The Moon by Night (16 page)

Dr. Duncan Gilder, a rather cocksure son of privilege, exclaimed, “So Dr. Duvall is going to, in essence, be a part of the surgical team as a pathologist?”

“Just so,” Dev answered. “Understand that these two procedures illustrate what might be called surgical pathology as opposed to clinical pathology. In a dissection we saw and learned of the changes occurring in an organ and in the bodily fluids caused by a disease, which is classical clinical pathology. Today we hope to find out the pathology of a disease in order to determine the correct surgical procedure, which I have termed surgical pathology.”

Light seemed to dawn on the three fresh eager faces. Dev nodded with satisfaction and continued, “We will have a discussion after the surgery, but I must stress to you that though I am using this as a teaching case, I will not be lecturing during the procedure, and I do not want anyone to ask any questions. I insist that you remain silent throughout the surgery. Mrs. Green is very young and impressionable, and naturally she is very frightened. As I'm sure you all observed this morning, Mr. Green, in insisting that he must be present here in the surgery, upset the patient even more. Of course I can't allow him to be in here, and I finally persuaded him of that. But the point is that the entire episode only agitated the patient more, so in this room there must be nothing but a calm, professional, confident air.”

The students nodded solemnly.

Dev turned to Nurse Flagg and asked, “Did you give her the absinthe?”

“Yes, sir,” the nurse answered, “but she just tossed it back, and it didn't seem to do much good for her, the poor thing. So I asked Dr. Pettijohn for permission to give her another dose, and he consented. After that she calmed down somewhat.”

Dev nodded. “All right, let's go get her.”

They left through the swinging door that connected into Surgery 2. Rebecca Green and her husband had been in Surgery 2 for an hour as she was being prepared for surgery. Ira Green had finally begrudgingly agreed to wait in this room during his wife's procedure.

Dev and Nurse Flagg wheeled the tall surgical bed into Surgery 3 and positioned it. Nurse Flagg was at the head with her rolling table of instruments and supplies. Dev and Cheney were on the patient's left side, as was Cheney's table with her instruments, paper and pencil for sketching and notes, her microscope, her slides and dissection instruments, and a small but very high-burning oil lamp for lighting up the microscope.

Dev bent close over the girl and took both of her hands in his. They were icy cold. He asked quietly, “Now, Mrs. Green, are you relaxed?”

She nodded rather tremulously. Her eyes were dulled and heavy-lidded, but she did not have that pleasant dreaminess that the powerful narcotic drink usually induced. Dev asked, “Are you cold?”

“N-no,” she whispered with a darting look at the people in the room. She was familiar with everyone, of course, for she had been in the hospital for ten days and knew all the staff and doctors. But she was still fearful, it was plain to see, and this troubled Dev.

He rubbed her hands lightly, then placed them on her abdomen and kept his hand over hers. He said, “Now Nurse Flagg is going to place a cloth over your nose and mouth. It will smell sweet. I don't want you to be afraid, Mrs. Green. Just try to breathe as normally as you can, and you will drop off to sleep.” He nodded at the nurse.

She uncorked a brown bottle, inserted a long eyedropper with a rubber bulb, withdrew it, and carefully dropped two sizable swatches onto a piece of gauze that had been folded many times to give it thickness and absorbency. Carefully she placed the square over Mrs. Green's face. Above the cloth the young woman's eyes darted back and forth, then fixed, with some desperation, on Dev. Immediately he began speaking to her, but he couldn't get very close or he, too, would be affected by the chloroform fumes. She clung to his hand like a vise. “Just relax, Mrs. Green…don't be afraid. I'm right here. I'll take good care of you. That's it…just let your eyes close.”

He kept speaking softly to her, but twice he exchanged quick grave looks with Nurse Flagg. It was taking much too long for her to go into the drugged sleep. Once the nurse motioned silently toward the brown bottle—a question—but Dev shook his head very slightly, continuing to speak in the same soothing, hypnotic tone. Finally the girl's eyes closed, and her head lolled slightly to the side.

Dev let go of her hands and quickly washed his in the basin of carbolic acid on Cheney's supply table. With quick efficient movements Cheney scrubbed Dev's hands and fingernails with a small brush, then dried them on a clean towel. Nurse Flagg bent over Mrs. Green, lifted up her eyelid, nodded with satisfaction, and lifted the cloth from Mrs. Green's face to store it on her supply table.

“Your patient is ready, Dr. Buchanan,” she said. Cheney pulled back the coverlet to expose the surgical area and neatly tucked it securely around the patient, leaving her right hand outside the covers. Sometimes a patient would move slightly, and talk too, under the anesthesia, so it was necessary to restrict them as much as possible. But Dev liked his patients' pulse and the temperature of the extremities to be monitored closely, which was why Cheney had left Mrs. Green's right arm outside the sheet. Now Nurse Flagg checked Mrs. Green's pulse as Cheney handed a scalpel to Dev. He bent over Mrs. Green and made the incision, an S-shaped one to include the lump and both the axillary and shoulder lymph glands.

He and Cheney worked quickly and efficiently, their hands never bumping each other, as they tied off the largest of the severed veins and packed the smallest ones with fine rolled gauze to lessen the blood flow. Cheney often used a baby aspirator to suction excess blood. Dev's and her eyes met in a mutually understood signal:
Shiloh's invention
.

Dev was tying off a spurting vein when his hands jerked and he frowned ferociously. Cheney looked up, and Nurse Flagg quickly handed him more sutures. The suture had broken as he knotted it.

It happened again. He looked up and barked, “Are all of these from the same lot?”

“I-I don't know, Doctor,” Nurse Flagg said nervously.

He and Cheney both looked closely at the lengths of black thread in their hands. Cheney narrowed her eyes as she lifted a single thread up to a better light. “I can see tiny bits of lint on these,” she said. “Have they been soaked in carbolic acid?”

“I d-don't know—”

“Do you know if they have been treated with chromic salts?” Cheney demanded.

Nurse Flagg was getting flustered. She bit her lip and looked confused.

“Never mind that now, Cheney,” Dev said calmly. “Nurse Flagg, go tell whoever is at the nurses' station—”

“I know where the treated sutures are stored downstairs, sir. I can go fetch them quickly,” Dr. White blurted out, then looked appalled at her impulsiveness.

One of Dev's eyebrows arched, but he said evenly, “Very well, Dr. White. Hurry, please.” The girl flew out of the room, while the two male students rolled their eyes as if to say,
Teacher's pet
.

Dev continued, “Dr. Duvall, here, just hold—yes, that's good, right there. Nurse Flagg, please roll more gauze just in case there is no suitable catgut to be had.”

Catgut was not truly the intestines of a cat. It was string made from the intestinal lining of sheep and other animals. Its great virtue was that after staying intact for about a week it gradually dissolved in the healing tissues and could be absorbed by them.

According to Dr. Lister's newly published work on antisepsis, catgut must be soaked in carbolic acid just as all instruments and hands must be in order to maintain an antiseptic environment for the surgery. Lister had found that soaking the catgut weakened it somewhat, so it did have a tendency to break. With further study, he had discovered that by permeating the sutures with salts of chromic acid, the material was re-strengthened, which gave the sutures longer life. Lister's study had barely been published, but Dev, who was acquainted with the gentleman, had been apprised of his progress in this area several months before. Consequently one of the requirements Dev had made for the surgical unit of the hospital was that the plain catgut, upon delivery, be immediately sterilized and processed into chromic sutures.

Dr. White burst back into the room holding a thick loop of catgut. Carefully she placed it on Nurse Flagg's instrument table and backed away. Quickly the nurse cut suitable lengths and started handing them to Cheney and Dev.

Cheney's broke.

Dev's broke. His second one broke.

Cheney made a sound of furious exasperation. Dev was frowning darkly, and Nurse Flagg's face was filled with dread. Cheney opened her mouth, her cheeks colored with indignation, but Dev said quietly, “Never mind, Cheney, let's just see if we can find enough to tie off the largest vessels, and we'll pack enough to have tamponotic arrest of the bleeding. At least the gauze is working,” he added with arid humor.

They worked quickly, Nurse Flagg rolling small lengths of gauze into tight cylinders and handing them to Cheney as fast as she could.

Finally Dev was free to resume the procedure. With a scalpel as small and delicate as an artist's brush, Dev began the painstaking procedure of removing a sample of the tiny nodes called lymph glands. Cheney readied the slides and her microscope.

Suddenly under Dev's hands, Mrs. Green jumped.

Dev froze.

His abrupt stillness alerted Cheney. Nurse Flagg stopped rolling gauze. They all focused on Mrs. Green's face. Her eyes were open, wide with pain and filled with horror. Before anyone could move, she screamed. It was the worst sound Cheney had ever heard.

“Nurse Flagg,” Dev said sternly but calmly, “hurry.”

The patient began trembling, and her free arm jerked up and struck Dev's chest hard. Of necessity he had to pin her down. A patch of bright crimson spread rapidly across Mrs. Green's chest and onto the white sheets.

Nurse Flagg was dropping more anesthesia on the cloth, and Cheney was going to move to help her, but at that instant the patient drew a deep shuddering breath and screamed again, and her feet started drumming against the bed. Cheney had to hold her ankles down.

Then—the nightmare worsened every second—the connecting door swung open, and Ira Green came charging in. Cheney would never forget the look of blind fear and rage on his face. He was pale but his cheeks were slashed with furious red; his eyes bulged; he had flecks of spittle on his mouth; sweat poured down his face. “Becky, Becky, I'm here. I'm coming,” he roared, then grabbed Dev by the shoulder.

Incredibly Dev was still calm and as solid as a brick wall. Though Ira Green was a stout manual laborer, even his strength of panic couldn't move Dev. He stood still, his shoulders bunched with fighting the pressure the man was putting on him. Crazily Mr. Green seemed to be trying to spin him around.

Mrs. Green still screamed.

Nurse Flagg finally clapped the cloth over the patient's face, but now Mrs. Green was like a savage cornered animal, without reason. Her scream became a garbled high undulating shriek that was even worse than before. Maniacally she yanked her head from side to side. Mrs. Flagg leaned close over her, trying to hold the cloth over her nose without suffocating the struggling woman.

Still Mr. Green shouted and pounded on Dev's back.

Finally Cheney regained her senses and shouted, “Dr. Varick, Dr. Gilder! For heaven's sake, get him off of Dev!”

All three of the students were frozen with horror, but Cheney's angry shout galvanized the two men and they quickly grabbed Ira Green's arms and dragged him out of the room. Mrs. Green was struggling and making the same terrible strangled screeching noise. With amazing patience Dev stood still, holding her down, and asked, “Mrs. Flagg? Mrs. Flagg, can you—no, no, step back, step back—”

The nurse had bent close over the patient's face, holding the anesthetized cloth in place. Evidently she had inhaled too much of the chloroform, because now she looked pasty and ill, and her eyes were rolling in that telltale manner of one who is about to lose consciousness. She faltered, staggered. Dr. Lawana White ran to her and supported her, leading her out of the room.

At that moment Mrs. Green slowly relaxed, and her limbs stopped their wild flailing. Quickly Dev began blotting the many bleeders that had worked open with the patient's exertions. “Cheney, I don't know what's going on with her, but we've got a real problem here. Forget the lymph glands. See this tumor? I've got to have enough time to excise that, and I'm afraid there may be another mass just under it. I had planned to make another dissecting incision here, but now I'm afraid we're only going to have time to do a quick cut-and-stitch. I suppose we'll just have to try the chloroform again and bring in any men around here to hold her down in case she comes out again.”

“Oh, horrors. Dev, can you really operate with her conscious like that?” Cheney said, grabbing length after length of sutures. One corner of her mind told her that only about half of them were usable.

“I don't know,” he admitted. “I've never had anything like this happen. But one thing I do know, I've got to get this cancerous mass right now. She's not going to be able to go through another surgery for—”

She woke up again. Her horrified eyes filled, and tears rolled down her cheeks. She began flailing again and screaming.

Dev held down her arms—she was trying desperately to fight him—and again Cheney held her feet. Suddenly Cheney said, “Dev, Shiloh's here.”

Dev, startled, turned to stare at her. Their eyes met.

Shiloh had assisted Cheney in many procedures, and he had even assisted Dev twice. Shiloh was, in both of their opinions, the best anesthetist they'd ever known. He was almost uncannily attuned to a patient and seemed to know by some mysterious instinct the levels of consciousness the patient was passing through. Cheney had once asked jokingly if he wandered the twilight world of their consciousness with them. He had grinned and drawled, “Huh? Where's that?”