The surgeon

by Wilfred Charles Heinz

  "You will remember," his Gross Anatomy professor was saying thirteen years later, "that the cadavers to which you will be introduced within the next few minutes were once human beings. I remind you of this not to unnerve you, but to caution you that they are to be treated with the respect to which a human being is entitled."

  It was the second day of medical school. On the first day they had registered in the morning, and signed for and picked up their instruments, their microscopes and their books. In the afternoon they had sat in the amphitheater and had listened for an hour while they were told that if they were not ready to do their best every day this was their time to leave medicine for another field. On the way out they had all complained, and that night he had had an asthmatic attack for the only time in his life.

  "As a matter of fact," the Gross Anatomy professor named Thiel was saying the next morning, "one of these cadavers was a highly respected member of the profession you are about to enter, and a graduate of this institution. He willed his body to his school, so that you might learn as he did. Only I know which of the bodies was his, and none of you will ever know, for they are all to be regarded with the same respect. Who are we to judge the dead?"

  Then Thiel, gray-haired, wearing his white smock and those thick-lensed glasses, led them down the hall. In their own smocks they had lined up and paired off alphabetically, two for each cadaver, and their footsteps echoed in the hall and here and there along the double column someone murmured something to his partner.

  "Let's try to get a thin one," Stu Chase said to him. "They say it's easier to get to the anatomy if you don't have to go through a lot of fat."

  "I know," he said, although he had never thought of it before.

  Thiel opened the door and they walked in. It was a large, cement-floored, gray-walled room, and down the length of it ran four rows of narrow, hip-high tables, each one covered with a black oilcloth bulked up from beneath by the body.

  He and Stu Chase started down the middle aisle, and he was aware of his nervousness and of the heavy but sharp scent of formaldehyde. Halfway down the aisle the two in front of them stopped and he and Stu Chase walked around them and Stu stopped two tables beyond and looked at him and they pulled the black oilcloth and then the damp, yellowish-gray cheesecloth down.

  "Does he look all right?" Stu said. "I mean, is he thin enough?"

  "I guess so," he said.

  "Where does a guy get sick around here?" Stu said.

  "I don't know," he said. "I was wondering the same thing."

  It looks like a mummy, he was thinking, looking at the nut-brown, taut-over-the-chest-and-cheekbones skin. He needs a shave, and there's no reason to be nervous about a dead man. I saw the sheriff when I was just a kid and there's no reason to be nervous if you're going to be a doctor, and this is where you have to start being a doctor right now.

  "You think it's that doctor?" Stu was saying. "I mean the one who willed his body?"

  I hope not, he was thinking. I hope he wasn't a doctor and I'm glad I don't know who he was or what he did.

  "I don't know," he said. "I don't think so."

  "I don't think so, either," Stu said. "He doesn't look like it."

  "He looks like a mummy."

  "Yeah," Stu said, "but what are we supposed to do now?"

  "May I have your attention?" Thiel was saying, standing back by the door and raising his voice. "You will have the rest of the morning to acclimate yourselves as you desire. Tomorrow morning you will bring your manuals and you will start dissecting, but before that you will wash your cadavers. You'll find the soap, towels, and everything you need in the room here to my left. You may do that today, or at the start of class tomorrow morning. That is up to you, and unless there are any questions I have nothing more to say today."

  Out of the whole class only one pair washed their cadaver that day. The rest of them covered them again and wandered out to gather in groups outside on the steps in the September sunlight and make small jokes that seemed much funnier than they were and concerned how they had felt in the lab and whom their cadavers resembled and what the deceased probably had done for a living.

  The next day it pleased him that he felt remarkably composed as he and Stu Chase washed and dried the body. Before the period was over, however, it surprised him and he felt a sense of small shock and of guilt that so soon, and so easily, they could sit there, Stu on a stool on one side and he on a stool on the other, their Cunningham's Dissecting Manuals open on the varnished oak racks in front of them, and that they had already cut into this body and that Stu was dissecting the right arm and he the left.

  At the end of each session they would cover the dissected areas with cheesecloth soaked in formaldehyde, and the formaldehyde bumed in their nostrils and brought tears into their eyes. No matter how often he washed, the smell of it seemed to be under his nails and all the food he ate tasted of it, and he found that, for more than a year after the course was completed, he could never eat fried pork chops because of their color.

  Because the laboratory periods were never long enough most of them also dissected at night and on Sundays and holidays. They would often bring sandwiches and pint bottles of milk to the lab and sit on the wide window sI'lls and eat, and there were several who, once or twice, made a show of unwrapping their sandwiches on the chests of their cadavers and of sitting right beside them while they ate and made casual talk.

  There were no displays of sadistic exhibitionism, but they heard of the time that Thiel found the left lobe of a human liver on the steps outside and of the night when he walked in and saw the student skipping rope with a small intestine in the aisle next to his cadaver. Thiel told him to take his dissecting kit with him when he left, because he was expelled, but the only incident in their year was relatively mild and Thiel never heard of it or, if he did, he never mentioned it. Somebody inserted a theater-ticket stub through the superior vena cava into the right atrium of the heart of the cadaver of the only two girls in the class.

  If there were a ghoul in the lab, it was Tony. Tony was the custodian and he was in his mid-forties, small, sallow-skinned, and balding. He wore a black rubber apron over his worn rust-brown trousers and blue short-sleeved shirts, and he moved around almost noiselessly in his dirt-gray, stained sneakers, cutting off arms and legs with his hack saw, carrying them out under his arm and every now and then coming back with a spare part from the basement.

  Only Thiel and Tony had the three keys for the three doors that led to the long narrow room in the basement where the cadavers were preserved. There was the door from the hall, the middle door and then the final steel door, and the cadavers, chains under their arms, were suspended upright in the tank in the concrete floor, the tops of their heads about three inches below the surface of the embalming fluid.

  For a long while he thought that Tony was a mute. Tony never spoke to any of the students, but one day he heard Tony say something to Thiel and when he discovered that Tony could talk he wondered what Tony talked about when he got home at night.

  Only twice, after the first day, did he feel any uneasiness or revulsion. In the fifth week they started dissecting around the eye, and that open brown eye, looking back at him, bothered him. Months later, when they were down to the leg, he detected a foul odor, and when he lifted the leg he saw a cluster of what seemed to be moving eggs, almost the size of flies and the color of cigarette ash. When he showed them to Stu Chase, Stu made a wry face and turned away.

  "Maggots," Thiel said. "Tell Tony to cut it off."

  By the time he and Stu had reached the legs it would no longer have occurred to him to stand back and look at what was left and say: "That's a man." They had dissected to isolate each organ, to trace each muscle from its origin to its insertion into the bone, to follow each nerve that motivated that muscle and each blood vessel that nourished it. What remained might have been the model of an early airplane or an invention of Leonardo da Vinci, all lines and levers, and he himself, more easily than he might onc
e have thought possible, had made the step that would leave him forever stranded, one foot in the world of the medical scientist but the other still anchored in the world of what he had been and would be still, although he would see death approach and understand its causes and see the living die hundreds of times in his professional life.

  "The degree to which you are affected by a death," he was to say, "depends upon several things, but in large part upon the degree of your emotional involvement with the patient. I don't think I'm being dramatic when I say that you die a little with each, that something, however small it may be, goes out of you. I know that the older you get, the more you try to shield yourself from this. I know that you ask yourself how much emotional investment, how much empathy, how much more of myself can I continue to give along the way and still have anything left?"

  The beginnings of his giving were in the second half of his second year in medical school. At the lectures in Physical Diagnosis the patients with their heart murmurs, their breast tumors, their skin diseases would walk or be wheeled into the amphitheater, as mute and submissive as chastised children. Just sitting there and looking at them, he felt more a part of them than he did of the professor who, it occurred to him, discussed them and their ailments with the aloof objectivity of an engineer analyzing a drainage problem or some other kind of land-reclamation project.

  Then they went around to the wards, five or six in a group with an instructor. The instructor would listen to a heart and then he would step aside and they would take turns listening, and again he felt pity for the patient and guilt in his own health. Finally this pity was mixed with fear of the patient when he was sent into a ward alone to make his own examinations and his own diagnoses.

  "Excuse me," he said to the patient, the first time. "I'm Dr. Carter, a student doctor, and I wonder if I can examine you?"

  "Are you a specialist?" the old man, who was a heart case, asked.

  "No," he said. "I'm a student doctor assigned to report on your case."

  "Then, please, you're going to be taking care of me from now on?" the old man said, not having heard his answer. "You're going to make me well, Doctor?"

  "You're going to be all right, I'm sure," he said, trying to keep his guilt from showing. "There are great doctors here who will help you."

  "Then you're going to take care of me now, Doctor?" the old man said. "Please."

  There were the ones who, embittered by the first realization that nature had not provided them with ever-healthy bodies, resented him. Having already been examined by their own doctor, by an intern, and by an assistant resident, and checked by the resident, unaware and unconcerned that he, to prove himself, had to make the most detailed report of all, they resisted him.

  "So you feel this patient's difficulty during pregnancy is due to hypertension?" the professor said.

  "Yes, sir."

  He had just presented his first case. They had wheeled the woman out onto the floor of the amphitheater, the nurse present to protect the patient's modesty, the professor standing to one side, his arms folded across his chest. She was one of those who resented and had resisted him, and now, before the whole class, he had gone through the past history into the present I'llness, the tests, the studies, the diagnosis, and the therapeutic plan, with the management outlined, A, B, C, D. Then the professor had thanked the patient and the nurse had wheeled her out.

  "The tests for albumen in the urine, did you do those yourself?"

  "Yes, sir."

  "Have you examined the patient when she was completely at ease in the quiet of the evening?"

  "Yes, sir."

  "Do you feel her blood pressure might be influenced by her mood?"

  "Yes, sir."

  "Has she had any trouble with her nurses?"

  "I don't know, sir."

  "Oh?" the professor said. "You don't know? What about her relations with her husband?"

  "I don't know, sir."

  "Well, we know she's about to have a baby, so we do know she's had some relations and we presume that they were with her husband."

  "Yes, sir," he said, and he heard a couple of them in the class laughing behind him.

  "But you don't know if, perhaps, her husband might have a disturbing emotional influence on her?"

  "No, sir."

  "You didn't check in on her after a visit by her husband?"

  "No, sir."

  "All right, Carter," the professor said. "That was still a good presentation. Thank you."

  He waited for Stu Chase to come down out of the seats and they walked out together.

  "You did all right, Matt," Stu said.

  "Sure," he said. "I always leave them laughing when I say good-bye."

  "Wait tI'll some of those guys have to stand down there and present a case."

  "Do you think he knows something about her and her husband?"

  "You mean that it isn't his baby?"

  "I don't know. How should I know?"

  "I think he was just making a point," Stu said.

  "He made it all right," he said.

  The point had been, of course, that when the emotions may be involved you cannot know too much, but in his internship and then his residency he was to find that the more he knew the more his own emotions were involved. He was encouraged to know not only the patient but the patient's family, to act as a buffer between the family and the surgeon, to appear to answer their questions when he was never allowed to tell them anything, and so he became an accomplished liar, or performer, as he was to call it in later years.

  "But Doctor," Mrs. Kroner said to him, sitting beside her husband's bed, "from Dr. Williams we still know nothing, and they must have now the report."

  "No," he said, lying. "It takes quite a while to make those tests, and Dr. Williams will let you know as soon as he learns the results."

  Dr. Williams had known for three days. Three days ago he had opened Herman Kroner, a sixty-two-year-old carpenter, and found an inoperable cancer of the esophagus. Within fifteen minutes the Pathology lab had called back to say it was an adeno-carcinoma.

  "When it's a squamous-cell carcinoma," Dr. Williams had said to the resident and to him, "it'll take X-ray treatment, but when it's adenocarcinoma it originates in the stomach and by the time it has spread this far it's resistant to everything."

  "But what's going to happen now?" he had asked Williams.

  "He'll probably go with pneumonia within three weeks," Williams said. "You know that we produce about a quart of saliva a day. When nothing can get through the esophagus the saliva overflows into the windpipe and when they sleep at night they can't cough it up. As a result pneumonia gets them."

  "But isn't there anything that can be done?" he said.

  "Yes," he said, "you can keep the patient as comfortable as possible. The wife is too upset right now about the operation to be told. She's got two grown daughters and a sister of hers and I can see they'll be on my neck all the time. I'm going to tell them to appoint a spokesman and I'll deal with that one and nobody else. In a day or two I'll tell her what we've found, and she can tell the others or the patient as she sees fit. What I've told you, of course, is professional between us."

  "Yes, sir," he said, but he had walked away wondering if Williams wasn't giving up too easily, wondering if Williams could be wrong, if maybe there was someone somewhere who could do something that Williams couldn't. Doesn't he know, he wondered, that this is a nice old guy and these are nice people and that nobody wants to die?

  As it turned out, Mrs. Kroner was the one whom Williams told. He did not tell her that Mr. Kroner would be dead within weeks, but he did tell her what they had found and that there was no known cure. He said that they would do everything they could for Mr. Kroner and, having explained all that, and because there was then nothing that he could do that the house staff couldn't, he had seen less and less of the patient and of Mrs. Kroner and he had had no time for the two daughters and for Mrs. Kroner's sister, who had traveled halfway across the coun
try by bus to be there in this time of trouble.

  All of this had come as a shock to Dr. Matthew Carter, six months out of medical school and on his first terminal case. In his mind was still that picture of the old family physician keeping the bedside vigil, and even as he found Dr. Williams was now primarily occupied with those cases he could cure or give relief, he found himself drawn more and more to Mr. Kroner and to his family.

  When he could answer their questions he did, and when he could not he professed ignorance and then tried to find something to say to ease their anxiety. It was three weeks before Christmas, and when Mrs. Kroner, short, plump, and pink-complexioned, found that often he missed a meal and would grab a snack when he could she brought him a box of home-made Christmas cookies. She called them kuchen and there were three or four kinds, some flat and thin and brittle and in the shape of Christmas trees and stars, some round and soft and with grated nuts in them and others smaller and round with a hollow shell of what must have been egg white and sugar on top.