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a LANGE medical book

CURRENT
ESSENTIALS
of SURGERY

Gerard M. Doherty, MD
N.W. Thompson Professor of Surgery
Section Head, General Surgery
University of Michigan
Ann Arbor

Lange Medical Books/McGraw-Hill

Medical Publishing Division
New York Chicago San Francisco Lisbon London Madrid Mexico City
Milan New Delhi San Juan Seoul Singapore Sydney Toronto
Copyright © 2005 by The McGraw-Hill Companies, Inc. All rights reserved.
Manufactured in the United States of America. Except as permitted under the United
States Copyright Act of 1976, no part of this publication may be reproduced or
distributed in any form or by any means, or stored in a database or retrieval system,
without the prior written permission of the publisher.

0-07-146958-3

The material in this eBook also appears in the print version of this title: 0-07-142314-1.

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DOI: 10.1036/0071469583
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 For more information about this title, click here

Contents

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

I. Burn, Trauma, & Critical Care . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1. Fluids & Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
2. Shock & Acute Pulmonary Failure . . . . . . . . . . . . . . . . . . .23
3. Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
4. Burns & Thermal Injury . . . . . . . . . . . . . . . . . . . . . . . . . . .49
5. Surgical Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
II. Acute Abdomen & Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
6. Acute Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
7. Peritoneal Cavity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85
8. Hernias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .95
III. Noncardiac Thoracic Surgery. . . . . . . . . . . . . . . . . . . . . . . . . 103
9. Noncardiac Thoracic Surgery . . . . . . . . . . . . . . . . . . . . . .105
10. Adult Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . .139
11. Congenital Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . .151
12. Arteries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171
13. Veins & Lymphatics . . . . . . . . . . . . . . . . . . . . . . . . . . . . .197
IV. Upper Gastrointestinal Surgery . . . . . . . . . . . . . . . . . . . . . . . 207
14. Esophagus & Diaphragm . . . . . . . . . . . . . . . . . . . . . . . . .209
15. Stomach & Duodenum . . . . . . . . . . . . . . . . . . . . . . . . . . .225
16. Pancreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
17. Spleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .259
18. Small Intestine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273
V. Hepatobiliary Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
19. Liver & Portal Venous System . . . . . . . . . . . . . . . . . . . . .291
20. Biliary Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .305
VI. Lower Gastrointestinal Surgery . . . . . . . . . . . . . . . . . . . . . . . 321
21. Colon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .323
22. Anorectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .343
iv Current Essentials of Surgery

VII. Oncology & Endocrine Surgery . . . . . . . . . . . . . . . . . . . . . . . 355

23. Head & Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .357
24. Thyroid & Parathyroid . . . . . . . . . . . . . . . . . . . . . . . . . . .365
25. Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .395
26. Adrenals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .405
27. Sarcoma, Lymphoma, & Melanoma . . . . . . . . . . . . . . . . .413
VIII. Pediatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .445
 Contributors

Gorav Ailawadi, MD
Department of Surgery
University of Michigan
Ann Arbor
Noncardiac Thoracic Surgery; Adult Cardiac Surgery; Congenital
Cardiac Surgery; Arteries; Veins & Lymphatics

Charles E. Binkley, MD
Department of Surgery
University of Michigan
Ann Arbor
Esophagus & Diaphragm; Stomach & Duodenum; Pancreas; Spleen;
Small Intestine

Derek A. DuBay, MD
Department of Surgery
University of Michigan
Ann Arbor
Acute Abdomen; Peritoneal Cavity; Hernias; Sarcoma, Lymphoma, &
Melanoma

Theodore R. Lin, MD
Department of Surgery
University of Michigan
Ann Arbor
Surgical Infections; Colon; Anorectum

John W. McGillicuddy, MD
Department of Surgery
University of Michigan
Ann Arbor
Fluids & Electrolytes; Shock & Acute Pulmonary Failure; Trauma;
Burns & Thermal Injury
Brian D. Saunders, MD
Department of Surgery
University of Michigan
Ann Arbor
Head & Neck; Thyroid & Parathyroid; Breast; Adrenals

Copyright © 2005 by The McGraw-Hill Companies, Inc. Click here for terms of use.
vi Current Essentials of Surgery

Theodore H. Welling III, MD

Department of Surgery
University of Michigan
Ann Arbor
Liver & Portal Venous System; Biliary Tract; Pediatric Surgery
 Preface

Current Essentials of Surgery, organized by body system and disease,

is designed to provide rapid access to important information regarding
general surgery problems. This book was compiled by a select group of
residents from the General Surgery training program at the University
of Michigan and covers the information we expect residents and med-
ical students, in particular, to know. The individual topics included in
each body system chapter are the important diseases that must be con-
sidered in a general surgery differential diagnosis. Concisely presented
within each disease topic are the Essentials of the Diagnosis, the
Differential Diagnosis to consider for that disorder, the Treatment of the
condition, and relevant Reference material. For further emphasis, there
is also a Clinical Pearl that highlights an important teaching point for
each entry.
We hope that Current Essentials of Surgery will be a useful resource
for medical students and junior residents in surgery. It provides the nec-
essary background material from which to build a solid fund of knowl-
edge in the field of surgery.

Gerard M. Doherty, MD
Ann Arbor, Michigan

Copyright © 2005 by The McGraw-Hill Companies, Inc. Click here for terms of use.
This page intentionally left blank.
 Section I
Burn, Trauma & Critical Care

Chapters
1. Fluids & Electrolytes ..................................................................... 3
2. Shock & Acute Pulmonary Failure ................................................ 23
3. Trauma ......................................................................................... 35
4. Burns & Thermal Injury ................................................................ 49
5. Surgical Infections........................................................................ 57

Copyright © 2005 by The McGraw-Hill Companies, Inc. Click here for terms of use.
This page intentionally left blank.
 1
Fluids & Electrolytes

Acidosis, Metabolic ........................................................................... 5

Acidosis, Respiratory ........................................................................ 6
Alkalosis, Metabolic .......................................................................... 7
Alkalosis, Respiratory ....................................................................... 8
Dehydration (Volume & Electrolyte Depletion) ................................. 9
Hypercalcemia .................................................................................. 10
Hyperkalemia .................................................................................... 11
Hypermagnesemia ............................................................................ 12
Hypernatremia .................................................................................. 13
Hyperphosphatemia .......................................................................... 14
Hypocalcemia ................................................................................... 15
Hypokalemia ..................................................................................... 16
Hypomagnesemia ............................................................................. 17
Hyponatremia ................................................................................... 18
Hypophosphatemia ........................................................................... 19
Renal Failure ..................................................................................... 20
Volume Overload .............................................................................. 21

Copyright © 2005 by The McGraw-Hill Companies, Inc. Click here for terms of use.
This page intentionally left blank.
 Chapter 1 Fluids & Electrolytes 5

Acidosis, Metabolic
■ Essentials of Diagnosis
• Decreased serum pH (<7.35)
• Decreased serum HCO3
• Causes include diarrhea, diuretics, renal tubular disease,
ureterosigmoidostomy, lactic acidosis, diabetic ketoacidosis,
uremia
• Diagnostic tests include arterial blood gas (ABG) measurements
• Calculate anion gap: Na – (Cl + HCO3)
• Anion gap >15: H+ excess, lactic acidosis, diabetic ketoacidosis,
uremia, methanol ingestion, salicylate intoxication, ethylene
glycol ingestion
• Anion gap <15: HCO3 loss, diarrhea, renal tubular disease,
ureterosigmoidostomy, acetazolamide, NH4 Cl administration

■ Differential Diagnosis
• Differentiate between anion gap or hyperchloremic causes

■ Treatment
• Conservative HCO3 administration
• Estimate need by multiplying base deficit by one half total body
water

■ Pearls
Gap acidosis = SLUMPED: salicylates, lactate, uremia, methanol, par-
aldehyde, ethylene glycol, diabetes.
Non-gap acidosis = 2 renal (renal tubular acidosis, renal failure), 2
gastrointestinal (enterocutaneous fistula, urine diversion to gastroin-
testinal tract), and 2 drugs (ammonium chloride, acetazolamide).

Reference
Adrogue HJ et al: Management of life-threatening acid-base disorders [two
parts]. N Engl J Med 1998;338:26, 107.
6 Current Essentials of Surgery

Acidosis, Respiratory
■ Essentials of Diagnosis
• Inadequate ventilation
• Carbon dioxide accumulation
• Somnolence
• Decreased serum pH (<7.35)
• Increased PCO2
• Causes include acute airway obstruction, aspiration, respiratory
arrest, pulmonary infections, pulmonary edema, chronic respira-
tory failure

■ Differential Diagnosis
• Causes may be neurologic, mechanical, or rarely from diffusion
abnormality
• May be acute or chronic

■ Treatment
• Restore adequate ventilation
• Intubate if necessary
• Chronic or rapid correction may lead to severe metabolic alkalo-
sis (post-hypercapnic metabolic alkalosis)
• Perform serial ABG measurements

■ Pearl
Ensure adequate ventilation.

Reference
Adrogue HJ et al: Management of life-threatening acid-base disorders [two
parts]. N Engl J Med 1998;338:26, 107.
 Chapter 1 Fluids & Electrolytes 7

Alkalosis, Metabolic
■ Essentials of Diagnosis
• Elevated serum pH (>7.45)
• Increased serum HCO3
• Most common acid-base disturbance in surgical patients
• Pathogenesis involves loss of H+ via nasogastric suction, volume
depletion, and hypokalemia
• Paradoxical aciduria
• Hypokalemia
• Diagnostic tests include serum electrolytes, ABG measurement,
urine electrolytes, urine pH

■ Differential Diagnosis
• May be mixed, most commonly with respiratory acidosis, but
ventilatory compensation is limited
• Usually marked volume depletion

■ Treatment
• Fluid resuscitation (usually with normal saline)
• Potassium repletion as KCl
• Monitor treatment with serial ABG measurements

■ Pearl
Correct volume; kidneys will correct pH.

Reference
Adrogue HJ et al: Management of life-threatening acid-base disorders [two
parts]. N Engl J Med 1998;338:26, 107.
8 Current Essentials of Surgery

Alkalosis, Respiratory
■ Essentials of Diagnosis
• Acute hyperventilation lowers PaCO2 without concomitant changes
in plasma bicarbonate concentration
• Chronic respiratory alkalosis occurs in pulmonary and liver dis-
ease
• May be an early sign of sepsis
• Paresthesias
• Carpopedal spasm
• Positive Chvostek sign

■ Differential Diagnosis
• Electrolyte pattern of chronic respiratory alkalosis is the same as
in hyperchloremic acidosis; they can be distinguished only by
ABG pH measurement
• May be a sign of sepsis, pulmonary embolus, or other stress

■ Treatment
• Chronic respiratory alkalosis does not generally require treatment
• Treatment of chronic respiratory alkalosis may lead to metabolic
acidosis and hyperchloremia

■ Pearl
Respiratory alkalosis is usually a symptom; find the underlying cause.

Reference
Adrogue HJ et al: Management of life-threatening acid-base disorders [two
parts]. N Engl J Med 1998;338:26, 107.
 Chapter 1 Fluids & Electrolytes 9

Dehydration (Volume & Electrolyte Depletion)

■ Essentials of Diagnosis
• Water deficit without solute deficit
• Water deficit can be estimated from serum Na concentration:
water deficit = [(140 – serum Na) × total body water]/140
• Occurs in patients unable to regulate water intake
• Rare in surgical patients
• Insensible water loss from fever
• Tube feedings with inadequate water content
• Diabetes insipidus
• Concentrated urine
• Central nervous system depression
• Lethargy
• Coma
• Muscle rigidity
• Tremors
• Spasticity
• Seizures
• Hypernatremia
• Low urine Na despite hypernatremia

■ Differential Diagnosis
• Pure water deficit occurs in people unable to regulate their own
intake and in diabetes insipidus
+
• Water deficit is usually accompanied by solute (Na ) deficit

■ Treatment
• Replace enough water to return serum Na concentration to normal
• Treat patient with D5W unless hypotension has developed, in
which case use hypotonic saline
• Monitor serum Na

■ Pearl
Correct intravascular volume first, then slowly replenish water deficit.

Reference
Palevsky PM et al: Hypernatremia in hospitalized patients. Ann Intern Med
1996;124:197.
10 Current Essentials of Surgery

Hypercalcemia
■ Essentials of Diagnosis
• Elevated serum calcium
• Fatigability
• Muscle weakness
• Depression
• Anorexia
• Nausea
• Constipation
• Polyuria
• Polydipsia
• Metastatic calcification
• Coma
• Excess parathyroid hormone (PTH)
• Perform physical examination

■ Differential Diagnosis
• Hyperparathyroidism
• Cancer with bone metastases
• Ectopic PTH production
• Vitamin D intoxication
• Hyperthyroidism
• Milk-alkali syndrome
• Prolonged immobilization
• Thiazide diuretics
• Addison disease

■ Treatment
• If severe (>14.5 mg/dL), intravenous (IV) isotonic saline should
be given
• Furosemide
• IV sodium sulfate
• Plicamycin is useful to treat those with metastatic cancer
• Corticosteroids for sarcoidosis, vitamin D intoxication, and
Addison disease
• Calcitonin can be useful for patients with impaired renal or car-
diac function who might not tolerate forced diuresis

■ Pearl
Hyperparathyroidism is the only cause of hypercalcemia with PTH
>15% above normal.

Reference
Bilezikian JP: Management of acute hypercalcemia. N Engl J Med
1992;326:1196.
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'Have you heard Mass this morning?' Chiarastella asked, without
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Standing in front of her, the sisters said the words of prayer; she
said them too, in her vibrating voice, her hands clasped in her lap on
her black apron. The cat rose on its long black legs, holding down its
head. Then, altogether, the three women, after bowing three times
at the Gloria Patri, said the Salve Regina. The prayers were ended.
The witch opened the wrought-iron casket, holding the lid so as to
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taking out some little things, still hiding them in her hands, she got
mortally pale, her eyes became wild, as if she saw a terrible sight.
'Holy Virgin, help us!' Annarella uttered in a low tone, shaking with
fear.
Now Chiarastella, with a yellow lighted taper, burnt two queer
scented pastilles, which were pungent and heavy at the same time;
she gazed intently at the flying smoke-rings; her eyes dilated,
showing the whites streaked with blue, as if she was trying to read a
mysterious word. When the smoke had disappeared, only a heavy
smell was left; the sisters felt stupefied already, from that smell,
perhaps. Monotonously, not looking at them, Chiarastella asked:
'Have you made up your mind to work a spell on your husband?'
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replied feebly.
'You want to tie his hands, two or three times, so that he never at
any time can stake at the lottery, do you not?'
'Yes, that is it,' the other answered eagerly.
'Are you in God's grace?'
'I hope I am.'
'Ask the Virgin's help, but under your breath.'
Whilst Annarella raised her eyes as if to find heaven, the witch took
out of the iron casket a thin new cord, looked at it, muttered some
queer irregular verses in the Naples dialect, invoking the powers of
heaven, its saints, and some good spirits with queer names. The
chant went on; the witch, still holding the cord tight in her hand,
looked at it as if filling it with her spirit; she breathed on it and
kissed it devoutly three times. Whilst she was carrying out this deed
of magic, her thin brown hands shook, and the cat went up and
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Annarella now repented more than ever of having come, of trying to
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extreme measure; she had done it more out of pity for her, seeing
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mind when Beelzebub tells him to gamble. Believe in God; have
faith; hope in Him.'
Trembling, feeling hot all over from excessive emotion, Annarella
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and let three drops fall on Carmela's forehead, who at a sign had
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had brought, and went on muttering Latin and Italian words. The
candle-wick spluttered as if water had been thrown on the flame.
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which stretched up to devour it; a second after there was a
disagreeable smell of burnt hair, and nothing was seen on the dish
but a morsel of stinking ashes. The incantation went on, Chiarastella
singing under her voice her great love-charm, which was a queer
mixture of sacred and profane names—from Belphegor's to Ariel's,
from San Raffaele's, the girl's protector, to San Pasquale's, patron
saint of women—partly in Naples dialect, partly in bad Italian. She
afterwards took a small phial from the wrought-iron box, which held
all the ingredients for her charms, and put three drops from it into
the plate of water, which at once became a fine opal colour, with
bluish reflections. The witch looked again to try and decipher that
whitish cloud which whirled round in spirals and volutes, and
dropped the ashes of the hair in. Gradually under her gaze the water
got clear and limpid again in the dish; then she told Carmela to hand
her a new crystal bottle, bought on Saturday morning after making
her Communion, and she filled it slowly with water from the dish.
The love-philtre was ready.
'Take it,' the witch said in her solemn tones, ending the incantation
—'take and keep it jealously. Make Raffaele drink some drops of it in
wine or coffee. It will inflame his blood and burn in his brain; it will
make his heart melt for love of thee. Believe in God, have faith, and
hope in Him.'
'It is not poison, is it?' Carmela ventured to ask.
'It will do him good, and not harm. Have faith in God.'
'And what if he goes on despising me?'
'Then, that means that he is in love with someone else, and this
charm is not enough. You must find out who the woman is that he
has left you for, and bring me here a bit of her chemise, petticoat, or
dress, be it wool, linen, or cotton. I will make a charm against her.
We will drive in a bit of her chemise or dress with a nail and some
pins into a fresh lemon; then you must throw this bewitched lemon
into the well of the house where the woman lives. Every one of
these pins is a misfortune; the nail is a sorrow at the heart of which
she will never be cured. Do you see?'
'Very well, I will try and find out,' said Carmela, in despair at the
very idea of Raffaele being unfaithful.
'Let us go away,' said Annarella, who could bear no more.
'Thank you for your kindness, ma'am,' said Carmela.
'Thank you so much,' added Annarella.
'Thank God! thank Him!' the witch cried out piously.
She cast herself down again, kneeling, fervently praying, while the
big black cat gently mewed, rubbing its pink nose on the table. The
two women went out, thoughtful and preoccupied.
'That witchcraft is not good,' said Annarella, in a melancholy way to
her sister.
'Then, what should be done—what can be done?' the other asked,
wringing her hands, her eyes filled with tears.
'Nothing can be done,' said Annarella, in a solemn voice.
They went down slowly, tired, worn out by that long scene of
witchcraft, which was above their intellectual capacity, and
depressed by the tension on their nerves. A man went up the steps
of Centograde Lane quickly, turning towards the witch's house. It
was Don Pasqualino De Feo. The sisters did not see him; they went
on, feeling the weight of their unhappy life heavier, fearing to have
gone beyond the limits allowable to pious folk, and that they had
drawn God's mysterious vengeance on the heads of those they
loved.
 CHAPTER XIII
THE CONFECTIONER'S SHOP BANKRUPT

Cesare and Luisella Fragalà had shut the shop that rainy summer
evening at nine o'clock, half an hour earlier than usual, because with
that bad weather, that boisterous, warm scirocco wind, which made
the hot rain whirl round, few people were in the streets, and no one
would come out to buy coffee, a bottle of brandy, or a fancy
chocolate-box, at that hour in the storm. Only some purchaser of a
penny-worth of cough-lozenges came in occasionally, bringing in a
puff of wind into the hot shop, dirtying the marble floor with his wet
shoes. The evening had been unsuccessful, like the rest of the
summer.
Luisella, who was suffering from low spirits, had not had the courage
even to go to Santo Jorio for country quarters; it is one of the
villages round Naples favoured by the towns-folk. She saw too many
clouds coming down on her family peace, just as in the Naples skies,
to dare to go from home and leave the shop. The humble pride of a
rich tradesman's wife who stays at home with her children and does
not think about the shop was all over. She left Rossi Palazzo, that
had been the joy of her middle-class ambition, early, only to come
back at the dinner-hour, go out again at once, and just come back in
the evening to sleep. It was quite another affair from staying with
the children.
Little Agnesina, who was three years old now, was a florid, quiet,
well-behaved little creature, and often came to see her mother in the
shop. She did not ask for sweets or tarts, but, hidden behind the tall
counter, she cut out silently those slips of paper that are put like
cotton-wool between one sweet and another in the boxes sent to
country places. Agnesina made herself useful without making any
noise or giving trouble, so that she should not be sent away nor be
left at home with the cook and housemaid, who were always
bickering. The mother, when she weaned her, would have liked to
indulge in a nurse, a Tuscan by preference, so that she should not
learn the Naples dialect; but just as she was going to get one, on
thinking it over, she felt the subtle bitterness of a presentiment, and
gave up the idea. The little girl would have grown up with no
training; so, not to be separated so long nor see her unhappy,
Luisella allowed her to be brought to the shop now and then.
When Agnesina saw her mother go away in the morning, she ran
after her, not crying nor yelling, not saying anything, just looking up
in a questioning way. The compassionate mother understood, and to
console her, seeing her so quiet and obedient, she made her a
promise she might come to the shop later on. That made the tiny
arms let go, quite satisfied, as if she had made up her mind to wait.
When she opened the big glass door, coming in in her plain cotton
frock and big straw hat, she smiled at her mother as if she was a big
child already. She silently went to put down her hat in the back-shop
without any outburst of greed, very happy to stay beside her mother
behind the high counter. Only her mother, after the moment of the
little one's arrival was over, got sad. She had never thought of this,
of coming to the shop every day for twelve hours to sell caramels
and chocolate, to fill paper bags and wooden boxes, always to have
to be ready to serve the public, whilst her little one cut paper strips,
not saying a word, as neatly as a big girl. She had never dreamt her
baby would be a shop-girl, too.
Luisella certainly did not despise a tradesman's life; but she would
have liked to be a house, and not a shop, keeper, a housewife, and
not a sweetmeat-seller. She had not dreamt of this. She would have
liked to sew white work, make her baby's clothes, teach her
something—carols at Easter and Christmas, the way to knit
stockings, sewing, embroidery, all that is the humble but glorious
inheritance of happy wives. But instead she spent her life in public
with a stereotyped smile on her lips, not able to say a word privately
to her husband and daughter, nor collect her thoughts a single
moment. She had taken up that duty of selling in the shop from
feeling the financial embarrassments her husband was in. It seemed
to her that the shop-lads robbed him, or that they had bad ways
with the customers—that, in short, there was need of a woman. For
this she gradually sacrificed her whole day. Now no source of
commercial aggrandisement was beyond her; while she was a
zealous counter-up of pence, she kept house on a still more
economical footing always. That was not enough, evidently, because
her husband's low spirits began to be still more frequent. It must
have to do with large transactions, buying sugar, flour, coffee,
liqueurs—matters she could not go into. Cesare kept them out of her
reach purposely. Still, she knew the price of goods, and it made her
wonder the more at the discomfort they were in. When Cesare, not
able to hide the straits he was in, ended by owning that he could not
pay a bill, that he had not the weekly money to pay the workmen in
the bakeries, she raised her eyebrows in sad surprise, saying:
'I cannot make it out. I do not see why we are so short of money.'
Cesare tried to humbug her, talking some nonsense about Customs
and colonial tariffs. He spoke vaguely about losses by some
speculations he was not responsible for, saying the whole trade was
going to the bad. So she, getting thoughtful, ended by saying:
'Then it would be better to shut up shop.'
'No, for goodness' sake, don't say that!' he cried out.
Ah! she had found out what her misfortune was in the end. Three or
four times, without intending it, she had discovered that Cesare was
not so honest as he used to be, that he told lies. This made her start
with fright, dreading worse evils. When they made up accounts
together, he said he had paid so much, at such a price, and it was
not true, or he had paid a part of it only. He had got to be a bad
payer. The two landlords of the flat and the shop complained several
times; they had their burdens, too; they could not wait so long for
their money. She had discovered this with a sharp, secret anguish.
When she questioned her husband severely, he got pale and red,
stammered, letting out his hidden sin by his whole attitude. For a
moment Luisella thought she was deserted for another woman, and
the flames of jealousy scorched her blood; but Cesare was always so
tender and loving, so sincerely and thoroughly in love with his wife,
that she was reassured. No, it was not that. She could hardly make
out at first what subtle, dissolving element melted away the money
in the house. She discovered that the increasing debts were always
getting fatally larger, from her husband's growing absent-
mindedness, in spite of the sad lies he told her. She could not make
out by what tiny wound the blood of the Fragalà house was going
drop by drop. It was in vain that the shop was successful, that she
did wonders in economy: the money disappeared all the same. She
felt a hollowness under the seeming solidity of their commerce; she
felt the incurable languor of a body losing all its blood. But she saw
no reason for it. It was not a woman, in so far; then who and what
was it? Only by dint of searching minutely and lovingly into her
husband's daily life had she ended by understanding what it was.
First of all, Cesare Fragalà had fallen into the habits of all keen
Cabalists; instead of tearing up the lottery tickets he played each
week, he was so foolish as to keep them, to compare and study
them. One day, in a jacket-pocket, Luisa found a whole sheaf, a
week's collection of lottery tickets, four or five hundred francs
thrown thus to the greedy Government, given to an impersonal,
hateful being, to try for an elusive fortune. Perhaps, in spite of the
fright she got then, amid the blaze of light that blinded her, she
thought it was the aberration of one week only. But Cesare was too
simple about deceiving, for her to go on thinking so. Luisa's clever
eyes now saw that Friday was a day of the greatest excitement with
him. She saw his nervousness in the early hours of Saturday, and
the evening depression. Now, Luisa's heart was divided by two sharp
sorrows that opposed each other: first, seeing their prosperity
always flying away, then finding Cesare to be a victim to an incurable
moral fever. That fatal period began with her when one may suffer
from seeing a loved one given over to a tragic passion, and yet dare
not even oppose his self-indulgence, or show one is aware of it. She
was still patient, for she disliked the idea of having a grand
explanation with her husband, of confronting him with his vice; she
still hoped it would be a fleeting fancy.
But, to dash her hopes, day after day she saw Don Pasqualino De
Feo, the medium, in the distance, circling round her husband
continually, trying not to let her see him; but she guessed he was
there, as a woman guesses her rival's presence. She felt the ill-
omened, mean beggar was in the back-lane, at the street corner, or
under the gateway waiting for Cesare, so as to draw more money
out of him, and incite him to gamble again by saying silly fantastic
things for Cesare to draw lottery numbers from, figures that would
never come out of the urn. Now and then, in spite of Don
Pasqualino's prudence that also seemed to be fear, Luisella found
him at the doorway, or at the street corner, and looked so coldly and
disdainfully at him that he cast down his eyes and went off in his
awkward way like a man who does not know what to do with his
body. Once Cesare Fragalà named Don Pasqualino De Feo before his
wife, watching to see if her face changed; her sweet, affable look
went off: she got to have a cold expression, and frowned. He dared
not name the medium again. Indeed, he had had to warn him of his
wife's ill-will, so Don Pasqualino got still more cautious; if he wanted
to call Fragalà when he was at business, he sent a newsboy from the
Bianchi corner. But Luisella found out whence these mysterious calls
came also; she shook her head as she saw her husband go out of
the shop with an affectation of carelessness.
The more the medium circled around, always dressed like a pauper,
still torn and dirty, always a sucker-up of money, of everything, the
more she felt her husband's rage for the lottery was not a temporary
caprice, but incurable vice. Now, on Friday nights, he came in very
late; she, pretending to sleep, heard quite well that he was awake,
uneasy, turning in his bed, knocking his head on the pillows.
Besides, while Cesare's fever did not go down, the shop's prosperity
did visibly. The wholesale dealers, seeing that Fragalà was always
asking for renewals of bills, or that he barely paid a part of them,
got suspicious; they put off sending the goods, they even got to
sending them on consignment, which is a grave proof of want of
confidence commercially, a thing that ruins a trader; for he has to
keep the goods in the Custom-house, not having money to take
them out. He goes on paying storage, knowing all the time that the
things are deteriorating.
The warning that Fragalà was not quite solvent must have run from
Napoli Square to other parts, for he began to find all doors shut if he
did not come money in hand; his having signed money-lenders' bills
spoilt his credit altogether. Still, his reputation and means stood it so
much the more that it was the reputation of all the Fragalàs
together. But that could not last. One final blow, and his commercial
standing would go also.
Now the bad summer season had come, with a scarcity of country
visitors, which caused a languor of all Naples' forces, a crisis that
went on increasing among all classes; for everyone lives off
strangers in that town of no commerce. It was no use for Luisella
Fragalà to give up her change to the country that year for the first
time; nothing had come of it. Goods were short in the storehouses
from the suspiciousness of dealers, and customers were still scarcer
from the bad weather.
Luisella could not manage to keep down her depression now; the
pretty young face had got to have a grave expression, her head was
often down on her breast. She thought and thought, as if her soul
was absorbed in a most difficult problem; for one thing, she saw that
her husband's mental malady was always getting worse. He was so
sorrowful at some moments, it wrung one's heart to look at him.
Besides, the bad weather affected her, too; all suffered from it, rich,
well to do, and poor, for in this great country everything radiates, joy
as well as grief, good fortune as well as bad. Now she had decided
to speak, to question her husband's heart, for the situation was
getting gradually worse, it was desperate; in a short time he would
be ruined.
Being quite decided now in her loving, strong, womanly heart,
having made up her mind to act, she kissed her dear little one, who
was so quiet and prettily behaved, saying to herself she would
speak, she would bring out everything. Her life was already grievous
from her responsibilities as wife and mother; the gay, idyllic time
was past for ever, the long sad hour was come when she needed all
her courage to influence and convince Cesare. It was really a battle
she intended to hold that evening in the steamy shop, whilst the
summer rain rattled sadly outside.
It was Friday; still, for a wonder, Cesare Fragalà had not left the
shop that evening, as he had got into the habit of doing every week
at dusk, not to return till three in the morning, the time the last
lottery-shop shut. He went backwards and forwards nervously; twice
the usual newspaper boy had come to call him for Don Pasqualino:
he answered that the person must wait, because he was busy. Pale
and trembling, feeling she had got to an important crisis, his wife
followed, with a side-glance, her husband's wanderings. Outside, the
rain beat sadly on the windows, the gas-flame looked sickly.
'Shall we shut up shop now?' Fragalà said impatiently.
'It would be best, no doubt,' she said, with a slight sigh, 'especially
as no one will be coming in.'
The two shopmen, helped by the porter and message-boy, made
haste to put up the iron gates, put out the outside gas, and give a
general cleaning up before going away by the little back-shop door
in Bianchi Lane. Quickly they said good-night and set off, one by
one. The white shop, its shelves brilliant with colour from the
chocolate-boxes, was now lit by one gas-jet only. Luisella was seated
behind the counter, as usual, and little Agnesina had gone to sleep in
her chair, her knees covered with shreds of paper. Cesare often
disappeared into the back-shop, as if he could get no peace. Neither
of them could make up their mind to speak, feeling that it was a
grave crisis that they had come to. She, above all, felt herself
choking. It was he who spoke first.
'Look here, Luisella,' he said, in a low voice: 'you know what a bad
season we have had.'
'Yes, a wretched one,' she muttered.
'It is a real disaster, I assure you, my dear—enough to make one
give up keeping shop. You carry out economies, I work hard ... and
it goes from bad to worse.'
'I know that,' she muttered again, as if tired of those grumbles.
'You cannot know the full extent of it ... you would have to deal
directly with the wholesale houses to know what ruin——'
'Come to the point,' she said, rather bitterly.
'Are you angry with me?' Cesare asked humbly.
'No, it is not that,' she replied, in a curious tone.
'Well, I want you to do me a favour—a great favour, so great I am
ashamed to ask it, even.'
'Say what it is,' she just uttered, keeping down the pained feeling
her husband's words caused her.
'I have a payment to make to-morrow morning....'
'To-morrow, in the morning, do you say?'
'Yes; it is a bill that falls due. I had forgotten it. It is a big bill.'
'Still, you had forgotten it?'
'You know I have got rather confused lately ... in short, I must pay,
and I am not ready. I asked in vain for a renewal or if I might pay
part only. Everyone wants his money just now. I cannot pay, and
there is no money to be had.'
'Then, what is it that you want of me?' she said, looking coldly at
him.
'You could help me; you could get me out of this momentary
embarrassment. I will give you back the money at once.'
'I have no money.'
'You have some valuables. Those diamond earrings I gave you: they
are worth a great deal. One could get a lot for them.'
'Would you like to sell them?' said she, shutting her eyes as if she
saw something horrible.
'I would pledge them—just take them to the pawn-shop, only for a
few days. They will be redeemed at once.'
'Do you intend to pawn the diamond earrings?'
'And the star—the star Don Gennaro Parascandolo gave you,' he said
hurriedly, in an anxious tone.
She said nothing, just kept her head down and looked at the baby
quietly sleeping. Then, in a whisper, with an irrepressible shudder,
she said to her husband:
'You want to pawn my jewels so as to stake on the lottery.'
'That is not true!' he cried out.
'Do not tell lies. Can you say before me and your daughter that you
won't use the money for the lottery?'
'Do not speak to me like that, Luisella!' he stammered out, with
tears in his eyes.
'You want them to stake on the lottery with. Have the courage of
your vices; don't load your conscience with lies,' his wife answered
with the cruelty of desperation.
'It is not a vice, Luisa; it is for good ends I gambled, for good
motives, for your sake and Agnesina's.'
'A father of a family does not gamble.'
'It was to open the new shop in San Ferdinando Square. Seventy
thousand francs were needed for it, and I had not got it. You know
all our money is in use.'
'A family man ought not to play.'
'It was for the happiness of us all, Luisella. I swear to you, believe
me, it was because of my love for Agnesina.'
'You don't love her. If you cared for her, you would not gamble.'
'Luisella, don't humiliate me—don't make me out mean. Be kind. You
know how much I loved you—how I do love you!'
'It is not true. If you loved me, you would not gamble.'
He threw himself on an iron seat, leant his arms and head on a
marble table, and hid his face, not able to bear his wife's anger and
his own remorse. He felt great grief and sorrow, only surmounted by
that sharp, piercing need of money. With that agony he raised his
head again, and said:
'Luisella, if my honour is dear to you, don't force me to make a poor
figure to-morrow. Give me your jewels; I will give them back on
Monday.'
'Take the jewels; they belong to you,' she said slowly, with her eyes
down; 'but do not say you will give them back on Monday, because it
is not true. All gamblers lie like that, but pledged goods never come
back to the house. Take all the jewellery. What can I say against
your taking it? I was a poor girl with no dowry, and you, a rich
merchant, condescended to marry me, and gave me a higher
position. Should I not thank you for that all my life? Take everything;
be master of the house, of me and my daughter. To-day you will
take the jewels and stake them; next time you will take the best
furniture, the kitchen coppers, the house linen; it always goes on like
that. The Marquis di Formosa, too, who lives above us—has he not
done that? His daughter has not a bit of bread to put in her mouth
now: and if Dr. Amati did not help them secretly, both would die of
hunger. Who will help us when, in a year or six months, we are like
them? Who knows? Perhaps I will go mad, too, as the poor young
lady up there threatens to do. Her father makes her see spirits. It is
a scandal amongst all those who know her. But what are we women
to do? Fathers, husbands, are the masters. Take the diamonds,
pawn them, sell them, throw them into the gulf where your money
has fallen and is lost; I do not care for them now. They were my
pride as a happy wife. When I put them in my ears and hair, when I
opened the casket to look at them, I blessed your name, because,
among other pleasures, you had given me this. It is ended; it is all
over. We are done with pleasures now; we are at the last gasp.'
'Luisella, have some charity!' he screamed out, feeling his flesh and
soul burn from these red-hot words.
'Charity! we will soon be asking for it. The diamonds go to-day, the
other valuables next; then all, everything we possess, will disappear.
It will all be a flying dream,' she replied, looking in front of her as if
she already saw the frightful vision of their ruin.
'Still, I need them; it is necessary for me to take them!' he cried out
with the doleful persistence of a desperate man who only feels his
evil tendencies pushing him on.
'Who is denying you anything? Even Agnesina has pearl earrings. Put
them in; it will make a larger sum. Her cradle has antique lace on it;
Signora Parascandolo presented it to her. It is valuable. Take it; it will
bring up the sum.'
'Look here, Luisa,' her husband began saying pantingly, emotion
choking his utterance, 'I swear to you the money is not intended for
gambling; I would not have dared to ask it from you, a good
woman, if it was. You have such good reasons to despise me
already. But it is a debt for former stakes I made—a terrible debt to
a money-lender. He threatens to protest it to-morrow—to seize my
goods. This cannot be allowed to happen; a merchant whose bills
are protested ought to die.'
'That is true,' she said, hanging her head.
'It may be,' he added after a short hesitation. 'Perhaps I would have
taken some of it to gamble with—just a little, only to try and recoup
myself—only for that, Luisella.'
'In short, you cannot keep from gambling!' his wife cried out in a
rage.
He trembled like a guilty boy, and did not answer.
'Can you not keep from it?' she asked again, attacked by a most
terrible fear.
'Look here, this is how it is: it is a perfidious passion. You do not
know what it is; you must have felt it to know; you must have
panted and dreamt, or you cannot think what it is like. One starts
gambling for a joke, out of curiosity, as a little challenge to fortune.
One goes on, pricked to the quick by delusions, excited by vague
desires that grow. Woe to you if you win anything—an ambo, a small
terno! It is all up with you, for your chance of winning seems
certain. Do you see? You feel certain of winning a large sum, as you
have managed to get a small amount, and you put back not only all
you have gained, but you double, treble the stake in the weeks that
follow your success. It is the devil's money going back to hell. What
a passion it is, Luisella! It is bad for one to win, and bad not to win.
Then the dream, that for seven days keeps you alive, on the eighth
day gives you a bitter disappointment; it ends by setting your blood
on fire, and to increase your chances of winning at any cost, your
stakes increase frightfully; the desire of winning gets to be a
madness. The soul gets sick; it neither sees nor hears anything. No
family ties, position, nor fortune, can stand against this passion.'
'My God!' she said softly, just as if she were going to fall into a
chasm.
'You are right, Luisella, to ill-use me, to strike at me with your scorn;
you have a right to do it. I am a bad husband, a worse father; I
have beggared my family. You are quite right,' Cesare said again
convulsively. 'I was a cheerful, industrious young fellow; all wished
me well; my business was going splendidly; you were a joy, and
Agnesina a pleasure to me. What fascination has overcome me?
That cursed idea I had of winning seventy thousand francs at the
lottery to open a shop at San Ferdinando with—a cursed idea that
has put the fire of hell into my blood. I wanted to enrich you by
gambling, whereas grandfather and father taught me by example
that only by being content with a little, by putting sou upon sou, one
gets rich. What folly was it seized me? What was the infection?
Where did I catch it? What a horrible passion gambling is!'
The poor woman listened to that anguished confession, pale, her lips
shaking from the effort she made to restrain her sobs, leaning
against the elbows of the chair, feeling crushed by a nameless
agony.
'How much have I staked?' Cesare went on. He seemed to be
speaking to himself now, without seeing his wife or hearing his
sleeping child's breathing. 'I do not know, I do not remember now.
The lottery is a great melter-down of money; it is like a crucible the
metal runs out of. At first I played moderately; I tried to be
moderate and wise about it, as if the lottery was not the most
laughable trick that fortune plays on man. At that time I wrote down
the money I staked in a pocket-book where I note my ordinary
expenses; but afterwards the fever seized me, and has grown so, I
remember no more. I do not remember how many thousands of
francs I threw away so madly in an ugly dream, a delirium that came
back again every Friday. Luisella, you do not know it, but we are
ruined.'
'I do know it,' she said very softly, looking at the little one's pink face
sleeping in childish serenity.
'You do not know, you cannot know, everything. I have given bills
for the money put aside for yearly payments; I have staked the
thousand francs we put in the savings bank for Agnesina; I have
robbed her of the money I gave her—her own money; I have failed
to carry out my bargains commercially. Our correspondents have no
confidence in my soundness; they will have no more to do with me;
they send me no goods. You see the shop is getting empty; I have
no ready money to fill it again. I have not even paid the insurance
money; if the shop was burnt down to-morrow, I would not get a
farthing. I am a bad payer. You do not know—you can't. I have tried
for money everywhere in desperation; put myself in a money-
lender's hands, mostly in Don Gennaro Parascandolo's, and they
have eaten me up to the bone.'
'Did you borrow money from Agnesina's godfather?' Luisella
exclaimed sadly, hiding her face in her hands.
'In money matters no relationship counts; money hardens all hearts.
These debts are my shame and torment. A tradesman who takes
money at eight per cent. a month is thought to be ruined, and they
are right. Money-lending is dishonest both in the borrower and
lender. What shall I do? The season is a very bad one for poor and
rich; but even if it was a splendid one, the gains would not be
enough even to pay the interest on my debts. Just think; it is a
miracle that Cesare Fragalà, the head of the Fragalà house, has not
yet been declared bankrupt, and a discreditable bankrupt; for a
merchant cannot take creditors' money to stake on the lottery. It is
theft, you understand, theft, and thieves go to the gallows. After
reducing my family to wretchedness, I will take their honour from
them by this hellish madness.'
Not able to bear his unhappiness any longer, he burst into sobs,
choking and crying like a child. She, shaking with emotion, feeling in
her heart a great pity for her husband and a great fear for the
future, raised her head resolutely.
'There is no remedy, then?' she said, in her firm voice, like a good,
loving woman.
'There is none,' he answered, opening his arms in a despairing way.
'We are on a precipice. I understand—I see it. But there must be
some way of mending matters,' she reiterated obstinately, not willing
to give in without a struggle.
'Pray to the Virgin for help—pray!' he whispered, like a child—more
lost than a child.
'Let us try and find some cure,' she still answered softly.
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