Eliza stood with her hand pressed to her mouth, her stricken gaze on Charles. — Then there is nothing else to be done? No other way? —
— I have attended too many cases like this. Men whose limbs were crushed in accidents or pierced by bullets. I've learned that once wet gangrene sets in, there is only a finite time in which to act. Too many times I've delayed, always to my regret. I've learned that it's better to amputate sooner than later. — He paused, his voice softer, gentler. — The loss of a hand is not the loss of a soul. With luck, you will still have your son, madam. —
— He is my only child, — Eliza whispered through her tears. — I cannot lose him, or I swear I shall die. —
— Neither of you will die. —
— Do you promise it? —
— Fate is always in God's hands, madam. But I will do my best. — He paused and glanced at Grenville. — Perhaps it would be best if Mrs. Lackaway stepped out of the room. —
Grenville nodded. — Go, Eliza. Please. —
She lingered for a moment, staring hungrily at her son, whose eyelids were drifting shut in a narcotic daze. — Let nothing go wrong, Aldous, — she said to her brother. — If we lose him, there will be no one to comfort us in our old age. No one to take his place. — Stifling a sob, she left the room.
Sewall turned to the three medical students. — Mr. Marshall, I suggest you remove your topcoat. There will be blood. Mr. Holmes, you will hold down the right arm. Mr. Kingston, the feet. Mr. Marshall and Dr. Grenville will take the left arm. Even four draughts of morphine will not be enough to mask this pain, and he will fight us. Complete immobilization of the patient is vital to my success. The only merciful way to do this is quickly, with no hesitation and no wasted effort. Do you understand, gentlemen? —
The students nodded.
Wordlessly, Norris removed his topcoat and placed it on a chair. He moved to Charles's left side.
— I'll try to preserve as much of the limb as possible, — said Dr. Sewall as he tucked sheets beneath the arm to protect the floor and the mattress from blood. — But I'm afraid the infection has advanced too far for me to preserve the wrist. In any event, there are some surgical authorities? Dr. Larrey, for instance? who believe it's always advantageous to take off the forearm higher up, in its fleshy part. And that's what I plan to do. — He tied on an apron and looked at Norris. — You will have a vital role in this, Mr. Marshall. Since you appear to me to be the strongest and the one with the steadiest nerves, I want you to take hold of the forearm, right above where I make my incision. Dr. Grenville will control the hand. As I work, he will be the one to pronate or supinate the forearm, which allows me access to all structures. First the skin is cut, then it's detached from the fascia. After I have divided the muscles, I will need you to apply the retractor, so that I can see the bones. Is all this clear? —
Norris could barely swallow, his throat was so dry. — Yes, sir, — he murmured.
— You cannot quail from this. If you think this is beyond your ability, say it now. —
— I can do it. —
Sewall gave him a long, hard look. Then, satisfied, he reached for the tourniquet. His eyes betrayed no apprehension, no flicker of doubt about what he intended to do. There was no finer surgeon in Boston than Erastus Sewall, and his confidence revealed itself in the efficiency with which he wrapped the tourniquet around Charles's upper arm, above the elbow. He positioned the pad over the brachial artery and ruthlessly tied it tight, cutting off all circulation to the arm.
Charles stirred from his narcotic-induced sleep. — No, — he moaned, — please. —
— Gentlemen, take your positions. —
Norris grasped the left arm and pinned the elbow to the edge of the mattress.
— You're supposed to be my friend. — Charles focused his pitiful gaze on Norris, whose face was right above his. — Why are you doing this? Why do you let them hurt me? —
— Be strong, Charlie, — said Norris. — It has to be done. We're trying to save your life. —
— No. You're a traitor. You just want me out of your way! — Charles tried to pull free, and Norris tightened his grip, fingers digging into clammy skin. Charles was straining so hard, the muscles bulged in his arm, tendons taut as cords. — You want me dead! — screamed Charles.
— It's the morphine talking. — Sewall calmly reached for his amputating knife. — It means nothing. — He looked at Grenville. — Aldous? —
Dr. Grenville grasped his nephew's gangrenous hand. Though Charles was bucking and twisting now, he could not fight them all. Edward had pinned down the ankles and Wendell, the right shoulder. No amount of struggling, no piteous pleas, could stop the knife.
With the first slash of Sewall's blade, Charles shrieked. Blood splashed onto Norris's hands and dripped onto the sheets. Sewall worked so swiftly that in the few seconds Norris glanced away, repulsed, Sewall had finished his circling incision all the way around the forearm. When Norris forced himself to focus again on the wound, Sewall was already peeling the skin back from the fascia to form a flap. He worked with grim determination, heedless of the blood splattering across his apron, of the agonized shrieks, a sound so terrible it raised the hairs on the back of Norris's neck. The arm was now slippery with blood and Charles, fighting like a wild animal, almost wrenched free of Norris's grasp.
— Hold him, damn it! — roared Sewall.
Mortified, Norris tightened his grip. This was no time to be gentle. Deafened by Charles's screams, he hung on ruthlessly, his fingers digging in like claws.
Sewall put down his amputating knife and picked up a larger blade, to divide the muscles. With the brutal efficiency of a butcher, he made a few deep cuts and was down to bone.
Charles's screams choked into sobs. — Mother! Oh, God, I am dying! —
— Mr. Marshall! —
Norris stared down at the retractor that Sewall had just positioned in the wound.
— Take it! —
With his right hand, he kept his grip on Charles's arm. With his left, he tugged on the retractor, exposing the wound. There, beneath a scrim of blood and tissue strands, was the whiteness of bone. The radius, thought Norris, remembering the anatomical illustrations in Wistar's that he'd pored over so carefully. He remembered the mounted skeleton that he'd studied in anatomy lab. But those had been dry, brittle bones, so different from this living radius.
Dr. Sewall picked up the saw.
As Sewall cut through the radius and ulna, Norris felt the mutilation transmitted through the arm he was holding: the teeth of the saw rasping, the splintering.
And he heard Charles's screams.
In seconds, mercifully, it was over. The severed part came away in Grenville's hands, and only the stump remained. The worst of the butchery was finished; what came next was the more delicate task of tying off the vessels. Norris watched, awed by the skill with which Sewall teased free the radial and ulnar and interosseous arteries and ligated them all with silk sutures.
— I hope you've all been paying close attention, gentlemen, — said Dr. Sewall as he proceeded to sew the skin flap closed. — Because one day, you will be called upon to perform such a task. And it may not be as simple an amputation as this one. —
Norris looked down at Charles, whose eyes were now closed. His screams had faded to exhausted whimpers. — This hardly struck me as simple, sir, — he said softly.
Sewall laughed. — This? This was only a forearm. Far worse is a shoulder, or a thigh. No mere tourniquet will suffice. Lose control of the subclavian artery or the femoral artery, and you will be stunned by how much blood can be lost, in mere seconds. — He wielded the needle like an expert tailor, closing the fabric of human skin, leaving only a small gap open as a drainage hole. His suturing complete, he neatly bandaged the stump and looked at Grenville. — I've done what I could, Aldous. —
Grenville gave a grateful nod. — I would not have trusted my nephew to anyone but you. —
— Let's hope your trust was well placed. — Sewall dropped his bloody tools into the basin of water. — Your nephew's life is now in God's hands. —
