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.”
“There may yet be complications,” said Sewall.
A fire burned brightly in the parlor hearth, and Norris had gulped down several glasses of Dr. Grenville’s excellent claret, but he could not seem to shake the chill that still lingered after what he had witnessed. He was once again wearing his topcoat, which he’d pulled on over his stained shirt. Looking down at his cuffs, peeking out from his jacket sleeves, he could see stray spatters of Charles’s blood. Wendell and Edward, too, seemed to feel chilled, for they had pulled their chairs close to the hearth where Dr. Grenville was seated. Only Dr. Sewall seemed not to notice the cold. His face was flushed from so many glasses of claret, which had also served to slacken his posture and loosen his tongue. He sat facing the fire, his generous girth filling the chair, his stout legs splayed out before him.
“There are so many things that may yet go wrong,” he said as he reached for the bottle and refilled his glass. “The days ahead are still dangerous.” He set down the bottle and looked at Grenville. “She does know that, doesn’t she?”
They all knew he spoke of Eliza. They could hear her voice upstairs, singing a lullaby to her sleeping son. Since Sewall had completed his terrible operation, she had not left Charles’s room. Norris had no doubt she would be at his side for the rest of the night.
“She is not ignorant of the possibilities. My sister has been around physicians all her life. She knows what can happen.”
Sewall took a sip and looked at the students. “I was only a bit older than you, gentlemen, when I was called on to perform my first amputation. You have had a gentle introduction. You’ve witnessed it under ideal conditions, in a comfor
table room, well lit, with clean water and the proper tools at hand. The patient well prepared with generous doses of morphine. Nothing like the conditions I faced that day in North Point.”
“North Point?” said Wendell. “You fought in the Battle of Baltimore?”
“Not in the battle. I’m certainly no soldier, and I wanted no part of that stupid, wretched war. But I was in Baltimore that summer, visiting my aunt and uncle. By then, I had completed my medical studies, but my skills as a surgeon were largely untested. When the British fleet arrived and began their bombardment of Fort McHenry, the Maryland Militia had urgent need of all available surgeons. I opposed the war from the beginning, but I could not ignore my duty to my countrymen.” He took a deep swallow of claret and sighed. “The worst of the carnage was on an open field, near Bear Creek. Four hundred British troops had marched overland, hoping to reach Fort McHenry. But at Bouden’s Farm, three hundred of ours stood waiting for them.”
Sewall stared at the fire, as though seeing that field again, the British soldiers advancing, the Maryland Militia standing their ground. “It started with cannon fire, from both sides,” he said. “Then, as they closed in, it advanced to musket fire. You’re all so young; you probably have not seen the damage a lead ball can inflict on a human body. It does not pierce the flesh so much as crush it.” He took another sip. “When it was over, the militia had two dozen dead and nearly a hundred wounded. The British suffered twice that many losses.
“That afternoon, I performed my first amputation. It was a clumsy one, and I have not forgiven myself for my mistakes. I made too many that day. I can’t remember how many amputations I did on that field. The memory tends to exaggerate, so I doubt it was as many as I imagine. Certainly I did not approach the numbers that Baron Larrey claims he performed on Napoleon’s soldiers in the Battle of Borodino. Two hundred amputations in a single day, or so he wrote.” Sewall shrugged. “At North Point, I did perhaps only a dozen, but at the end of the day I was quite proud of myself, because most of my subjects were still alive.” He drank down his claret and reached for the bottle yet again. “I didn’t realize how little that meant.”
“But you saved them,” said Edward.
Sewall snorted. “For a day or two. Until the fevers started.” He looked hard at Edward. “You know what pyemia is, don’t you?”
“Yes, sir. It’s blood poisoning.”
“Literally, ‘pus in the blood.’ That was the worst fever of all, when wounds started to ooze a copious yellow discharge. Some surgeons believe that pus is a good sign—that it means the body is healing itself. But I believe quite the opposite. That it is, in fact, a signal to begin building the coffin. If not pyemia, there were other horrors. Gangrene. Erysipelas. Tetanus.” He looked around the room, at the three students. “Have any of you witnessed a tetanic spasm?”
The three students shook their heads.
“It begins with a locked jaw, with the mouth clamped into a grotesque grin. It progresses to paroxysmal flexion of the arms and extension of the legs. The muscles of the abdomen become rigid as a board. Sudden spasms make the torso bow backward with such violence that it can snap bones. And through it all, the subject is awake and suffering the most heartbreaking agonies.” He set down his empty glass. “Amputation, gentlemen, is only the first horror. Others may well follow.” He looked at the students. “Your friend Charles faces dangers ahead. All I’ve done was remove the offending limb. What happens next depends on his constitution, his will to live. And on providence.”
Upstairs, Eliza had ceased singing her lullaby, but they could hear the creak of floorboards as she paced Charles’s bedroom. Back and forth, back and forth. If a mother’s love alone could save a child, there would be no medicine more powerful than what Eliza now dispensed with every agitated step, every anxious sigh. Did my own mother hover with such devotion over my sickbed? Norris had only one vague memory, of waking up in a feverish daze to see a lone candle flickering by his bed, and Sophia bent over him, stroking his hair. Murmuring: “My one true love.”
Did you mean it? Then why did you leave me that day?
There was a knock on the front door. They heard the parlor maid scurry down the hall to answer it, but Dr. Grenville made no attempt to rise. Exhaustion had pinned him to his chair, and he sat unmoving, listening to the conversation at the front door:
“May I speak to Dr. Grenville?”
“I’m sorry, sir,” the parlor maid answered. “We have had a crisis in the household today, and the doctor is not up to seeing visitors. If you would leave your card, perhaps he will—”
“Tell him that Mr. Pratt of the Night Watch is here.”
Grenville, still slumped in his chair, wearily shook his head at the unwelcome intrusion.
“I’m sure he’ll be happy to speak to you another time,” the maid said.
“This will only take a minute. He will want to hear this news.” Already they could hear Pratt’s heavy boots stomping into the house.
“Mr. Pratt, sir!” said the maid. “Please, if you could just wait while I ask the doctor—”
Pratt appeared in the parlor doorway, and his gaze swept across the men gathered in the room.
“Dr. Grenville,” the maid said helplessly. “I did tell him you were not taking visitors!”
“That’s all right, Sarah,” said Grenville as he rose to his feet. “Clearly Mr. Pratt feels the matter is urgent enough to warrant this intrusion.”
“I do, sir,” said Pratt. His eyes narrowed as he focused on Norris. “So here you are, Mr. Marshall. I’ve been looking for you.”
“He’s been here all afternoon,” said Grenville. “My nephew has taken seriously ill, and Mr. Marshall was kind enough to offer his assistance.”
“I wondered why you were not at your lodgings,” said Pratt, his gaze still fixed on Norris, who felt sudden panic. Had Rose Connolly been discovered in his room? Was that why Pratt was staring at him?
“That’s the reason for this interruption?” asked Grenville, barely able to conceal his scorn. “Merely to confirm the whereabouts of Mr. Marshall?”
“No, Doctor,” said Pratt, turning his gaze to Grenville.
“Then why?”
“You have not heard the news, then.”
“I’ve been occupied all day with my nephew. I’ve not even left the house.”
“This afternoon,” said Pratt, “two young boys playing under the West Boston Bridge noticed what looked like a bundle of rags lying in the mud. When they took a closer look, they saw it was not rags, but the body of a man.”
“The West Boston Bridge?” said Dr. Sewall, straightening in his chair at this disturbing news.
“Yes, Dr. Sewall,” said Pratt. “I invite you to examine the body yourself. You’ll have no choice but to draw the same conclusions I have, based on the injuries. In fact, it seems pretty clear to me and to Dr. Crouch that—”
“Crouch has already seen it?” asked Grenville.
“Dr. Crouch was on the wards when the body was carried into the hospital. A fortunate circumstance, actually, because he also examined Agnes Poole. He saw, at once, the similarities in the injuries. The peculiar pattern of the cuts.” Pratt looked at Norris. “You would know what I’m talking about, Mr. Marshall.”
Norris stared at him. “The shape of a cross?” he asked softly.
“Yes. Despite the…damage, the pattern is apparent.”
“What damage?” asked Sewall.
“Rats, sir. Perhaps other animals as well. It’s clear that the body has been lying there for some time. It’s logical to assume that his death coincided with the date of his disappearance.”
It was as if the temperature in the room had suddenly plunged. Though no one said a word, Norris could see stunned realization on all the faces.
“Then you have found him,” Grenville finally said.
Pratt nodded. “The body is Dr. Nathaniel Berry’s. He did not flee, as we all believed. He was murdered.”
Twenty-four
The present
JULIA LOOKED UP from Wendell Holmes’s letter. “Was Wendell Holmes right, Tom? Did that case of childbed fever have anything to do with Charles’s blood poisoning?”
Tom stood at the window, staring out at the sea. The fog had started to lift that morning, and although the sky was still gray, they could finally see the water. Gulls skimmed past a background of silvery clouds. “Yes,” he said quietly. “It was almost certainly related. What he described in his letter barely begins to touch on the horrors of childbed fever.” He sat down at the dining table, across from Julia and Henry, and the light through the window behind him cast his face in gloomy shadow. “In Holmes’s era,” said Tom, “it was so common that during epidemics, one of every four new mothers died of it. They died so quickly, hospitals had to cram them two to a coffin. In one maternity ward in Budapest, laboring mothers had a view of the cemetery through the window, and a view of the autopsy room down the hall. No wonder women were terrified of childbirth. They knew that if they went into the hospital to have a baby, there was a good chance they would come out in a coffin. And you know the worst part of all? They were killed by their own doctors.”
“You mean through incompetence?” said Julia.
“Through ignorance. In those days, they had no concept of germ theory. They wore no gloves, so doctors used their bare hands to examine women. They’d perform an autopsy on a corpse that was putrid with disease, then they’d go straight to the maternity ward, with filthy hands. They’d examine patient after patient, spreading infection right down the row of beds. Killing every woman they touched.”
“It never occurred to any of them just to wash their hands?”
“There was one doctor in Vienna who suggested it. He was a Hungarian named Ignaz Semmelweis, who noticed that patients attended by medical students were far more likely to die of childbed fever than those attended by midwives. He knew that the students attended autopsies while the midwives didn’t. So he concluded that some form of contagion was being spread from the autopsy room. He advised all his colleagues to wash their hands.”