"And he takes the money and builds national highways," Gus Schroeder said, "so more crazy people can kill themselves with their cars."
"I couldn't detect it by feel or sight," he said, "but I should have suspected it when I noticed that the wall was thick on one side."
"Now you're thinking," Gus Schroeder said. "How is the patient?"
"He's got a recurrence. I esophagoscoped him the other day and passed some bougies down through there and dilated it."
"It won't last," Gus Schroeder said. "You have to do him again."
"I know."
"And get it all this time," Gus Schroeder said. "I'll send you the report when we write it up. Tell them over there they should frame it and put it on the wall."
"I'll do that, Gus, and thanks."
"None of us is entitled to any thanks," Gus Schroeder said. "It's our job."
That night he told his wife. They were having a drink before dinner.
"Gus Schroeder found that kid's problem," he said. "He's got aberrant gastric mucosa. The mucous membrane that lines the stomach and manufactures hydrochloric acid, there's some of it up there in the esophagus which can't accept it."
"I'm glad he found it," his wife said, "but Gus Schroeder is still a boor."
The next day Carrie McKeen called Bernard Waterman's parents and asked them to come in to see Dr. Carter. Two days later Dr. Carter explained the problem to them.
"Your son's trouble," he said, "is caused by what is known as aberrant gastric mucosa. The mucous membrane that lines the stomach manufactures hydrochloric acid. Now, some of this membrane is present in your son's esophagus. The lining of the stomach is able to accept the high concentration of acid, but the esophagus isn't. As a result an inflammatory ulcer was bound to occur, and this heals in the form of a scar, or stricture. As it gradually closes, it forms a dam and blocks the passage of food."
"But you took that stricture out," the mother said. "That's what you told us."
"I did," he said, "but at that time we had no means of knowing the origin. It was impossible to tell by feel or by sight the cause of the stricture, and these things are so rare that a surgeon might go a whole lifetime without seeing one or he may see two or three at the most. In fact, it took a second laboratory analysis to discover it just three days ago."
"So you didn't get it all out?" the father said.
He's right, he thought. He's an intelligent man and he'll get an intelligent answer and we'll have to see what happens then.
"That's true," he said. "I resected what to all appearances and to the best of our knowledge was a sensible segment. There was no reason at that time to do anything more radical."
"I just don't understand this, Doctor," the mother said. "I don't understand it at all."
"Look at it this way," he said, but talking more for the father than the mother. "In the normal embryological development of the fetus in the womb all goes along in an orderly fashion. The ectoderm and mesoderm and endoderm come from three different sources at different times but they seek out each other and finally they all join up in proper fashion. The timing and the anatomical architecture are perfect.
"Sometimes, however, there's a slight mistiming. In that case, if it involves, let's say, the eye, astigmatism may result, so you wear glasses. The miracle, of course, is that with this same thing happening in the formation of all the organs and blood vessels and nerves and muscles and bones and tissues of the body so many people are perfect, or essentially perfect. In your son's case something wandered away from the parent group of cells of the gastro-intestinal tract. It was the wayward sheep that left the pack, and it ended up in the wrong location, in the esophagus."
"I see," the father said, nodding.
"But why?" the mother said. "Bernard is our only child. Why should this happen to him?"
"I don't know," he said. "No man can answer that."
"Please, Linda," the father said. "The doctor isn't God."
"I don't know," the mother said.
"So what do you recommend now?" the father said.
"Well," he said, "I've given him some relief by dilating the stricture, as I explained the other day. The probability is that it will only be temporary."
"But I don't want him to have another operation," the mother said, shaking her head. "I don't want that poor child to have to suffer any more."
"Please, Linda," the father said. "Why don't we just listen to what the doctor has to say?"
"But the poor child has suffered enough. He's never been able to do the things the other boys do. What kind of a life has he had? You just don't understand, Doctor."
"I do understand, and that's why I want to cure him."
"So listen to the doctor, Linda."
"The relief I've given him, as I said, will almost certainly be only temporary. We can effect a permanent cure only if we remove that section of the esophagus that contains the remaining gastric mucosa. That's the decision you'll have to make."
"I don't want him to have to have another operation," the mother said, shaking her head.
"You'll have to excuse my wife, Doctor," the father said. "She's upset now, and we'll have to have more time to think about it and make up our minds."
"That's completely understandable."
"What I want to know is, how long do you think hell be able to swallow now? I mean, how long will he be all right as a result of this last treatment?"
"That's hard to say. That stricture may start to close again almost immediately, or it may close so slowly that it will remain open for weeks or even months. We don't know."
"Then when it closes, you'd do the same thing again that you did the other day?"
"That's correct. He'd have to come into the hospital and we'd have to put him under anesthesia and, using those bougies—those dilators— we'd enlarge the opening again. It's a simple procedure and not painful, but he'd lose a day or two of school each time."
"I'm not worried about his school," the mother said. "He's way ahead in school."
"He's just ten years old," the father said, "and he's teaching himself algebra."
'You may have a genius."
"He's just a little boy, Doctor," the mother said. "We don't want a genius. We just want a boy who can be like other boys his age and enjoy himself."
"It's good he has his brain and his books," his father said. "Otherwise what would he have?"
"I don't know," the mother said.
For almost ten years she was unable to bring herself to submit her son to another major operation. Over those years the periods of relief following the treatments shortened from months to weeks, and Bernard Waterman's diet was thinned from baby foods, mashed potatoes and Jello to beef juice, sherbets, fruit juices and liquid Jello. Dr. Matthew Carter saw more of Bernard Waterman than he had ever seen of any other patient, and yet he knew less about him.
"Did I hurt you today?" he would say.
"Nope," the boy would say.
"You know, I like you," he said to him one day. "What do you think of me?"
"I don't know," the boy said. "I guess you're all right."
When the boy was coming in for treatments once a month the mother finally consented. The night before the operation Dr. Matthew Carter, as he used to do regularly when he was younger but as he had not done for a long while, fell asleep planning his procedures.
I can take a section of the jejunum, he was thinking and meaning the middle portion of small intestine, and use it as a graft to replace the removed piece of esophagus. If I just take another piece of the esophagus and don't put in a graft of jejunum I'll have to pull the stomach up into the chest, so I'll use the jejunum. In the old days, he was thinking, they used to believe that the jejunum was empty at death and out of that came the word "jejune" to mean barren or dull or uninteresting or unsatisfying. It is not much of a word, jejune, because you cannot use it without making a show of it, like that girl at the Wintons' and she used it at least three times. The book she was reading was jejune and
the play was jejune and so was everybody's apartment and I should have shocked her out of it by telling her to forget her bowels.
The operation took six hours, and it did not go as he had planned it the night before. After opening the chest and after removing the section of the esophagus containing the stricture, he decided that if he took a sufficiently long section of the jejunum he would put the blood supply to the intestines under too much tension. Instead, he chose to remove the spleen and mobilize the stomach so that he could connect it to the shortened esophagus, and he also opened permanently the muscular valve between the stomach and the duodenum to prevent retention of acids in the stomach.
Given this opportunity again, he was thinking, walking down the hall to see the mother and father, I'd still do exactly as I did today. That's the test, really, except that I'd cut the front lip of the esophagus longer because it joins the stomach at about a forty-five-degree angle. When I cut it straight across and it recoiled I lost about fifty minutes, and I had to put more tension on the sutures than I would if I had cut a semicircular lip.
Rob knew it too, he was thinking. When it recoiled up under the arch of the aorta Rob knew exactly what I'd done but he was aware that I knew it only too well and he never said a word and he probably never will.
"Your son is doing fine," he said walking into the lounge and seeing them stand up to face him. "He's in the recovery room now."
"He's really all right?" the mother said.
"Absolutely. You'll be able to see him in a few hours."
"But it took so long," the mother said.
"That didn't bother him," he said, trying to reassure her. "You see, he had the anesthetist and her machine breathing for him. He was being fed intravenously, and he didn't have to move a muscle. He actually did less work than if he'd been just lying in bed."
"But did you get that stricture out, Doctor?" the father said.
"Yes, indeed. In order to get all that gastric mucosa that's been causing all the trouble I took a very generous piece of the esophagus."
"Then he's going to be all right from now on?" the mother said.
"I believe so. I certainly can't guarantee it, but it's my belief."
"Then you don't know for sure even yet?" the mother said.
"Who knows anything for sure, Linda," the father said. "Dr. Carter is telling us just what he believes."
"I know this," he said. "I know you should both feel very relieved. We've gotten to the core of your son's difficulty and I believe we've cured him. We'll put him on some solid foods in a few days and when you get him home he should be able to eat anything he wants."
"But when will we know for sure?" the mother said.
"If he's cured, as we believe, you're going to know it in three months."
"That long?" the mother said. "We have to wait that long?"
"It won't be just waiting. Your son is going to enjoy his food again and put on weight and gain strength. You three are going to enjoy some of the rewards now."
"Thank you, Doctor," the father said. "Thanks very much."
"Yes, thank you, Doctor," the mother said.
How I hope he's cured, he had thought, walking away. If he isn't, I've got two or three other procedures that I won't even burden them with because I'll believe we've cured him until I find out otherwise.
"So, Dr. Bernard Waterman," he said to the boy now, and it was two days later, "you're sure you have no other complaints, except about the tubes?"
"I'm hungry," the boy said.
"Fine," he said. "That's what I've been waiting to hear. You know, though, that you're getting a steak through that tube right from that bottle up there."
"I know, but it goes right through me."
"That's what it's supposed to do, but pretty soon well be giving you some real food. Then do you know what's going to happen?"
"Nope."
"You're going to go home, and you'll be able to eat anything you want. One day you're going to say to your mother: 'Mom, I'd like a real good steak.' I'm going to tell your mother that when you say that she's to call me, and that night I'll come over and buy you and your parents your first real good restaurant steak. Okay?"
"All right," the boy said, but his expression did not change.
"Any other complaints?"
"Nope."
"Excuse me, Doctor," the nurse said. "He'd like to hang his legs over the side of the bed. Is that all right?"
"Sure. That's fine."
"You see?" the nurse said. "I told you the doctor would let you."
"And in return for that, Dr. Waterman," he said, "can you explain combinations and permutations to me?"
"I don't know."
"Your father tells me you've been studying them and I want to learn about them this time from a real Doctor of Mathematics."
"I don't know whether I can explain them to you."
"All right. You can try to teach me that night I buy you that steak. Is that a bargain?"
"All right," the boy said.
"Dr. Robinson will be in to see you this afternoon/' he said. "You like him, don't you?"
"I guess he's all right."
And I will buy him that steak, he was thinking, walking to the nurses' station. If his mother calls me, I will.
On Bernard Waterman's chart he filled in the progress report and wrote out the orders. When he looked at the clock he saw it was 9:47.
Mrs. Brower, he thought, Mrs. Louise Brower. The talker said she'd checked in so I'd better do her now down in Emergency, and Stan must be about finished in Three. If I'm going to get my Mr. Scheller in there as soon as I do Mrs. Brower he'd better be finished in Three.
"Excuse me," he said to the talker, "but is that Louise Brower on this floor?"
"Louise Brower?" the talker said. "Yes. She's in 435."
9:48 A.M.
X
Walk slowly, he was thinking, conscious of the urge to hurry but too long a professional to show it. Leonard Furman's old lesson: No matter how pressed you are for time, never exhibit it. Every patient has the right to think that you have nothing else on your mind but him. That was Furman's old lesson and I haven't even thought of it since I don't know when, and he must be dead now fifteen years.
"Oh, excuse me Dr. Carter," the nurse-anesthetist said.
She was coming out of the room, carrying her tray with the vials and the blood-pressure sleeve on it.
"My fault," he said. "I wasn't looking."
"This is your patient, isn't it? Mrs. Brower?"
"That's right. What's the trouble?"
"She won't let me prepare her," the anesthetist said, lowering her voice and motioning him aside. "I can't do anything with her."
"Why?"
"She says she doesn't want to be bronchoscoped. She says she's not having any discomfort now and she feels fine. She wants to go home."
That's just what I need, he thought. Right now, after what I've been through already this morning, I don't need this at all.
"Come back in with me," he said. "Let's see what I can do."
"I wish you luck," she said.
She stepped aside and followed him into the room. Mrs. Brower was sitting up in bed, middle-aged and plump and with a round, even face.
"Mrs. Brower?" he said. "I'm Dr. Carter."
"How do you do?" she said.
"I'm fine. How are you?"
"I'm fine, too."
"That isn't what your doctor told me on the phone this morning. That's not why you're here."
"Dr. Fineman?" she said. "I should never have called him."
"You were right to call him, and he was right to call me. Last evening you swallowed, or inhaled, a piece of meat that became lodged somewhere. Isn't that correct?"
"I thought so, but I must have been wrong. I don't feel anything there now, and I want to go home."
"Tell me what happened when the meat went down the wrong way."
"This whole thing is foolish, Doctor."
"Did you start to choke?"
"How long was it before you could breathe all right again?"
"I don't know. It seemed like ten minutes, but it was probably two."
"When your coughing spasm was over, how did you feel?"
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