The Necessary Evil

by André Couvreur

  Bordier finished cleaning the abdomen, preparing the operational area. After having swept the abdomen and the vulva with a razor, he soaped the skin until it was red, bathed it in a solution of phenol, dried it with sterilized compresses that he took out of a nickel box as needed. Finally, he surrounded the region in which the operation was about to take place with aseptic cloths.

  “Are you ready, Bordier?” asked Caresco. “Do you have everything you need to hand?” He palpated the abdomen, delimiting a region. “You see, Messieurs, that it’s a large fibroma, rising well above the navel. Daylight, Messieurs, I beg you—move back a little.”

  He spoke authoritatively. The spectators stepped back. A frisson of expectation passed through them, as at the approach of an important event. From among the instruments drowned in the phenol solution that filed two trays on a movable table within arm’s reach, the surgeon seized a scalpel, and without seeming to be in a hurry, while cleaving the skin from the navel to the pubis, continued speaking.

  “I’m carrying out a total abdominal hysterectomy in accordance with my own method. Sponge, Bordier.”

  A large furrow was traced; blood filled it. When Bordier had sponged it with tampons of wadding steeped in a solution of sublimate, the sides of the furrow appeared, a granite of yellow fat, and at the bottom, a gleaming white nacreous tissue, the aponeurosis.

  With a single stroke, the surgeon had brought his scalpel directly to the place he wanted to go. That magisterial cut immediately denoted the astonishing precision of gesture with which he was endowed.

  He replaced the scalpel on the tray, seized a pair of scissors, and with a single stroke, like a seamstress cleaving fabric, he cut through the aponeurosis and the subjacent peritoneum, the envelopes of the viscera. A flood of entrails sprang forth, which he compressed with his hand, while Bordier fixed the peritoneum with two clamps. Beneath Caresco’s hand, a monstrous block of flesh, rounded in form and violet in color, striped with red vessels, surged in its turn from the cage that imprisoned it, coming to float on the surface of the enormous gaping wound. It was the fibrous tumor.

  During the impressive minute that the surgeon’s maneuver had lasted, silence had reigned. The watchers had even held their breath, and the patient, in that grave moment, seemed to be doing likewise. Her respiration, having become calm, elevated the disgrace of her bare breasts regularly, while the sister administering the chloroform parted the eyelids in order to appreciate the insensibility of the cornea—red, congested and tearful—with her index finger. When the tumor appeared, however, a murmur of astonishment ran through the assembly. What! So rapidly! The young master had scarcely had time to pick up his instruments, and the fibroma was already uncovered! Only the Austrian professor and a French physician conserved the placidity of their physiognomy

  Armand Caresco turned to the audience. He saw the three rows of the thirty faces attentive and excited. A surge of pride brushed his heart, but he suppressed it, determined to be entirely modest today and not to say, as he usually did: “Well? I don’t think there’s another surgeon in Paris capable of opening a belly as rapidly!” He merely smiled.

  “It’s a very simple case, Messieurs. There are no adherences. I would have liked to show you something more difficult, but I think the operation will be swiftly terminated.”

  He was gripped again by the interest of his work. Bordier sponged; once the tampons were soiled with blood he threw them on the floor. The wound remain neat and clean. The intestines were pushed back, maintained by sterilized cloths that Soeur Cunégonde presented with forceps. The tumor, lifted as far as possible outside the abdominal cavity, was thrown toward the thighs, and Bordier arranged cloths around it, ornamenting it with a kind of coquetry

  They paused momentarily to pass their hands through the sublimate again.

  “Now, Messieurs,” said Caresco, “I incise the vagina behind the neck, guiding myself with forceps introduced through the vulva.”

  His gesture followed his voice. While working with an astonishing presence of mind, Caresco gave his audience a veritable lesson, without departing from the minutiae of his precautions. He sensed the approbation and the astonishment behind him; he garnered it like an intoxication that ran through his veins, rose to his brain and multiplied the agility of his fingers tenfold.

  A journalist asked: “My God, what is he doing? It’s frightful!”

  A physician in the entourage took responsibility for whispered explanations. “The operation known as total abdominal hysterectomy consists of removing, along with the fibrous body, the matrix on the flanks of which the fibroma is implanted, like a kind of monstrous parasite. The first condition of success is not to spread blood in the abdomen. The surgeon must, in order to succeed in that, make ligatures in the principal blood vessels nourishing the matrix before cutting them. Those vessels are located in special ligaments known as broad ligaments, which also serve to maintain the matrix; you can see that Caresco is occupied in searching for the ligaments—and with what mastery, Messieurs, with what genius! The rapidity, precision and audacity are marvelous!”

  Indeed, his hands plunged into the abdomen whose walls Bordier was holding agape with the aid of broad-tipped separators, the ardent operator was palpating the sinuous contours of the tumor. He gazed. The light shed by the ceiling window only illuminated a dark opening where blood was coagulating.

  “Sponge, Bordier!”

  Bordier swept the abdomen with a compress imprisoned in the jaws of a forceps. Again the surgeon’s hands plunged. His brows were furrowed. All of his will-power, and all of his attention, were absorbed in that obscure search. The tumor was in his way; with the back of his hand, he nudged it.

  Around him, the people who could not follow the delicate work straightened their curved stances, abandoning a fatiguing pose. The Viennese professor put an end to all the whispered conversations with a gesture.

  “There’s the broad ligament on the left!” exclaimed Caresco. “The ugly brute—it wasn’t easy to find. Bordier, a double silk thread!”

  The aide took special threads from a tray and applied them to the needle that Caresco was holding out. The needle was plunged into the black void, pricked, brought back, and Bordier made a knot. The ligament was ligatured.

  “You see how my needle functions, Messieurs. Is it not practical? And can you imagine that it isn’t used by all the surgeons in Paris? But then, I’m not in the Club myself. It appears that I frighten them...”

  He turned to the grave Viennese professor and continued in German: “Herr Stermann, it’s truly regrettable that public education is not organized in France as it is in your homeland. I’d have all the students of the Faculté at my operations…whereas they dare not come...”

  While speaking he had tied the second broad ligament. A few strokes of the scissors permitted the detachment of the uterine body. The surgeon’s fingers plunged into the mass of tissues, lacerating and tearing adherences, twisting shreds, decorticating the perineum, accomplishing as much work as the instruments. An abrupt traction brought the tumor and the matrix out of the abdomen. Violently projected, the fibrous mass bounced on the floor, rolling to Soeur Cunégonde’s feet; she kicked it to one side. Another sister picked it up and plunged it into a bucket. Approving murmurs ran through the audience. A pale journalist, with large drops of sweat on his face, was obliged to sit down.

  Armand Caresco calculated the depth of the abdominal wound. At the bottom, a pool of blood was slowly expanding; a blood vessel must have been torn by the violence of his movements. He looked at the patient, whose lips were pale, but nevertheless allowing a regular breath to escape.

  “Sponge, Bordier.”

  Compresses plunged into the viscera, bringing forth streams of blood.

  “There’s the vessel that’s bleeding,” said Bordier, imprisoning it with the jaws of a forceps.

  Caresco took a piece of thread and tied it.

  “You see, Messieurs, how simple it is,” he went on. “I pass the th
reads of the ligature through the vagina, I complete the hemostasis of the broad ligaments with a few clamps, which I leave in the vagina, and which I shall retract tomorrow. I shall also leave a drain in place there that will permit liquids to flow away, and I shall stuff the vaginal cavity with iodoformic gauze. My method is elegant and rapid. It remains now for me to close the pelvic peritoneum by means of an oversown suture; then I stitch the abdominal wound, after having taken care to clean out the cavity completely.”

  Indeed, he swept the floor of the abdomen by plunging in compresses fixed to long forceps. To begin with, those compresses came back stained with blood, but were clean and dry thereafter.

  As the patient seemed to be waking up, he ordered the sister to render chloroform, and by means of a long needle, into the eye of which Bordier passed threads, he brought together the walls of the abdomen, linking them with several rows of sutures.

  “A little more chloroform, Sister, for the closure of the skin. That’s always the most painful part.

  The sister poured anesthetic on to the compress. The patient’s breathing accelerated noisily, with inarticulate noises, vague and incoherent plaints that emerged from her throat. For greater surety, the sister gripped the tongue with special forceps, and pulled it out of the mouth. And the operation was concluded thus, without any further alert, with a general contentment at seeing that everything had gone well, without the abrupt asphyxias that throw alarm into hearts.

  While Bordier surrounded the wound, now closed, with a pad of cotton wool and a tightly-secured body-bandage, in the relaxation that followed, the surgeon took off his waxed cloth apron and made the stains on his arms disappear under the hot water tap.

  Colleagues pressed around him, indifferent to the cares consecutive to the operation, to the bustle of the sisters and male nurses, and to the hasty words of Soeur Cunégonde, who was supporting the swaying body of the patient in her arms, passing a decent chemise over it, and ordering: “Over the arms now. Quickly! Lift up the basin! Clean the thighs, over the undersheet...”

  No, all of that counted for nothing compared with the interest of what the young master was saying—who, while soaping his muscular and powerful arms scrupulously, was affirming once again the value and rapidity of his method, citing statistics and offering the standard fare of denigrating the surgeons of Paris, his competitors, in ironic terms...

  “Do you think that Monant and the rest would have operated as I have just done? Get away! An old fossil, Monant, who has never known how to hold a scalpel. For one thing, his statistics are false! What he tells the Societé de Chirurgie doesn’t stand up, I can assure you!”

  Then, his toilette concluded and his hands dry, in the triumph of his young and vigorous talent, he accompanied his guests to the reception room, desirous of sensing yet again the incense of congratulations, abandoning his patient to the care of the two sisters who replaced her on the wheeled bed that had already served to put her to sleep, and pushed her on that apparatus to the elevator. They took her out on the third floor in order to transport her, still asleep, her breathing agonized, to the room she occupied.

  As for Bordier, he remained in the operating theater to supervise the cleaning that the sisters were carrying out on the parquet and the tables, and to prepare, with the same scrupulous precaution, the instruments utilizable in the trepanning operation that was to be carried out on the little girl dying of tubercular meningitis.

  Upstairs, on the fourth floor, in an attic room, the old grandmother, sitting next to a child’s cradle, was contemplating the atonal face of her granddaughter despairingly. She had arrived the previous evening, on foot, carrying her precious burden in her weary arms. As soon as she had crossed the threshold, an anguish had swollen her heart. The sisters had received her in an indifferent fashion. Pressed by the urgency of their work, and insouciant in regard to a poor client, they had not cast the benevolent dew of consolation over her, or soothed her with the pious words that calm simple natures.

  After being taken through the luxury of the stairway, she had been shown to a stifling little mansard, scarcely ventilated by a narrow hinged panel, only furnished with a commonplace bed, a chair and a miserable wooden table. Very late, a domestic had come to shave the head of the dying girl, make up a crib without curtains, and, after having lit a night-light, had retired, indifferent and mute.

  Terribly sad and worn out, she had not gone to bed, allowing the ashes of the cold and darkness to fall upon her shoulders, desolate and exhausted, without revolt, spending the night beside the crib, holding the hands of the dying child in her own withered hands, watching out for a glimmer of consciousness in the child’s extinct gaze, frightened by the croaks emerging from the dry throat and the contractions that reawakened the numb limbs. Her poor, hollow aged eyes had no more tears to shed; her brain was devoid of thought; there was a dolorous annihilation, which only permitted her a heart-breaking contemplation, rendering her insensitive to hunger and the torpor of the shadows.

  Then, the daylight had appeared, slowly, wan and gray at first—as gray as her soul—until the moment when the sun’s rays, entering triumphantly through the window, had come to pose on the child’s dear and pitiful head, bringing out the bumpy contours and inequalities of the lamentably shaven head. And that ray, the kiss of the dawn, as gentle as a heavenly caress, had finally reawakened the dried-up source of her tears, and brought large bitter drops to the furrowed wrinkles of her cheeks, subtly bringing the obsession of external joys, of the nature that was waking up, of the triumph of life.

  “It will be early tomorrow morning,” Soeur Cunégonde had said to her.

  How long the hours were in passing, how slowly time marched in its course!

  Now, a madness took hold of her, bidding her to flee, to take her treasure away, not to submit her to the frightful practices of surgeons. What if they were going to kill her? What if her darling might get better without the operation?

  And yet she stayed, nailed down by the force of reason, of hope.

  Down below, footsteps made the parquet creak. An agitation rose up. A ringing bell made her shiver. Others succeeded it, which were followed by the sound of male voices.

  Someone came in, who spoke to her. It was a sister with blue eyes. What was she saying? She did not reply. More time went by, punctuated with muffled sounds, of footsteps on the stairway, of the banging of doors, of more ringing of the doorbell. The old woman did not let go of her darling’s hand.

  Finally, Soeur Cunégonde came in, followed by a domestic.

  “It’s your turn now,” she said.

  She was in a great hurry, out of breath from climbing the stairs. She went back down right away. The man took the child in his arms and followed her. The grandmother did not make a single gesture, did not pronounce a single word. Her head in her hands, she was frozen in stupid contemplation of the empty crib.

  When the child was brought in, Bordier, instead of putting her to sleep on the chloroform bed, put her down on the operating table immediately. While the sisters attached her arms and legs with thongs, he soaped and passed sublimate over the swaying shaven head. He garnished the operating area with compresses, and then, very gently, began to provoke sleep.

  At the same moment, Caresco came back from the reception room, followed by his cortege of admirers.

  “Go gently with the chloroform, won’t you, Bordier?” he said, as he went to scrub his arms again, while the spectators arranged themselves. Then, while continuing to soap himself, he went on: “Messieurs, this little girl is, as you can observe, in the final phase of tubercular meningitis. All the signs are there; in any case, the diagnosis has been made by my father, here present.”

  Old Caresco inclined his head, and then straightened up proudly. Gazes attached themselves to him, fixing on his multicolored rosette.

  “This patient is irremediably lost. I shall therefore attempt to snatch her from death by means of the following operation: I shall trepan each side of the cranium, or, in pr
eference to the trepan, carry out a veritable craniotomy and draw back two large bony flaps, which will uncover the encephalum.

  “If I’m fortunate enough to happen upon a meningitis only affecting the convexity of the brain, I shall remove the fibrino-purulent exudate that covers it; I shall clean all that surface of the encephalum and destroy with fire the tubercular granulations seated on the lymphatic sheath of the vessels of the pia mater. I shall then fold back the bony flaps, being careful to leave drains in place for the outflow of liquids; the bones, at that age, will fuse together rapidly.

  “Evidently, there is a chance to attempt. I believe that I’m the first to try such an intervention for meningitis. It goes without saying that in the incision of the scalp I shall avoid the region of the temporal artery. In any case, we are going to make a kind of preventative hemostasis by circling the base of the cranial hemisphere with a taut rubber band. Let’s place the band, Bordier.”

  The inert head of the child was lifted up; an elastic band was placed around it, circling the forehead with a black strip passing above the ears. During that maneuver, Caresco, to while away the time for those surrounding him, continued his self-promotion.

  “Remember today’s date, Messieurs. I ask you for that favor because others, as soon as my intervention becomes known, will inevitably want to snatch the priority away from me. Those are present surgical mores, and every new step taken in the domain of the science is followed by a struggle to defend one’s rights. Yes, I’m the first to open the skull for this reason. Has not one of our colleagues, who is not of the Faculté, had the idea of using a dentist’s drill powered by an electric motor for uncovering the encephalum? Get away! The blind force of electricity will never replace the powerful intelligence of muscles. Muscles and reason! That’s what I have at my service.”