It is like that Latin motto, he sometimes thought. From the old oxen the young leam to plow. There is nothing you can do about the pI'll pushers and the Great Jaffreys except wait for attrition to get rid of them, but you can teach these kids how to do it the right way and then there is always hope that they will be good.
"Now, Orphan Annie," he said, "you're going to have to work. You're going to have to breathe for this man, because I'm going to open the pleura."
"I'm ready, Doctor."
He knew she would be turning on the automatic respirator now, and he reached in and, with the slightly opened scissors, he split the inner periosteum and then the pleura, the soft, almost latex-like lining of the chest cavity. When he did, he heard it rushing in, the air destroying the chest vacuum but unable to collapse the lung because Orphan Annie, sitting there below the drape and watching her dials and feeling the pressure in the anesthetic bag with her hand, was maintaining Mr. Scheller's normal breathing. He could hear the tick-hiss-tick of the respirator.
"Rib spreader."
When he took the rib spreader and started to place it he had the feeling that something was loose. He turned the spreader over.
"Hey!" he said. "Where's the wing nut? There's no wing nut here."
"Oh," the scrub nurse said. "Oh, it's all right. If s right here."
"Why, Mary," he said. "I'm glad you're not fixing my car."
She handed him the nut and he put it on. He started to place the spreader but saw that the lung, expanding under the set pressure of the respirator would be in the way.
"Orphan Annie," he said. "Take five or six good breaths and then cut him off so we can get this spreader in."
"Yes, Doctor."
He waited then, until he saw the lung go down. When it did he placed the spreader where he wanted it, between the fourth and fifth ribs, and set it firmly. Then Bob Robinson gave the handle four turns and the opening began to enlarge.
"Fine," he said, releasing the spreader. "Keep cranking."
As Bob Robinson turned the handles, the sides of the spreader moved out and the rectangle framed by the steel of the spreader opened to about five inches by eleven.
"Okay, Orphan Annie," he said. "You can go back to normal now."
There within that rectangle now lay the lung, the pink and purple and black marbleized whole of it rising and almost filling the opening and then receding, the ebb and flow of it controlled by the machine as Orphan Annie resumed the rhythmic breathing.
"What time is it?" he said.
"It's 11:33, Doctor," the floating nurse said.
That's nineteen minutes, he thought. Sometimes you can open in twelve minutes, if he's a real skinny one and everybody is loose and doing his job.
"Orphan Annie?" he said. "How much blood has he had?"
"Only about 120 c.c.s, Doctor."
That's about right for going in, he was thinking, and now she wants to continue that normal breathing but that lung is in our way.
"Can you drop your pressure a little?" he said. "I want you to collapse the lung a little so we can see what's wrong with our man."
'Yes, Doctor."
"Lung forceps," he said. "Two of them."
He positioned them on the lung. Then he handed them across to Bob Robinson, and Bob Robinson pulled the lung toward himself.
"Fine. That does it."
This, now, was what it was all about. He reached in with his left hand and, with the rest of them watching in silence and even Orphan Annie half standing and looking down over the end of the drape but still reaching down and feeling the pressure bag, he moved his left hand under the lung and then slowly up toward what, until this moment, had been first just a succession of symptoms and then a light shadow on an X-ray.
He felt the lung, normal and pliable, and then through the so-thinness of the glove he felt his fingers come to the edges of it, the beginning of the hardness, the spreading patch. He was above the root of the lung and he could just get his index finger between the root and the hardened mass above it. Then he reached in with both hands and traced its outlines between them and cornered it.
"Tilt the table toward me, please," he said to the floating nurse, withdrawing his hands and waiting while she bent under the table and turned the handle. "That's enough. That's fine."
He took the two forceps from Bob Robinson and pulled the lung toward his own side. Then, reaching in with his right hand and moving back the under portion of the lung, he could see the grayish-white cancerous growth spreading onto the superior vena cava. It covered about a half-inch and extended off the vena cava to the pericardium, the thin covering over the heart.
"You were right," he said to Bob Robinson.
"Right?" Rob said.
"About a half-inch of the superior vena cava is invaded and it's on the pericardium, too."
"Roberto Leon?" Rob said.
"Almost an exact duplicate," he said. "Take a look for yourself."
And it is, really, almost an exact duplicate, he was thinking, holding the lung back and waiting for Rob. For months I have seen it again and again in my mind and now it is no longer just in my mind but right here on the table.
"He's got it on there, all right," Bob Robinson was saying. "He's a ringer for Roberto Leon."
"I want to check his liver," he said, handing the forceps back to Rob.
He reached down to the diaphragm and through it the liver felt good. It was soft and smooth and he knew that it was free of the disease.
"His liver is fine," he said.
He was looking over the rest of the pleura now. He was searching for other signs of spread of the disease but he found none.
"This is a patient," he said, for Darrow and Orphan Annie and Mary Geary, "who was afraid he had cancer of the lung, so for months he tried to forget it. He thought that, if he could forget it, it would go away, and now he not only has cancer of the lung but it has extended onto his superior vena cava and his pericardium."
So when I get inside the pericardium, he was thinking, I may find I can scrape the cancer right off the vena cava. Then I won't have to remove a section of it and use the pulmonary artery for a graft to replace it and he won't be Roberto Leon at all.
"Toothed forceps," he said, "and a knife with a number eleven blade."
"Forceps here, too," Bob Robinson said.
They placed the forceps about a quarter of an inch apart and about an inch from the cancer and picked up the pericardium. With the scalpel and between the forceps he cut a half-inch incision through the pericardium.
"Scissors."
Inserting the scissors into the opening and staying well outside the cancerous area he made a curving cut around it. Then he lifted it, the heart beating there in the opening, and saw that the cancer had extended through the pericardium and was visible on the interior surface. Above, where the pericardium becomes a sheath over and around the superior vena cava, he saw that the normal space between the sheath and the superior vena cava no longer existed, but had been obliterated by the disease. He released the pericardial flap and, with the forceps, picked up the sheath in the free area above the cancer. He made another opening, entered it with the scissors, and dissected down until he could go no further, until he had run into another dead end where again the cancer plaque was adhering to the vena cava.
"We're not going to peel this one," he said, handing the forceps to Bob Robinson. "The cancer hasn't completely encircled the vena cava, but it's adhering on three walls. Take a look."
So it really is Roberto Leon at that, he was thinking, standing there with his hands clasped priestlike in front of him and waiting for Rob. If I do anything, if I take that lung, I've got to take that section of the vena cava and do that graft. If I try it he may die right here on this table, but if I don't, if I just close this chest and send him back to that wife and that son he won't have much more than six weeks or two months at the most and that's it, just as plain as that and right now.
"I guess I was right at that," Bob Robinso
n said, straightening up.
"You were. Now I want this table tilted back again. I want to look at the right pulmonary artery."
It is the large blood vessel carrying the dark venous blood from the heart to the right lung, and running behind the superior vena cava. As he opened, from the back, the sheath covering the artery, it dissected so easily that he knew that it was not cancerous and could serve as the graft for the vena cava. Then he checked the superior pulmonary vein and found it also free.
"The artery is fine," he said looking at Bob Robinson. "What do you say now?"
"Well," Rob said, looking back at him. "I say his system can stand it and I say we've been waiting for this and we're ready for it and we can do it."
At times like this, he had often thought, the only thing to do is to see yourself as the patient. If I'm ever like this, I hope to heaven they don't just sew me up again and send me back. If they do lose me, all they have to lose is a little off their reputations while I lose my life, but still I want that chance.
"So I say yes," Rob was saying, waiting for him, "because we have to give him a chance to see which way he goes."
"If we don't give him that chance we know which way he'll go," he said, "so I say yes, too."
He had known he would say it, but he had needed to think it all out once more and to take that last breather. Now, having said it, having committed himself, he felt the small ground-spring of anticipation rising in him, the small welling of excitement that at the beginning was a part of every operation until, after so many years, he had done so many that now only rarely, only in the tough ones, was he aware of it.
"Now if you'll hold this lung forceps," he said to Darrow, "Dr. Robinson will hold the other and you people will keep this lung out of my way."
He started to dissect the tissue around the tubelike bronchus, freeing it. As he did, he isolated the bronchial arteries, the small blood vessels bringing blood to the bronchial tubes.
"In going around the bronchus," he said for Darrow, "you point your instrument always toward the trachea and not the artery. If you should break into the artery you're in trouble because you can't see for the blood and besides, with this patient, we want to use the right pulmonary artery later for a graft on the vena cava."
"Yes, sir," Darrow said.
As he isolated the smaller vessels now he clamped them. Then he divided them and, with Bob Robinson holding the clamps, he tied them off and held the sutures up as Darrow cut them.
"Now two right angle clamps," he said. "Now, Orphan Annie, I want this lung to collapse a little once more because I'm going to divide his bronchus."
With Bob Robinson and Darrow holding the lung out of the way he placed the first clamp, cutting off the air to the lung, on the tubular bronchus about a half-inch from where it branches off the trachea, or windpipe. He placed the second a half-inch from it and, with one cut, he went through the cartilaginous arch and the membranous floor.
"The bronchus is divided," he said. "Now I'm going for the right pulmonary artery, and I want the full length of it."
He reached around to the front and depressed the artery. Bob Robinson reached in and put his right hand under the aorta, the main trunk of the arterial system, and between it and the artery, and pulled the aorta up.
"Fine, Rob," he said, seeing the artery, pinkish-gray, starting at the main pulmonary artery and running behind the aorta and the adjacent vena cava to the lung. "What's his heart doing now, Orphan Annie?"
While you are in there, it had occurred to him once, you are almost one with the patient You are so much a part of a man who is really a stranger to you that, like the beat of a musician's foot, your head moves a little with the rhythm of the patient's heart, and he had felt it miss just that once.
"His pulse is 100, Doctor. His pressure is 120 over 80."
"Good."
Going around to the back again he finished the isolation of the artery that he had started earlier, dissecting the weblike tissue around it, as close as possible to its origin at the main pulmonary artery. He placed the second one about a quarter-inch from it and, holding the two of them in his left hand and with the scalpel in his right hand, he cut between them and watched the end retract to the first clamp but leave a cuff.
"Four-o silk with an atromatic needle," he said. "I'll need eight of them."
Taking the curved needle in the scissor-action, locking-clamp needle holder he put the first of the eight interrupted, or individual, sutures in the cuff of the artery. Then, estimating his spacing, he started to put in the others, rotating his hand and the needle with each.
"The tendency is to pull the needle straight," he said to Darrow, "but if you pull it on the curve of the needle the hole in the artery will be no bigger than the needle. If you sew up a blood vessel and see it leaking you'll know what you did wrong. Right?"
"Right, sir," Darrow said.
When he had finished he waited for Darrow to cut the threads. Then, using a running stitch, and placing the needle each time between the other eight, he completed the closure and removed the clamp.
"No leaks," he said. "It must be the great help I'm getting today."
"No doubt about it," Bob Robinson said.
He isolated then the superior and inferior pulmonary veins, the two of them returning the blood from the upper and lower lobes of the right lung and converging in a Y just before they enter the heart. Then he clamped them, cut them and tied them.
"Scissors."
Continuing the incision he had made earlier in the pericardium, the covering over the heart, he cut around the cancer plaque on the superior vena cava. He reached over and took the lung forceps, from Bob Robinson and handed it to Darrow, who was holding the other.
"Hold these in both hands, Doctor," he said. "Now lift. Lift hard."
As Darrow lifted the lung came out. Darrow stood there, holding it, looking at it and then at him.
"You see, Doctor?" he said to Darrow. "You came here wanting to be a surgeon, and you've just performed your first pneumonectomy. You've removed a lung."
"Well, hardly," Darrow said, "but thanks anyway."
"I'll take it," he said, "and Mary, make some room on your instrument table so I can get the pulmonary artery off it."
On the table he cut the artery at the point near the lung where it divides into its branches. With the forceps he passed it to the scrub nurse.
"Now take good care of this," he said, "and I'm not kidding. Wrap it in a saline sponge and don't drop it. This is our only chance, so if anything happens to it we're sunk."
"Yes, Doctor."
"We lost a little blood here," Bob Robinson was saying, examining the empty chest cavity. "Tonsil sucker."
He handed Bob Robinson the metal suction tube used in tonsI'llectomies and waited while he drained the area. Then he started to remove the first of the chain of lymph nodes, the steppingstones at which cancer stops as it spreads through the lymphatic channels. They are about the size and shape of small kidney beans, and as he took them he saw that those that had been closest to the lung were speckled white with cancer but that the ones beyond, near the trachea and the main bronchus going to the left lung, were a normal black.
"The adjacent ones are diseased," he said, "but we're running into a little luck after that. They look fine."
"Do you want these to go to Pathology, Doctor?" she said.
"Yes," he said, passing her another, "and I want this one and two others I'll give you from here marked tracheal bifurcation nodes and put in a separate bottle."
"Yes, sir."
"Now look at that," he heard someone say behind him. "I wonder if he knows what he's doing."
"Who's that?" he said, recognizing Maury Rand's voice. "Maury?"
"Yes, sir," Maury Rand said. "I guess he knows what he's doing."
"Mark this one peri-esophageal node," he said to the scrub nurse, and then for Maury Rand: "Listen. I'd be almost out of here by now, but I have a patient who didn't want to believe he had carcinoma
, so while he was trying to wish it away it spread not only to his pericardium but also to his superior vena cava."
"Don't complain to me " Maury Rand said. "You wanted to be a chest surgeon."
"I'm not complaining," he said.
He had washed out the chest cavity with saline solution. He was waiting now while Bob Robinson drained it with the tonsil sucker.
"Knife," he said to the scrub nurse, "and have your steel-wire sutures ready with those long forceps. This is a bad bronchus to close because the cartilage of the wall has almost turned to bone."
"I don't think I care to stay to see this," Maury Rand said.
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