Carriscant was tidying away his papers into his desk when there was a knock at his door and one of the nursing sisters appeared.

'Excuse me, Dr Carriscant, Dr Cruz sends his compliments and would like you to visit him in his theatre. It's a matter of some urgency.'

Carriscant was very surprised. He and Cruz had barely exchanged a word since the row over Delphine's appendicitis.

'In his theatre, you say?'

'Yes. At once, if you please.'

Carriscant crossed the courtyard towards Cruz's consulting rooms. He followed the nurse down an ill-lit corridor towards the operating theatre. The walls here were painted with ancient yellow distemper which was flaking and peeling, and there was a curious smell in the air, a sweetish fatty cloying reek which lingered in the nose, coating the palate almost as if it were designed to be tasted rather than smelt. It was the smell of old untended food, an exudation of dirty kitchens. Carriscant recognised it at once as the smell of putrefaction.

Cruz's operating theatre was, to Carriscant's eyes, a scene from one of the circles of hell. Old cracked terracotta tiles on the floor and smudged plaster walls covered, for some reason, in scribbles of handwriting, ancient wooden trays and tables. Cruz stood tall in his domain, in his famous frock coat with its filthy veneer, its pustulent lichen, the cuffs unbuttoned and the sleeves of his coat and shirt folded back to reveal his powerful forearms with their pelt of dark hair. His hands were smeared with blood as he towelled them off on a scrap of cloth. Three theatre nurses stood around the operating table alongside another doctor, Dr Filomeno, who acted as Cruz's anaesthetist. Dr Filomeno wore a light brown suit, ruined by a splash of blood down the right side. He was dabbing at this with a bundle of swabs and complaining vigorously to one of the nurses.

'Ah, Carriscant,' Cruz said, tossing the towel away on to a tray of instruments. 'Glad you could make it.' The self-satisfaction, the barely suppressed delight in his voice, made him drawl the words out as if he were intoxicated. 'I very much wanted you to see this.' He waved Carriscant up to the table.

A man lay there, his chest cavity open, retractors holding the wound wide. Peering closer, Carriscant could see that the pericardium had also been cut open, the sides held back by clamp forceps.

'Look,' Cruz said. There, amidst the coagulated blood and the severed tissue Carriscant saw the man's beating heart, pulsing irregularly like some sea creature, half vegetable, half shell-less bivalve, something that clung to rocks deep at the bottom of the sea, expanding and contracting weakly, only just alive. Carriscant turned back to Cruz. The man ran his hands through his wiry hair and began to roll down his cuffs.

'I've summoned a photographer,' he said proudly. 'The world is about to learn about Isidro Cruz. You're not the only surgeon around here that can make an impression.'

'What're you talking about?'

'Look,' Cruz said, approaching the body. 'Just look, Carriscant.'

He stared at the twitching heart. Six taut sutures, knotted silk. Cruz's blunt finger entered the chest cavity and touched the pulsing organ.

'Cardiac sutures, Carriscant. In a knife wound.'

The nurses fussed over the body, checking the drains from the pericardium and pleura.

'Dr Filomeno will replace the rib and close the wound. I shall be issuing a statement to the press.'

Carriscant could not resist it: he reached out a finger and gently touched the surface of the beating heart as it wobbled and bulged, slick in its cavity. The six stitches sealed a neat wound about an inch long in the left ventricle. Carriscant's eye fell on a bag of ice on a nearby trolley. He looked at the man's face.

'May I?' He removed the mask that covered it: the man's skin was practically grey. Carriscant recognised him.

'The left lung collapsed,' Dr Filomeno explained.

Carriscant nodded. This was the man he had seen in Cruz's ward just two days previously. But the nurse had said nothing about a wound in the heart. In the pericardium, she had said. Carriscant's mind began to work: the man could not have had this gash in the heart then or he would have died within the hour. A tiny perforation perhaps, that had been his diagnosis, but not a wound of this size. So where had he received this neat wound that Cruz had sutured? Surely, not even Cruz could be so – 'Cardiac sutures,' Cruz taunted. 'Cardiac sutures, Carris-cant.'

'This man will die.'

'I doubt it. The bleeding has stopped. The lung will reflate.'

'Even so. No, it's the filth of this place that will do for him. Look at you. I saw you run your fingers through your hair just before you touched his heart.'

'Modern nonsense, Carriscant. Modish dogma.'

'You might as well have operated on a cadaver.'

'Professional jealousy is the most demeaning of emotions, wouldn't you say, Filomeno?'

'Without any kapffneu!'

Filomeno sneezed, his hand going to his nose a second too late. Carriscant turned away and looked around at the foetid, badly lit room full of people in their street clothes, scratching and sniffing, the dried blood and feculence of dozens of operations stiff and crumbling on their coat fronts.

A porter appeared at the doorway. 'A gentleman is here from the Manila Times, sir,' he said.

Carriscant could not resist. Later he wished he had let Cruz suffer the full force of public humiliation and ignominy but this personal victory was too sweet to be resisted.

'I congratulate you on your sutures, Cruz. Neat work, as always. But you're too late. If I were you I would set out straightaway on the road of aseptic surgery. Who knows, you might achieve great things.'

'What do you mean, "too late"?'

'Seven years too late to be precise. The first cardiac sutures performed on a living patient-who survived – took place in 1896. Frankfurt-am-Main. Dr Louis Rehn was the surgeon.' He smiled. 'Nice try. Now if you'll excuse me I have an official entertainment to attend.'

The launch was waiting for them at the wharf by the Cold Storage buildings. Carriscant helped Annaliese down into the well behind the engine and waited as the other members of their party climbed aboard. The night air was sultry and warm and he found himself wondering why formal receptions in the tropics had to be governed by the same manners and decorum suitable for temperate climates. To be wearing a tail coat, a stiff collar and white tie to attend a function on an island in the middle of the China Sea seemed to be ludicrously pretentious, not to say sheer folly. All his satisfaction at having put Cruz so unequivocally in his place had evaporated, to be replaced by irritation and bad grace. He dropped down into the launch and it was pushed away from the wharf and began to motor up the Pasig towards the Malacanan Palace. Here at least was some relief, a little coolness, and he stretched his neck above his collar and spread his moist palms to catch the breeze created by their progress. Around him, chattering excitedly, were the members of their party – Annaliese's friends, not his, he corrected himself. The invitation had been extended to the bishop and his staff, hence Annaliese's insistence that they go. He looked back at them: Mr and Mrs Freer, middle-aged English, he an oculist; Monsieur and Madame Champoursin, he was a journalist; Senora Pilar Prospero, headmistress of the cathedral school; Father Agoncillo, a plump young priest and a special friend of Annaliese; and Mrs Kelly, a friend of the Freers, wife of a veterinary surgeon in Iloilo, visiting Manila for a month. What an impoverished crowd, he thought sourly. The men were all in evening dress like him, the women might have been going to a ball in any provincial city in Europe – long dresses, petticoats, demure jewels, silk, lace and taffeta, corsets and hair-combs and high-heeled slippers. One or two carried fans, otherwise they might have been in Aberdeen or Bristol, Lyons or Hamburg, Genoa or Seville. He was determined, at all costs, not to enjoy himself.