“There are moments,” Denise said, “when I have grave doubts about the value of progressive education. That, I think, will be all.” She stepped lightly to Philippa. “Good night, dear.”
“Oh, Mother!” the girl said. “Sometimes you’re so antediluvian.”
“Good night, dear.” Denise repeated it firmly.
Philippa turned to O’Donnell. “I guess I have to go.”
He said, “It’s been a pleasure, Philippa.”
The girl came to him. She said artlessly, “If you’re going to be my stepfather, I suppose it’s all right to kiss you.”
He answered, “Why don’t we chance it?—whichever way it goes.”
He leaned toward her and she kissed him on the lips, then stood back. There was a slight smile, then she said, “You’re cute.” She warned Denise, “Mother, whatever you do, don’t lose this one.”
“Philippa!” This time the note of discipline was unmistakable.
Philippa laughed and kissed her mother. Waving airily, she picked up her book of poems and went out.
O’Donnell leaned back against the terrace wall and laughed. At this moment his bachelorhood at Burlington seemed incredibly empty and dull, the prospect of life with Denise in New York more glowingly attractive by the second.
Eighteen
The amputation of Vivian’s left leg began at 8:30 a.m. precisely. Punctuality in the operating rooms was something that Dr. O’Donnell had insisted on when he first became chief of surgery at Three Counties, and most surgeons complied with the rule.
The procedure was not complicated, and Lucy Grainger anticipated no problems other than routine. She had already planned to amputate the limb fairly high, well above the knee and in the upper part of the femur. At one point she had considered disarticulating at the hip in the belief that this might give a better chance of getting ahead of the spreading malignancy from the knee. But the disadvantage here would be extreme difficulty later on in fitting an artificial limb to the inadequate stump. That was why she had compromised in planning to leave intact a portion of the thigh.
She had also planned where to cut her flaps so that the flesh would cover the stump adequately. In fact, she had done this last night, sketching out the necessary incisions in her mind, while allowing Vivian to believe that she was making another routine examination.
That had been after she had broken the news to Vivian, of course—a sad, strained session in which the girl at first had been dry-eyed and composed and then, breaking down, had clung to Lucy, her despairing sobs acknowledging that the last barriers of hope had gone. Lucy, although accustomed by training and habit to be clinical and unemotional at such moments, had found herself unusually moved.
The session with the parents subsequently, and later when young Dr. Seddons had come to see her, had been less personal but still troubling. Lucy supposed she would never insulate entirely her own feelings for patients the way some people did, and sometimes she had had to admit to herself that her surface detachment was only a pose, though a necessary one. There was no pose, though, about detachment here in the operating room; that was one place it became essential, and she found herself now, coolly and without personal feelings, assessing the immediate surgical requirements.
The anesthetist, at the head of the operating table, had already given his clearance to proceed. For some minutes now Lucy’s assistant—today, one of the hospital interns—had been holding up the leg which was to be removed, so as to allow the blood to drain out as far as possible. Now Lucy began to arrange a pneumatic tourniquet high on the thigh, leaving it, for the moment, loosely in position.
Without being asked the scrub nurse handed scissors across the table, and Lucy began to snip off the bandages which had covered the leg since it had been shaved, then prepped with hexachlorophene, the night before. The bandages fell away and the circulating nurse removed them from the floor.
Lucy glanced at the clock. The leg had been held up, close to vertical, for five minutes and the flesh appeared pale. The intern changed hands and she asked him, “Arms getting tired?”
He grinned behind his face mask. “I wouldn’t want to do it for an hour.”
The anesthetist had moved to the tourniquet and was looking at Lucy inquiringly. She nodded and said, “Yes, please.” The anesthetist began to pump air into the rubber tourniquet, cutting off circulation to the leg, and when he had finished the intern lowered the limb until it rested horizontally on the operating table. Together the intern and scrub nurse draped the patient with a sterile green sheet until only the operative portion of the leg remained exposed. Lucy then began the final prepping, painting the surgical area with alcoholic zephiran.
There was an audience in the O.R. today—two medical students from the university, and Lucy beckoned them closer. The scrub nurse passed a knife, and Lucy began to scrape the tip of the blade against the exposed flesh of the thigh, talking as she worked.
“You’ll notice that I’m marking the level of the flaps by scratching them on first. That’s to give us our landmarks.” Now she began to cut more deeply, exposing the fascia immediately below the skin, with its layer of yellow fatty tissue. “It’s important always to make the front flap longer than the back one, so that afterward the suture line comes a little posterially. In that way the patient won’t have a scar right at the end of the stump. If we did leave a scar in that position it could be extremely sore when any weight was put upon it.”
Now the flesh was cut deeply, the lines of both flaps defined by the blood which had begun to seep out. The effect, front and rear, was rather like two shirttails—one long, one short—which eventually would be brought together and sewn neatly at their edges.
Using a scalpel and working with short, sharp movements, Lucy began to strip back the flesh, upward, exposing the bloody red mass of underlying tissue.
“Rake, please!” The scrub nurse passed the instrument and Lucy positioned it, holding back the loose, cut flesh, clear of the next layer below. She signaled to the intern to hold the rake in place, which he did, and she applied herself to cutting deeper, through the first layer of quadriceps muscle.
“In a moment we shall expose the main arteries. Yes, here we are—first the femoral vessel.” As Lucy located it the two medical students leaned forward intently. She went on calmly, matching her action to the words. “We’ll try to free the vessels as high up as possible, then pull them down and tie off so that they retract well clear of the stump.” The needle which the scrub nurse had passed danced in and out. Lucy tied the big vessels twice to be sure they were secure and would remain so; any later hemorrhage in this area could be catastrophic for the patient. Then, holding her hand for scissors, she took them and severed the main artery leading to the lower limb. The first irrevocable step to amputation had now been taken.
The same procedure followed quickly for the other arteries and veins. Then, cutting again through muscle, Lucy reached and exposed the nerve running parallel downward. As her gloved hands ran over it exploringly, Vivian’s body stirred suddenly on the table and all eyes switched quickly to the anesthetist at its head. He nodded reassuringly. “The patient’s doing fine; no problems.” One of his hands was against Vivian’s cheek; it was pale, but her breathing was deep and regular. Her eyes were open but unseeing; with her head fully back, untilted to one side or the other, the pockets of her eyes were deep with water—her own tears, shed in unconsciousness.
“We follow the same procedure with the nerve, as with the arteries and veins—pull it down, tie it off as high as possible, then cut and allow it to retract.” Lucy was talking almost automatically, the words following her hands, the habit of teaching strong. She went on calmly, “There’s always been a lot of discussion among surgeons on the best way to treat nerve ends during amputation. The object, naturally, is to avoid pain afterward at the stump.” She deftly tied a knot and nodded to the intern, who snipped off the spare ends of suture. “Quite a few methods have been tried—injection of alcohol; burning the nerve end with an electric cautery; but the method we’re following today is still the simplest and most widely used.”