The reason he won't find any beauty here, he was thinking, is that he remembers that under this sheet there lies a man and, not yet able to forget this, he thinks of pain. Only Rob and I really know that we are about to do all that can be done for this man and so we will find what he will not find until, all the observing and the assisting and waiting over, he is here with his own patient and they have agreed that this is the best, the only, bargain and he is on his own. Then he'll find it, if he's going to make a good surgeon, or perhaps he won't.
"Now we make a trough here," he said, placing two rolled towels upright in the fold of the drape in front of him. "That's so that any instruments that slide off his hip or thigh will slip in here instead of falling on the floor."
"Yes, sir," Darrow said.
"And this is our clothes line," he said, placing four lengths of gauze along the edge of the drape. "It keeps this gauze out of the middle of the instrument field. I've seen knives fly when they've been caught in the gauze."
"Yes, sir," Darrow said.
He moved back now to his left, and leaning over the drape, he looked down at the anesthetist, sitting on her stool next to the Stevenson respirator and the gas tank and bending over Mr. Scheller's head.
"Good-bye, Orphan Annie," he said. "I'll see you later."
"Good-bye, Doctor," she said, looking up at him.
"Is everybody ready?" he said.
"Right, Matt," Bob Robinson said, from the other side.
"You?" he said to the intern on his left.
"Yes, sir."
"Yes, Doctor," the scrub nurse said.
"What time is it?"
"It's 11:14, Doctor," the floating nurse said.
"Okay, let's go," he said, and he held out his right hand. "Knife."
XIX
The first knife he ever used was the bone-handled pocketknife that his father gave him. He was about nine years old, and for a long time he wore it on a chain and his father showed him how to skin rabbits with it until he became very good at it himself.
Now he felt the handle of the scalpel press into his hand and he closed on it. With one long, easy, I-have-done-this-three-thousand-times motion he made the long, curved cut. Following the pink-on-pink line of the scratch he applied just enough pressure to get through the skin and the fat to the fascia, the tough tissue over the muscles, and as he did he saw the pink-painted skin pull back and the yellow of the fat layer follow it and then the white fascia lying beneath.
One day, when he must have been about ten or eleven, he was walking out in the canyon east of town with the single-shot .22. It was about 3 o'clock in the afternoon and he saw the cottontail in the shadow of the gray volcanic rocks and he got it with the first shot. When he started to skin it, he found four young inside, and as he opened each sac there was a gasp. He didn't know then that these were the last breaths of life, so he carried the four unborn back the four miles, carefully wrapped in the skin and cradled in his hands. He put them on the warm asbestos covering on the top of the furnace in the basement, where his father found them that night and explained to him what he had done.
"You see, Doctor?" he said to Darrow now. "The bigger the incision you make, the more money you can charge. Do you believe that?"
"No, sir."
I'll have to loosen him up, he was thinking. During the early routine you have to keep them loose, these interns and Little Orphan Annie and Mary Cleary. You don't want them tired when you get to the critical part of the problem, so you have to keep thinking of ways to relax them.
"You'll note," he said, "that this patient has been very considerate of us. He has kept himself thin."
Across from him Bob Robinson was starting to clamp the stockinet material onto one edge of the wound, so he reached out and the scrub nurse handed him his. He clamped it to the skin along the outer edge and folded it back to cover the skin.
In the old days they all used linen skin towels, but in France when they ran out of them, he borrowed the knitted stockinet that the orthopedic people used. How many amputations he did in those days he never knew, but everybody was an orthopedist as well as a general surgeon anyway. Except when there was a big push on, they worked at night because the wounded wouldn't come in until 4 or 5 o'clock in the afternoon. Then they had to be separated by that triage system into the walking wounded, the wounded, and the shock cases, so he'd sleep until 4 o'clock. When he got up he'd look them over and have supper and then he'd start about 9 and work until 7 in the morning. They wore their operating gowns right over their field jackets, and when there was a big push on like the break-through at St. Lo and during the Bulge they'd work for twenty-four hours before they'd take a few hours' sleep. If any good came out of it, it was the experience they got out of the enormous volume they handled and the confidence they derived from the blind faith that the poor kids had in them, and then a few little things like that elastic stockinet that molds itself over the chest wall so much better than the linen towels that now a lot of them use it.
"Where did you go to school, Doctor?" he said, smoothing down the stockinet.
"Right here at the University," Darrow said.
"Good," he said. "Then you think a good deal of Dr. Winton."
"Yes, sir. I do."
In his own fife, and before Pete Church, Leonard Furman was the first of the big ones. The first operation he ever saw was that cyst that Furman did on Jim McClain's sister. When, watching, he began to feel weak, Furman noticed the sweat on his forehead and told the nurse to take him out, but he saw it through and then fainted on the way downstairs to tell Jim that his sister was all right and to play it as if it were nothing.
"There's a bleeder," he said, spotting the small spurt where the vessel had been severed. "He thinks he can hide, but I recognize him."
Sponging with the gauze in its holder in his left hand and taking the hemostats, or scissor-action locking clamps, in his right, he clamped the bleeders on his side while Bob Robinson worked the other. Going into the chest, as Pete Church first taught him, is really just three cycles of cutting and clamping and tying off—first down to the muscles, then to the ribs and finally into the chest—and there would be perhaps a hundred more of these small veins and arteries that they would cauterize with the Bovie or tie.
"How's your car behaving?" Bob Robinson said to him.
"Fine," he said, "but I had to have the plugs replaced. Those German plugs won't take our high-octane gasoline."
"It serves you right," Bob Robinson said.
They were starting now to tie the first of the three hundred or more knots. A surgeon's knot is a square knot, but Pete Church's hands used to move so fast when he tied that, the first time he assisted him, he asked if he were really tying square knots or just grannies that tend to slip. Then Pete Church had taken him into the scrub room and right there, tying to one of the faucets, he had shown him how you put in two grannies and then the square knot to snug it down. He had shown him how you use the two middle fingers as a shuttle, instead of twisting the wrists. It is really a one-handed knot and after that he carried silk with him for months, practicing with it whenever he had a few minutes, tying thousands of knots around the round, chipped, white-enameled bed posts in his room and even practicing to tie blind inside an empty tennis-ball container as Alexis Carrel, who invented that perfusion pump with Charles Lindbergh to keep organs alive outside the body, said he used to practice inside a penny match box.
He held one of the clamps now on Bob Robinson's side while Bob Robinson passed the black silk thread behind it, slid it down, tied it, and knotted it twice more. Then Bob Robinson held for him while he tied.
"No, Doctor," he said as Darrow cut the first thread. "You're holding those scissors like a woman. Here."
When you are beginning you have to learn to pick up scissors all over again. He took the scissors from Darrow, and he showed him how to hold them, with the thumb and ring finger in the eyes of the scissors, the middle finger to the right side, and the index finger down the length of them as a
pointer.
"And when you cut," he said, showing him, "you slide the scissors down to the knot, turn them up like this, and then cut. That cuts it the width of the scissor blade above the knot and you're in no danger of cutting the knot."
"I see," Darrow said.
"Also," he said, "that's how you cut blind. When you can't see the knot you just ride the scissors down the silk until you come to it, rotate, and cut."
"Yes, sir."
"Now you're ready for anything."
When they had finished the tying and discarded the clamps he sponged again along the walls of the cut. As he did he saw a small bleeder, close to the underlying fascia and at Bob Robinson's side.
"There's a sneaky one," he said.
"I've got it," Rob said, clamping it.
"Is this thing working?" he said, picking up the forceps of the Bovie and finding with his left foot the pedal under the table.
"Yes, sir," the floating nurse said. "I think it is."
"It's not working now," he said, touching it to the nose of the clamp as Bob Robinson held it. "What's it set at?"
"Forty, Doctor," the float said, bending over the dial on the Bovie.
"Move it up to forty-five," he said.
He touched the nose of the clamp again and saw the small blue-white flame and heard the small crackling sound. He saw the blackening beneath the clamp and then the slight odor of burning came to him.
"That does it," he said. "Knife."
He started at that auscultatory triangle where the trapezius and the latissimus dorsi, the shoulder and back or shrugging and rowing muscles, join and frame that perfect port through which, the week before, he had heard more clearly than anywhere else that squeaking-door, broken-reed sound in Mr. Scheller's chest. With the forceps in his left hand he picked up the fascia over the opening and he cut down through it. He discarded the forceps and, turning his left hand palm up, he slid the first two fingers into the opening and under the trapezius and the rhomboids, the muscles that connect the shoulder blade with the vertebrae and stabilize and elevate it. Spreading the fingers and moving them ahead of the scalpel, he made the incision back-handed and saw the clean snap-back of the muscles released by the cut. Then he shifted the scalpel to his left hand, inserted the two fingers of the right, spread them, and made the left-handed cut back-handed through the latissimus dorsi. With each cut, and certain of himself, he went all the way through the rhomboids, too, and down to the periosteum, the tissue covering the ribs as again, at the very beginning, Pete Church had given him the assurance to do when, like all beginners, he tended to be a scratcher.
"You notice that we don't divide the serratus anterior," he said, referring to the lifting muscle. "In fact, we go out of our way to preserve it by just liberating the back edge because this man is a house painter. If you save a patient but leave him a semi-cripple you've only won half the battle."
"Yes, sir," Darrow said. "I understand."
The trouble with scratching, he had often thought, is that you are never in command. You're like a water bug, always hovering on the surface. You don't seem to be able to get down in and run the operation and so it runs you until, finally, with experience, you master it, except that the born scratchers never do.
"Sponge," Bob Robinson said.
"Did you ever play football, Doctor?" he said to Darrow.
He had discarded the scalpel and was tying another bleeder for Bob Robinson. They would tie about two dozen of the major vessels here but the smaller ones had retracted into the muscles and would seal themselves off.
"No, sir," Darrow said. "I never played much, but I enjoy watching the pros on Sundays when I get a chance."
"Did you see that game on Sunday?" he said, watching Darrow hold the scissors properly now as he cut the tie.
"No, sir," Darrow said. "I was on duty."
This is just like football," he said, holding a clamp while Bob Robinson tied behind it "Say you're a halfback going wide. You have to have two speeds. That's what we have. These chest openings are automatic, so we just go along one-two-three at top speed."
"I understand," Darrow said.
Alex Johnson was the master of pace. Because of that TB that finally got to his spine and his kidneys, he had to save time and save himself and so he learned, and taught, how to race through the openings to get to the problem.
"Then when we get inside and see what the problem is we slow down," he said, sponging and flipping the sponge back onto the towel draped across the kick bucket on the floor behind him. "However, there's one difference. We always start out fast, but when you're a halfback on that wide play you start out at three-quarter speed. Then when the defensive man commits himself, you go into high. You give him that reserve burst and you're around him. Right?"
"Yes, sir."
When Alex Johnson got to the problem, however, he slowed to a walk. He became as meticulous as a brain surgeon, all that preciseness in his nature that revealed itself as he walked around his office straightening the pictures and squaring the chairs against the wall coming out again now at the table.
"That was a pretty good game on Sunday at that," Bob Robinson said. "I saw the second half."
The scrub nurse was wringing the saline solution out of a hot pack and Bob Robinson took it and placed the wet gauze over and around the exposed wall of the cut on his side. The next one he placed himself, and Bob Robinson hooked the curved end of the first retractor over the hot pack and around and under the shoulder blade. The second retractor he placed next to Rob's, and then he handed it to Darrow and waited as the two of them pulled back on the retractors and the opening began to widen.
"Oh come on, you guys, lift," he said. "You two should go to the gym more often. Let's pull that up there."
As they pulled harder now, he reached up and under the shoulder blade, once more the way Pete Church first showed him, and felt the serratus anterior muscle attached to the second rib. It is always conspicuous there, so you know at once where you are and don't have to fight your way up to the first rib and now, starting with the second rib and moving his fingers down over the ribs, he counted them slowly.
"Two, three, four, five," he counted, and he reached over and pulled the retractor for Bob Robinson while Rob reached up and counted.
"Right," Rob said.
"How are you, Orphan Annie?" he said.
"We're all right, Doctor," she said, her voice coming up over the drape. "His pulse is 86, and his pressure is 130 over 85."
"Good," he said. "Knife."
Over the fifth rib he made the cut, about ten inches long, through the periosteum, the tough, adherent covering of the rib. When he dropped the scalpel onto the towel at his right the scrub nurse handed him the periosteal elevator, which is badly named because what it really resembles is a dinner knife with its blunt end bent over.
"Good girl," he said. "You can scrub on my Olympic team any time."
The elevator is the one the Army developed in 1918 and that he has always used, and if you know how to use it correctly you can do it with just two basic moves. With the first move and back-handed he scraped the periosteum back from his incision and across the upper half of the rib. With the second move he scraped it down across the lower half. And, as he did, he saw the clean, almost bloodless gray-white arch of the rib emerge.
"Your hand must always lead this instrument," he said to Darrow. "If you were to push it and it slipped it could puncture the chest. As long as you're dragging it, you're in no danger."
He was going around the rib now, scraping in two quick moves the periosteum away from the nearer half of the under side of the rib. Then he did the other side, completely exposing the section of rib.
"Very nice, Matt," Bob Robinson said.
"Don't flatter me," he said, packing gauze under the rib at both ends of the exposed section to elevate it slightly. "You know it's just as easy as shelling peas. Rib cutter."
With the double-action cutter he severed the rib in the back and then in the f
ront He handed the cutter back and, with the other hand, gave the severed ten-inch portion of the rib to Darrow.
"If you need another rib," he said, "you can have this. Our man here will grow a new one in three months."
"No, thank you," Darrow said, turning the rib over, looking at it. He handed it to the scrub nurse and she placed it in a towel.
"Bone wax please. Then the rib cutter again."
He took the sterile beeswax and packed the two remaining ends of the rib to keep the marrow from oozing. Then he took the rib cutter once more and cracked the fourth and sixth ribs toward the back.
"I discovered," he said, explaining to Darrow, "that these ribs would crack under the rib spreader anyway, but in the wrong place. Now I crack them where I need the extra exposure in the back."
"Yes, sir."
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