“Matters became worse.”
“Exactly.”
“So.” Thomas leaned back. “Is there any pain? Especially around the ribs?”
“Only a little ache when the coughing is persistent.”
“Well, to be sure. The rib muscles are assaulted. The discharge from the nose is clear, or of a color?”
“From time to time, colored. It is the itching that is most troubling.”
“Your throat, you mean?”
She nodded. “The itching extends back into my ears.” She made a claw of one hand. “Most irritating.”
“And visiting Portland helped immediately. Is that what you feel?”
“Assuredly so.”
“Have you been able to identify any particular thing that is irritating to you? That makes the nasal discharge more significant?”
She hesitated. “I’m not altogether sure.”
Thomas looked thoughtfully at the journal in his lap. “I would like to listen to your lungs, to be sure. Shall we adjourn to the examination room?” He nodded at Bertha Auerbach, who turned to the door.
“Alvi…she is well?” Carlotta asked.
“She is wonderful, thank you.”
“I thought I would stop by and call on her, if you think that would be appropriate.”
“She would love to see you.” He pointed toward the back of the examination room, where Bertha waited with a soft wrap. “If you’d step behind the screen, Nurse Auerbach will assist you.”
In a moment, as Mrs. Schmidt returned and sat on the end of the examining table, Thomas noted how graceful and elegant she was, each movement so measured and careful. The nurse slipped a glass thermometer under Carlotta’s tongue, and stood nearby to manage the decorous draping of the wrap as Thomas worked the bell of the stethoscope through its course. He listened, he thumped, he searched, but heard only one thing—the sound of healthy lungs moving air about—no rasping, no rales, no sounds of lung damaged or infected.
The delicate tissues lining the patient’s throat were inflamed, her nasal passages swollen and painful, and the thermometer registered a scant 99.1 degrees.
After a time, Thomas relaxed back and regarded Carlotta Schmidt for a moment. “I think that we can reassure both you and your husband,” he said. “Now…” but he interrupted himself at a subtle gesture by Bertha. Thomas assumed that she was reminding him that other patients were gathering. He could hear quiet voices out in the waiting room, one of them sounding very like his wife. But other visitors were not on the nurse’s mind.
“Doctor, I’m sorry, but if I might be so bold?” Bertha didn’t wait for permission from Thomas, but added, “If you would raise your left arm?” When Carlotta did so, the nurse rearranged the wrap ever so slightly, at the same time stroking two fingers together down the curve of the left breast. She looked up at Thomas, waiting.
From a pace away, he could see the small irregularity, the ever-so-slight dimpling.
“If you please,” he said gently, and Bertha stepped aside to give him room. He nodded at her thankfully, wanting her to be absolutely certain that he had forgiven her forward intrusion. Thomas had known professors who would have exploded in rage at such behavior by a nurse. To them, nurses should be cooperative, deferential pieces of furniture.
The tips of his fingers traced the soft, spongy outline of the tumor, an elastic mass the size of a walnut. He continued the examination with his eyes closed, trying to picture the perimeter of the mass, trying to assess the infiltration into surrounding tissues. He could feel nothing beyond the breast, nothing up in the arm pit. “Your age, Mrs. Schmidt?”
She didn’t hesitate a heartbeat. “I am forty-one in July.”
Thomas nodded. “Children?”
This time, Carlotta did hesitate, and for a moment Thomas thought that she might be considering the question a silly one. Thomas had met the Schmidts on more than one occasion, and had never heard rumors of a family. After a moment, she replied, “One who died in infancy. It was with my first husband. I was twenty.”
“I’m sorry to hear that,” Thomas said. “Mrs. Schmidt, you appear to have a small…perhaps we could call it a knot, here. You are aware of it?” A soft rap on the door interrupted them, and Bertha handed the corner of the wrap she was holding to Carlotta and then stepped quickly to block the door should the visitor enter. She held the knob and opened the door just enough to look through the slot. Thomas recognized his wife’s voice again.
“It will be but a moment,” Bertha said, and then added, “Oh? For heaven’s sakes. Well, a moment.”
“You are aware of it?” Thomas repeated, ignoring the interruption.
“Yes.”
“It pains you?”
“No.”
“When did you first notice its presence?”
“Some weeks ago.”
“Weeks.” He frowned at her in mock vexation. “Lie back, if you please.”
When Bertha had assisted her and tended to the drapes, Thomas again traced the lump’s outline and beyond, until he was satisfied with his exploration. “The right side, now,” he said quietly, and continued, once again closing his eyes and forcing himself to concentrate only on what his fingertips could trace.
When he opened his eyes, he discovered that Mrs. Schmidt was watching his face attentively.
Chapter Six
He motioned for Carlotta to sit up again and then stepped back as Bertha Auerbach slipped the modesty wrap off the woman’s shoulders. Carlotta’s flush deepened perceptibly at being so openly disrobed, but she made no comment. At the same time as Bertha placed a hand between Carla’s shoulder blades, Thomas said, “Shoulders back, if you please.” Other than the left being minutely smaller than the right, the two breasts were from the same mold, regular, full, and healthy. He nodded at Bertha. “Thank you.” By the time Mrs. Schmidt had donned her clothing and made herself presentable, some of the blush had faded from her cheeks.
Thomas sat down, giving himself time to think.
“Mrs. Parks is in the waiting room,” Bertha interrupted. “Along with Dr. Hardy.”
“Really?” He turned back to Mrs. Schmidt. “How fortuitous,” he said. “Mrs. Schmidt, as long as you are here, might we take advantage of yet another opinion in this matter?”
“I…”
“Another physician experienced in such matters has just arrived, and I would appreciate his opinion. I know that it’s an ordeal for you, but we should not let the opportunity pass in such a case.”
“Such a case?” Carlotta said. “It is but a small lump.”
Thomas looked down at her in deep sympathy. “Mrs. Schmidt, may I be blunt?”
“I would appreciate that, Doctor.”
“For the tumor to have grown to walnut size in mere weeks, for it to have influenced the lie of skin over it, it must indeed be aggressive, perhaps even now invading the lymphatic tissues. That is my best understanding of the case. Delay is foolish. In fact, delay is dangerous.”
“You seem sure of this.” She watched his face intently, the linen hanky pressed to her nose, her luminous eyes close to tearing.
“In matters of this nature,” Thomas said carefully, “time is of the essence, Mrs. Schmidt.” He paused. “Lesions of this nature are known to be highly malignant.”
“It is a small imperfection,” the woman said, and Thomas noted the quaver in her voice. “It has not changed in the past week.”
“That’s good. I don’t mean to be argumentative or unpleasant, but it’s also impossible to measure the tumor’s size and behavior with any assurance, Mrs. Schmidt.”
She dabbed at her eyes and then lowered the handkerchief. “All right. Do what you must. This is the new physician who is joining the clinic?”
“Indeed it is. Good. Good.” He strode to the door and opened it to see his wife in animated but quiet discussion with a rotund man of early middle age, waistcoat drawn drum tight over an ample belly, expensive coat draped in a custom cut from square, powerful shoulde
rs, and a face so round that he might have been drawn by a caricaturist.
Dr. Lucius Hardy turned and threw up both hands in surprise. He reached up and doffed his English-style woolen cap to reveal a shock of russet hair. “And here he is!” He stepped forward and pumped Thomas’ hand, then drew him close in a bear hug. “Go ahead, say it. You’ve grown so bloody successful that you won’t confess to recognizing an old chum!” The man beamed, his mouth splitting a perfectly manicured mustache and beard to reveal impossibly white teeth saved from perfection by looking as if they’d been inserted by a cross-eyed dentist.
“You can’t imagine how good it is to see you, Lucius,” Thomas said. “I’m sorry to have kept you waiting.”
“Well, I think I can survive a few more moments after three weeks as an itinerant, Thomas. But let me tell you…you’ve been holding out on me. This young lady has absolutely captivated me for the past few moments.” He beamed at Alvi, and then surveyed the waiting room with open admiration. “And here I thought you were practicing out of a small log cabin, the ocean surf pounding on your doorstep…”
Thomas laughed. “We lead the vanguard toward the twentieth century, Lucius.” He clapped him on the shoulder. “You came down in the carriage from One-oh-one?” Thomas had not heard the horses, and he peered out the window, expecting to see Horace, the groundskeeper at their home at 101 Lincoln, six blocks up the hill.
“It is a gorgeous day for a stroll,” Alvi allowed. “Although I must confess, we’ve given sedate a whole new definition at the rate I walk these days.”
“I offered options,” Hardy said. “She would hear none of them. So arm in arm we promenaded, and I’m sure we’ve set some of the local tongues a-wagging.” He grinned at both Thomas and Alvi and held out his hands. “So here I am. And you’re with a patient. I apologize if I am intruding.”
“As a matter of fact, you couldn’t have timed your arrival for a better moment.” Thomas lowered his voice. “It is a simple enough case, I believe, but I would appreciate your opinion.”
“My mind has been numbed by travel,” Hardy chuckled, but rubbed his hands in anticipation. “But I would welcome such an opportunity.”
“If you please, then. Alvi, will you join us?” He turned again to Hardy. “I depend on my wife’s intuition, you see. If I knew a tenth of what she does, I should be a happy man.”
Carlotta Schmidt straightened a bit as the three entered the examining room. Thomas saw that Bertha had already assisted the woman, the modesty drape arranged like a Roman toga.
“Mrs. Carlotta Schmidt,” Thomas announced. “May I introduce Dr. Lucius Hardy? And of course you know my wife, Alvina.”
Carlotta extended a hand and Lucius Hardy took it in both of his own beefy paws. He bowed his head, his direct gaze assessing her carefully.
“Mrs. Schmidt, my greetings. Give me but a moment.” While Alvi engaged Carlotta in animated conversation about Alvi’s condition, Thomas watched while Dr. Hardy strode for the back counter and made use of hot water and then the antiseptic drench as if he were a veteran of this very room.
“You know,” Hardy said, his voice a whisper, “there are still those among us who think all this preoccupation with asepsis is a waste of time, Thomas.”
“And would that they all continue to practice elsewhere,” Thomas replied. Hardy held his hands up for a moment while the alcohol drench evaporated.
For the next ten minutes, Carlotta endured a repeat examination. Lucius Hardy was thorough, almost maddeningly methodical. Thomas curbed his impatience. Alvi remained at Carlotta’s right shoulder, holding her hand, while Bertha stood sentry behind the left, tending the wrap.
“Indeed,” the physician said at last. He straightened up, and popped his back with a stretch. When nothing else was obviously forthcoming, it was Carlotta Schmidt who demanded an answer.
“What must be done, Dr. Parks?” She directed the question to Thomas, and Hardy stepped back out of the way.
“The tumor is reasonably small, Mrs. Schmidt,” Thomas said, “and its location is to our advantage. A single, simple incision allows us to enucleate the tumor from the surrounding tissue.”
“And then?” Her shoulders squared a bit, her hands clenched in her lap. She did nothing to hide her left breast from the view of her audience.
“And then, we see,” Dr. Hardy explained. “Careful microscopy will help us establish the tissue’s malignancy.”
“And then?”
“If there is reason to believe that the tumor is malignant, then the surrounding tissue must be removed as well,” Hardy said gently, and Thomas nodded his agreement.
Carlotta’s expression didn’t change, but tears flowed unhindered down her cheek. Her eyes never wavered from Thomas’.
“You have accomplished this surgery before?”
“No. But I will have assistance.” He did not add that Dr. Hardy was himself but thirty-five years old, and far from an experienced hand as a surgeon.
Carlotta was not blind, however. “Should I travel to Portland, perhaps?”
“That is your choice, of course.”
“Their facilities would be more…”
“Certainly. But ours are entirely adequate and becoming more so by the day. And I would remind you that our nursing staff is superb. Your post operative care would be unfailing and attentive.”
“Still…”
“The decision is yours alone, Mrs. Schmidt. You, and then with your husband. But I would counsel this. Any delay on your part merely exacerbates the dangers to you. You are young, strong, in otherwise good health. Delay is…well, I cannot emphasize enough. In this case, delay is your worst enemy.”
“And if I choose to leave this in God’s hands? If I do nothing?” Her eyes searched his, and he took a moment, thinking of a dozen responses.
“Don’t be ridiculous,” Dr. Hardy interjected, and his abrupt answer reminded Thomas of Alvi’s late father, Dr. John Haines. “The prognosis of carcinoma of the breast is always most serious, Mrs. Schmidt. Treatment is not something best left to chance.”
“Will you speak with my husband?” Again, she directed the question to Thomas. He noticed that, although his wife had said nothing, Alvi still held Carlotta’s right hand in both of hers, a simple, consoling touch.
“I will insist on it,” Thomas replied. “Regardless of what course of action the two of you might take, I wish to see you both tomorrow morning. The both of you. You and Bert. Promptly at nine o’clock, if you will. I shall interrupt whatever matter engages me at that moment to speak with you both. If you elect surgery here, I shall want to operate the following morning. That would be Saturday.” He reached out a hand and pulled the drape up over her shoulder. “No delays, now. If you decide that Portland or some such is the answer, I would expect to see your departure for their facility within a day or two.” He squeezed her shoulder hard. “Delay is the enemy, Mrs. Schmidt.”
Carlotta turned to Alvi as if she had spent all the moments in consideration that she could afford. “And you are well?”
“Fit as can be,” Alvi said.
“I keep listening for the heart beats of twins, but I doubt we shall be so fortunate,” Thomas added.
Carlotta Schmidt arose carefully and accepted Bertha Auerbach’s assistance behind the screen. “I shall see you tomorrow morning, then,” she said as she donned her cloak.
“With your husband.”
She nodded and Thomas held the door for her. After the woman had left, he turned to Lucius. “She drove herself into town today. A most resourceful woman.”
“Apparently so. Her husband is a reasonable man?”
“Oh, indeed he is. At least, in the dealings I’ve had with him so far, most reasonable. He owns the largest mill on the coast.”
“Shall I summon Howard?” Bertha asked, and Thomas regarded her with affection.
“I am in your debt, you know. As is Carlotta Schmidt.”
“I think not.”
“I had not noticed the le
sion,” he explained to Hardy, and the other physician’s eyebrow shot up. Thomas couldn’t tell if Hardy was reacting to his admission, or the failed observance, or his expression of gratitude to his nurse. “Nor had I looked for it. She visited for a separate issue.” He hesitated and watched his nurse, who busied herself changing the rinse water.
“We depend in large part on the patient to guide us,” Hardy said with a shrug.
“But I should have seen it. We can make all the excuses we like, but that’s the simple truth. I have been preoccupied with other things. But I should have seen it.”
“A questioning of procedure is healthy, sir,” Dr. Hardy said.
“You sound just like Dr. Roberts,” Thomas laughed. “So…tell me. Should she go to Portland?”
“Now that’s unfair, my good man,” Hardy said. “I’ve been inside your clinic door for what, ten minutes? What I think should hardly matter.”
“Ah, but…” Thomas interrupted. “I want to know exactly…exactly… what you think. Always.” He nodded at Berti and Alvi. “Just as I expect a frank opinion from each of you.”
Bertha Auerbach took a long breath, her dark brown eyes unwavering. She folded her hands over her stomach, looked as if she wanted to speak, thought better of it, then again thought better of any reticence. “Were I Carlotta Schmidt, there would be no choice. I would have the surgery done here.”
“There you have it,” Hardy said, and it seemed to Thomas that he detected a slight flair of irritation in the physician’s tone. Perhaps he was of the older school whose contention it was that nurses should be seen, but not heard.
“Sonny Malone might argue with you,” Thomas said.
Bertha laughed abruptly, and covered her mouth with her hand as if embarrassed by the outburst. “There is no parallel with the two cases, Dr. Parks. We accept what we can do, and move on.”
“Now I obviously know nothing of this Mr. Malone of whom you speak, but I’ll say this…Mrs. Schmidt has but a fifty-fifty gambler’s chance of surviving the surgery,” Hardy said. “Fifty-fifty, here or anywhere else. And not to put too fine a point on it, without surgical intervention, she has no chance.”
Comes a Time for Burning Page 5
