"Civil engineering? Why?"
"An engineer is never allowed to forget his mistakes. I envy him this, really."
"I don't get you."
"An engineer designs a lousy bridge or building and if it stands at all, it stands as a monument to his idiocy all the rest of his life and beyond."
"I'll never buy that," Rob said. "Our profession doesn't need a public audience or a public jury."
"The profession doesn't," he said, "but at a time like this I think the individual does."
"Stop berating yourself," Rob said. "If you hadn't tried that bridge, Mr. Roberto Leon would have died on that shore waiting for a boat that was never coming. You know that."
"You said that before," he said. "What are you doing Saturday?"
"Saturday?" Rob said. "Nothing. Why?"
"I want to do another dog. In fact, I want to do at least two more dogs."
"I'm all for that."
"Are you sure you're not doing anything Saturday?"
"Come to think of it," Rob said, "I am."
"What are you doing?"
"I'm assisting while you do a superior vena caval graft from a right pulmonary artery on a dog. Do you want another drink?"
"Not right now," he said. "I've got to call that lawyer."
"Who?"
"That associate of Mr. Leon."
"Do you want me to call him?"
"Of course not," he said. "Don't be so solicitous."
"Who needs a public jury?" Rob said. "Certainly not you."
So the wife must know by now, he was thinking, lying in bed four hours later. That lawyer took it all right. That lawyer, when I finally located him, was very decent about it but who knows how the wife is taking it? All that wife knows is that her husband came all the way up here alone to the great Matthew Carter and now she hears this and who knows what she thinks or how she's taking it?
Anyway, he was thinking, I've told the lawyer. I've done that and on Tuesday afternoon I'll stand up at weekly conference and I'll do that, too. That resident, that young Bauman, will present the case and then he'll pause and look at me and I'll stand up. I'll stand up in front of Ross Young and Maury Rand and Gene Parente and Stan and Sid Berkman and the Great Jaffrey and the rest of them. The Great Jaffrey is great all right. The Great Jaffrey is great at editing operations. He never says he could have done it. He just implies it, but there'll be no implications by me. There'll be none of those inferences that, after all, any operation is a team effort and that maybe the patient got light under the anesthesia and moved or that there were unexpected complications. I'll stand up there and tell them what I tried to do and why I tried it. It's true enough that he had no chance if I didn't make the try, but I'll tell them what we've done in the dog lab and what happened and when I get done it will still all come down to the same thing and I'll say that this patient died of a technical error. When I say it young Bauman will write it, T.E., write it in that big, long, cloth-bound book, and it will be there after my name.
"Matt?" his wife said, from the other bed.
"Yes?"
"Why don't you try to get some sleep?"
"I will."
"For God's sake, Matt," she said, "after all these years you know what kind of a surgeon you are."
"I know," he said. "Get some sleep yourself."
"I will," she said, "if you'll stop turning every two minutes."
"All right," he said. "Good night."
"I hope you're not asking yourself why you ever wanted to be a surgeon. You haven't done that in years."
"I'm not doing it now," he said. "Good night."
And I'm not doing it now, he was thinking. I wanted to be a hero. They were all my heroes. It was that old hero fixation that I've had all my life and I can remember when it was obstetrics. It was obstetrics because it's the beginning of life, the beginning of everything, and you think then that you'd like to be a part of it always. If there's a birth during lunch hour you're running off to watch it and you sit there at the lectures about the right oblique and the left oblique and the buttocks presentation and the internal podalic version and you can't wait to get your first one just to deliver one of your own and when you get it you're so scared that you're afraid your hands will shake and the poor woman will know it and ask you if you're really a doctor or just a medical student and then you'll have to tell her the truth.
They never ask, though, he was thinking. They never ask and I went out on that first one with that field nurse who seemed to me to be about sixty years old but she probably wasn't more than forty. We went out in her new Ford and she'd been taking medical students through it for a dozen years and she said: "Are you scared?" I was honest because I was too scared to he and she was driving and she said: "Relax. It'll be easy. It's this woman's sixth, and remember what they say about taxicab drivers. The mortality rate is lowest in the hands of a cab driver because he doesn't know what to do and so he does nothing. Ninety-five times out of a hundred, nature takes care of it and you won't have any trouble."
That's what she said and it was out at the east end of town in one of those factory houses and it was about 7:30 in the evening in the spring of that third year and the woman was still about two hours away. The husband was down at a bar getting courage and the grandmother had taken the other kids and we sat there, that nurse and I, on the porch listening to the groans and counting the length of time between the pains. When it came, it popped its head first and there was that rotation so that the shoulders would come as they should. You get one shoulder by depressing the head and when you see part of the arm you put your forefinger under the armpit and deliver the arm. Then you raise the head, if I remember it now, until it shows you the other arm and after you get the shoulders if s easy. The hips are smaller than the shoulders and it takes only a little pressure on the abdomen to get the hips and after I'd clamped the cord and tied it off I held it that way with the ankles between the thumb and forefinger and middle finger and whacked it and when it cried I turned it up and handed it to the nurse and she took it and said: "Congratulations." Then, leaning forward with that baby, and it was a boy, between us, she kissed me and that woman lying there saw it and said: "Cut it out, you two. That's the way I got into this trouble."
For ten days I saw that woman and those were the first house calls. She never knew, none of them ever knew, the real truth, so I was a big doctor instead. I was a big doctor and a big hero all right with my how's your appetite? Your bowels? How many pads are you wearing now? Fine, and how's the baby feeding? Well, that's the main thing, that you and the baby are both fine, and I'm sure that when work picks up at the factory again your husband will cut down on the drinking and everything will work out again just fine.
So the baby was fine, he was thinking, and I can remember resolving then that I would follow that kid all his life and I don't think I've thought of it in twenty-five years and he must be twenty-six, no, twenty-seven years old now if he's still alive and I haven't even the faintest idea of his name. I don't know any of their names, any of the names of the dozen I had in the six months and the next thing was gynecology and what a hero I was going to be there, reconstructing the damage from childbirth, repairing, you might say, the woman you delivered. There was the curiosity involved there, too, the desire to see in great detail all the anatomy, the mysterious anatomy of which you've been conscious ever since you pulled on your first pair of long pants, or pulled them off, you might say, and then there was the wonder about what the effect of all this would be. The fact was that it had no effect whatsoever, that even after you've seen it all a hundred times you haven't changed a bit and any thoughts of the corrugations of the vagina or the size of the labia still never enter your mind.
Your mind, the human mind, he was thinking, and what an arena for personal heroics that was going to be. Every psychiatrist is a hero to his patients and it's great in class with everybody reading the seven volumes of Havelock Ellis when they won't read the other things and everybody looking for paranoidal
tendencies in everybody else. It's completely fascinating and you can't get enough of it until they take you out to the psychiatric pavilion and without warning they walk you into the lunch room and there they are, some of them rubbing the food into their hair and some of them throwing it at one another and the keepers finally herding them out like animals.
And upstairs. And upstairs in that bathtub, in that bathtub with the canvas jacket on him with the ropes on it and the four orderlies trying to hold him was that big red-haired O'Connell. I can't remember his first name but I remember him and I remember that little blond cheer leader he was babbling about and how when he used to wrestle for us he'd just pick the other man up and throw him onto the mat. That's how big and powerful he was and he won the conference title and he may have won the nationals, too, for all I know, and nobody knew I knew him. I can see him now, right now trying to get out of that tub, red-faced and the jugulars showing in his neck and the orderlies holding him and big O'Connell babbling about that girl. I can hear the lecturer explaining when we got outside, explaining that the patient had fallen in love but that, actually, it had been nothing more than a mental romance. He had never even spoken to the girl, because he was extremely religious and they were of different beliefs and so, he was saying, what we had just witnessed was the result of his sexual desire versus his rigid religious training and what that lecturer said after that I don't remember.
I remember, though, that nobody had to write me a letter to tell me it wasn't for me. Nobody ever had to write me a letter, really, to tell me that for me it was Pete Church and Alex Johnson and even Leo Kastner, and after Pete Church took me those years went like months and I remember standing in his office that afternoon when he made that phone call. He picked up that phone and told his secretary to get Alex Johnson and when he got him he said in that quiet way of his: "Alex, I've had a young world-beater here with me now for five years. I've taught him all I know, but apparently that's not enough and now he wants to work under you."
So Pete Church gave me $25 out of his own pocket and I drove for two days and two nights to get there for that interview, driving that old black Chevy coupe and sleeping in it at the side of the road and washing and shaving in the men's rooms at the gas stations and there were twelve of us applying. Twelve of us wanted three jobs and Alex Johnson was sitting at his desk with the twelve cards in front of him and he looked up and said: "Good morning. As long as Pete Church recommends you, you can't be all bad." Then he got up and straightened a picture on the wall. He was always doing that while he was talking, straightening a picture or moving a chair or rearranging the papers on his desk into neat piles and walking with that exaggerated backward arch in his spine from the Pott's disease, the tuberculous caries of the vertebrae, from the TB he picked up as a young assistant and that hit him first in both lungs and then the spine and finally the kidneys.
When you think of it he was imprisoned in a plaster cast and lying on his back for two years and they rigged up mirrors and that typewriter from the ceiling and he wrote, like that, the first book of thoracic surgery. He reviewed, first, all the world's literature on TB and then he wrote that first book and it's still the classic text book of thoracic surgery after almost forty years.
"So you think you'd like the job?" he said on the third day. I said I certainly would and he said: "I can't pay you the first year and you'll need about $125 a month. Have you got any money?" I said: "No, but I can borrow it." "Good," he said, and then about a week later the wire came from him and I can still remember the wording. I can still see it on that yellow telegram paper and I can still remember it said:
BENEVOLENT DONOR HAS ESTABLISHED ENDOWED INSTRUCTORSHIP STOP IF
YOU HAVEN'T BORROWED MONEY IT WON'T BE NECESSARY SIGNED ALEXANDER JOHNSON.
There were the three of us there with him then and one of the things he was proudest of was that he never kept any secrets from us and he always left that door open between his office and ours. When he wanted one of us he'd just call through the open door and I'll never forget when he came back from the three months in Arizona and I'd been running his service like crazy and he called me in and started walking around the room and straightening things and I couldn't tell what he was getting at when he started to talk.
"As you know," he was saying, walking and straightening, "I came here in 1922 as an assistant professor of surgery. As you also know the Board of Regents then saw fit to promote me to a professorship and each year since then they've seen fit to reappoint me. Also, over the years, we've developed the service to the point where it's well known throughout the world. Now on January first of this year I went to Arizona and I went feeling secure that everything would be under control and that I wouldn't be greatly missed. On April first I returned and I did so to discover that I had not only not been missed but also to discover that we've now got two services here. We've got the Johnson service and the Carter service, and I've called you in here now to ask you if perhaps I might be allowed to work on your service."
I just didn't know what to say. I remember I just looked at him and he said: "You've done a fine job. As a matter of fact I've come to the conclusion that in all my years you and Byron Frank are the two best I've ever trained and I thought it was time I told you."
He knew he'd had the best of it by then, too. When the tuberculosis finally hit his kidneys and one of them quit, his bladder would hold only an ounce of urine, so to finish an operation he had to have that rubber bag, that water bottle, strapped to his leg and when I went back and scrubbed with him for that last time he emptied it into the slop sink before we scrubbed.
The night before, though, at that dinner party, he was standing by the fireplace while they were all having drinks before going in to eat and he saw me come into the room. I remember him calling across the room and I didn't know how bad it was then but streptomycin was still new then and he was taking four grams a day instead of one and it had knocked out his eighth nerve and he staggered.
"Say, Matt," he said, calling across the room. "Come over here and tell me about all the money you're making." So I went over and he was leaning on the mantel over the fireplace. Then he put his arm around my shoulder and, talking to me, he walked me over to somebody else he wanted to talk to and I realized then that that was the way he got around the room. It was the way he got to the O.R., too, because when he was operating there at the end there were always a couple of nurses who waited around outside the locker room door for him to come out. When he came out they'd say: "How are you today, Doctor?" and they'd put their arms around him and, kidding with him, one on each side, that was the way they'd walk him to the O.R. Then in the O.R. they'd strap him to the side of the table and that was the great thing. He could barely walk, but strapped to that table he was as steady as he'd ever been and he was as great as he'd ever been, too.
And I remember, too, before he got that bad and I'd been away maybe five years and I couldn't wait to show him my segmental resection, my segmental resection that I'd refined and refined some more until I thought, and I still do, that I could do it better than anyone else in the world. He watched me do three and then he said: "It's no good." It was like a slap in the face and I looked at him and I said: "What do you mean, it's no good?" "Oh," he said, "it's beautiful. It's absolutely lovely, but rating it as a contribution to the whole field of thoracic surgery it's a luxury. In China they couldn't be bothered with it."
He was right. I was getting a swelled head over it and so he placed it in perspective although he knew as well as I did that it's a lovely surgical shot to have in your repertoire. It wouldn't he any good in China and it's strange that I should be thinking of this now, twice within a week, because before the insurance companies get done they'll turn it into a luxury in this country, too. He'd be amazed, Alex Johnson would be amazed, that those statisticians will end up dictating what we do. He'd be amazed that those statisticians have it all figured out that if you take a lobe of a lung it's worth so much, but that if you do a segmental resecti
on, if you take only a segment, it's only worth half as much. So what they're penalizing you for is the precision you've perfected and before they get done posting their price tags precision surgery and perfected post-operative procedures that get the patient out of the hospital in eight days instead of two weeks will be a luxury that only the independently wealthy surgeons will be able to afford to perform.
It's true, and it's strange that it was just this week that Carrie showed me the letter and the senior statistician, or whatever he is, wrote: "In reviewing the surgical procedure performed by you, we feel that the fee for the service performed should not exceed $750." So I said to Carrie: "What did we bill him?" And she said: "We sent a bill for $1500. For John's sake, Matt, the man makes $30,000 a year and for what you did for him I've figured out that we charged him five per cent of his annual income. I'll bet you he pays three times as much for a new car." And I said: "I don't care about that. What I care about is that statisticians who are unequipped to perform, edit, or assess surgical procedures are now putting a price not only on talent but also on operative difficulties."
So Carrie said: "Don't tell me." She said: "Don't ask me to write a letter. You write it." So I sat down and I wrote it and I said: "Should the surgeon be penalized because through his skill the operative procedure took two hours instead of four? Is the surgeon to believe that his fee will be reduced because his proficiency and close post-operative supervision allows the patient to be discharged from the hospital in eight days rather than the usual two weeks? Should the surgeon be encouraged to take larger segments of lung to get a larger fee when an anatomical segmental or sub-segmental resection requires more surgical skill and post-operative attention but preserves the patient's function and allows him to return to normal pre-operative activities? Is it possible that you believe that all surgeons are of an equal skill and ability that can be regulated by a standardized fee schedule? Are you saying that I, as the leading proponent of this operative procedure and with more experience than perhaps any other surgeon in the world in this particular procedure should receive the same fee as the graduating resident?" I wrote that, and then I wrote: "In answer to your request for an adjustment, my adjusted fee is $1500. Sincerely yours."
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