His daughter opened her eyes quite suddenly and looked at him. Her eyes were slanted; he wondered if they would stay that way, like her mother’s. A sort of soft, middle blue, like the sky in mid-morning—nothing remarkable, at a glance, but when you looked straight into it . . . vast, illimitable.
“No,” he said softly, staring into those eyes. Could she see him yet? he wondered.
“No,” he said again. “Her name’s Amanda.”
I HADN’T SAID anything to begin with. It was a common thing in newborns—especially babies born a bit early, as Amanda had been—nothing to worry about.
The ductus arteriosus is a small blood vessel that in the fetus joins the aorta to the pulmonary artery. Babies have lungs, of course, but prior to birth don’t use them; all their oxygen comes from the placenta, via the umbilical cord. Ergo, no need for blood to be circulated to the lungs, save to nourish the developing tissue—and so the ductus arteriosus bypasses the pulmonary circulation.
At birth, though, the baby takes its first breath, and oxygen sensors in this small vessel cause it to contract—and close permanently. With the ductus arteriosus closed, blood heads out from the heart to the lungs, picks up oxygen, and comes back to be pumped out to the rest of the body. A neat and elegant system—save that it doesn’t always work properly.
The ductus arteriosus doesn’t always close. If it doesn’t, blood still does go to the lungs, of course—but the bypass is still there. Too much blood goes to the lungs, in some cases, and floods them. The lungs swell, become congested, and with diverted blood flow to the body, there are problems with oxygenation—which can become acute.
I moved my stethoscope over the tiny chest, ear pressed to it, listening intently. It was my best stethoscope, a model from the nineteenth century called a Pinard—a bell with a flattened disc at one end, to which I pressed my ear. I had one carved of wood; this one was made of pewter; Brianna had sand-cast it for me.
In fact, though, the murmur was so distinct that I felt as though I barely needed a stethoscope. Not a click or a misplaced beat, not a too-long pause or a leaky swish—there were any number of unusual sounds a heart could make, and auscultation was the first step of diagnosis. Atrial defects, ventral defects, malformed valves—all have specific murmurs, some occurring between beats, some blending with the heart sounds.
When the ductus arteriosus fails to close, it’s said to be “patent”—open. A patent ductus arteriosus makes a continuous shushing murmur, soft, but audible with a little concentration, particularly in the supraclavicular and cervical regions.
For the hundredth time in two days, I bent close, ear pressed to the Pinard as I moved it over Amanda’s neck and chest, hoping against hope that the sound would have disappeared.
It hadn’t.
“Turn your head, lovey, yes, that’s right. . . .” I breathed, delicately turning her head away from me, Pinard pressed to the side of her neck. It was hard to get the stethoscope close to her fat little neck . . . there. The murmur increased. Amanda made a little breathy noise that sounded like a giggle. I brought her head back the other way—the sound decreased.
“Oh, bloody hell,” I said softly, so as not to scare her. I put down the Pinard and picked her up, cradling her against my shoulder. We were alone; Brianna had gone up to my room for a nap, and everyone else was out.
I carried her to the surgery window and looked out; it was a beautiful day in the mountain spring. The wrens were nesting under the eaves again; I could hear them above me, rustling round with sticks, conversing in small, clear chirps.
“Bird,” I said, my lips close to her tiny seashell of an ear. “Noisy bird.” She squirmed lazily, and farted in reply.
“Right,” I said, smiling despite myself. I held her out a little, so I could look into her face—lovely, perfect—but not as fat as it had been when she was born a week before.
It was perfectly normal for babies to lose a little weight at first, I told myself. It was.
A patent ductus arteriosus may have no symptoms, beyond that odd, continuous murmur. But it may. A bad one deprives the child of needed oxygen; the main symptoms are pulmonary—wheezing; rapid, shallow breathing; bad color—and failure to thrive, because of the energy burned up in the effort to get enough oxygen.
“Just let Grannie have a little listen again,” I said, laying her down on the quilt I’d spread over the surgery table. She gurgled and kicked as I picked up the Pinard and placed it on her chest again, moving it over neck, shoulder, arm . . .
“Oh, Jesus,” I whispered, closing my eyes. “Don’t let it be bad.” But the sound of the murmur seemed to grow louder, drowning my prayers.
I opened my eyes to see Brianna, standing in the doorway.
“I KNEW THERE was something wrong,” she said steadily, wiping Mandy’s bottom with a damp rag before rediapering her. “She doesn’t nurse like Jemmy did. She acts hungry, but she’ll only nurse for a few minutes before she falls asleep. Then she wakes up and fusses again a few minutes later.”
She sat down and offered Mandy a breast, as though in illustration of the difficulty. Sure enough, the baby latched on with every evidence of starvation. As she nursed, I picked up one of the tiny fists, unfolding her fingers. The minute nails were faintly tinged with blue.
“So,” Brianna said calmly, “what happens now?”
“I don’t know.” This was the usual answer in most cases, truth be told—but it was always unsatisfactory, and clearly not less so now. “Sometimes there are no symptoms, or only very minor ones,” I said, trying for amendment. “If the opening is very large, and you have pulmonary symptoms—and we have—then . . . she might be all right, only not thriving—not growing properly, because of the feeding difficulties. Or”—I took a deep breath, steeling myself—“she could develop heart failure. Or pulmonary hypertension—that’s a very high blood pressure in the lungs—”
“I know what it is,” Bree said, her voice tight. “Or?”
“Or infective endocarditis. Or—not.”
“Will she die?” she asked bluntly, looking up at me. Her jaw was set, but I saw the way she held Amanda closer, waiting for an answer. I could give her nothing but the truth.
“Probably.” The word hung in the air between us, hideous.
“I can’t say for sure, but—”
“Probably,” Brianna echoed, and I nodded, turning away, unable to look at her face. Without such modern assistances as an echocardiogram, I of course couldn’t judge the extent of the problem. But I had not only the evidence of my eyes and ears, but what I had felt passing from her skin to mine—that sense of not-rightness, that eerie conviction that comes now and then.
“Can you fix it?” I heard the tremor in Brianna’s voice, and went at once to put my arms around her. Her head was bent over Amanda, and I saw the tears fall, one, then another, darkening the wispy curls on top of the baby’s head.
“No,” I whispered, holding them both. Despair washed over me, but I tightened my hold, as though I could keep time and blood both at bay. “No, I can’t.”
“WELL, THERE’S NO choice, is there?” Roger felt preternaturally calm, recognizing it as the artificial calm produced by shock but wishing to cling to it as long as possible. “You’ve got to go.”
Brianna leveled a look at him, but didn’t reply. Her hand roamed over the baby, sleeping in her lap, smoothing the woolly blanket over and over again.
Claire had explained it all to him, more than once, patiently, seeing that he could not take it in. He still did not believe it—but the sight of those tiny fingernails, turning blue as Amanda strove to suck, had sunk into him like an owl’s talons.
It was, she had said, a simple operation—in a modern operating room.
“You can’t . . . ?” he’d asked, with a vague motion toward her surgery. “With the ether?”
She’d closed her eyes and shaken her head, looking nearly as ill as he felt.
“No. I can do very simple things—hernias, appendixes, tonsils—and even those are a risk. But something so invasive, on such a tiny body . . . no,” she repeated, and he saw resignation in her face when she met his eyes. “No. If she’s to live—you have to take her back.”
And so they had begun to discuss the unthinkable. Because there were choices—and decisions to be made. But the unalterable basic fact was clear. Amanda must go through the stones—if she could.
JAMIE FRASER took his father’s ruby ring, and held it over the face of his granddaughter. Amanda’s eyes fixed on it at once, and she stuck out her tongue with interest. He smiled, despite the heaviness of his heart, and lowered the ring for her to grab at.
“She likes that well enough,” he said, skillfully removing it from her grip before she could get it into her mouth. “Let’s try the other.”
The other was Claire’s amulet—the tiny, battered leather pouch given to her by an Indian wisewoman years before. It contained assorted bits and bobs, herbs, he thought, and feathers, perhaps the tiny bones of a bat. But in among them was a lump of stone—nothing much to look at, but a true gemstone, a raw sapphire.
Amanda turned her head at once, more interested in the pouch than she had been in the shiny ring. She made cooing noises and batted wildly with both hands, trying to reach it.
Brianna took a deep, half-strangled breath.
“Maybe,” she said, in the voice of one who fears as much as hopes. “But we can’t tell for sure. What if I—take her, and I go through, but she can’t?”
They all looked at one another in silence, envisioning the possibility.
“You’d come back,” Roger said gruffly, and put a hand on Bree’s shoulder. “You’d come right back.”
The tension in her body eased a little at his touch. “I’d try,” she said, and attempted a smile.
Jamie cleared his throat.
“Is wee Jem about?”
Of course he was; he never went far from home or Brianna these days, seeming to sense that something was wrong. He was retrieved from Jamie’s study, where he had been spelling out words in—
“Jesus Christ on a piece of toast!” his grandmother blurted, snatching the book from him. “Jamie! How could you?”
Jamie felt a deep blush rise over him. How could he, indeed? He’d taken the battered copy of Fanny Hill in trade, part of a parcel of used books bought from a tinker. He hadn’t looked at the books before buying them, and when he did come to look them over . . . Well, it was quite against his instincts to throw away a book—any book.
“What’s P-H-A-L-L-U-S?” Jemmy was asking his father.
“Another word for prick,” Roger said briefly. “Don’t bloody use it. Listen—can ye hear anything, when ye listen to that stone?” He indicated Jamie’s ring lying on the table. Jem’s face lighted at sight of it.
“Sure,” he said.