Cutting for Stone (5 page)

Matron would peek in to watch. “Pure ballet, my dear Marion. A heavenly pair. Totally silent,” Matron said. “No asking for instruments or saying ‘Wipe,’ ‘Cut,’ or ‘Suction.’ She and Stone … You never saw anything quicker. I suspect that we slowed them down because we couldn't get people off and on the table quickly enough.”

For seven years Stone and Sister Mary Joseph Praise kept the same schedule. When he operated late into the night and into the morning, she was across from him, more constant than his own shadow, dutiful, competent, uncomplaining, and never absent. Until, that is, the day when my brother and I announced our presence in her womb and our unstoppable desire to trade the nourishment of the placenta for the succor of her breasts.

CHAPTER 2
The Missing Finger

T
HOMAS STONE HAD
a reputation at Missing for being outwardly quiet but intense and even mysterious, though Dr. Ghosh, the hospital's internal medicine specialist and jack-of-all-trades, disputed that last label, saying, “When a man is a mystery to himself you can hardly call him mysterious.” His associates had learned not to read too much into Stone's demeanor, which a stranger might think was surly when in fact he was painfully shy. Lost and clumsy outside it, inside Operating Theater
3
he was focused and fluid, as if it was only in the theater that body and soul came together, and where the activity within his head matched the terrain outside.

As a surgeon, Stone was famous for his speed, his courage, his daring, his boldness, his inventiveness, the economy of his movements, and his calmness under duress. These were skills that he'd honed on a trusting and uncomplaining population, briefly in India, and then in Ethiopia. But when Sister Mary Joseph Praise, his assistant for seven years, went into labor, all these qualities vanished.

On the day of our birth, Thomas Stone had been standing over a young boy whose belly he was about to open. He held his hand out, palm up, fingers extended to receive the scalpel in that timeless gesture that would forever be the measure of his days as a surgeon. But for the first time in seven years, steel had not slapped into his palm the instant his fingers opened; indeed, the diffident tap told him someone other than Sister Mary Joseph Praise stood across from him. “Impossible,” he said when a contrite voice explained that Sister Mary Joseph Praise was indisposed. In the preceding seven years there hadn't been a time when he'd stood there without her. Her absence was as distracting and maddening as a bead of sweat about to fall into his eye when he was operating.

Stone didn't look up as he made his keyhole incision. Skin. Fat. Fascia. Split the muscle. Then, using blunt dissection, he exposed the glistening peritoneum, which he incised. His finger slithered into the abdominal cavity through this portal and rooted for the appendix. Still, with each step, he had to wait for a fraction of a second, or wave off the proffered instrument in favor of another. He worried about Sister Mary Joseph Praise even if he was unaware that he was worrying, or unwilling to admit it.

He summoned the probationer, a young, nervous Eritrean girl. He asked her to seek out Sister Mary Joseph Praise and remind her that doctors and nurses couldn't afford the luxury of being ill. “Ask her”— the terrified probationer's lips were moving as she tried to by-heart his message—”kindly ask her, if …” His eyes were free to look at the probationer, since his finger was now sounding the boy's insides better than any pair of eyes. “… if she recalls that I returned to the operating theater the very next day after performing a ray amputation on my own finger?”

That event took place five years before and was an important milestone in Stone's life. His own curved needle on a holder had nicked the pulp of his right index finger while he worked in a pus-filled belly. He'd immediately stripped off his glove, and with a hypodermic needle, he had injected acriflavine, precisely one milliliter of a solution diluted
1
:
500
, down the tiny track the errant needle had traveled. Then he'd infiltrated the fluid into the surrounding tissue as well. The orange dye transformed the digit into an oversize lollipop. But despite these measures, in just hours a creeping red wave extended down from the fingertip and into the tendon sheath in the palm. Despite oral sulfatriad tablets and, later, at Ghosh's insistence, injection of precious penicillin into his buttocks, scarlet streaks (which were the hallmark of streptococcal infection) showed at his wrist, and the epitrochlear lymph node behind the elbow became as big as a golf ball. The rigors had made his teeth chatter and the bed shake. (This later became an aphorism in his famous textbook, a Stonism as readers called it: “If the teeth chatter it is a chill, but if the bed shakes it is a true rigor.”) He had made a quick decision: to amputate his own finger before the infection spread farther, and to do the operation himself.

The probationer waited for the rest of his message, while Stone drew the wormlike appendix out of the incision and straightened up like a fisherman who'd reeled his quarry onto the deck. The few bleeders Stone snapped off with hemostats, like a marksman firing at pop-up ducks, while also clamping off the blood vessels to the appendix. He tied these off with catgut, his hands a blur, until all the dangling hemostats were removed.

Stone held up his right hand for the probationer's inspection. Five years after the amputation, the hand looked deceptively normal, though on closer study the index finger was missing. The key to this aesthetically pleasing result was that the metacarpal head—the knuckle of the missing finger—had been cut away, too, so that no stump was visible in the
V
between thumb and middle finger. It was as if the fingers had simply moved over one notch. Four-fingered custom gloves added to the illusion of normalcy. Far from being a disadvantage, his hand could negotiate crevices and tissue planes that others could not, and his middle finger had developed the dexterity of an index finger. That, together with the fact that his middle finger was longer than his former index finger, meant he could tease an appendix out from its hiding place behind a cecum (the beginning of the large bowel) better than any surgeon alive. He could secure a knot in the deepest recess of the liver bed with just his fingers, where other surgeons might resort to a needle holder. In later years, in Boston, he famously punctuated his admonishment to his interns of
“Semper per rectum, per anum salutem,
if you don't put your finger in it, you'll put your foot in it,” by holding up the former middle finger, now elevated to the status of index finger.

Those who trained with Stone never overlooked the rectal exam on their patient, not just because Stone had drilled into their heads that most colon cancers are in the rectum or sigmoid, many within reach of the examining finger, but also because they knew they'd be fired for this omission. Years later in America, a story circulated about one of Stone's trainees, a man named Blessing, who, after examining a drunk in the emergency room and taking care of whatever the problem was, returned to his call room. As he was about to sleep, he remembered that he hadn't done a rectal exam. Guilt and fear that his chief would somehow discover his lapse moved him to get up and go out into the night. Blessing tracked the patient down to a bar, where for the price of a beer the man agreed to drop his pants and be digitally examined—be “blessed” as the event came to be described—and only then was the young doctor's conscience eased.

THE PROBATIONER IN
Operating Theater
3
on the day of Sister Mary Joseph Praise's labor and our birth was a pretty—no, a
beautiful—
young Eritrean girl. Sadly, her humorless intensity, the dedication she showed to her training, made people forget her youth and her looks.

The probationer hurried off to find my mother, not pausing to question the propriety of the message she carried to Sister Mary Joseph Praise. Stone, of course, would never have imagined the message might be hurtful. As is so often the case with shy yet talented people, Stone was generally forgiven what Dr. Ghosh called his social retardation. The glaring gaps that in a bowel repair could have been fatal were overlooked when they occurred in such a personality; they weren't an impediment to him, only an irritation to others.

At the time of our birth the probationer was not yet eighteen, with a tendency to confuse penmanship and keeping a neat medical record (and thereby pleasing Matron) with the actual care of patients.

Being seniormost of the five probationers in Missing's nursing school had been a matter of pride for her, and most days she managed to push to the back of her mind the fact that her seniority was only because she was repeating her year, or, as Dr. Ghosh put it, because she was “on the long-term plan.”

Orphaned as a child by smallpox, which had also left a faint lunar landscape on her cheeks, the probationer had from a young age addressed her self-consciousness by becoming excessively studious, a trait encouraged by the Italian nuns, the Sisters of the Nigrizia (Africa), who raised her in the orphanage in Asmara. The young probationer displayed her studiousness as if it were not merely a virtue but a God-given gift, like a beauty spot or a supernumerary toe. What promise she'd shown in those early years, sailing through church school in Asmara, skipping grades, speaking fluent official Italian (as opposed to the bar-and-cinema version spoken by many Ethiopians, in which prepositions and pronouns were dispensed with altogether), and able to recite even her nineteen-times table.

You could say the probationer's presence at Missing was an accident of history. Her hometown of Asmara was the capital city of Eritrea, a country which had been an Italian colony from as far back as
1885
. The Italians under Mussolini invaded Ethiopia from Eritrea in
1935
, with the world powers unwilling to intercede. When Mussolini threw his lot in with Hitler, his fate was sealed, and by
1941
, Colonel Wingate's Gideon Force had defeated the Italians and liberated Ethiopia. The Allies gave Emperor Haile Selassie of Ethiopia a most unusual gift: they tacked on the very old Italian colony of Eritrea as a protectorate of newly liberated Ethiopia. The Emperor had lobbied hard for just this, so that his landlocked country could have the seaport of Massawa, not to mention the lovely city of Asmara. The British perhaps wanted to punish the Eritre-ans for their long collaboration with the Italians; Eritrean
askaris,
thousands of them, were part of the Italian army and had fought their black neighbors and died alongside their white masters.

For the Eritreans to have their lands handed to Ethiopia was an unimaginable wound, akin to giving liberated France to England merely because the people of both countries were white and ate cabbage. When, a few years later, the Emperor annexed the land, the Eritreans at once began a guerrilla war for their liberation.

But there were some advantages to Eritrea being part of Ethiopia: the probationer won a scholarship to the country's only nursing school in Addis Ababa, at Missing Hospital, the first young person from Eritrea to be so rewarded. The trajectory of her scholastic progress to that point was spectacular and unprecedented, a model for all youth; it was also an invitation to fate to stick a foot out and trip her.

Yet it wasn't fate that stymied the probationer when she came to her clinical years, and it wasn't her clumsiness with the Amharic language, or with English, since she soon overcame these obstacles and became fluent. She discovered that memorization (“by-hearting,” as Matron called it) was of no help to her at the bedside, where she struggled to distinguish the trivial from the life threatening. Oh yes, she could and did recite the names of the cranial nerves as a mantra to calm her own nerves. She could rattle off the composition of
mistura carminativa (one
gm of soda bicarb,
two
ml each of spirit of ammonia and tincture
c
ar
damom, point six
ml of tincture of ginger,
one
ml of spirit of chloroform, topped off with peppermint water to
thirty
ml) for dyspepsia. But what she couldn't do, and it annoyed her to see how effortlessly her fellow probationers could, was develop the one skill Matron said she lacked:
Sound Nursing Sense.
The only reference to this in her textbook was a statement so cryptic, more so after she memorized it, that she'd begun to think it was put there to antagonize her:

Sound Nursing Sense is more important than knowledge, though knowledge only enhances it. Sound Nursing Sense is a quality that cannot be defined, yet is invaluable when present and noticeable when absent. To paraphrase Osler, a nurse with book knowledge but without Sound Nursing Sense is like a sailor at sea in a seaworthy vessel but without map, sextant, or compass. (Of course, the nurse without book knowledge has not gone to sea at all!)

The probationer had at least gone to sea—she was sure of that. She was determined to prove that she did have map and compass, and so she would regard every assignment as a test of
her
skills, an opportunity to display Sound Nursing Sense (or to hide the lack of it).

SHE RAN AS IF
jinn
were chasing her, through the sheltered walkway between the theater and the rest of the hospital. Patients and relatives of those being operated on that day were squatting or sitting cross-legged on either side of her path. A barefoot man, his wife, and two small children shared a meal, dipping fingers into a bowl lined with
injera
on which a lentil curry had been poured, while an infant, all but hidden by the mother's
shama,
suckled at the breast. The family turned in alarm as she ran by, and it made her feel important. Across the yard she could see women in white
shamas
and bright red and orange head scarves crowding the outpatient benches, looking at that distance like hens in a chicken coop.

In the nurses’ quarters she ran up the stairs to my mother's room. When she knocked there was no answer, but the door was unlocked. In the darkened room she saw Sister Mary Joseph Praise under the covers, her face turned toward the wall. “Sister?” she called softly, and when my mother moaned, the probationer took that to mean she was awake. “Dr. Stone sent me to tell you …” She felt relieved to have remembered all the parts of the message. She waited for a response, and when my mother didn't volunteer one, the probationer imagined that my mother might be annoyed with her. “I only came because Dr. Stone sent me. I'm sorry to disturb you. I hope you feel better. Do you need anything?” She waited dutifully, and after a while, she eased out of the room. Since there was no return message for Dr. Stone, and since her pediatric nursing class was about to start, she did not return to Theater
3
.