Cutting for Stone

by Abraham Verghese

  Dear Dr. Giles,

  … there is a Chvostek's sign, a Boas's sign, a Courvoisier's sign, a Quincke's sign—no limit it seems to white men naming things after themselves. Surely, the world is ready for an eponym honoring a humble compounder who has seen more relapsing fever with one eye than you or I will ever see with two.

  Ghosh, working in an obscure African hospital, far from the academic mainstream, had his way. The paper was published in the prestigious journal, and no doubt led to his being invited to write a chapter in Harrison's Principles of Internal Medicine, the bible of senior medical students. Now, here he was, a professor. Hema bought our new professor two beautiful pin-striped suits, one black and the other blue. Also a tweed coat with leather elbow patches, as if to put “Professor” in quotes. The bow tie was his idea. In all things, especially when it cost little and did no harm to others, Ghosh was his own man. The bow tie told the world how pleased he was to be alive and how much he celebrated his profession, which he called “my romantic and passionate pursuit.” The way Ghosh practiced his profession, the way he lived his life, it was all that.

  CHAPTER 36

  Prognostic Signs

  LIFE IS FULL OF SIGNS. The trick is to know how to read them. Ghosh called this heuristics, a method for solving a problem for which no formula exists.

  Red sky in the morning, sailors take warning.

  Pus somewhere and Pus nowhere means Pus in the belly.

  Low platelets in a woman is lupus until proven otherwise.

  Beware of a man with a glass eye and a big liver …

  Across the outpatient department, Ghosh would spot a breathless young woman, her cheeks flushed, contradicting her general pallor. Hed suspect narrowing of the mitral valve of the heart, though he'd be hard-pressed to explain exactly why. It would make him listen carefully for the soft, rumbling murmur of mitral stenosis, a devilish murmur which, as he said, “you'll only hear if you know it's there,” and then it was only audible with the bell of the stethoscope lightly applied over the apex of the heart after exercise.

  I'd developed my own heuristics, my mix of reason, intuition, facial appearance, and scent. These were things not in any book. The army soldier who'd tried to steal the motorcycle had an odor at the moment of his demise, and so, too, had Rosina, and the two odors were identical—they spoke of sudden death.

  But I didn't trust my nose when I should have, when it picked up signals from Ghosh that put my nerves on edge. I wrote it off as being a function of his new job as a professor, a side effect of his new suits and new environment. When I was around him it was easy to be reassured. He'd always been upbeat, a happy soul. But now he was even more jovial. He'd found his best self. For a man who prided himself on “the three Ls: Loving, Learning, and Legacy,” he'd excelled in all three.

  On the anniversary of Hema and Ghosh's marriage, I woke myself at 4:00 a.m. to study. Two hours later, I walked over from Ghosh's old bungalow to the main house. Shiva had moved back to our boyhood room. It was still dark outside. I planned to creep into Shiva's room to see if a shirt I was missing had been laundered and hung in his closet. I came in as Almaz arrived. I hugged her and then waited as she made the sign of the cross on my forehead and murmured a prayer.

  Hema was still sleeping. The hallway bathroom door stood open, steam coming out. Ghosh stood in front of the washbasin, a towel around his waist, leaning heavily on the sink. It was early for him. I wondered why he was using this bathroom. So as not to wake Hema? I could hear his labored breathing before I saw him and, certainly, before he saw me. The effort of bathing had winded him. In his reflection in the mirror, I saw his unguarded self. I saw terrible fatigue; I saw sadness and apprehension. Then he saw me. By the time he'd turned around, the mask of joviality which had fallen into the sink had been slapped back on, not a seam showing.

  “What's wrong?” I asked. I felt my stomach flutter. The scent was there. It had to be connected to what I just saw.

  “Not a thing. Scary, isn't it?” He paused to take a breath. “My beautiful wife is sleeping like an angel. My sons make me so proud … Tonight I'm going to take my wife dancing and I'll ask her to extend our marriage contract for another year. The only thing wrong is that a sinner like me doesn't deserve such blessings.”

  Hema came out to the hallway, shaking sleep from her hair. Ghosh flashed me an anxious look.

  He turned back to the mirror, whistling as he slapped on cologne. His eyes pleaded with me not to alarm Hema. The effort of holding his arms up made his “Saints Come Marching In” full of staccato notes and pauses. I got my shirt and left.

  I had an early morning class, an important one. But I followed my instinct, my intuition—my nose. I dressed and then hid myself behind Shiva's toolshed. Soon, the Volkswagen appeared out of the mist, with just Ghosh in it. I followed on foot.

  I got to Casualty in time to see him enter Matron's office. Not only was Matron there at this early hour, she was waiting. I stood there considering what this meant, when Adam appeared carrying a bottle of blood. Matron's door opened for him. Adam emerged moments later empty-handed. He was startled to see me, and he tried to close the door behind him, but I had a foot there.

  Ghosh was on a lounge chair, his feet up, a pillow behind his head, smiling. Bach's “Gloria” chorus sounded on Matron's ancient phonograph. Matron bent over his arm, taping the needle that carried blood into his vein in place. They looked up, thinking perhaps it was Adam returning for something.

  Ghosh's lips moved.

  “Son, you know I—”

  “Don't bother to lie to me,” I said.

  He looked to Matron, as if for a cue. She sighed. “This is fate, Ghosh. I always thought Marion should know.”

  I'll never forget the stillness, the hesitation, and a trace of something I'd never before seen on Ghosh's face: cunning. Then it gave in to resignation and a faraway look. For a moment I saw the world through his eyes, his intellect, his sweeping vision that took in Hippocrates, Pavlov, Freud, and Marie Curie, the discovery of streptomycin and penicillin, Landsteiner's blood groups; a vision that recalled the septic ward where he wooed Hema, and Theater 3 where he was the reluctant surgeon; a vision that recapitulated our birth and looked to the future, looked past his life to the end of mine and beyond. And then and only then did it settle, gather, and focus, on the now, on a moment when the love was so palpable between father and son that the thought that it might end, and this memory be its only legacy, was unacceptable.

  “All right, Marion, you budding clinician. What do you think it might be?” He loved the Socratic Method. Only this time, he was the patient, and it was my heuristic I would invoke.

  I'd noticed his pallor before, but I'd refused to let it register. Now I remembered that I'd seen bruises on his arms and legs for the past few months—bruises for which he always had explanations. Was it just a week ago he had the paper cut on his finger? It happened in front of my eyes, and it bled for a while; when I saw him a few hours later, the wound was still oozing. How had I managed to dismiss that? I remembered, too, his hours exposed to radiation from the Old Koot, the ancient X-ray machine which, despite everyone's protests, he'd continued to use until Missing finally got a new machine. The Koot was broken apart with hammers and the pieces hauled to the Drowning Soil. There it would keep the army man company, while making his bones glow.

  “A blood cancer? A leukemia?” I said, hating the sound of those ugly words on my lips. Ghosh's disease was only born, it only came to life, the moment I named it, and now it couldn't go away.

  He beamed, turned to Matron, raising his eyebrows. “Can you believe this, Matron? My son, the clinician.”

  Then his voice lost its ebullience; he spoke in a manner in which pretense had fallen off like leaves after a frost.

  “Whatever happens, Marion, you mustn't let Hema know. I had my slides sent off about two years ago through Eli Harris to Dr. Maxwell Wintrobe in Salt Lake City Utah, USA. He's a fabulous hematolo-gist. I love his textbook. He pe
rsonally wrote me back. What I have is like an active volcano, rumbling and spitting. Not quite a leukemia, but brewing into one; it's called ‘myeloid metaplasia,’ “ he said, pronouncing it carefully as if it were something delicate and exquisitely wrought. “Remember the term, Marion. It's an interesting disease. I still have many years left, I'm sure. The only troublesome symptom I have now is anemia. These blood transfusions are my oil changes. I'm going dancing tonight with Hema. It's our big day, you know. I wanted more gumption.”

  “Why won't you let Ma know? Why didn't you let me know?”

  Ghosh shook his head. “Hema will go crazy … She'll, she shouldn't, she can't … Don't look at me that way, my son, I'm not being noble, I promise you.”

  “Then I don't understand.”

  “You didn't know about my diagnosis these last two years, did you? If you had known, it would've changed your relationship with me. Don't you think?” He grinned, and he ruffled my hair. “You know what's given me the greatest pleasure in my life? It's been our bungalow, the normalcy of it, the ordinariness of my waking, Almaz rattling in the kitchen, my work. My classes, my rounds with the senior students. Seeing you and Shiva at dinner, then going to sleep with my wife.” He stopped there, silent for a long time as he thought of Hema. “I want my days to be that way. I don't want everyone to stop being normal. You know what I mean? To have all that ruined.” He smiled. “When things get more severe, if it ever comes to that, I'll tell your ma. I promise.”

  He looked at me intently. “You'll keep this a secret? Please? It's what you can do for me. A gift, if you like. Give me as many normal days as I can possibly have. And you mustn't tell your brother either. That might be hardest for you. I know you two have had a … rift. But you understand Shiva better than anyone. I know you care enough for him to protect him from this news getting to him prematurely.”

  I gave him my word.

  ABOUT THE NEXT FEW MONTHS, I remember very little, except that Ghosh's wisdom was revealed. It had been a blessing not to know for the last two years. Now that I knew, there was no turning back time or erasing that knowledge; it was as if he were back in jail again and, in a way, so was I. I read everything I could about myeloid metaplasia (how I hated that term which he loved). His bone marrow was quiet when I first learned of his diagnosis. But then the disease became more active, the volcano started rumbling, oozing lava, spitting telltale traces of sulfurous gas when the wind was right.

  I spent as much time as I could with Ghosh. I wanted every bit of wisdom he could impart to me. All sons should write down every word of what their fathers have to say to them. I tried. Why did it take an illness for me to recognize the value of time with him? It seems we humans never learn. And so we relearn the lesson every generation and then want to write epistles. We proselytize to our friends and shake them by the shoulders and tell them, “Seize the day! What matters is this moment!” Most of us can't go back and make restitution. We can't do a thing about our should haves and our could haves. But a few lucky men like Ghosh never have such worries; there was no restitution he needed to make, no moment he failed to seize.

  Now and then Ghosh would grin and wink at me across the room. He was teaching me how to die, just as he'd taught me how to live.

  SHIVA AND HEMA went about their days ignorant of Ghosh's condition. They were caught up in their own excitement. Shiva had coaxed Hema into a major commitment to treating women with vesiculovaginal fistula, or “fistula” for short. It wasn't a condition that Hema (or any gynecologic surgeon) relished seeing because it was difficult to cure.

  Now I can explain why that little girl whom we'd seen when we were young children—the one who came walking up the hill with her father, her head bowed with shame, dribbling urine at every step, carrying about her an unspeakable odor—had such a profound influence on Shiva's life.

  Unbeknownst to Shiva and me, Hema had operated on her three times. The repair broke down the first two times; the last one held. We never got to see her leave Missing, but we had Hema's word that she was cured and had left happy. The mental scars, though, would never heal. We understood little at the time of what ailed her; it wasn't a subject Hema would speak about to us. But now, Shiva and I knew. In all likelihood, perhaps before she was a teen, the girl was married off to a man who could have been as old as her father. The painful consummation of her marriage (more traumatic if circumcision had left scar tissue at the entrance to the vagina for the husband to batter down) would have ter-rifed her. She may even have been too young to connect this act with becoming pregnant, but soon she was swollen with child. When labor began, the baby's head jammed against her pelvic bones, the pelvic inlet already narrowed by rickets. In a developed country or a big city she might have had a Cesarean section as soon as her contractions started. But in a remote village, without the help of anyone but her mother-in-law, she would suffer for days, her uterus trying to do the impossible, but succeeding only in ramming the baby's head against the bladder and the cervix, crushing those tissues against the unyielding bony pelvis. The baby soon died inside the womb and the mother's death would follow shortly, most often due to a ruptured uterus or infection and septicemia. It was the rare family who managed to transport the mother to a health center. There the lifeless fetus could be removed piecemeal, by first crushing the skull and then pulling the rest out.

  During her convalescence from that dreadful labor, the dead and gangrenous tissues inside her birth passage eventually sloughed off, leaving her with a jagged hole between bladder and vagina. Instead of urine passing from bladder to urethra to emerge just under the clitoris (and only when she chose to void), the bladder now constantly leaked its contents directly into the vagina and down her legs. She was never dry, her clothes always soaked, and she dribbled all day. The bladder and its urine quickly became infected and foul-smelling. In no time her labia, her thighs, became wet and macerated and oozed pus. This must have been when her husband cast her off, and her father came to the rescue.

  Fistulas have been described since antiquity. But it wasn't till 1849 in Montgomery, Alabama, that Dr. Marion Sims, my namesake, first succeeded in repairing a vaginal fistula. His first patients were Anarcha, Betsy, and Lucy, three slave women who had been cast out by their families and their owners because of this condition. Sims operated on them—willing subjects we are told—in an attempt to cure the fistula. Ether had just been discovered but wasn't in widespread use, so his patients were wide awake. Sims closed the gaping hole between bladder and vagina with silk and thought he had cured them. But a week later, he found pinhole openings along the line of his repair through which urine was leaking. He kept trying. He operated on Anarcha some thirty times. He learned from each failure, modified his technique until he ultimately got it right.

  When Hema operated on the girl wed seen, she used the principles of repair established by Marion Sims. She first put a catheter through the urethra into the bladder to divert the urine away from the fistula to allow the wet, macerated tissues to dry and heal. A week later, Hema operated vaginally using the bent pewter spoon the Alabama surgeon had fashioned—the Sims speculum, we now call it—which allowed for good exposure and made vaginal surgery possible. She had to carefully dissect out the edges of the fistula, trying to find what had once been discrete layers of bladder lining, bladder wall, then vaginal wall and vaginal lining. Once she had trimmed the edges, she made her repair, layer by layer. Sims, after many failures, had a jeweler fashion a thin silver wire which he used to close the surgical wound. Silver elicited the least inflammatory reaction from the tissues, inflammation being the reason a repair would break down. Hema used chromic catgut.

  At dinner, a month after Id learned of Ghosh's blood disorder, Hema shared with us that she and Shiva had operated on fifteen successive fistula patients with not one recurrence. “I owe this to Shiva,” she said. “He convinced me to take more time preparing the women for surgery. So now, we admit the patients and feed them eggs, meat, milk, and vitamins for two weeks. We tr
eat with antibiotics till the urine is clear and use zinc oxide paste on their thighs and vulva. It was Shiva's idea to deworm them and correct iron deficiency anemia before surgery. We work on strengthening their legs, getting them moving.” She looked at Shiva with pride. “I am embarrassed to say, he's seen and understood their needs better than I have after all these years. Like the idea of physical therapy—”

  “Can't get them to walk after surgery if they won't walk before,” Shiva said.

  On four of their patients the hole into the bladder was so large, so scarred down and shrunk back, that it was impossible to pull the edges together. In these patients, Hema and Shiva had learned to expose a narrow but thick “steak” of flesh under the labia and, while keeping it connected at one end to its blood supply, tunnel its free end up and pull it into the vagina and use it as a live patch in the fistula.

  “Matron has a donor who wants to support nothing but fistula surgery,” Shiva said. “We're getting one thousand American dollars every month.” I found it difficult to look at him, let alone congratulate him.

  I STOPPED FRETTING over Genet. When she failed two of the four courses the first year and had to repeat both semesters, I was too distracted by Ghosh's illness to care. She wasn't having a good time and living it up. Instead she'd lost her desire, lost sight of her target if she'd ever had one. All it took was one week of not studying, missing class, to get impossibly behind, so hectic was the pace of the first year of medical school.

  Halfway through my second year, I learned that Genet had again missed a few anatomy lab sessions. I felt obliged to check on her.

  At Mekane Yesus Hostel, the door to her room was open. Her visitor's back was to me; neither of them saw me at first. Genet shared the room with another girl who wasn't there. The tiny room which had once been so neat was now cluttered and messy. The room held a bunk bed and a small table for two. When he was alive, Genet acted as if Zemui annoyed her. Her brave and loyal father had died in a hail of bullets, and now she had his picture on the ceiling, inches from her face when she lay on the top bunk.