Many Changeful Years

By Graham Lister

Many Changeful Years might well have the subtitle The Moulding of a Surgeon for it tells of the early life of a man who became one of the first dozen or so microsurgeons to reattach amputated limbs (as outlined in the prologue, the story of an injured infant).

Throughout the main theme, the author interjects, as a counterpoint, tales and commentaries from his later life as an established surgeon, dealing with unique patients and colleagues, the working life of an emergency surgeon, errors and their causes, nursing practice, the adverse impact of managed care, changes in discipline and surgery in the less developed world.

The formative times that are the theme of the tale gave little hint of where Lister was going, for he grew up in a working class family in wartime Britain, a family that for several years lived in one room, often in straitened circumstance.

The memoir describes a Britain long since gone, a Britain still wedded to ancient measures and currency, confident of its Empire and its preeminence, but whose inhabitants suffered blackouts, night bombing raids, smoke screens, gas masks, and austere rationing not only of food but of clothing and household wares. And it was a Britain whose menfolk, such as the authors father, were absent, often not to return. If they did return it was as strangers, many bitter about the cards life had dealt them.

Many Changeful Years follows the author through these war years, examines life in the back streets of Glasgow, describes the pursuits of the times, carries him through school and on to an ancient University, supplementing the family budget throughout by working delivery trucks, cleaning guesthouses,cutting grass, delivering the Royal Mail, chicken farming, laying sewage pipe, serving as a hospital porter, a bus conductor and a mortuary attendant.

The British National Health Service is a daring innovation, appealing to the author, then both a nationalist and a socialist. Glasgow Royal Infirmary, where Joseph Lister developed antiseptic surgery, has a 200-year history; its casualty department is the busiest in Europe; in it physicians learn of the ways of gangland, managing wounds inflicted by chains, razors and sharpened metal combs.The nursing staff of the 1950s, which has a proud legacy, rigidly controls the open wards. Obstetric training requires that the undergraduate perform deliveries; the author goes to a working class London hospital where he learns much from the mothers and midwives. Prejudice is strong in Glasgow society, similar to that in Northern Ireland. He works as a substitute doctor in the back streets of Glasgow and around Britain.

Five years in the Royal Navy commence with basic training; instructors attempt to create leaders of men from physicians, dentists and pastors. The author joins a frigate bound for the West Indies; officers and training exercises are described. Damage control at sea demands a strategy for tending multiple casualties
The frigate was designed for 120 but carries over 200. The authors report shows that it is unfit for habitation with conditions worse than those prescribed in the Poor Houses Act of 1887. The frigate acts as guard ship at the talks between Macmillan and Kennedy in the Bahamas in December 1962; the author remarks in his journal on the lapses in the Presidents security. Riots break out in British Guiana; the frigate assists. During the Cuban missile crisis the vessel encounters the U.S. blockade.

Studies at the Royal College of Surgeons of England follow. At the Naval Hospital he serves under a surgeon who first used antibiotics in the military on HMS Hood in 1938. The author treats the Admiral who saved the British Far Eastern fleet from a fate similar to Pearl Harbor.
The author goes to the island of Mauritius for three years; there are multiple ethnic groups in one of the highest population densities in the world. The Navy occupies a re

• Language: English
• Publisher: Xlibris US
• Release date: Jun 14, 2005
• ISBN: 9781462842452

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Copyright © 2005 by Graham Lister.

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Contents

PREFACE

PROLOGUE

Utah, 1990

CHAPTER 1

England, 1940

CHAPTER 2

Images of War

CHAPTER 3

And When Did You Last See Your Father?

CHAPTER 4

A Schoolboy’s Tale

CHAPTER 5

Moments of Destruction

CHAPTER 6

Enthusiasms of the Young

CHAPTER 7

Time Ill-Spent

CHAPTER 8

Pigeonholes and Chicken Coops

CHAPTER 9

Glasgow Transport

CHAPTER 10

Innocents Abroad

CHAPTER 11

Of Chains and Razors and Cheap Steel Combs

CHAPTER 12

Of Babies, Errors and Prejudice

CHAPTER 13

A Brand New Doctor

CHAPTER 14

Good Order and Military Discipline

CHAPTER 15

They Sailed Away for a Year and a Day

CHAPTER 16

A Would Be Surgeon

CHAPTER 17

A Right Little, Tight Little Island

CHAPTER 18

Out of Africa

CHAPTER 19

Plastic Gods

CHAPTER 20

. . . This Microsurgical Nonsense

CHAPTER 21

Go West Young Man

"All men of whatsoever quality they be . . .

ought, if they are persons of truth and honesty,

to describe their life with their own hand . . ."

Benvenuto Cellini, 1558

PREFACE

I’ve seen mony changefu’ years,

On earth I am a stranger grown;

I wander in the ways of men,

Alike unknowing and unknown.

Robert Burns

There are advantages of travel and of changing one’s location, both in experience gained and in experience shared. But you never quite belong. In the United States I am often asked where I am from, while in Scotland acquaintances comment on my American accent. Were I to return there, to my birthplace, I would now be a stranger grown. Even within these United States, so varied are their inhabitants, the more I wander, the more I become unknowing and unknown. One of the benefits of wandering, of visiting many countries, is the worldwide network of talented folks whom one can count amongst one’s friends. That talent is represented here by the art of Katharina Germann, to whom I give thanks; a detail from one of her works, generously donated, illuminates the cover.

This is a memoir, not an autobiography. To quote Gore Vidal, "A memoir is how one remembers one’s own life, while an autobiography is history, requiring research, dates, facts double-checked." As I record my memories, in probably more instances than I would admit, that memoir is remembered fiction. As Mark Twain wrote When I was younger I could remember anything, whether it had happened or not; but my faculties are decaying now and soon I shall be so I cannot remember any but the things that never happened. It is sad to go to pieces like this but we all have to do it.

The theme of the book is formed by my recollections of my first four decades, growing up in Britain during the Second World War, attending an ancient University and medical school, serving in the Royal Navy and learning my trade as a surgeon. As I wrote I was often reminded of events from my later life in the United States, of surgical practice as it was and is, of patients I treated and who illustrate with their stories the advances I have witnessed. I have inserted some of those tales as a counterpoint to the main theme. For those who are irritated by time changes in the flow of a story, I have set these forward glances in italic type, so that the reader who so wishes can pass them by to pursue the underlying narrative. The Prologue is such a tale of the recent past, to show at the start the person I became and the work that I did. In that account, as in the remainder of the book, names have been changed to preserve anonymity.

PROLOGUE

Utah, 1990

Matthew was not quite one year old when he chopped off the index and middle fingers of his right hand; between the chain and the sprocket of the exercise bicycle his mother Ellie was riding.

I was in surgery when Matthew had his accident. We were making a thumb for a baby born without one, using her index finger, shortened and rotated. Amy, the little girl on the table, was approaching her first birthday, the same age as the Matt I was yet to meet.

As we were finishing up the new thumb, the phone rang. My chest constricted. Apprehension. The ring of a telephone had that effect when I was on call. In truth, it had become so much of a warning bell that it had a similar impact even when I was not. Why was I apprehensive? After all, I had been dealing with emergencies and other unanticipated surgical problems for decades. Was it fear of work, the knowledge that I may be about to spend another night under bright lights, with a full day to follow? Surely not. Like many surgeons I am a workaholic, only at peace when several responsibilities are competing for my undivided attention, and are likely to do so for the foreseeable future. Was it dread of failure? Although not the sole explanation, that may be a little closer to the truth. Perhaps this will be the case that finally exposes my technical limitations, or, if not that, my sense of insecurity. That insecurity so well hidden beneath an air of confidence that even to hint at my anxiety would cause any observer to scoff.

There’s a baby boy in the emergency room, said Jane, the circulating nurse, turning towards the table where we were working, with two amputated fingers. They want to know if you can see him.

I’ll go, volunteered Jim, a qualified plastic surgeon who was spending an extra year training in the capacity of a Fellow in Hand and Microsurgery. A tall, lean New Zealander, Jim had the broad shoulders and quiet confidence that told of his origins on a sheep farm, his recreations as a mountaineer and rugby lock forward.

No thanks, I replied. Why don’t you put on the cast and then join me?

Most surgeons leave the evaluation and scheduling of emergency cases to their juniors, preferring to appear only when all is ready, indeed when repair has commenced. Contrary to this widespread practice, I relish the opportunity to make first contact with an injured patient. My ever-present sense of urgency, yes, perhaps my fear of failure are best allayed if I have personally taken a thorough history of the accident and examined the patient. Only then could I chart a plan of action in which I had a semblance of confidence. I have also learned that meeting the patient and examining the injury dispels the apprehension that would haunt otherwise idle moments.

Most important, I knew that the patient, and especially the parents of a young patient, must be desperate in many ways, some of which I may never learn. Paramount amongst those must be their need for information and reassurance. They want to be told, in understandable language, the nature of the injury and its effect on function. They want to know what is to be done, what are the chances of full recovery and what dangers and complications are involved. Also of consequence is their unspoken demand, their right, to be assured that they are in competent hands. Rightly or wrongly, I feel that my thin and graying hair, my wrinkles, even the slump of my shoulders suggest experience that cannot be conveyed by the best educated but fresh-faced junior.

Did we know this baby was coming? I asked, as I turned from the table, peeling off my gloves.

No, said Jim. He must be local.

Well, that’s a blessing, I thought. While others may rest while awaiting a serious injury from afar, I always tune up my neurosis. If free of other commitments, the worst circumstance, I would lie, wide-eyed and damp with perspiration, planning how I was to deal with the patient yet to arrive. The planning, though unavoidable, was invariably worthless for I had only the information gleaned third-hand from a telephone message.

Reaching behind my back, I popped the strings holding my gown at the neck and waist. As I did I looked around at this, my second home . . . perhaps in truth my first. The room was identical to the other eleven in the suite: beige walls broken by the X-ray viewing boxes on the wall and by three doors, one to the scrub room, one to the central supply area and one the exit; an eight-foot ceiling, many of its panels transparent covering fluorescent tubes that cast light into every corner, a light that was dimmed by that coming from the two circular operating assemblies suspended from the roof over the operating table. On their long articulated arms they hovered over the central grouping like creatures from Jurassic Park. Appropriate to that analogy, everything in that grouping was covered in jungle green, the drapes that concealed all of Amy save her hand and forearm that lay on a board at right angles to the table, the gowns, caps and masks worn by Jim and Liz, the tall, rangy scrub nurse, the screen that concealed the anesthesiologist, John Park. Outside in the corridor there was a shout, one orthopedist to another, arranging a time to meet for that night’s football game.

I stripped off the paper garment, crumpled it into a large ball and flipped it across the room into the large waste bag, green, of course. Jane, the circulating nurse, short, plump, jovial as ever, clapped her hands.

Three points, said the anesthesiologist absentmindedly.

I checked my green scrub-suit for bloodstains. There were none, so I grabbed a white coat from the rack outside the OR, pulled off my shoe covers and dropped them in the trash; with a finger I lifted the strings of my mask off my ears. I stripped the Micropore tape from my nose; during surgery the tape prevented my breath from escaping above the mask, where it would condense on my magnifying glasses, called loupes, and obscure my view. I pulled the mask from over my mouth on to the front of my neck. I headed down the fire stairs to the emergency room.

Hi, said the emergency room (ER) nurse who was standing at the desk as I entered. They brought the fingers with them. I am having them X-rayed and I’ll put them back on ice. They’ll be in the ‘fridge’ in the utility room.

The ER nurse, Madeline, was of medium height, blonde and trim in a way that only vigorous exercise can produce. Despite my preoccupation with the new arrival, I still noted that she was good to look at. And she was very good at her job. She had come to the hospital only three months previously, but already I valued her expertise, gained from working with a hand service back East. She knew that we could learn valuable details from the X-rays of the amputated parts. She remembered that X-rays of the baby himself, awake and struggling, would tell us little or nothing and that they were better taken when he was anesthetized in the O.R. Madeline also knew not to bring the fingers into the same room as the infant. The parents had enough grief and guilt already, without those sad reminders.

The baby is not even a year old, said Madeline, shaking her head. Mother’s a wreck. Understandably.

How did it happen, d’you know?

The mother, Ellie Blair is her name, thinks that the baby must have grabbed at the chain of her exercise bicycle. She wasn’t looking at the time, but that’s where she found the fingers, on the floor below the back wheel.

Lordy, I said. I wonder what the chances of that are?

They’re in Room 3, she said, gesturing down the hall. Dad came straight from his work.

Ellie Blair was small and slender, pale and trembling, frantic with worry. Her dark, curly hair was uncombed, still damp from exercise, and from tears. She cradled the sleeping Matthew in her arms. John, her husband, some six feet tall, balding and bulky from regular manual labor, still in grease-stained dungarees, had his left arm around Ellie’s shoulders in support. A family in distress.

Hello, I said, I’m Graham Lister, extending my hand to shake with John, laying the other on Ellie’s forearm. I am one of the hand surgeons here.

I had no need to tell patients more about myself. Not that I believed it redundant, far from it. It was important that they learn of the qualifications, experience and skills of the surgeon to whom they were committed. But I knew that Clare, the nurse who worked with me, would remain with the parents after I had gone; as she explained again what was to happen, and as she answered their questions, she would reassure them about my experience, adding substance to the impression they may have gleaned from my evident middle age: the twenty plus years that I had been doing microsurgery, the large number of babies I saw, the teaching I did in various parts of the world. Unlike myself, she could tell it the way it was, without seeming boastful.

Can you put Matt’s fingers back? blurted Ellie.

I don’t know, I replied, I need to know more about what happened. Then I need to look at the fingers under a microscope. What I can tell you is that we will keep trying until we succeed or until nothing else can be done.

I paused, holding her gaze, to let that reassurance sink home. For it was true. There are many reasons, both absolute and relative, for not attempting to reattach amputated parts, a procedure known as replantation: severe injuries to other parts of the body, extensive damage to the limb or the part, and others. However, in certain instances, all but the most extreme of these were disregarded; one such instance was amputation in a child. With their almost miraculous powers of recovery and adaptation, their future as yet unplanned, for them we would persist however long it took. And that could mean many hours.

I had also had the chance to use one of my favorite phrases, I don’t know. Whether with patients or trainees, I searched for that opportunity. I don’t know, says several things. It suggests that one does not have the omnipotent complex often associated with physicians, especially surgeons. Most of us do not feel that way, even if we act it. Ours is a job of decisions and their successful execution. Once the decision is made we must proceed with confidence; from that confidence comes the persistence, the refusal to be thwarted by the vagaries of surgery, that may be the only route to success. And what would be gained if we were to display the doubts that nag at us to those who could do nothing but worry; staff and patients and relatives? It would be a personal catharsis that might assuage our fears, exculpate us from any impending disaster, but it would only heighten impotent concern in those good people. An undefined but significant part of the healing process is optimism shared by all concerned, optimism largely based on trust in those administering care. I don’t know also conveys honesty. Provided it is not the answer to an unacceptable number of questions, it reassures the listener that the speaker knows what he is talking about when he declares other facts to be true.

How did it happen? I asked.

Ellie recounted how she believed Matt had lost his index and middle fingers. She wept as she spoke, gulping every so often, glancing at John.

I should have been watching him, she sobbed. He embraced her more firmly, his arm tightening around her shoulder.

You know, Mrs. Blair, I said, "we see a lot of injured babies here. None of them are hurt because they were neglected. Accidents happen. It wasn’t your fault.

Really, I emphasized, seeing her doubt.

Do you need to look at his hand? Ellie asked. Matt’s arm had been encased in thick bandages by the Emergency Medical Techs who had responded to her 911 call.

Tears were streaming down Ellie’s face. She held the sleeping baby even more closely, leaning back against the linen-covered examination table that stood against the wall opposite the counter, over which were glass-doored cabinets stocked with boxes of sutures, syringes, gloves, instrument packs and local anesthetic agents.

No, I said, that would be hard on all of us, most of all Matt and yourself. And we wouldn’t be able to see anything that would help us. We’ll wait until he is asleep. Then we can take a close look.

By now Jim, the Hand Fellow, one of the anesthesiologists and Clare the nurse had arrived. Clare nodded at each parent in turn, catching their eye, and laid a hand on Matt; her crisp white dress, the neat way her golden hair was pulled back, her manner and bearing all attested to her competence and compassion. It was time for Jim and me to go to work. I gripped Ellie’s shoulder.

We will take the best care of Matt, I reassured her as I turned a little to grasp John’s hand again.

She nodded, meeting my eyes. Good, I thought, we may just have taken the first tiny step in her therapy. I was glad that Clare would keep up the process, for this family unit was now at risk. Clinical studies had shown that to be so, whatever we could do for Matt.

Jim and I went into the utility room. Its main feature was a large double sink and draining board of stainless steel. From the ice bucket in the refrigerator standing tall in the far corner I took out the small plastic pot containing the fingers. I emptied them on to a sterile towel on the counter. What pitiful fragments of tissue, each the size of a pencil stub. And each, if successfully replaced, capable of reading Braille, supporting the weight of a rock-climber, making love, who knows, perhaps doing what we were about to do, handling nylon invisible to the naked eye. I lifted the mask back on to my nose and slipped on a pair of rubber gloves. Lifting each finger in turn, I held it while Jim directed a stream of sterile normal saline on to the cut end.

Good, said Jim, there are no ‘dangles’.

He was referring to the fact that no nerves or vessels were dangling from the amputation site; if there had been, it would have meant that they had been pulled out of the hand. That would have meant a definite need for vessel and nerve grafts (grafts are spares taken from elsewhere in the patient’s body). Jim knew that grafts reduced the chance of success. But he also knew that, while the nerves were commonly avulsed from the hand and would therefore dangle from the finger, the all-important artery was more often pulled out of the finger as its small branches were torn free, like the roots of a plant plucked from the ground. Such an injury may negate the use of grafts, making our efforts worthless.

On the cut end of each finger we were looking at the cartilage of the joint surface of the middle bone, in other words, at one half of the middle joint of the digit. To the naked eye the cartilage appeared undamaged.

They’ve been taken off through the joint, I commented. If the surfaces are intact on the hand, we should save the joint. We can shorten the skeleton at the proximal phalanx (the bone of the finger closest to the hand).

We next looked at the skin of the fingers.

No other wounds, murmured Jim, and no red streaks.

He was referring to the bruising that occurs along the line of a blood vessel if its branches have been torn off under the skin—a bad sign.

Madeline came in with the X-ray of the fingers. Over her uniform she now wore a cloth gown, a cap concealed her short-cut hair and a mask hung around her neck. She handed the films to Jim who was not wearing gloves. He held the X-ray up to the light at an angle so that we could both study it. The two bones of each amputated finger were clearly displayed white against the dark ground, skeletons in space.

No bony damage, he remarked. This gave some evidence that there was no crush away from the amputation, crush that might well make impossible the replantation of the fingers.

Nothing bad so far, he said. Shall I tell anesthesia that it’s a go?

Yes, but don’t say anything more to the parents, I warned.

It was preferable if relatives had lower expectations than the possible outcome. It avoided raising their hopes prematurely, and perhaps wrongly. Jim grinned. He already knew not to say anything; in the ten weeks we had worked together, Jim had learned that I was superstitious about predicting results.

I’ll take the fingers and get started, I said, if you would move things along here.

I could do a lot of preparation on the fingers while Jim did all the paper work, and the staff moved Matt upstairs and put him to sleep.

The operating room was deserted when I returned, the floor moist from mopping, the air pungent with strong antiseptic. On the black rubber surface of the operating table, bright beneath both light assemblies, Jane had laid out microsurgical instruments, fine forceps, spring loaded scissors with blades one quarter the size of nail clippers, a scalpel, all on a green surgical towel. She had also brought in the operating microscope. Like a mutant heron, it stood over six feet tall, challenging the light assemblies for space. The two binocular eyepieces on an operating microscope are arranged opposite one another at the end of a sturdy arm that contains lamps even brighter than those overhead. The arm is articulated, having an elbow and a wrist to aim it as the surgeon wishes; it can also be swung around a central cylindrical column. The column is mounted on a heavy, three-footed base. At the ends of each foot are hand pieces; when turned clockwise the hand pieces raise the base on wheels so that the ‘scope can be moved. With those handles turned the other way, the microscope is immobile. It takes a strong man to tilt it, never mind knock it over. Which renders the eyepieces rigid in space, an essential feature.

After putting on a fresh mask, I scrubbed my hands, donned gloves and sat at the table on which I had laid Matt’s amputated fingers on a sterile towel. Using the three-pedal foot control for the microscope I zoomed to a magnification of times six, and focused down on the first of Matt’s fingers held firmly in a fold of flexible lead. I trimmed away just over a millimeter of skin all around the cut end of each finger, ensuring that the edges would be free of soiling from the chain. As I did so on the back of the digits, I hunted for veins. After a persistent search I found three in each finger. They were all under a millimeter in diameter, but firm to the touch of the forceps, suggesting that they were uninjured. I marked each with a stitch of 10/0 nylon, cutting one end of the stitch half the length of the other, to identify it as a vein.

I made a cut of about eight millimeters along either side of each finger; the incisions allowed me to lay back the skin, both back and front. On the back the veins went with the skin, so I freed them with fine scissors and laid them on the flat, thin extensor tendon (the one that straightens the finger). On the front I searched for and found the two arteries and two nerves in two matching bundles in each finger, one on each side of the flexor tendon sheath (the flexor tendons, of which each finger has two, bend the digit down into the palm). As was common, the two arteries in the middle finger were of equal size, while that in the index nearer to the thumb was smaller. That, together with the slight difference in length and the match of the joint surfaces would ensure we put the correct finger on each stump. Dissecting along the artery, I saw no bruising, and all the arterial branches were intact; two more good signs. I marked each of the arteries and nerves with a further stitch of 10/0 nylon, cutting the ends of each stitch differently so that they could be readily identified.

Although I was concentrating on finding all the parts needed for repair, I could not help but marvel, as ever, at the beauty that the microscope revealed. The tendon sheath was a delicate shade of pearl tinted with yellow; on its surface ran a delicate, red filigree made up of the minute blood vessels that supplied the sheath. The flexor tendons, which I brought out of the sheath by bending the end joint, were smooth and the color of ivory, handsome and immensely strong. The two flexor tendons have an intertwined relationship with one another that makes engineers drool. I placed a strong holding stitch deep into each flexor tendon, leaving the ends long; we would later complete the repair to the cut end of the tendons in the hand.

By the time I was through, Matt had arrived and been anesthetized. X-rays of his hand had been taken; they showed no bony injury other than the amputations through the joint. Jane had prepped his injured hand and arm with antiseptic solution, and draped all but that upper limb with sterile towels. After we had scrubbed, gowned and gloved, Jim and I went to work on the stumps of the amputated fingers. We first dilated the arteries with fine, very smooth forceps designed for the job; we held the vessels out to length. Each sent a pulsating stream of blood several inches across the table, like a small boy peeing in the gutter. Great! Flow like that only came from healthy arteries.

Jim now wrapped the arm with a rubber bandage to drive out most of the blood; Jane inflated the rubber balloon cuff on Matt’s upper arm that would act as a tourniquet. We washed the wounds free of blood. The rest of our work would be done in a bloodless field, letting the tourniquet down for twenty minutes every two hours. Just as I had done on the fingers, we trimmed away a similar amount of skin around the stumps; we raised skin flaps (flaps are portions of tissue that receive their blood supply through the vessels they contain, as opposed to grafts, which rely on vessels growing in from surrounding structures); we tagged the arteries and nerves and veins, all with 10/0 nylon cut to different lengths matching the tag stitches previously placed in the amputated parts. When we reattached the skeleton and perforce jammed the soft tissues together, those tags of nylon would make it easier to relocate those vessels and nerves.

The joint surfaces on the hand were both unharmed, like those on the fingers.

That’s amazing, said Jim, the bike chain must have popped the fingers off. There’s not even a mark on the cartilage.

We removed a segment just under one quarter of an inch from the bone closest to the hand in each of the injured fingers. This was difficult, for the bone itself was not much over a quarter of an inch wide. The task would have been well nigh impossible without the power saw and fine blades we employed. In taking out the segment, we first drilled holes on either side for the wires we would use to fix the fracture we were going to create. This would have been more difficult after the bone was cut, with two small fragments hard to grasp. We then started the first of the two cuts but did not complete it. This meant that in starting the second cut we still worked on a stable bone and, further, that we could more easily make the two cuts parallel. If they were not, the finger would be crooked.

Such precise work is totally absorbing. All else is forgotten. My anxiety vanishes. Herein lies the peace, the satisfaction of surgery, identical to that of the craftsman building a dry stone wall, making a violin, preparing lasagna, painting a canvas, repairing a motor, the sublime experience of using the skills with which you have been blessed.

And the operating room was silent, save for the click of the anesthetic machine. Jane, who must have taken a double shift, was sitting at a small wheeled table, writing. The anesthesiologist was reading the Journal of the American Medical Association. The corridor outside was hushed; all had gone home. There were no other rooms working. Peace.

Shortening the skeleton, or hard tissue, permitted us to trim away crushed soft tissues—skin, nerves, arteries, veins and the rest—and still have sufficient length to repair all of the soft tissues directly, without tension. Provided they functioned, the fingers would regain proper length in a year or so, one of the magical properties endowed by Matt’s being so young. Taking each amputated finger in turn from the ice tray on the nurse’s table, we fitted the joints together and repaired the ligaments around them. We repaired the tendons, extensor and flexor, and the sheath around the flexors.

Jim and I had been working for almost three hours. There was no haste. Unlike organ transplants, because fingers have no muscle, they can survive for a very long time without a blood supply. Kept on ice, they have been replanted several days after amputation.

We’ll need the ‘scope, please, I said to the Jane. Has anyone spoken to the parents?

No, not yet, she answered.

Well, would you tell them that we are moving along, but we won’t have any news for them for at least another four or five hours. We’ll take a break.

It was a good idea to pause at least once every four hours, to visit the rest room and to top up on fluids and carbohydrates. Some surgeons press on with the attitude I can do this. Who needs a break? Only wimps! But who knows to what extent their performance is diminished? If ever I attempted it, it seemed that just at the moment I was doing the most difficult part of the microsurgery, my bladder would start to send me messages or I would feel the lightheadedness of a low blood sugar. Time in the operating room is expensive, but not as expensive as a fatigued surgeon.

Jim and I sat together in the doctors’ lounge, eating dry crackers, the only sustenance available on short notice, and drinking fresh coffee. The small room, with its cubicles along one side for dictation, contained two long blue couches and three matching chairs, all normally full of chattering surgeons and trainees, but now empty. There was a bare coffee table, two standard issue hospital prints of unidentified landscapes and a notice board on the wall, and that was it.

It’s going well, don’t you think? said Jim.

Hush, I said.

Oh, sorry.

It’s okay, but it makes me nervous.

I firmly believed that some being, the good Lord or the Fates or whoever, watched over us. At any premature suggestion of impending success, that almighty being pointed the finger of condemnation, Zap! and wreaked some dire complication on the procedure.

There were ten vessels to repair; each would take about twenty minutes, even if we encountered no difficulties. And there were many pitfalls along the way; this was plumbing with one-millimeter pipes.

When we returned Jane had positioned the microscope over Matt’s hand. Wearing additional gloves Jim and I adjusted the eyepieces and checked the focus and zoom, which were controlled by the foot-pedal. Zooming in to full power, we manhandled the ‘scope so that the tiny vessels were in the middle of the range for the focus and in the center of the field over which the third foot control, a joy-stick, could move the ‘scope. This would avoid our losing definition or position at a critical point in the vessel repair. We peeled off the extra gloves.

With Matt’s hand turned palm down, laid over a rolled towel and held in place with a restraining device made of soft lead, we started on the veins of the middle finger. Now the preparatory work began to pay off; we stitched the skin flaps out of the way; six fragments of 10/0 nylon, barely visible with the naked eye, clearly marked the ends of the veins on each finger when viewed through the ‘scope. We matched up the veins by location and diameter. Even after trimming the damaged ends of the vessels, there was still sufficient length to join them; the bone shortening had been sufficient. I picked up the end of a vein with fine forceps (years ago the first such instruments had been made from jeweler’s forceps, like delicate tweezers; then they had cost about $2 apiece; the ones we used were priced at over $60). Retaining the hold on the vein with one hand, with the other I slipped a vessel dilator, forceps with highly polished tips, inside the vein and opened them. This widened the vessel, which had contracted at the time of injury; the stretching would also paralyze the muscle in the vessel wall for the time it would take us to repair it. Dilated, the vessel measured just over a millimeter.

Nice vessel, Jim remarked.

Why don’t I do four of the veins, I said to Jim, you do the other two and we’ll split the four arteries?

Jim was a good microsurgeon, but I was faster. Both of us knew that we should move the case along. We may not achieve blood flow. That would mean doing the vessels over. That might require vein grafts. Hours would pass. And who could tell what other emergency cases might arrive?

Fine, Jim replied. Thanks.

I brought the vessel ends together with approximating clamps; the clamps are like minute hair clips, less than one quarter of an inch in size, with a spring-loaded hinge at one end; the spring is calibrated so that it will hold the vessel without crushing it. A pair of these was mounted on a narrow steel bar, so that the clamps and the vessel ends they held could be moved together or apart. (In the past, for larger blood vessels, hair clips bought at the local drug store had been used; the price difference was even greater than it had been for the jeweler’s forceps). I joined the two ends, one millimeter in diameter, with nine stitches of 11/0 nylon (finer even than 10/0). Nine stitches around a floppy tube one millimeter wide. This requires the hand to make movements not detectable by the eye unaided by magnification. The hand-eye coordination and the brain that controls it are sufficiently complex that any human being, with devotion and without disability, can be taught to do such work in a week or so. It is a little like finding functions on your computer that have been thus far unused but are ready to go; but on a geometrically more sophisticated level. As Robert Acland, a pioneer in microsurgery, was wont to remark, this ability must mean that the good Lord intended for us to invent the microscope.

The first stitch was at 12 o’clock (microsurgeons think of the circular end of the vessel as being like a clock face). I then flipped the clamp over to show the other side of the vessel and put stitches at 4 and 8 o’clock. Two further stitches were then put between each pair of the three initial stitches. With these last six stitches, the ends are left untied until all are placed, so that one can see inside the vessel and make sure that the needle does not snag the opposite wall. The needle I was using was the finest available, 75 microns thick. That’s about ten times the width of a red blood cell. If all went well, there would be millions of those cells in every cubic centimeter of blood that flowed past the repair.

We completed the vein repairs without incident and closed the skin to keep the blood vessels moist. It was now over six hours since we had started.

We turned the hand over and repaired the digital nerves, two to each finger, aligning the cut fibers therein.

Here we go, said Jim. We had only the arteries left to repair. But of course they were the absolute essential, bringing blood to the still lifeless fingers. Jim knew that I liked to repair every other structure in the finger before attempting the arteries. Not only did this keep the wounds clear of blood, the presence of which makes microsurgery more tiring, but it also meant that if the arteries worked, we were finished. I disliked the prolonged letdown, the denouement, of having to repair veins after there is flow, especially amidst all the bleeding from the replanted part. That blood loss was another concern, especially in one as young as Matt; we had eliminated that concern by first repairing the veins, the outflow channels. The arteries were somewhat larger than the veins, they had thicker walls; their repair was completed without problems.

Now came the crucial test. I removed the vessel clamps. With that rush of delight that always accompanies the return of flow, all in the operating room watched the flush of blood returning to the pale, replanted fingers.

We looked through the ‘scope, searching for leaks at the points where we had joined the vessels. There were none. The arteries wriggled with the pleasure of restored flow. The fine filigree of vessels on the tendon sheath flushed with renewed life. Exquisite.

Using the tip of closed forceps, I pressed the end of each replanted digit in turn. The finger pulp blanched briefly, but filled rapidly with blood when the pressure was released. And there was no excessive bleeding from the newly attached parts; this meant that the vein repairs were carrying the outflow satisfactorily. Matt was going to have all of his fingers again, God willing. And the hand so ill served would be as good as the other, with equal strength, equal sensibility and equal manipulative skills.

This was the moment. The moment primarily, of course, for Matt and for his distraught parents. But also for me. An instant far more rewarding than wearing the white coat or the academic robe, listening to words of praise, receiving awards, or looking at embossed certificates on an office wall. Total relaxation. Complete joy.

It was to be savored. All too soon would come the moments of critical refection, moments that follow every case, simple or complex. I could have done that better, I will tell myself, or I was lucky that worked out. Not that such analysis is sterile, far from it; only from that can come future improvement. And with that critical scrutiny, the anxiety will return. Is this dressing correct? If not, the vessels may be compressed or Matt may wriggle out of the cast, even pull off a finger. Such a disaster happened to the patient of a friend of mine. How are we going to ensure that the flow is checked? What if one or both of the fingers loses flow, what then? Can we get him back here in time? Would we need vein grafts? From where would we take them? And what if I’m in the middle of that big case tomorrow? Can Jim handle that alone for a while? Wonder what Bill has on his schedule? He would be a great asset.

But for now, this was the moment. The moment in which I could reflect on my blessings.

CHAPTER 1

England, 1940

Some might say that my later fascination with the surgical care of fingers, thumbs, wrists and the like began at the age of four, when I stuck both of my hands into a coal fire.

During my childhood in Britain, an open fire was the only source of heat in the majority of homes. In towns and even many rural areas, the fuel was coal. Logs were little used. The only firewood widely available in Glasgow, my birthplace, was in the form of six-inch long sticks, about one inch wide, rough hewn and tied together with coarse, brown twine into bundles of about a dozen. Even these bundles were in short supply and expensive; they were the well-to-do way of kindling a fire. For poorer folks paper sticks were the substitute. In my home, a newspaper was only purchased on Sunday for two reasons: it contained all the soccer news and the comics (Oor Wullie, about a city urchin, was an especial favorite), and its pages were sufficient in number to light the next week’s fire. That is correct: one fire per week, whatever the temperature, in a building with no other source of heat. Paper sticks were made by taking a sheet of newspaper and folding it obliquely and repeatedly into a thick strip just over one inch wide. This long strip was then folded again lengthwise over and over every five inches, the end being tucked in to bind the construction. The ability to make a good paper stick was something of a social accomplishment. It was a grand skill for a child; it could be quickly learned, it required no equipment and it served as a fine demonstration of manual dexterity for admiring relatives on our rare visits to their homes. They never visited ours.

The coal was delivered by the horse-drawn carts that could be seen plodding through the streets of my home town, each announcing on a large chalkboard at the top of a metal post the merchant’s price for one hundredweight of coal. One British hundredweight was, inexplicably, 112 pounds. By contrast, in the United States the hundredweight weighs, with tedious logic, 100 pounds. Such archaic measures were our daily fare in mid-twentieth century Britain: the inch, which equaled the length of three barleycorns; the yard, based originally on the girth of the 10th century Saxon king Edgar; the rod, measuring 16.5 feet, also known as a pole, or perch, which was once defined as the combined length of the left feet of 16 men lined up heel to toe as they emerged from church on Sunday; the chain, 66 feet long; the furlong, one eighth of a mile, 220 yards, originally the length of one furrow in a square ten acre field.

Even if the visitor to Britain learned to convert the measures, the coinage reduced him to economic impotence. Four farthings, or two half pence, known as ha’pennies, made one penny; all three coins were copper-colored. Three of the pennies equaled the thruppenny bit, an octagonal brass coin; six pence was represented by a silver coin similar to a dime, known as a tanner, especially in London slang. Two tanners equaled a bob, or a shilling. Two shillings were represented by another coin, the florin. Five shillings made up a crown, a rare coin only issued as a commemorative piece; the half-crown was, by bewildering contrast, very common. The smallest bank note was for ten shillings and was reddish-brown in color. The next was the pound and was blue, a feeble replacement for the gold sovereign that was discontinued in 1914. Very rarely, and usually in the distant hands of the wealthy, one would see the five pound note. This was large, about the size of four dollar bills laid out side by side at their long edges, and was white. And finally there was the guinea, worth twenty-one shillings, represented by neither coin nor note after 1813, but which continued to flourish as the currency of professional fees and horse races.

In daily transactions, the denomination was rarely mentioned. Fifteen and nine meant fifteen shillings and nine pence, as everyone knew. Everyone except the tourists, that is. And they were all American in those days. And all Americans had more money than one could imagine, correct? We all delighted therefore in the story of the London cabdriver dropping off the American he had brought straight from the transatlantic airport to his downtown hotel.

How much do I owe you? asked the tourist.

Fifteen and nine, guv, the cabbie responded.

Fifteen and nine? What’s that? queried the visitor, holding up a fist full of pound and ten shilling notes, all unfamiliar to him.

Fifteen of the blue ones, guv, and nine of the red.

Hostility towards Americans and all things American was common amongst the workingmen of Britain during and even after World War II.

They were late joining in the fight, weren’t they? would go the comment. "Waited until we had taken all the punishment and softened up Hitler and his cronies. And then they only signed on because the Japs bombed Pearl Harbor. And when they did come in, what did they do? Came over here with all their money and flash, lounged around in our pubs and seduced our young girls and war widows and lonely wives, while our men were away fighting the Jerries and the Eyeties. Carted them off to America. GI brides, they called ‘em. Cheap trash! And then, when it was all over, they had the bloody nerve to claim they had won the war! Damn Yanks!"

So went the popular wisdom, accompanied by much nodding of heads and exclamations of agreement. And the hostility was multiplied towards those local girls who dared to be seen with an American. The animosity shown to those who fraternized, as it was called euphemistically, was more open, more venomous, often involving physical abuse, for, after all, these women were traitors, weren’t they?

The aversion to America extended to its manufactured goods, a fact clearly recognized by American corporations who took care never to mention their origins. Although I never troubled to research my beliefs, I remained under the delusion until late in the fifties that companies such as Kraft and Ford were British.

Admittedly we watched American films, but they weren’t up to the British ones, and anyway their stars were mainly British, Bob Hope and Cary Grant and Elizabeth Taylor. (Anyone foolish enough to point out that Hope had emigrated at aged four, Grant before he was twenty and that Taylor was born to American parents living in England, was disbelieved and roundly condemned.) Of course we listened to American music, but surreptitiously, on 78 rpm records played on hand-cranked gramophones in attics, like agents behind enemy lines.

It was a complicated contempt, for it was mixed with reluctant and concealed admiration, much as one might feel for a brash and successful colleague. You envy his new car and fine clothes, wish you had them, but cannot abide the man for his triumphs and the manner in which, to your eye, he flaunts them.

Orders for delivery of coal had to be placed well in advance, timed with care to fit between a tight budget and a cold bath. In those days of scarcity, these commitments were often not met. I would be sent on to the streets to watch out for a coal cart, preferably of our usual supplier, but, if not, of any, for sometimes a merchant could be cajoled into giving up one hundredweight to keep ye goin’. Such pirate suppliers would upend the contents in the gutter outside your tenement, as apartment buildings are called in Scotland. All available family would work to shovel the coal into a bucket or similar container for the long haul up many flights of stairs to safety. No pile so dumped could be left untended; even amongst the scrupulous honesty of working people, coal lying unclaimed in the street was considered common property.

If you were favored by the coal merchant, which favor probably related to the generosity of a remembered monetary gift the previous Christmas, he would heft the coarse-woven burlap bag up to your coalbunker. The bunker was a sturdy timber structure, measuring six feet long by four high and three deep, standing outside each home, or just inside. The merchant upended the sack into the bunker, shaking it out vigorously when empty; this added to the clouds of gritty, black dust already fouling the air. But no customer complained. The coal merchant might take offense. After all, he was always black from head to toe, anticipating the youthful styles of the 90s by wearing his bunnet, a soft hat, backwards so that the skip protected his neck from the rough sack. And further, when it settled the dust would be swept up and saved. Once sufficient dust had been gathered, it was made into ‘briquettes’ using a mold and a binding solution. The merchant also sold such briquettes; they were in steady demand both in times of coal shortage and to sustain dwindling purses, for briquettes were cheaper than coal.

Fragments of coal somewhat larger than dust were collectively known as slack. "Nutty slack’ was, as the name suggests, composed of somewhat larger pieces. Wet slack was used to bank the fire overnight that is, to keep it burning; this both heated the house and avoided the need to rekindle the fire in the morning.

As with all commodities in short and unpredictable supply, there were those who would hoard coal. But where to keep it? Some used the largest container in the house . . . the bath. This confused me, since the solution seemed to defeat one of the major reasons for having the coal in the first place. This was because in the average home a single coal fire was the only means of heating, not only the house, but also the water for bathing or laundry. The fire in the hearth heated a water container at the foot of the chimney behind the coals; the hot water circulated from there to the main tank. As fuel was in such short supply and, if obtainable, too expensive for the average family to use every day, the fire was lit only when hot water was essential, which in my home was for twenty-four hours each week. On other days, when the house was cold, we simply wore more clothes. It was rumored that some children were sewn into their underclothes throughout the winter months. This was never true in our family. If any youngster was caught with underwear less than spotless, they were ordered to change immediately, always with the comment What if you were in an accident? as if the main concern of the family for the injured was that, when they were examined for their broken limbs and crushed vital organs, their knickers would be clean.

As a child I knew of no homes with central heating. It was the popular wisdom in Scotland that such a fancy device was needed only by the decadent—meaning Americans—whereas for Scotland, heating the house was achieved by a combination of ‘the Gulf Stream and one lump of coal.’ On cold nights during the working week (and the high humidity of the Glasgow climate made many nights seem cold) my father would, rarely and grudgingly, consent to the lighting of a fire. Little coal was wasted on such frivolity, so that we had to huddle close to the fireplace, becoming very hot in front, though still chilly behind. If this proximity was oft repeated, of which there was no risk in our house, the scorching over one’s shins caused a chronic and irregular redness of the skin, known as ‘tinker’s tartan.’ The nether chilliness was ascribed to a draught which was any movement of the unheated air in the rest of the house. My father was obsessive to a degree typical of the males of our family; draughts drove him wild. Often his only comment in the hours spent clustered around the fire was ‘There’s a hell of a draught! This set him off on another mission of occlusion. He would spend much of the evening packing materials over any crack he could detect around the door. All windows were sealed with tape. Spring, if and when it came, led to a lengthy debate about opening a window. This bold deed required that the tape be ripped loose, exposing us to all draughts the elements may send in punishment for our rash and premature act. Spring was always viewed with suspicion, justified by years of infidelity on the part of that season. Any suggestion of lighter clothing on an unexpectedly hot day in April or even May was greeted by the counsel Cast ne’er a cloot, ‘til May be oot. (Cloot" is an article of clothing.) And so one ventured forth in unnecessary layers of wool.

Because they were heated by circulated water, schools and libraries perhaps had more popularity than was prompted by their primary function. The heat was delivered into the rooms by means of convoluted metal grids called radiators, some two feet tall and six to twelve inches deep. They were of varying length. When the boiler was working well, they were searingly hot. Children coming in from the cold jostled one another to apply their backsides to the pipes, as they were known. Having acquired a coveted spot, one was reluctant to leave, only moving away when threatened by a second-degree burn of the buttocks. Once class started, the pipes were a prime spot to park one’s woolen gloves, if a tolerant teacher permitted it and if your position in the pecking order was high enough to ensure that some bully would not pitch them out through a rapidly opened window into the rain or frost outside.

The paper and coals for the weekly fire were laid on the Saturday morning, as part of a ritual of house cleaning in which all family members participated. The grate and the pan beneath it were emptied of ash, from which any cinders were salvaged for later addition to the fire. The ash was so fine that it could not be carried in an open container, from which the gentlest of air movement would send it swirling. Rather did we wrap it in a single sheet of newspaper and bear it away. Once the ash was gone, the fire was laid. One sheet of newspaper was crumpled in the fireplace. Sticks were stacked around and on it according to one’s personal construct—mine was rather like a wigwam. Coals of the correct size, previously created by breaking up larger lumps with a hammer, head down in the dark and dusty bunker, were then placed in sequence, like bricks building a conical wall, up around the sticks.

When the moment came on Sunday to start the fire, the first central, crumpled, sheet of paper was lit, taking care to use only one match, for they also were to be conserved.

(In Boy Scout camps, youngsters were given the luxury of two matches for fire lighting, which was probably fair, as the terrain and the fuel were invariably sodden and windswept.

Whenever my father heard reference to the meanness of the Scots, a standard taunt of English music hall comedians, he retorted by telling of an incident that occurred when he worked in South Britain. While walking through the Post Office where he was employed he found that he had no match for his cigarette. He stopped an English colleague and asked him for a light. The man emptied out a matchbox into the palm of his hand. He counted the matches. He returned them to the box. He shook his head. Sorry, mate, he said, and walked on.)

Once the fire caught, it was foolhardy to leave. Fires were proud and unpredictable and demanded respect. Control of air flow was a subtle skill; each fireplace had its own unique and obligatory recipe of open or closed room door, open or closed grid beneath the grate, open or closed chimney flue. If, despite careful attention to its needs, a fire threatened to go out (something of a crisis as the bulk of the only newspaper had been committed to that first attempt) I would desperately resort to tested means of reviving it. These all involved increasing the flow of air. So as to blow a stream of air on to any region that still showed evidence of life, in the form of a faint glow or a feeble spiral of smoke, I lay on the floor with my face in the hearth. Success, or failure, left me red-faced and dusted with ash. Alternatively, I could increase the airflow by placing a sheet of newspaper (preserved for that purpose by experienced pessimism) over the entire opening of the fireplace; the paper was supported from behind and at its center with a coal shovel precariously balanced between the edge of the grate below and the lintel of the fireplace above. Using this method, success was heralded by an increasing roar and a brightening glare behind the paper. If its removal were not well timed, the paper would burst into flames. It then had to be thrust hastily into the fireplace. If it were simply released by fearful hands, the blazing paper would float out into the room to wreak whatever havoc, before collapsing into a glowing flake of blackness.

The fire was lit around noon on Sunday, providing sufficient hot water for children to take their weekly bath, communally, immediately before the main meal of the week, father later in the evening, and mother whenever. Showers did not exist in British houses; rather were they associated with public swimming pools, where they were often luxuriously hot, and Scout camps, where they were so cold as to set your teeth to chattering for the rest of the day.

Even when an adolescent had reached the age at which privacy was deemed proper, the water was to be shared. The first one in the bath washed quickly in water scaldingly hot; the same tub of water was then surrendered to the next occupant. This custom led to my lifelong habit of filling a bath while sitting in it. The time of immersion is thereby increased and the water temperature that can be tolerated is several degrees