Date: February 26th, 2023 4:29 PM
Author: Umber toilet seat
A t seven a.m. on Thursday Mr Reagan was
wheeled through the swinging doors and down
the corridor to operating room six. He was
lying flat on the gurney, and his gaze was fixed on the
ceiling; he had the glassy stare of a man in shock. I
was concerned that he had been given analgesia, but
the attendant assured me that he had not. As we were
talking, Mr Reagan turned his eyes to me: the pupils
were wide, dark as olives, and I recognized the dilation
of pain and fear. I felt sympathy, but more, I was
relieved that he had not inadvertently been narcotized,
for it would have delayed the operation for days.
I had yet to scrub and placed my hand on his shoulder
to acknowledge his courage. His skin was coarse
beneath the thin sheet that covered him, as the pili
erecti tried in vain to warm the chill we had induced.
He shivered, which was natural, though eventually it
would stop — it must — if we were to proceed with
the surgery. I removed my hand and bent to examine
the plastic bag that hung like a showy organ from the
side of the gurney. There was nearly a litre of pale
urine, which assured me that his kidneys were func-
tioning well.
I turned away, and entering the scrub room, once
more conceptualized our plan. There were three teams,
one for each pair of extremities and a third for torso
and viscera. I headed the latter, which was proper, as
the major responsibility for this project was mine. We
had chosen to avoid analgesia, the analeptic properties
of excruciating pain being well known. There are
several well-drawn studies that conclusively demon-
strate the superior survival of tissues thus exposed,
and I have cited these in a number of my own mono-
graphs. In addition, chlorinated hydrocarbons, which
still form the bulk of our anesthetics, are tissue-toxic
in extremely small quantities. Though these agents
clear rapidly in the normal course of post-operative
recovery, tissue propagation is too sensitive a pheno-
menon for us to have risked their use. The patient was
offered, routinely, the choice of an eastern mode of
anesthesia, but he demurred. Mr Reagan has an obdu-
rate faith in things American.
I set the timer above the sink and commenced to
scrub. Through the window I watched as the staff
went about the final preparations. Two large tables
stood along one wall, and on top of them sat the
numerous trays of instruments we would use during
the operation. Since this was the largest one of its kind
any of us at the center had participated in, I had been
generous in my estimation of what would be needed.
It is always best in such situations to err on the side of
caution, and so I had ordered duplicates of each pack
to be prepared and placed accessibly. Already an
enormous quantity of instruments lay unpacked on
the tables, divided into general areas of proximity.
Thus, urologic was placed beside rectal and lower
intestinal, and hepatic, splenic, and gastric were
grouped together. Thoracic was separate, and ortho-
pedic and vascular were divided into two groups for
those teams assigned to the extremities. There were
three sets of general instruments — hemostats, forceps,
scissors, and the like — and these were on smaller
trays that stood close to the operating table. Perched
above them, and sorting the instruments chronologic-
ally, were the scrub nurses, hooded, masked, and
gloved. Behind, and throughout the operating room
circulated other, non-sterile personnel; these were
principally nurses and technicians, who carefully
avoided the sterile field being constructed about the
perimeter of the operating table but otherwise roamed
freely, thus functioning as the extended arm of the
team.
For the dozenth time I scrubbed my cuticles and the
space between fingernail and fingertip, then scoured
both sides of my forearms to the elbow. The sheet had
been removed from Mr Reagan, and his ventral surface
— from neck to foot — was covered by the yellow suds
of antiseptic. His pubic parts, chest, and axilla, had
been shaved earlier, although he had no great plethora
28
of hair to begin with. The artificial light striking his
body at that moment recalled to me the jaundiced hue
I have seen at times on certain dysfunctional gall
bladders, and I looked at my own hands. They seemed
brighter, and I rinsed them several times, then backed
into the surgical suite.
A nurse approached with a towel, whose comer I
grabbed, proceeding to dry methodically each finger.
She returned with a glove, spreading the entrance
wide as one might the mouth of a fish in order to peer
down its throat. I thrust my fingers and thumb into it
and she snapped it upon my forearm. She repeated
the exchange with the other, and I thanked her, then
stood back and waited for the final preparations.
The soap had been removed from his skin, and now
Mr Reagan was being draped with various-sized linens.
Two of these were used to fashion a vertical barrier at
the mid-point of his neck; behind this, with his head,
sat the two anesthesiologists. Since no anesthetic was
to be used, their responsibility lay in monitoring his
respiratory and cardio-vascular status. He would be
intubated, and they would make periodic measure-
ments of the carbon dioxide and oxygen content of his
blood.
I gave them a nod and they inserted the intracath,
through which we would drip a standard, paralytic
dose of succinylcholine. We had briefly considered
doing without the drug, for its effect, albeit minimal,
would still be noticeable on the ablated tissues. Finally,
though, we had chosen to use it, reasoning — and
experience proved us correct — that we could not rely
on the paralysis of pain to immobilize the patient for
the duration of the surgery. If there had been a lull,
during which time he had chosen to move, hours of
careful work might have been destroyed. Prudence
dictated a conservative approach.
A fter initiating the paralytic, Dr Guevara, the
senior anesthesiologist, promptly inserted the
endotracheal tube. It passed easily for there
was little, if any, muscular resistance. The respirator
was turned on and artificial ventilation begun. I told
Mr Reagan, who would be conscious throughout, that
we were about to begin.
I stepped to the table and surveyed the body. The
chest was exposed, as were the two legs, above which
Drs Ng and Cochise were poised to begin.
“Scalpel,” I said, and the tool was slapped into my
palm. I transferred it to my other hand. “Forceps.”
I bent over the body, mentally drawing a line from
the sternal notch to the symphysis pubis. We had
studied our approaches for hours, for the incisions
were unique and had been used but rarely before. A
procedure of this scale required precision in every
detail in order that we preserve the maximal amount
of viable tissue. I lifted the scalpel and with a firm and
steady hand made the first cut.
He had been cooled in part to cause constriction of
the small dermal vessels, thus reducing the quantity
of blood lost to ooze. We were not, of course, able to
use the electric scalpel to cut or coagulate, nor could
we tie bleeding vessels, for both would inflict damage
to tissue. Within reason, we had chosen planes of
incision that avoided major dermal vasculature, and
as I re-traced my first cut, pressing harder to separate
the more stubborn fascial layers, I was re-assured by
29
paucity of blood that was appearing at the margins of
the wound. I exchanged my delicate tissue forceps for
a larger pair, everting the stratum of skin, fat, and
muscle, and continuing my incision until I reached
the costochondral junction in the chest and the linea
alba in the belly. I made two lateral incisions, one from
the pubis, along the inguinal ligament, ending near
the anterior superior iliac spine, and the other from
the sternal notch, along the inferior border of the clavicle
to the anterior edge of the axilla. There was more
blood appearing now, and for a moment I aided Dr
Biko in packing the wound. Much of our success at
controlling the bleeding depended, however, upon
the speed at which I carried out the next stage, and
with this in mind, I left him to mop the red fluid and
turned to the thorax.
Pectus hypertrophicus occurs perhaps in one in a
thousand; Billings, in a recent study of a dozen such
cases, links the condition to a congenital aberration of
the short arm of chromosome thirteen, and he postulates
a correlation between the hypertrophied sternum, a
marked preponderance of glabrous skin, and a mild
associative cortical defect. He has studied these cases;
I have not. Indeed, Mr Reagan’s sternum was only the
second in all my experience that would not yield to
the Lebsche knife. I asked for the bone snips, and with
the help of Dr Biko was finally able to split fire structure.
My forehead dripped from the effort, and a circulating
nurse dabbed it with a towel.
I applied the wide-armed retractor, and as I ratcheted
it apart, I felt a wince of resistance. I asked Dr Guevara
to increase the infusion of muscle relaxant, for we
were entering a most crucial part of the operation.
“His pupils are fixed and dilated,” he announced.
I could see his heart, and it was beating normally.
“His gases?” I asked.
“O 2 85, CO 2 , pH 7.37.”
“Good,” I said. “It’s just agony then. Not death.”
D r Geuvara nodded above the barrier that separated
us, and as he bent to whisper words of encourage-
ment to Mr Reagan, I looked into the chest.
There I paused, as I always seem to do at the sight of
that glistening organ. It throbbed and rolled, sensu-
ously, I thought, majestically, and I renewed my vows
to treat it kindly. With the tissue forceps I lifted the
pericardium and with the curved scissors punctured
it. It peeled off smoothly, reminding me fleetingly of
the delicate skin that encloses the tip of the male
child’s penis.
In rapid succession I ligated vena cava and cross-
clamped the descending aorta, just distal to the bron-
chial arteries. We had decided not to use our bypass
system, thus obviating cannulations that would have
required lengthy and meticulous suturing. We had
opted instead for a complete de-vascularization distal
to the thoracic cavity, reasoning that since all the
organs and other structures were to be removed anyway,
there was no sense in preserving circulation below the
heart. I signalled to my colleagues waiting at the lower
extremities to begin their dissections.
I isolated the right subclavian artery and vein, ligated
them, and did the same on the left. I anastomosed the
internal thoracic artery to the ventral surface of the
aortic arch, thus providing arterial flow to the chest
wall, which we planned to preserve more or less intact.
I returned to the descending aorta, choosing 3-0 Ethilon
to assure occlusion of the lumen, and oversewed twice.
I released the clamp slowly: there was no leakage, and
I breathed a sigh of satisfaction. We had completed a
crucial stage, isolating the thoracic and cephalic
circulation from that of the rest of the body, and the
patient’s condition remained stable. What was left
was the harvesting of his parts.
I would like to insert here a word on our behalf, our
in the larger sense of not just the surgical team but the
full technical and administrative apparatus. We had
early on agreed that we must approach the dissection
assiduously, meaning that in every case we would
apply a greater, rather than a lesser, degree of scrupu-
lousness. At the time of the operation no use — other
than in transplantation — had been found for many of
the organs we were to resect. Such parts as colon,
spleen, and vasculature had not then, nor have they
yet, struck utilitarian chords in our imaginations.
Surely, they will in the future, and with this as our
philosophy we determined to discard not even the
most seemingly insignificant part. What could not
immediately be utilized would be preserved in our
banks, waiting for a bright idea to send it to the regen-
eration tanks.
It was for this reason, and this reason alone, that the
operation lasted as long as it did. I would be lying if I
claimed that Mr Reagan was not in constant and excru-
ciating pain. Who would not be to have his skin
fileted, his chest cracked, his limbs meticulously
dissected and dismembered? In retrospect, I should
have carried out a high transection of the spinal cord,
thus interrupting most of the nerve fibers to his brain,
but I did not think of it beforehand and during the
operation was too occupied with other concerns. That
he did survive is a testimony to his strength, though I
still remember his post-operative shrieks and protes-
tations. We had, of course, already detached his upper
limbs, and therefore we ourselves had to dab the
streams of tears that flowed from his eyes. At that
point, there being no further danger of tissue damage,
I did order an analgesic.
After I had successfully completed the de-vascu-
larization procedure, thus removing the risk of life-
threatening hemorrhage from our fields, I returned to
the outer layer of thorax and abdomen. With an Adson
forceps I gently retracted the thin sheet of dermis and
began to undermine with the scalpel. It was pains-
taking, but after much time I finally had the entire
area freed. It hung limp, drooping like a dewlap, and
as I began the final axillary cut that would release it
completely, I asked Ms Narciso, my scrub nurse, to
call the technician. He came just as I finished, and I
handed him the skin.
I confess that I have less than a full understanding
of the technology of organ variation and regenera-
tion. I am a surgeon, not a technologist, and devote
the major part of my energies toward refinement and
perfection of operative skills. We do, however, live in
an age of great scientific achievement, and the icono-
clasm of many of my younger colleagues has forced
me to cast my gaze more broadly afield. Thus it is that
I am not a complete stranger to inductive mitotics and
controlled oncogenesis, and I will attempt to convey
the fundamentals.
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