Chapter 10

The Thoracoplasty

March 1934

At Sea View in the nurses’ dressing room, Edna and her team began prepping for surgery. In the small space, the women moved around silently, each focusing on the task at hand. One flipped her wrists and unfurled a gown; another in a cap and mask counted gauze pads, which she passed to her colleague, who stacked them in neat piles.

Edna stood at the sink holding a soapy scrub brush and began moving it over the creases of her palms, in between her fingers, and under her nails, counting the minutes as if Miss Mitchell were standing behind her. While scrubbing, she considered the instruments she would handle in the operating room and pushed aside any pre-op doubts, those “what if . . . ?” and “did I . . . ?” moments that wormed their way into the psyche of many nurses prior to surgery.

All of them always checked and rechecked their work, but certain pieces of equipment nagged at them, especially the bone-cutting tools and the cannulas, long tubes used for irrigating and draining a surgical site. These were difficult to clean; they accrued micro-remains of human tissue, pieces of bone, hair, or fecal matter, all fodder for pathogens to fester and potentially infect a patient. If that happened, many surgeons immediately blamed the nurses, scolding them and calling them “saboteurs” and “slovens.”

Edna rinsed her hands, and one worry replaced the others: Miss Mitchell.

After five years, the men running Sea View and the Department of Hospitals had finally recognized her dedication to make the hospital top-notch at whatever cost. Their approval brought her peace of mind, job security, and an enhanced confidence to exert her power, sometimes indiscriminately.

Recently, she had embarked on a firing spree, purging the ranks of nurses. It was “distinctly an advantage to have the turnover in personnel,” she wrote in the annual report to Sea View’s medical superintendent. Some nurses had left of their own accord, but many, she explained, had lost interest in Sea View and “were requested to leave.” Those who were fired, she continued, “were unwilling to cooperate with the new regime,” one focused on training outstanding nurses, experts in tuberculosis, who would have long careers here at Sea View.

Edna could not afford a single misstep.

She dried her hands, pulled on her gloves, and pushed open the double doors leading to the operating room. It was bright, submerged in sunlight that gushed through the immense window, whose glass curved upward toward the ceiling and melded with the skylight. Her eyes took a moment to adjust to the rays gleaming off the white tiles, the metal basins and bowls, and the young woman who was lying anesthetized on the narrow steel slab with an endotracheal tube protruding from her mouth. It was Elke.

She was turned on her left side and held in place by four-inch adhesive strips that passed over her buttocks and attached to the table. Earlier nurses had draped her body in sheets, leaving only a large patch of exposed skin on the upper right side, where the surgeon would operate. It was bound by towels, clamped to the bare skin that a nurse was cleaning with different topical antiseptics: benzoin, followed by ether, then alcohol, and finally two coats of picric acid, a pale yellow antiseptic.

As the nurse stepped away from Elke, holding the used gauze pads soaked in antiseptics, the surgeon moved forward, a cue for Edna to take her place beside him. Standing there, she gave a final glance at the instruments lying on the different trays: scissors, trocars, and elevators, used for scraping and dissecting bones; retractors, heavy L-shaped instruments for holding back organs and tissues; rongeurs, for gnawing holes in bones; mouth gags and bone cutters and rib cutters, whose tips were molded into shapes that resembled steel beaks.

Seeing them lined up, their handles and blades and tips glistening in the light, excited and unsettled her. Each one was symbolic of medicine’s progress but also of its stagnation, a reminder that tuberculosis still lacked drugs, that opening the body and whittling out the illness remained the only option.

The surgeon leaned his head toward Elke and Edna blotted out the world, focusing all her energy on his hands. “Scalpel,” he said.

Edna had already picked it off the tray; now she placed it in his hand, which was covered by a thick black rubber glove. It had a sinister look, otherworldly, inhuman, and appeared a strange contrast to the life-preserving effort it was undertaking and to its curious history of romance and love.

Some forty-four years earlier, in 1890, Dr. William Halsted, chief of surgery at Johns Hopkins and a proponent of aseptic techniques, hired a scrub nurse, Miss Caroline Hampton. Halsted had stringent rules for working in the operating room, including that hands be disinfected with mercuric chloride, now known to have toxic effects and cause corrosive injury, gastrointestinal issues, renal failure, and death. Fortunately, Hampton, who followed her boss’s request, developed only a severe case of dermatitis on her arms and hands, but the rash and peeling skin were enough to render the junior nurse unable to work. The news devastated Halsted, who’d fallen in love with his talented young nurse. In an effort to solve the problem, he asked the Goodyear Tire & Rubber Company to make thin rubber gloves with gauntlets.

The gloves arrived, and Halsted proposed and then gifted them to Hampton, who tested them out. Again and again, her hands remained rash-free following surgery. The two were overjoyed, celebrating not only their love but also what it had brought: the invention of rubber gloves. In the words of Halstead’s assistant, “Venus came to the aid of Aesculapius.” Soon after, rubber gloves became the standard for doctors and nurses, but unlike modern latex surgical gloves, these gloves were not disposable, and in between uses, nurses were given the arduous task of cleaning them.

Days ago, before Elke’s surgery, Edna had sterilized the gloves and then checked for holes and minute tears by blowing into them. Slowly, she watched as her breath inflated each glove, the palm and fingers growing bigger, stretching and swelling, expanding like a bloated hand. When she was done, she had listened for leaky air. Nothing. The glove had remained full. But as she watched the surgeon’s hands moving closer to the bare skin, preparing to slice into Elke, the usual fear arose: What if there were a tiny hole, one invisible to the naked eye, that would allow bacteria to pass through and enter the girl’s body? Germ transmission through gloves happened all the time.

It was too late now—the knife came down some centimeters from Elke’s neck, and in a swift motion continued moving along the perimeter of her shoulder blade, curving just under the armpit and then stopping. The skin sprang apart. Blood. There was always so much blood. It spilled forth from the capillaries and arterioles, and multiple nurses rushed over, holding forceps with gauze pads soaked in 110-degree saline solution. They stuffed the pads into the incision and clamped off blood vessels to stop the bleeding.

After separating the skin, the surgeon cut through the connective tissue and arrived at the rib cage.

“Bone clamp,” he said, and then inserted it into the incision and seized a rib.

“Rib cutter.” He clasped it without looking and deftly maneuvered the tool with its beaklike tip deep inside, past the wall of muscles being held back by a retractor, toward the base of rib 4. Once there, he opened the tip and with force pressed the handle.

The snap of bone echoed into the sterile, white-walled room; he repeated the procedure for ribs 3, 2, and 1. As each one slipped away from its juncture, leaving behind a knob of bone, he placed it on a tray, where the growing pile resembled a sequence of shrinking crescent moons. After snipping out the final one, he cut out the stumps of remaining bone and removed any clots and tissue fragments from the incision. Nurses doused the wound with ether to prevent infection, and he inserted a drainage tube.

Edna checked the time. Almost twenty-five minutes had passed; it was astonishing how a rib cage that took years to reach adult form could be dismantled that quickly. Imagine what might happen in an hour or two or three.

“Sutures,” said the surgeon.

Edna handed him the sutures from a glass tube stamped “Catgut with Needle”—a misnomer, as they really came from sheep or cow intestines. Taking the needle, he reached back into the incision and began stitching the muscles. When he finished, Edna handed him a thinner strand of sutures, “Catgut 1,” and watched as he hooked the needle into the skin and pulled the string through the flesh. He repeated the motion over and over, moving the needle down the long gash and leaving behind a trail of brownish stitching.

It was a sloppy job; the stitches were too wide apart. Sewing like that on a garment would have split the seams. Edna’s mother had taught her the importance of alignment, of making small, evenly placed stitches on fabric to create a clean and balanced effect. If Edna had become a surgeon, she would not have sewn so recklessly.

With the top half of her ribs gone and gauze bandages covering a shoddily stitched-together wound, Elke was wheeled to the recovery room, where Edna would stay with her for the next twelve hours, refilling her IV drip and making sure her pulse and respiration and oxygen counts were stable.

Every half hour she took Elke’s blood pressure and roused her to try to cough and spit so that her body wouldn’t fill with mucus and blood. Elke tried, and with every breath, her face crumpled from a searing pain. Edna wished she could give her a painkiller, but their effect on the body caused the respiratory tract to narrow, and so patients were forced to endure hours and hours of postoperative pain without any drugs.

In the days following surgery, Edna tended to her. Every afternoon, in the light of the setting sun, Elke appeared almost healthy. But up close, her face had the color and texture of finely ground chalk, and when Edna lifted the sheet, her body looked old and ravaged and broken. Bones jutted in sharp geometric angles, and her skin was thin and mottled, like aged butterfly wings.

One afternoon, while preparing to change her bandage, Edna noticed Elke’s chest heaving, wheezing, laboring to breathe, and the gauze was saturated in a grayish-yellow liquid, purulent drainage. She took scissors from her cart, slipped her finger between the top of the gauze and the skin, and began snipping it down the middle, each cut letting loose the stench of infection.

Pulling apart the bandage, she saw the long, swooping wound snaking across Elke’s right side. It was swollen and bright red, and the crooked, sloppy stitches had grown taut, inuring themselves into the skin. Long red streaks trailed from the edges of the incision; they moved across her belly toward the lymph nodes in her groin. Heat emanated from the infected skin. Edna knew it was strep.

Underneath a microscope, Streptococcus pyogenes was beautiful, appearing like a strand of broken pearls. But uncontained, it was deadly. The bacteria lurked almost everywhere—in dirt, skin, nasal passages, and unsterilized instruments—and was easily passed on from the hands, nasal secretions, and contaminated food sources. Most strains were harmless, but a handful weren’t. Those baffled doctors.

Unlike tuberculosis, strep replicated with lightning fastness. Scratches easily became skin infections or, worse, cellulitis, an infection of the subcutaneous tissue. In the blood, the germ caused sepsis, which often led to multi-organ failure. In the 1920s, Europe and North America saw over 1.5 million yearly deaths from strep-related illnesses. If Elke’s infection spread, it could set off a bacterial brushfire, sickening the entire ward; inevitably, the surgeon and Miss Mitchell would cast the blame on some nurses, including Edna.

She called a doctor, who removed the stitches, and then Edna began cleaning the wound with gauze soaked in Dakin’s solution, a diluted bleach used to kill bacteria and viruses, and azochloramide, a powerful germicide. Her hands moved gently across the raised line running down Elke’s upper right side, but every touch caused a milky-colored pus mixed with blood to ooze out. The young woman flinched and shuddered and squeezed her eyes tight, as if the gesture could magically erase the pain.

Edna saw her reaction, but kept going, sliding the gauze around Elke’s navel, her concave stomach, and the indented area where her ribs once sat. When she was done, she repeated the process with picric acid, the yellow antiseptic, swabbing the area until Elke’s right side was the color of a brilliant sunset. Then she covered it with alcohol-soaked towels. The work was a formality, a token gesture. Aside from an antibacterial drug that didn’t exist in America, nothing could stop the catastrophe unraveling inside Elke’s body.

Edna pulled up the sheet, readjusted the pillows, and sat down. At this point, Edna would have called Elke’s parents, telling them to come, to bring a holy man or just themselves. They could have stayed long into the night saying goodbye to their daughter. But they were in Europe. No one would come for Elke, whose mind was reeling, her years of life distorting and falling away at dizzying speeds.

The dying girl looked at Edna. She wanted water, but the words wouldn’t form. They flitted around her tongue. A jumble of syllables and consonants, nouns and verbs and adjectives, crashed together. She tried to talk, but the words melted into a low gurgling sound.

Edna took hold of Elke’s hand, feeling the fingers that were once agile, that held books and pens and all those pretty hats. She clutched it tight, fastening the young girl to her, to this place, this life. If she could have, with this simple gesture and her will, saved her, kept her in this world, magically made her heal, she would have, but Elke was called to die. Within hours, her body would fall into septic shock, and her organs would begin closing down: kidneys, liver, lungs, and heart. And the crooked stitches and deformed right side wouldn’t matter anymore.

That night, Edna stayed beside Elke as she fell further away from the living. Soon her mother would find out and feel that unimaginable sorrow of loss, of infinite mourning, of waking and remembering that her baby, her daughter, was no longer there, that she would never come back.

And here at Sea View, word of her death would trickle down to the administration building, and the clerk would turn the pages of the oversize registry, find Elke’s name, and then, beside it, end her story by penning a single word: deceased.