Abraham Verghese - Cutting for Stone

MATRON SIGHED and was surprised to hear words tumble out of her mouth, and she felt the others in the operating theater staring at her. Only then did she realize that her lips had been busy shaping prayers. Since turning fifty, Matron had noticed such dissonances and disconnections between her thought and action; they were becoming common. For example, at inopportune moments her mind busied itself pasting images into a mental scrapbook. Why? When would she ever have occasion to recall all these memories? At a testimonial dinner? On her deathbed? At the pearly gates? She'd long ago stopped thinking literally about such matters. Her father, a miner who had lost himself in alcohol and the darkness of the tunnels, had loved the words “pearly gates.” On his tongue it sounded like the name of a blowsy woman, one of many that had come between him and his conjugal duties.

Still, Matron was sure of one thing: the image she witnessed when she'd inadvertently looked up a short while before, that was one she'd never ever forget. What happened was this: the sun had suddenly freed itself from behind a cloud, and by some accident of elevation and season presented itself directly on the ground-glass window of Operating Theater 3. Lambent and white, it had bounced off the walls, reflected off glass, metal, and tile, and there it was just when Hema or Stone or whoever it was made a loud exclamation, which was what had made Matron look up. That was when Matron saw them all bent over like hyenas over carrion, peering into Sister Mary Joseph Praise's open abdomen and its scandalous contents. She saw the light nosing its way between elbow and hip. Then the sunbeam fell directly on Sister Mary Joseph Praise's gravid uterus, which bulged out of the bloody wound like an obscenity on a saint's tongue. A blue-black collection of blood—a hematoma— stretched the broad ligament of the uterus, and it glowed in the light like the Host. Matron felt that this had been the sun's intent all along— to find the unborn. We have seen each other anew. We are unmasked. Yes, it was the kind of event that might be termed a “miracle”—except that nothing happened; the laws of nature weren't suspended (which Matron felt was the sine qua non for miracles). But it was as if the twins’ place in the firmament as well as in the earthly order of things had been secured for them even before they were born; she knew that nothing—not even the familiar scent of eucalyptus, or the sight of its leaves thrust into a nostril, or the drumroll of rain on corrugated tin roof, or the visceral odor of a freshly opened abdomen—could ever be the same again.

HEMA WIELDED HER SCALPEL like a woman on fire. No time to tie off bleeders, and, in any case, very little bleeding along the way—not a good sign. She opened the glistening peritoneum and quickly positioned retractors to hold the wound edges back. The uterus bulged out of the wound. Then, before her eyes, it seemed to swell and turn luminous … She stood frozen, until she realized it was because the sun had suddenly struck the frosted window and lit up the table. In all her years operating at Missing, she couldn't remember that happening before.

Just as Hema feared, there was a lateral tear in the uterus. Blood had filled the broad ligament on one side. That meant that once she got the babies out, shed have to do an emergency hysterectomy, no easy task in pregnancy, what with the uterine arteries being tortuous, thickened, and carrying half a liter of blood a minute. Not to mention the massive blood clot shimmering in the light, growing before her eyes and gloating at her like a smiling Buddha, as if to say, Hema, I have completely distorted the anatomy, dissection is going to be bloody difficult, and your landmarks will all be gone. But come on in anyway, why don't you?

Hema believed in numerology; next to one's name, nothing was as important as numbers. What is it about this day? she asked herself. It's the twentieth day of the ninth month. No fours or sevens in there … Airplane almost crashes, a child breaks his leg … I crack a Frenchman's nuts … What more, I say, what more?

She rapped Stone's knuckles with a scissors. “Stop!” He was fumbling with an oozing vessel when she needed him to retract.

She incised the uterus and tried to deliver the twin who sat higher in the uterus but was nevertheless head down, upside down. This twin would have been the second to come out had delivery proceeded through the birth canal, but now it would be the firstborn. But strangely, this twin, hand jammed against its cheek, wouldn't budge.

She extended the uterine wound.

She suctioned the infant's mouth.

She drew a sharp breath that inverted her mask against her lips because she could see the problem.

The babies were joined at the head. A short, fleshy tube passed from the crown of one to the other, a tube that was narrower and of a darker hue than the umbilical cords. They were tethered together, but there was a fatal tear in this stalk, a jagged opening caused no doubt by Stone's fishing with the basiotribe. And from this rent, what little blood the two infants possessed was pumping out.

Please God, she thought, let this be only a blood vessel, and a minor one at that. Let there be no brain or meninges or ventricle or cerebral artery or cerebrospinal fluid or whatnot in it. She spoke aloud to Stone now, to the room, to God, and to the twins whose lives, if they survived, might be irrevocably affected by this decision: “They could have seizures the minute I cut this. One twin could bleed out and the other overfill with blood. They could get meningitis …”

This was a technique surgeons used when difficult decisions had to be made: think aloud for your assistant because it might help clarify the issues for yourself. And theoretically it gave the assistant time to point out her faulty reasoning, though she wasn't about to take an opinion from the man responsible for this blunder. A careful decision was needed so as not to blunder again. It was often the second mistake that came in the haste to correct the first mistake that did the patient in.

“No choice,” she said. “I have to cut.” She put clamps across the stalk where it emerged from each infant's scalp. She invoked Lord Shiva's name, held her breath, and cut above each clamp, bracing herself for something terrible.

Nothing happened.

She tied off the stumps. She cut the umbilical cord and easily pulled out the first infant, a male. She handed it to the gowned and gloved probationer who stood nearby. This baby had been spared his father's probings. Then she pulled out the other infant—again a boy, an identical twin, whose scalp was bloodied from Stone's knife and whose skull would have been crushed had she not arrived.

Both infants were tiny, three pounds at best. Clearly less than full term. A month premature, perhaps more. Neither infant cried.

Distracted now by heavy oozing from Sister Mary Joseph Praise's soggy, friable uterus, Hema turned back from infants to the mother.

“What is her BP?” Hema asked, peering over the drapes, first at Nurse Asqual, and then at Sister Mary Joseph Praise's face. The anesthetist, the whites of her eyes showing like saucers, shook her head. Beautiful Sister Mary Joseph Praise's face now looked bloated and lifeless. “More blood! For God's sake. Pour it in!” Hema shouted.

As she toiled in the now deflated cavity of the belly, Hemlatha remembered that when she'd handed over the second baby to the probationer, she had been surprised to find the probationer still standing there, holding the first, a blank look on her face. But Hema had no time to worry about that. Once the babies were out, her duty as an obstetrician was to turn completely to Sister Mary Joseph Praise; her duty was to the mother.