She heard the door to the ward open and looking up from the patient saw two Serbian guards appear in the doorway, followed a moment later by Gabriel.
It was the first time she had seen him since he had collapsed so spectacularly in the school courtyard almost a month ago. Now, as she watched him walk towards her, Elspeth studied his appearance: a little thinner, perhaps, in his pale blue uniform, his black hair much shorter, of course, but a warm intelligence still perceptible in the silver of his eyes.
‘Captain Bayer,’ she said, nodding her head in greeting.
‘Dr Stewart,’ he said, bowing in return. ‘It is a pleasure to see you again. The last time we met, I was unfortunately not at my best.’
She smiled. ‘I’m glad to see you’ve recovered. Has Sister Calthorpe explained my problem?’
‘She has, and I am very sorry to hear about Dr Soltau. I met her only briefly as you know, but she struck me as being extremely nice. How is she doing, may I ask?’
‘She still has a high fever. But there is no rash and this morning she developed a sore throat. There is an exudate covering the back of the pharynx—’
‘Diphtheria, you think?’
‘Yes,’ she replied, reassured he had arrived at the same provisional diagnosis as her. ‘It is easy to assume every new case of fever is typhus, but in these conditions it’s important to keep an open mind.’
‘I agree. As well as typhus, I saw diphtheria, pneumonia, even meningitis in my camp. Well, I truly hope she recovers.’
His empathy for Dr Soltau was unexpected and warmed her to him. She could see why Sylvia was drawn to him: a confident yet kind manner, the look of someone you could trust. ‘Our lead surgeon, Dr Chesney, has also gone down with bronchitis.’
‘I see.’ He nodded. ‘Well, I am honoured to be asked to help and excited at the prospect of operating—’
She saw him flinch as an ear-splitting roar of a motor engine from the courtyard cut off his words.
‘Oh don’t worry,’ she said, trying to suppress a smile at the startled expression on his face. ‘It’s only our electricity generator.’
He straightened up, grinning sheepishly at her. ‘Sorry for being a…how you say…scaredy-cat. Yes?’
She gently laughed and then realised she was looking forward to being in theatre with him. ‘Dr Soltau brought it with us from England. It’s a noisy beast, but invaluable for guaranteeing a steady electricity supply for the theatre lights and X-ray machine.’
His eyebrows rose. ‘You brought an X-ray machine with you?’
‘Oh yes,’ she said pertly. ‘One of our women studied physics and radiology at Cambridge and brought a small device with her. It’s been invaluable.’
‘How we could have done with an X-ray machine in our field hospital,’ he said, and she saw him shake his head in wonder. For a moment there was a silence as they looked at each other, and then she broke the awkwardness of the moment by pulling her pocket watch out of her jacket and flipping open the lid. ‘Well, they’ll be waiting for us in theatre,’ she said, closing the lid with a snap. ‘I just need to see one more case. It’s the first on our list today and probably the most challenging.’
They crossed to one of the beds and Elspeth began to examine the patient; a Serbian corporal who became breathless with even the gentle effort of sitting forward to remove the top of his gown. His lips and fingers were purple with cyanosis, the skin of his chest scarred and puckered, and via Aurelia, the translator, Elspeth told the soldier there was a collection of pus – an empyema – surrounding his left lung, caused by a shrapnel injury received a few months ago. The X-ray showed a fragment of metal lodged close to his heart she told him, and the pus needed to be drained and the shrapnel removed to prevent a recurrence of the empyema.
***
As she explained all this to the soldier, Gabriel stood by Elspeth’s side and studied her with a growing sense of fascination. He had never met a female surgeon before, but now he was spellbound at her confident assessment and correctly proposed solution to the problem. She finished her examination and then led him out of the ward and along a corridor to a main staircase, then up one flight of stairs towards the first floor. As they reached the landing, she started to tell him about another patient on the list.
And as he listened to her enthusiastic analysis of this case, a smile of wonder spread across his face. He felt nothing but admiration for her, and her colleagues. To have travelled all the way to a war zone at such a dangerous time, showed a selfless dedication he had rarely witnessed before. So he was startled when – as they arrived outside the operating theatre – Elspeth stopped talking mid-sentence and suddenly turned towards him.
‘You appear amused, Captain Bayer,’ she said, her voice sharp, her hands on her hips, the diamond blue of her eyes alight. ‘Have I said something comical, something you don’t agree with?’
‘Oh,’ Gabriel said with dismay. ‘No, not at all. Please do not take offence, Dr Stewart. I’m just amazed…amazed that—’
‘Amazed?’ He saw that her eyes were now ablaze. ‘And why is that, may I ask?’
Gabriel blinked, then opened and closed his mouth without speaking, eventually finding his tongue. ‘I am sorry, Dr Stewart…my English…is a little rusty. What I wanted to say is that I am amazed at the competence and commitment of all the women in your unit. We have no women doctors in Austria. Yet having been nursed back to health by Sister Calthorpe, and now watching you at work, makes me realise what a valuable asset has been wasted all these years.’
At first she seemed surprised at his reply, and then he saw two spots of scarlet slowly appear on her cheeks. She looked down at her shoes for a moment; then looked up at him from under partly lowered eyelids.
‘I must apologise for my outburst,’ she replied. ‘In my country, the majority of men do not respect the abilities of female surgeons. So when I hear the word “amazed”, I am apt to assume it is being used in much the same way as when describing a talking pig, or a cow walking on its hind legs.’
Gabriel gently laughed at the images, relieved she had already forgiven him. ‘You have no need to apologise. I know that what you say is true about the majority of male doctors. But I am not one of them. I can see you understand surgical method.’
‘That’s kind of you to say, Captain Bayer, but you haven’t actually seen me operate yet.’
‘Well then,’ he said with a smile, pushing the theatre door open for her. ‘Show me.’
He followed her inside, into a classroom that had been converted into an operating theatre, the centre of the room dominated by an improvised operating table overhung by several lights mounted on a stand. Elspeth introduced him to three other nurses already in the room: Monica, a fresh-faced scrub nurse, preparing the sutures, scalpels, and other tools of surgery; Aurelia, a VAD, a cheery girl who spoke fluent Serbian and would act as a translator; and Lydia, a pretty but quiet nurse who Gabriel was told would administer the anaesthetic.
As they waited for the patient to be brought in, Elspeth held a roentogram plate up to the light and showed Gabriel the shadow of a large empyema – pus in the cavity surrounding the left lung. She also pointed out a small triangular density, the piece of shrapnel that had caused the empyema. Although the shard of metal was close to the heart, her plan, she told him, was to open the chest, wash out the pus, remove the shrapnel, and leave a drainage tube in place.
‘You mean Bulau drainage?’ he said and she nodded. His eyebrows rose. ‘That surprises me. We use Bulau’s method in Austria, of course, but I thought the British method for empyema was to resect a portion of the ribs and allow free drainage of the pus?’
She smiled. ‘In Paris we tried Bulau’s method of an underwater seal and chest drain and found it much less traumatic. So we are happy to adopt Germanic practice if it’s better for our patients—’
She was interrupted by the clatter of the theatre door swinging open. Two orderlies appeared with the Serbian corporal lying on a stretcher, whi
ch they hoisted onto the operating table. The soldier’s face was tense, his breathing rapid, his eyes wide as he scanned the unfamiliar surroundings. But Gabriel saw the man relax as Elspeth walked over to him and placed her hand on his wrist. She smiled reassuringly at him, and then looked across at Lydia and gave a subtle nod of her head.
As Gabriel washed his hands, Lydia took a gauze mask and held it an inch above the soldier’s face, dripping liquid from a bottle labelled ‘Chloroform’ onto the mask, while Aurelia – sitting at the soldier’s head – whispered gently soothing words of Serbian. Gabriel put on a white cotton gown, a cap, and a muslin veil that covered the lower part of his face. Then he squeezed his hands inside the largest pair of rubber gloves he could find, realising that the women must have smaller hands as even the largest gloves were a tight fit. He heard a change in breathing from the patient as the chloroform took effect and saw Lydia lower the mask tightly over the man’s nose and mouth. Now she took another bottle – labelled ether – and dripped liquid from this onto the mask. Gabriel heard the breathing become deeper, slower, more regular. After another minute Lydia pinched the soldier’s ear; there was no response. She turned to Elspeth and Gabriel.
‘He’s under. You can begin.’
Gabriel stood beside Elspeth as she pulled away the surgical gown to expose the soldier’s torso, the scars on the chest wall puckered and red. With Gabriel’s help she rolled the man onto his right side and slid a wooden wedge underneath his body; then rolled him back so that his left flank was elevated and exposed. Monica handed Elspeth a small pastry brush and a jar containing a brown liquid.
‘Iodine,’ Elspeth said to Gabriel, her voice slightly muffled by the face veil as she painted the chest wall with the solution. ‘Dr Alexander Fleming, one of our microbiologists at St Mary’s, has undertaken studies that suggest it is a more effective sterilising agent than carbolic acid.’
She stepped back as Monica covered the wedge and torso with sterile drapes, leaving only the iodine-coated chest wall uncovered. Then Elspeth stepped forward again and pressed her gloved fingers over the scar tissue. She palpated a gap between the ribs. Keeping her fingers in place she looked expectantly up at Gabriel, who already been given a scalpel by Monica; he placed its handle in Elspeth’s free hand. Without hesitation she made an incision, a stripe of red appearing as the skin parted beneath the blade’s razor edge and tiny hoses of blood began to spurt in the air.
They worked together quickly, efficiently and wordlessly: he clipping the spraying vessels with artery forceps and tying them off with catgut, while she dissected down through the skin and muscle between the ribs. He saw her push a gloved index finger through the chest wall into the pleural cavity: a spout of foul-smelling yellow fluid erupted from the hole. She waited for the flow of pus to stop and then widened the hole with the scalpel. Then she turned to Monica.
‘Tuffier, please.’
Monica handed her a metal device consisting of two wide steel blades separated by a serrated rod, a contraption Gabriel had not seen before. Without explanation Elspeth inserted the blades into the incision and then – using a ratchet which gripped the serrations on the rod – she levered the blades apart, causing the gap between the two ribs to spring open, widening the space into the lung. Gabriel was astonished: it was a novel type of rib separator, a hands-free device the like of which he had never seen before. Now he could see deep inside the lung cavity. He saw Elspeth lock the blades apart using a thumb screw on the rod; then she glanced up at him. Even though the lower part of her face was obscured by muslin, he could tell from the wrinkles around her eyes that she was smiling at him.
‘You haven’t seen one of these before, have you?’ she said to him.
‘No.’
‘It was invented by Theodore Tuffier in Paris only last year. Monsieur Tuffier was kind enough to lend us one and it proved so invaluable that I knew I had to bring it out here. It’s extremely useful, almost like having a third pair of hands.’
His initial surprise at the competency of these women was now surpassed by a feeling of inadequacy, as he realised that many of their innovations – first the iodine, now the Tuffier – were ahead of his own. And he could see that Elspeth was in her element: slipping her slender wrist between the blades of the Tuffier and into the man’s chest; pushing the lung aside with her fingertips; squinting along the back of her forearm.
‘Ah. I think I see it.’ She dropped her head, rotated her wrist, strained for position. ‘Damn, it’s wedged against the pericardium…must have passed through the cardiac notch in the pleura.’
He saw her wrist bob in time with the soldier’s heart-beat and knew her hand was touching the outer lining of the heart. This, he realised, was the critical moment of the operation. He saw Monica’s head jerk forward slightly, saw furrows appear on Lydia’s forehead. Aurelia stood motionless beside him. Everybody seemed to be holding their breath. Everyone that is, except for Elspeth, who by contrast appeared calmly absorbed in the procedure, still dipping her head, still scrunching her eyelids, still twisting her arm.
‘Oh…wait a minute…I think…’ She slowly removed her hand from the wound, and Gabriel saw a black, jagged, triangular piece of iron, the size of an arrow head, held delicately between her thumb and index finger.
‘Och, will you look at that,’ Lydia said, and Aurelia and Monica burst out laughing, causing the tension in the room to dissipate in an instant.
‘Very well done,’ he said with emphasis, studying the wrinkles around her eyes, which told him she was smiling with satisfaction.
An elbow nudged his side and he turned to see Monica holding a large metal syringe. ‘Sterile saline,’ she told him. He grinned behind the mask as he took it from her and flushed the pleural space, washing out as much pus and debris as he could. Then he peered into the hole.
‘The lung and pericardium seem undamaged. That piece of shrapnel must have ricocheted off a rib and lain undisturbed for months before declaring as an abscess.’
She was also looking inside the cavity. ‘Yes, I think we’re done,’ she said, placing a rubber tube into the wound and then unclipping the thumb screw on the Tuffier to allow the ribs to spring back into place around the drain. After removing the Tuffier, Gabriel began to stitch the wound, securing the tube in place with a purse-string suture. Elspeth placed the other end of the drain through a hole in the lid of a half-filled glass jar on the floor by her feet. Gabriel recognised it as a standard underwater seal for chest drainage, and the bottom of the tube began to bubble as the re-expanding lung displaced air from the soldier’s pleural space. Glancing at the clock on the wall, Gabriel saw that the operation had taken only thirty minutes. It had been fast, skilled work. This team, this woman; they knew their stuff.
There were another eleven cases on the list to be done that day. Five of the cases were minor procedures – draining abscesses, closing fistulas, debriding wounds – but the remaining six were more challenging: skull wounds, amputations, abdominal and chest explorations. They stopped briefly for bread and soup at lunchtime but continued to work through the afternoon and into the early evening. And suddenly they were on the final case.
‘This last patient will be interesting,’ Elspeth said. ‘He’s a bit of a brigand, a member of a Cheta, one of the irregular units supporting the Serbian army. We’ve treated a number of Chetniks; they’re a hardy lot and pride themselves on their resilience, but this poor chap’s got a bullet in his liver. Unless we get it out there’s a real chance he won’t pull through, although when I saw him first thing this morning he wasn’t at all keen on an operation.’
‘That doesn’t surprise me,’ Gabriel said. ‘We treated a few Chetniks in my field hospital. They hate us Austrians and it took a great deal of persuasion before they would let us even touch them.’
Elspeth nodded. ‘This one’s a rather large man and the roentogram shows a bullet in the upper right abdomen, possibly in his liver. He was shot by another member of his Cheta in an accidental dis
charge two weeks ago, and in Valjevo they tried conservative management without improvement. He has a swinging fever and probably has an abscess between the liver and diaphragm.’
Gabriel furrowed his brow. ‘I normally would leave a bullet embedded in the liver alone. This type of surgery can be very high risk you know.’
‘Well, of course I know, and I’m not keen on operating on him either,’ she replied. ‘But after two weeks of doing nothing, he is going downhill. I think an operation may be his best chance, but I’d be interested to hear your opinion.’
At that moment the door opened and Gabriel stepped back as two more stretcher-bearers – grunting and gasping with effort – slowly backed into the room. The man on the stretcher was huge and both orderlies strained to lift him and deposit him on the operating table. As they walked away, Gabriel stepped forward and the man turned his head towards him: it was a large head, the pallor of his face offset by a heavy growth of black beard, but Gabriel immediately recognised the eye-patch across the man’s left eye.
‘Luka,’ he said with surprise and quickly turned to Elspeth. ‘What an odd coincidence,’ he said to her. ‘I know this fellow. I’ve treated him before.’
The big bearded Chetnik had also recognised Gabriel and was waving his right hand at him. Gabriel stepped forward and saw that Luka looked ill, a grey pallor underneath his good right eye and a light sheen of sweat across his broad forehead. ‘I thought I told you to stay away from trouble,’ Gabriel said to him in German.
Luka grinned, then flinched and clutched the right side of his abdomen. ‘I pleased see you, Hirurga,’ he replied in pidgin German. ‘Not Austrian bullet. Stupid boy in Cheta…his rifle shoot by accident.’
‘First a Serbian grenade, now a Serbian bullet.’ Gabriel said, then tutted, shook his head, smiled.
Luka fixed his gaze on Gabriel. ‘You operate me?’ he asked.
But Gabriel didn’t immediately reply. Instead he pulled back the surgical gown and placed a hand on Luka’s grossly distended abdomen. He saw the blood-encrusted bullet hole, glanced at the Chetnik’s anaemic complexion, and then felt the heat of fever in the man’s brow. After two weeks like this, he knew that an operation was the Serbian’s best chance of survival. Elspeth’s opinion was good and he looked across at her and nodded; then he turned back to Luka. ‘Yes,’ he said in German. ‘Dr Stewart is right. You need an operation.’
The Furies Page 21