Cutting for Stone (9 page)

Her fellow passengers looked as terrified as she felt. Only the Armenian shook his head at her, and smiled as if to say,
This isn't what you think it is.

What an idiot, Hema thought.

An older Armenian—his father perhaps—was impassive, staring straight ahead. The older man had looked morose on boarding and his mood now was no better, and no worse. Hema found herself amazed that she should notice such trivial details at a time like this when, instead of deconstructing faces, she should be bracing for the moment of impact.

As the sea rushed up to meet the plane, she thought of Ghosh. She was shocked when a flood of tender feelings for him overcame her, as if
he
were about to die in a plane crash, as if
his
grand adventure in medicine and
his
carefree days were ending and with it any chance of his achieving the thing he wanted most: to marry Hema.

CHAPTER 4
The Five-F Rule

Y
OUR PATIENT, DR. STONE,”
Matron said again, vacating the stool between Sister Mary Joseph Praise's legs. Seeing his face, she wondered if he was about to throw something.

Thomas Stone was an occasional flinger of instruments, though never in front of Matron. It was rare that Sister Mary Joseph Praise ever handed him the wrong implement, but from time to time, a hemostat failed to release with light counterpressure, or a Metzenbaum didn't cut at its tip. He had good aim; one spot on the wall of Operating Theater
3
, just above the light switch and perilously close to the glass instrument cabinet, was his usual target.

No one but Sister Mary Joseph Praise took it personally—she would be crestfallen, even though she tested every instrument before she put it in the autoclave. Matron insisted the throwing was a good thing. “Feed him a ratchetless hemostat from time to time,” she said to Sister Mary Joseph Praise. “Otherwise he'll keep it bottled up till it comes oozing out of his ears and we'll have a right mess then.”

The plaster above the light switch had stellate pits and scratches as if a firecracker had gone off there. The strike on the wall occurred after the word “COMPLETELY” and before the word “USELESS!” left his mouth. Once in a great while he exploded at Nurse Asqual, the anesthetist, if the patient were too lightly under or had been given too little curare so that the belly muscles clamped down like a vice on his wrists as he fished inside the abdomen. More than one etherized patient had woken in holy terror hearing Stone bellow, “I'll need a pickax if you can't give me more relaxation down here!”

But at this moment, with Sister Mary Joseph Praise's lips ashen, her breathing shallow, her eyes seeing past him, her unrelenting bleeding, and then with Matron having passed the baton to him, Stone was speechless. He was experiencing the helplessness that patients’ relatives must feel, and he didn't like it in the least bit. His lips trembled and he felt shame at how his wet face displayed his emotions. But more than that he felt fear, and an astonishing paralysis of thought which only shamed him further.

When he finally spoke it was to say in a quavering voice, “Where is Hemlatha? Why isn't she back? We need her,” which was an act of uncharacteristic humility.

He swiped at his eyes using the back of his forearm, a childlike gesture. Matron watched in disbelief: instead of taking the stool she offered, he retreated. Stone walked to the wall that bore the marks of his anger. He struck his head on the plastered surface, a head butt worthy of a mountain goat. His legs wobbled. He clung to the glass cabinet. Matron felt obliged to murmur “Completely useless” on the off chance that if his violence had meaning, God forbid it should fail for lack of its accompanying mantra.

True, Stone could have done a Cesarean section, though, strangely for a tropical surgeon, it was one of the few operations he hadn't done. “See One, Do One, Teach One” was a chapter heading in his textbook
, The Expedient Operator: A Short Practice of Tropical Surgery.
But what his readers didn't know, and what I learned only many years later, was that he had an aversion to anything gynecological (not to mention anything obstetrical). It stemmed from his final year of medical school, when he did what was unheard of: he bought his very own cadaver so that he could master the anatomy he had already learned so well on a shared cadaver in his first year of medical school. The male poorhouse specimen of his first-year anatomy class had been ancient and shriveled with ghostly muscles and tendons, such being the common tender of Edinburgh anatomy theaters. He'd shared that body with five other students. But he lucked out with the cadaver he purchased in his final year: a well-fed, middle-aged female, a type he associated with the linoleum factories in Fife. Stone's dissection of the hand was so elegant (with just the tendon sheath exposed on the middle finger, while on the ring finger he carried it further to lay open the sheath and show the tendons
of flexor sublimis
like the wires of a suspension bridge, the
profundus
tendon coursing between them) that the anatomy professor preserved it to show the first-year students. For weeks Thomas Stone toiled over his cadaver, spending more time with her than he had with any other female save his mother. He felt an ease with her, a fluency that came from intimate knowledge. On one side, he had filleted her cheek to the ear, tying the flap back with sutures to expose the parotid gland and the facial nerve passing through, its branches splayed out like a goose's foot, hence the name
pes anserinus.
On the other side of the face hed removed all subcutaneous tissue and fat to reveal the myriad muscles of expression whose concerted movements in life had conveyed her sorrow, joy, and every emotion in between. He didn't think of her as a person. She was simply knowledge embodied, embalmed, and personified. Every evening he folded back the muscles and then the skin flaps dangling on narrow hinges, and then he spread the formalin-soaked rags over her to ensheathe her. Sometimes when he fastened the rubber sheet around her and tucked the edges in, it reminded him of his mother's ritual of putting him to bed. Back in his room, his solitude and loneliness always felt more acute.

On the day he removed the bowel to expose the aorta and kidneys, he saw her womb. It wasn't the shriveled purse he expected to find, sunk into the bowl of the pelvis. Instead, it peeked above the pelvic brim. A few days later he turned to the pelvis, his
Cunningham's
dissection manual open to the new section. He proceeded step by step, marveling at the book's genius as it unpeeled and unroofed and taught as it went.
Cunningham's
dictated a vertical slice through the front of the uterus and then the operator was to gently pry the uterus open. He did, and out fell a fetus, its head a little bigger than a grape, eyes tightly shut, limbs folded in like an insect. It dangled on the umbilical cord like an obscene talisman on a headhunter's belt. He could see the mother's cervix destroyed and black, from infection or gangrene. The catastrophe that befell this woman was memorialized in formalin.

Stone barely made it to the sink before his dinner came up. He felt betrayed, as if someone had been spying on him. All this time he'd imagined he and she were alone. He couldn't go on. He couldn't even look at her, or fold her back up or cover her. The next day he asked the puzzled attendant to dispose of the cadaver even though the dissection of the pelvis was incomplete and the lower limbs were untouched. But Thomas Stone was done.

At Missing Hospital, because of Hema, Stone never had to venture into the territory of the female reproductive organs. That area he conceded (and it was atypical for him to concede anything) to her.

He and Hemlatha were civil, collegial, and even friendly outside the operating theater. After all, Missing only had three physicians—Hema, Stone, and Ghosh—and it would've been awkward if they didn't get along. But in Operating Theater
3
, Hema and Stone managed to provoke each other. Hema's style was precise and careful—a living example, Matron thought, of why more women should be surgeons. Matron sometimes believed she saw Hemlatha listening and
then
thinking when with a patient in the clinic, rather than trying to do both things at once. Hema was a surgeon who would throw four casts to her knots where others might be content with three. She never left the operating room until her patient awoke from anesthesia. Her surgical field was as neat and tidy as an anatomical demonstration with vulnerable structures carefully identified and moved out of harm's way and with bleeding meticulously controlled. To Matron the field looked static, yet alive, like a painting by Titian or da Vinci. “How can a surgeon know where she is,” Hema was fond of saying, “unless she knows where she has been?”

For Stone, minimal handling of tissue was what counted the most, and he had no time for the aesthetic of the surgical field. “Hema, if you want pretty, dissect cadavers,” he once told her. “Stone, if you want bloody, become a meat cutter,” she said. So vast was his experience and the practice that he put into his craft that his nine fingers could find their way in a bloody field in which no landmarks were visible to others; his movements were economical and precise, and his results were excellent.

On those rare occasions when a woman with the mud of the field still fresh on her feet was brought in with a bull-gore wound that extended into the pelvis, or when a bar girl came with a knife or bullet wound near the uterus, Hemlatha and Stone would scrub together and enter the abdomen à deux, fussing at each other, bumping heads, and at times rapping each other's knuckles with the handle of the hemostat. Matron said she kept a register of which surgeon had stood on the right side at the last joint exploration, and she made sure they took turns. While Hemlatha meticulously resected uterus or repaired a bladder tear, Stone, who could not carry a tune, nevertheless whistled “God Save the Queen,” which riled Hema. If Stone went first, Hemlatha would talk about the famous surgeons of years past—Cooper, Halsted, Cushing—and what a shame it was that tropical surgeons showed no sign of that great surgical legacy.

Stone didn't believe in glorifying surgeons or operations. “Surgery is surgery is surgery,” he liked to say, and on principle he would no more look up to a neurosurgeon than down on a podiatrist. “A good surgeon needs courage for which a good pair of balls is a prerequisite,” he had even written in the manuscript of his textbook, knowing fully well that his editor in England would take it out, but enjoying the experience of putting those words on paper. Stone had found a volubility a combative-ness and forcefulness, in his writing that he didn't show in his speech. “Courage? What's this you write about ‘courage’?” Hema asked. “Is it
your
life you are risking?”

A Cesarean section was technically not beyond Stone's abilities. But on that fateful day, the
thought
of taking scalpel to Sister Mary Joseph Praise—his surgical assistant, his closest confidante, his typist, his muse, and the woman he realized he loved—terrified him. She was already in appalling shape, pale and clammy, her pulse so thready that he believed anything he did would send her over the precipice. On a stranger, he might not have hesitated to try a Cesarean section. “The doctor who treats himself has a fool for a patient” was an adage he knew well. But what about a doctor who performed an unfamiliar operation on a loved one? Was there an adage for that?

Increasingly, since the publication of his textbook, Stone had taken to quoting from it, as if his own written word had greater legitimacy than his unpublished (and heretofore unspoken) thoughts. He'd written, “The doctor who treats himself has a fool for a patient,
but there are circumstances when he has no recourse …
“ He had gone on to chronicle the tale of his own ray amputation, how he'd performed a nerve block on his right elbow, and then, with Sister Mary Joseph Praise “helping,” he had made the incision into his flesh, his left hand doing some of the work while Sister Mary Joseph Praise stood in for his right. He realized as he watched her make the bone cuts that she could do much more than assist if she chose to. It was the anecdote of the amputation, together with his picture in the frontispiece, his fingers—all nine of them—forming a steeple in front of his chin, which had made the book so successful. There were so many extant surgery texts that it was surprising how popular
The Expedient Operator
(or
A Short Practice,
as it was known in some countries) had become. For a tropical surgery book, most of its sales took place in nontropical countries. Perhaps it was its quirkiness, its biting tenor, and the often sharp and unintended humor. He drew only on his experience or his careful interpretation of the experience of others. Readers pictured him as a revolutionary, but one who operated on the poor instead of preaching land reform. Students wrote him adoring letters, and when his dutiful responses (penned by Sister Mary Joseph Praise) didn't match the gushy, confessional tone of their letters, they pouted.

The illustrations in the textbook (all drawn and lettered by Sister Mary Joseph Praise) had a simple quality as if done on a napkin; no attempt was made at getting proportion or perspective right, but they were models of clarity. The book was translated into Portuguese, Spanish, and French.

Daring operations performed in darkest Africa—
that was how the publisher had described the book on the back cover. The reader, knowing nothing about the “dark continent,” filled in the blanks, pictured Stone in a tent, a kerosene lamp held up by a Hottentot providing the only light, elephants stampeding outside while the good doctor recited Cicero and excised a part of himself as blithely as if he were cutting for stone on the body of another. What neither the reader nor Stone would accept was that his self-amputation was as much an act of conceit as it was an act of heroism.

“YOUR PATIENT,
Dr. Stone,” Matron said for the third time.

Stone took the spot between Sister Mary Joseph Praise's legs that Matron vacated, though, after all that, Matron seemed reluctant to let him by, as if she didn't want him to sit there any more than he wanted to sit. It wasn't a vantage point that he was accustomed to, at least not often with a woman. With men, he sat there to repair a watering-can scrotum, and in both sexes he might be seated to drain rectal abscesses, or to ligate and excise hemorrhoids or
fistula-in-ano.
But otherwise, he was a surgeon who was rarely seated.

When Stone clumsily parted the labia, blood poured out. He adjusted the gooseneck lamp and then his own neck to sight up the birth canal.

He tried to remember the citrus rule from his student days. What was it? Lime, lemon, orange, and grapefruit corresponded to four, six, eight, and ten centimeters of dilation of the cervix. Or was it two, four, six, and eight? And was there a grape or plum involved?