Cutting for Stone

by Abraham Verghese

  The Colonel, just back from London, had a rare bottle of Glenfid-dich for Ghosh, chocolates for us, and Chanel No. 5 perfume for Hema. The cigarettes in the ashtrays were Dunhill and 555—his contribution again. Though he wore a blazer and open shirt, his tucked-in chin and the shoulders drawn back made it seem he was still in uniform. If he left the party, I imagined the rest of them would slump over like toys whose spring had unwound.

  Evangeline, an Anglo-Indian, a bridge regular, turned to Colonel Mebratu: “A little bird told me that we might soon be calling you Brigadier General. Is that true?”

  Colonel Mebratu frowned. “Such vicious rumors. Such an incestuous community. And I fear, Evangeline, you are at the center of it. But in this case I must correct you, my dear. I am not soon to be called Brigadier General. As of yesterday, I am Brigadier General.”

  Well, there was no stopping them after that. Zemui and Gebrew made two runs for food from the Ras Hotel.

  Much later that night, Mebratu and Ghosh palavered over cognac and cigars. “In Korea in ‘52 we were one of fifteen countries in the UN forces. I wasn't long out of command training when I went there. The other countries underestimated us. You see, they knew nothing about Ethiopian courage or the battle of Adowa or any of that. By God, we proved ourselves in Korea. By the time we got to the Congo, they knew what to expect. We had an Irish commander, then a Swedish commander, and in the third year, they made our own General Guebre commander of allthe UN forces. You know, Ghosh, as a career military man that was my proudest moment. Even more than this promotion I got yesterday.”

  I'LL NEVER KNOW HOW, but Ghosh understood what I was going through after the pantry episode; perhaps he recognized that I was quarantined from Genet and that Shiva didn't share in that experience; perhaps he saw my confusion when Zemui was around. Maybe it was written on my face that I'd become aware of human complexity—that's a kinder word than “deceit.” I was trying to decide where to peg my own truth, how much to reveal about myself—it helped to have such a steadfast father in Ghosh, never fickle, never prying, but knowing when I needed him. Had Hema learned what went on in the pantry, I'd hear about it two seconds later. But Ghosh, if he knew, was capable of keeping his peace, biding his time, hearing me out; he'd have even kept it secret from Hema if he didn't think it served any purpose to tell her.

  One wet afternoon, when Genet and Shiva were having their dance lesson with Hema, Ghosh telephoned and asked me to meet him in Casualty. “I want you to feel a most unusual pulse.” Ghosh was primarily a surgeon now, operating electively three days a week and doing the emergency cases as needed. But, as he often said at dinner, he was still an internist at heart and couldn't resist coming down to Casualty to see certain patients who presented a diagnostic puzzle, one that neither Adam nor Bachelli could crack.

  I was grateful for Ghosh's call. I never had any interest in dancing, but it bothered me to see Genet enjoying something in which I had no part. I put on my gutta-percha boots and raincoat and dashed out with my umbrella.

  Demisse was in his twenties, sitting on the examining stool in front of Ghosh, wearing only torn jodhpurs. I noticed at once the bobbing of his head, as if an eccentric flywheel turned within him. It was my first formal visit with a patient, and I was embarrassed. What would this barefoot farmhand think of a young boy entering the exam room? But he was thrilled to see me. Later I realized that patients felt privileged to be singled out in this fashion. Not only had they made it past Adam, not only had they seen the tilik doctor, the same big doctor whom the royalty came to see, but now they got a bonus—me.

  Ghosh guided my fingers to Demisse's pulse at the wrist. It was easy to feel, unavoidable, a surging, slapping, powerful wave under my fingertips. Now I could see that his head bobbing happened in time with the pulse.

  “Now feel mine,” Ghosh said, holding out his wrist. It was harder to find, subtle.

  He had me go back to Demisse's pulse.

  “Describe it,” Ghosh said.

  “Big … strong. Like something alive under the skin, slapping,” I said.

  “Exactly! That is a classic collapsing or water hammer pulse. Its full name is the Corrigan's water hammer pulse.”

  He handed me a foot-long thin glass tube that Id seen lying across his table. “Hold it up. Now turn it over.” The tube was sealed at both ends and had a little water in it. When I flipped it, the water raced down to the bottom of the tube with an unexpected smacking sound and a shock. “There's a vacuum inside, you see,” he said. “It's a toy that kids played with in Ireland. It's a water hammer. Dr. Corrigan was reminded of the toy when he first felt a pulse like Demisse's.”

  Ghosh had made the water hammer for me. He had sealed one end of a glass tube with a Bunsen flame. Then he put a few drops of water inside the tube through the open end. He heated the length of the tube above the liquid to drive the air out and quickly sealed the open end under the flame.

  “Demisse's heart shoots blood out into the aorta. That's the big highway leading out of the heart,” he said, making a sketch for me on paper. “A valve right here at the exit from the heart is supposed to close after the heart contracts, to keep the blood from falling back into the heart. His doesn't close well. So his heart squeezes blood out just fine, but half of that ejected blood falls right back into the heart between squeezes. That's what gives it the collapsing quality.” How exciting to be able to touch a human being with one's fingertips and know all these things about them. I said as much to Ghosh, and from his expression you would think Id said something profound.

  He sent for me often during those holidays. Shiva came at times, but not if it interfered with his dance lesson or if he was in the middle of a drawing. I learned to recognize the slow, heaving, plateaulike pulse of a narrowed aortic valve. It was the opposite of a collapsing pulse. The small valve opening made that pulse both weak and prolonged. Pulsus parvus et tardus, Ghosh called it.

  I loved those Latin words for their dignity, their foreignness, and the way my tongue had to wrap around them. I felt that in learning the special language of a scholarly order, I was amassing a kind of force. This was the pure and noble side of the world, uncorrupted by secrets and trickery. How extraordinary that a word could serve as a shorthand for an elaborate tale of disease. When I tried to explain this to Ghosh, he was excited.

  “Yes! A treasure trove of words! That's what you find in medicine. Take the food metaphors we use to describe disease: the nutmeg liver, the sago spleen, the anchovy sauce sputum, or currant jelly stools. Why, if you consider just fruits alone you have the strawberry tongue of scarlet fever, which the next day becomes the raspberry tongue. Or how about the strawberry angioma, the watermelon stomach, the apple core lesion of cancer, the peau d'orange appearance of breast cancer … and that's just fruits! Don't get me started on the nonvegetarian stuff!”

  One day I showed Ghosh the notebook in which I kept a written cata log of everything he had told me, and every pulse I had seen. Like a birder, I listed the ones I sought: pulsus par-adoxus, pulsus alternans, pulsus bisferiens … and simple drawings of what they might look like. He wrote in the fly leaf: Nam et ipsa scientia potestas est! “That means ‘Knowledge is power!’ Oh, I do believe that, Marion.”

  We didn't stop at pulses. I went to Ghosh as often as I could. Fingernails, tongues, faces—soon my notebook was chock-full of drawings and new words. I found use at last for my penmanship: each figure was carefully labeled.

  On a Friday evening, our last weekend before school started, I rode with Ghosh to see Farinachi, the toolmaker. Ghosh handed Farinachi two old stethoscopes and a drawing of his idea for a teaching stethoscope. Farinachi, a dour, stooped Sicilian, wore a vest under his leather apron. He studied the drawing carefully through a haze of cigar smoke, tracing the outline with a large forefinger. He had fashioned several contraptions for Ghosh, including the Ghosh Retractor, and the Ghosh Scalp Clip. Farinachi shrugged, as if to say if that was what Ghosh wanted, he would do it.

  As we were
driving back, Ghosh pulled out a present hed wrapped for me. It was my very own brand-new stethoscope. “You don't have to wait for Farinachi. Now that you know your pulses, we're going to start listening to heart sounds.” I was moved. It was the first gift I'd ever received that wasn't one of a pair. This was mine alone.

  Looking back, I realize Ghosh saved me when he called me to feel Demisse's pulse. My mother was dead, and my father a ghost; increasingly I felt disconnected from Shiva and Hema, and guilty for feeling that way. Ghosh, in giving me the stethoscope, was saying, Marion, you can be you. It's okay. He invited me to a world that wasn't secret, but it was well hidden. You needed a guide. You had to know what to look for, but also how to look. You had to exert yourself to see this world. But if you did, if you had that kind of curiosity if you had an innate interest in the welfare of your fellow human beings, and if you went through that door, a strange thing happened: you left your petty troubles on the threshold. It could be addictive.

  CHAPTER 22

  The School of Suffering

  ONE MORNING toward the end of Michaelmas term, as Shiva, Genet, and I walked to Missing's gate, school satchels in hand, I saw a couple racing up the hill toward us, a child flopping lifeless in the man's arms. They were ready to drop, yet still trying to run up that incline when they had no breath to walk. But as long as they ran with the child in their arms, it was still alive to them, and there was hope.

  Without a moment's hesitation, ShivaMarion raced to meet them. The parents’ distress triggered this, gave us no time to debate our response, as a higher brain emerged, doing the deciding for us and guiding us to move as one organism if we knew what was best. I remember thinking, in the midst of that panic, how much I missed that state and how exhilarating it was to be ShivaMarion. Even as I grabbed the infant boy from the father (whose gait by now had become a weary shuffle) and raced away, Shiva's steady hand on my low back was my afterburner, and he matched my stride perfectly, ready to take over when I tired. I was conscious of the baby's skin, the way it chilled my hand, sucking the heat out of it as I ran—I knew I'd never again take being “warm-blooded” for granted, having now felt the alternative.

  We handed the child over in Casualty and we waited outside, panting. When the parents caught up, we held the doors open for them. Minutes later we heard a scream, then loud protests, and ultimately the wailing that means the same in any language. It was all too familiar a sound.

  There was another Missing sound that made my adrenaline flow: it was the shrieking, grating sound of Gebrew dragging the big gate open as fast as it would go. It always signaled a dire emergency.

  A childhood at Missing imparted lessons about resilience, about fortitude, and about the fragility of life. I knew better than most children how little separated the world of health from that of disease, living flesh from the icy touch of the dead, the solid ground from treacherous bog.

  Id learned things about suffering that weren't taught to me by Ghosh: First, that white was the uniform of suffering, and cotton its fabric. Whether it was thin (a shama or nettald) or heavy as a blanket (in which case it was a gabby), it must keep the head warm and the mouth covered—no sun or wind should hit because these elements carried the mitch, the birrd, and other evil miasmas. Even the minister with the waistcoat and fob watch would, when he was ill, throw a nettala over his coat, cram eucalyptus leaf up his nose, take an extra dose of kosso for tapeworm, and then hurry over to be seen.

  Day after day a white-robed mass flowed up our hill, gravity the current against which they swam. Those whose breath ran short as well as the crippled and the lame stopped at the halfway point to look up, to gaze past the tops of the flanking eucalyptus to where the African hawks soared against the blue sky.

  Once they crested the hill, patients went to the registration desk to get their card. From there it was on to Adam, the man whom Ghosh called the World's Greatest One-Eyed Clinician. “Short of breath, are you?” Adam might say to a patient. “But still you managed to run up the hill and get the fourth card of the day?” In Adam's book, a number under ten on the outpatient card identified a hypochondriac more accurately than any test Ghosh might do.

  From my spot observing the daily influx, I once saw a proud Eritrean woman carrying a heavy basket; inside was something large, sprouting, with a surface that was red, raw, and weeping. It was her breast. It had become so huge from cancer that this was the only way for her and her breast to come to Missing.

  I drew such sights in my notebook. My sketches were nothing like Shiva's, but they served me well. A glance at them allowed me to recall the memory, even if it was not Shiva's photographic kind.

  On page thirty-four I drew a child in profile, chubby-cheeked, healthy. But from the other side, his profile showed a chunk of his cheek, one nostril, and the eye missing, so that his glistening teeth and pink gum and the recess of the orbit were visible. I learned from Ghosh to call this ghastly sight cancrum oris. It came about from a trivial gum or tooth infection which spread because of malnutrition and neglect, often during an episode of measles or chicken pox. Once ignited, it progressed rapidly, usually causing death before the child could be brought to Missing. Sometimes, the disease simply ran out of steam, or the body's defenses were finally able to contain the march, but at the expense of half the face. Death was perhaps a better fate than to live with the disfigurement. I watched Ghosh operate on this child. It was terrifying, and then I was in awe at what this man who sat down to dinner with us each night was capable of doing: rotate a flap of skin to cover the cheek, and another the hole in the nose. Further flaps and reconstruction he planned for a later surgery. Even so there was no restoring to normal the face, much less the soul, of a child so scarred. After the surgery, what Ghosh said to me was, “Don't be too impressed. I'm an accidental surgeon, son. I do all I can do. But your father … what he could have done to that face would have been as good as the best plastic surgeon alive. You see, your father was a real surgeon. I don't think I've seen anyone better.” What made someone a real surgeon, I asked. Ghosh didn't hesitate: “Passion for his craft … and skill, dexterity. His hands were always ‘quiet.’ I mean he had no wasted movements, no dramatic gestures. It looked slow, routine, but when you looked at the clock you realized how fast it must have been. But even more important is the confidence once you make the first cut, the belief in yourself, which allows you to do more and get better results. I'm thankful I can do the simple things, the bread-and-butter operations. But I'm scared to death half the time.”

  He was being modest. But it was true that Ghosh was a different being in the outpatient department where he saw “consultations”—the patients Bachelli and Adam kept for him to render an opinion. Ghosh's real skill emerged with those who looked “normal” to my gaze. Hidden from us unschooled observers, a disease had left its traces. A woman who wove baskets said, “On St. Stefano's Day I passed urine on a barbed-wire fence …” Or this from a sad, distraught coolie: “The morning after the Wednesday fast, I accidentally stepped over the cast-off water from a prostitute's morning wash …” Ghosh listened, his eyes taking in the blister marks on the sternum which said the native healer had been consulted; he noted the thick speech and guessed that the uvula had probably been recently amputated on a second visit to the same charlatan. But Ghosh had an ear for what lay beneath those surface words, and a pointed question uncovered a story which matched with one in his repertoire of tales. Then it was time to look for the flesh signs, the bookmarks of the disease, and to palpate and percuss and listen with his stethoscope for clues left behind. He knew how that story ended; the patient only knew the beginning.

  THERE IS ONE LAST SIGHTING at Missing—which had nothing to do with Ghosh—that I must describe because it happened during that period: it explained Shiva's life course, and why it veered away from my mine.

  Late one morning as Shiva and I sat on the culvert by the side of Missing's hill, a frail, barefoot girl, no older than twelve, came stiff-legged up the hill. Prematurely
stooped like an old woman, she leaned heavily on her giant of a father. His muddy, patched jodhpurs ballooned above bare feet and horned toenails. He could have taken the hill in twenty strides. Instead he took small steps to accommodate hers. They crept forward like snails, while other visitors sped up when they neared these two, as if father and daughter created an animating field. When she reached us, I understood why. An unspeakable scent of decay, putrefaction, and something else for which the words remain to be invented reached our nostrils. I saw no point in holding my breath or pinching my nose because the foulness invaded instantly, coloring our insides like a drop of India ink in a cup of water.

  In the way that children understand their own, we knew her to be innocent of her terrible, overpowering odor. It was of her, but it wasn't hers. Worse than the odor (since she must have lived with it for more than a few days) was to see in her face the knowledge of how it repulsed and revolted others. No wonder she had fallen out of the habit of looking at human faces; the world was lost to her, and she to it.

  When she paused to catch her breath, a slow puddle formed at her bare feet. Looking down the road, I could see the trail she left behind. I'll never forget her father's face. Under that peasant straw hat he burned with love for his daughter, and rage against the world that shunned her. His bloodshot eyes met every stare and even sought out those who tried not to look. He cursed their mothers, and cursed the gods they worshipped. He was deranged by a scent he could have escaped.