passed what we call bougies down through the stricture. They come in graduated sizes, and we start with the largest one that will go through and then increase the size by degrees to stretch the opening. This may work."

  It worked, but with decreasing effectiveness, for six months. Following the treatment Bernard Waterman was able to swallow normally again, but Dr. Matthew Carter had the pathology slides and the remaining paraffin-preserved portion of the resected section of the esophagus sent from Mercy Hospital to Dr. Gustave Schroeder at University Hospital.

  "If anybody can find the cause," he was telling his wife that night, "it's Gus."

  "Gus Schroeder," she said, "is a boor."

  "But he's a great pathologist."

  Twenty-three years before, Gus Schroeder had left Germany to get away from Adolf Hitler, and then he had turned out to be a tyrant himself. He ruled the Pathology Department as if it were a duchy, and if he could have built a moat around it to exclude all surgeons he would have.

  "You know he hates surgeons."

  "He resents us," he said. "He envies the money and glamor associated with surgery."

  "He should ask me about all the money and glamor," his wife said. "He's a boor, and I don't know how you can be so fond of him."

  "Because a good pathologist is the only honest critic a surgeon has. Surgeons can't be completely honest with one another. I can't go down our staff and say: 'I rate you at ten points, you at nine and you at six, and I can't rate you because I haven't seen enough of your work.' You can't have any secrets from a good pathologist, though, because he does too many post mortems on the ones you lose. A surgeon can cover his mistake by closing the wound, but a Gus Schroeder reopens that incision and you're naked before him. A good pathologist is your conscience personified, and Gus Schroeder is great."

  "Cy Winton hates him," his wife said, "and you like Cy."

  "That's right," he said, "but that involves something else. They're in competition over hearts."

  "Hearts?" she said. "Don't tell me old Gus Schroeder fancies himself a Don Juan."

  "Of course not," he said, amused. "That's ridiculous. I'm talking about two men of science."

  "Oh, please."

  "I'm serious," he said. "Cy wants the hearts to dissect them. Gus wants to make beautiful, permanent plastic casts of them. He tells everybody around his lab: 'If Dr. Winton comes down to this end of the building he's not to put his hands on a heart. When those hearts stop beating they belong to me.'"

  "Don't tell me any more about it," his wife said. "The whole thing disgusts me, and Gus Schroeder is a boor."

  Two days later Gus Schroeder called him on the phone. There were no amenities.

  "Matt," he said, "what's the matter with you?"

  "I'm feeling all right."

  "You shouldn't be."

  "Why?"

  "That esophagus you sent me, it's aberrant gastric mucosa."

  That's right, he thought as soon as he heard it. Of course it is. It's the first one I've ever had and you won't get more than two or maybe three in a whole professional lifetime, but that's it.

  "I might have guessed it," he said.

  "Guess nothing," Gus Schroeder said. "You should have known. You know it can pop up anywhere in the alimentary canal."

  "It's the first time for me," he said, "but I should have remembered a paper I heard Murchison give on
it in New Orleans four or five years ago.

  "You're too busy making money, all of you surgeons. You all want to get rich."

  "Not me. I give mine to Uncle Sam."