The Final Diagnosis

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."

Lucy glanced up at the clock on the O.R. wall. It showed 9:15 - forty-five minutes so far since they had begun. She returned her eyes by way of the anesthetist.

"Still all right?"

The anesthetist nodded. "Couldn't be better, Lucy. She's a real healthy girl." Facetiously he asked, "You sure you're taking the leg off the right patient?"

"I'm sure."

Lucy had never enjoyed operating-room jokes about patients on the table, though she had known some surgeons who wisecracked their way from first incision to closure. She supposed it was all in your point of view. Perhaps with some people levity was a means to cover up deeper feelings, perhaps not. At any rate she preferred to change the subject. Beginning to cut the muscles at the back of the leg, she asked the anesthetist, "How's your family?" Lucy paused to use a second rake to hold back the flesh from the new incision.

"They're fine. We're moving into a new house next week."

"Oh, really. Whereabouts?" To the intern she said, "A little higher, please. Try to hold it back right out of the way."

"Somerset Heights. It's a new subdivision in the north end."

The back leg muscles were almost severed. She said, "I think I've heard of it. I expect your wife is pleased."

Now the bone was visible, the whole incision big, red, gaping. The anesthetist answered, "She's in seventh heaven - buying rugs, choosing draperies, all the other things. There's only one problem."

Lucy's fingers went around the leg bone, working up and freeing the surrounding muscles. Speaking for the students' benefit, she said, "You'll notice that I'm pushing the muscles as far out of the way as I can. Then we can sever the bone quite high so that afterward it will be entirely covered with muscle."

The intern was having trouble holding back the overlapping muscles with his two rakes. She helped him position them and he gumbled, "Next time I do this I'll bring my third hand."

"Saw, please."

Again the scrub nurse was ready, placing the handle of the bone saw in Lucy's outstretched palm. To the anesthetist Lucy said, "What problem is that?"

Positioning the saw blade as high as she could, Lucy began to move it in short, even strokes. There was the dull, penetrating sound of bone scrunching as the saw teeth bit inward. The anesthetist said, "Paying for it all."

Lucy laughed. "We'll have to keep you busier - schedule more surgery." She had sawed halfway through the bone now; it was proving tougher than some, but of course young bones were naturally hard. Suddenly the thought occurred to her: this is a moment of tragedy, and yet here we are, casually talking, even jesting, about commonplace things. In a second or two, no more, this leg would be severed and a young girl - little more than a child - would have lost, for always, a part of her life. Never again would she run freely, wholly like other people, or dance, or swim, or ride horseback, or, uninhibited, make love. Some of these things she would eventually do, and others with effort and mechanical aid; but nothing again could ever be quite the same - never so gay or free or careless as with the fullness of youth and the body whole. This was the nub of the tragedy: it had happened too soon.

Lucy paused. Her sensitive fingers told her that the saw cut was almost complete. Then, abruptly, there was a crunching sound, followed by a sharp crack; at the last moment, under the weight of the almost separated limb, the final fragment of bone had snapped. The limb was free and it fell to the table. For the first time raising her voice, Lucy said, "Catch it! Quickly!"

But the warning was too late. As the intern grabbed and missed, the leg slipped from the operating table and thudded to the floor.

"Leave it there!" Lucy spoke sharply as, forgetful of the fact that he would render himself unsterile, the intern bent to retrieve the limb. Embarrassed, he straightened up.

The circulating nurse moved in, collected the leg, and began to wrap it in gauze and paper. Later, along with more packages containing other surgical specimens, it would be collected by a messenger and taken to Pathology.

"Hold the stump clear of the table, please." Lucy gestured to the intern, and he moved around her to comply. The scrub nurse had a rasp ready, and Lucy took it, feeling for the rough edges of bone that the break had left and applying the rasp to them. Again for the students she said, "Always remember to get the bone end clean, making sure that no little spikes stick out, because if they do, they're likely to overgrow and become extremely painful." Without looking up, she asked, "How are we doing for time?"

The anesthetist answered, "It's been seventy minutes."

Lucy returned the rasp. "All right," she said; "now we can begin to sew up." With the end in sight she found herself thinking gratefully of the coffee which would be waiting in the surgeons' room down the hall.

Mike Seddons had, quite literally, sweated out the period while Vivian was undergoing surgery. With the Loburtons - Vivian's parents had remained in Burlington and planned to stay on for the time being - he had gone to one of the small waiting rooms reserved for relatives of surgical patients. Before that, in the early morning and with the hospital only just beginning to come awake, he had met them at the main doorway and taken them to visit Vivian in her hospital room. But there had seemed little to say, and Vivian, already drowsy from sedation, appeared hardly aware that they were with her. Then, a few minutes after they had come, she was wheeled away to the surgical floor.

Now, in the uneasy backwater of the sparsely furnished room with its uncomfortable leatherette chairs and varnished tables, the three of them had run out of even the most perfunctory conversation. Henry Loburton, tall and heavily built, his thinning hair iron gray, his face creased and weathered from years spent in the open air, stood by a window, looking down at the street below. Mike Seddons could predict that in a moment or two Vivian's father would turn from the window, go back to one of the leatherette chairs, then after a while get up and cross to the window again. It was a sequence the older man had been following for more than an hour, a slow-fire nervousness that caused Seddons to wish desperately that he would vary it a little - either move more quickly or, once in a while, change the interval of time between the two positions.

In contrast, Vivian's mother had remained still - almost, it seemed, unmoving since they had come here. She had chosen a straight-backed chair in preference to some of the others which appeared more comfortable and held herself upright in a way that suggested a habit of conscious self-discipline. As she had for some time now, Angela Loburton was looking directly ahead, her eyes, it seemed, on infinity, her hands crossed delicately in her lap. Today her color was paler than usual, but the high cheekbones, which accented a natural dignity and poise, were as noticeable as ever. At one and the same time she seemed a woman fragile but indestructible.

Since their first meeting a few days before Mike Seddons had wondered several times about Mrs. Loburton. Her emotion, her fears about Vivian, had been much less transparent than those of her husband; and yet, as the days went by, Seddons sensed that they were as deep, perhaps deeper. He also suspected that, despite the apparent masculinity of Vivian's father, her mother possessed by far the stronger character of the two and that she was the rock on which, over the years of their marriage, her husband had come to depend.

Seddons found himself wondering how it would be between himself and Vivian in the time ahead. Which of them would prove, in the end, more resolute and more enduring? He knew that no two people were ever quite equal, either in strength of character or in leadership, or even in the capacity to love. He knew, too, that difference in sex had little to do with it, that women were often stouter than men in mind and heart, and that apparent masculinity was sometimes a hollow pose designed to camouflage internal weakness.

Was Vivian stronger than himself, her character finer, her courage higher? The question had come to him last night and had remained with him since. He had gone to see her, knowing the decision had been made to amputate and aware that Vivian knew it too. He had found her, not in tears, but smiling. "Come in, Mike darling," she had said, "and please don't look so glum. Dr. Grainger's told me, and I've done my crying, and it's over now - or at least it will be in the morning."

At the words he had felt his love for her deepen, and he had held her and kissed her passionately. Afterward she had twisted his hair affectionately and, holding his head back, had looked directly into his eyes.

"I'm going to have just one leg, Mike," she had said, "for all the rest of my life. I won't be the girl you met - not as you met me, and not as you know me now. If you want out, I'll understand."

He had answered emphatically, "Don't talk like that!"

"Why?" she had said. "Are you afraid to talk about it?"

"No!" It was a loud, firm protest, but even as he made it he had known it to be a lie. He was afraid, just as he sensed that Vivian was not - not now, not any more.

It was a reflection of Vivian, he realized, that he could see now in her mother - or, he supposed, the other way around. The sense of strength was there, unmistakable, in both. Could he match it with his own? For the first time a feeling of uneasy doubt assailed him.

Mr. Loburton had broken his routine. He had stopped halfway between the window and the chair. "Michael," he said, "it's been an hour and a half. Can they be very much longer?"

Seddons found Vivian's mother looking at him too. He shook his head. "I don't believe so. Dr. Grainger said she'd come here . . . immediately after." He paused, then added, "We should all know something - very soon."