Abraham Verghese - Cutting for Stone

“When did this start?” he heard himself say, taking in the swollen abdomen that was so incongruent on this lean, muscled man. “Begin at the beginning …”

“Yesterday morning. I was trying to … move my bowels.” The patient looked embarrassed. “And suddenly I had pain here.” He pointed to his lower abdomen.

“While you were still sitting on the toilet?”

“Squatting, yes. Within seconds I could feel swelling … and tightening. It came on like a bolt of lightning.”

The assonance caught Ghosh's ear. In his mind's eye he could see Sir Zachary Cope's little book, The Diagnosis of the Acute Abdomen in Rhyme. He'd found that treasure on the dusty shelf of a secondhand bookstore in Madras. The book was a revelation. Who knew that a medical text could be full of cartoon illustrations, be so playful, and yet provide serious instruction? Cope's lines regarding sudden blockage of the normal passage through the intestine came to him:

… rapid onset of distention

Will certainly attract your keen attention.

He asked the next question, even though he knew the answer. There were times like this when the diagnosis was written on the patient's forehead. Or else they gave it away in their first sentence. Or it was announced by an odor before one even saw the patient.

“Yesterday morning,” Mebratu replied. “Just before the pain began. Since then no stool, no gas, no nothing.”

Sometimes a bowel-coil gets out of place

By twisting round upon a narrow base …

“And how many enemas did you try?”

Mebratu let out a short sharp laugh. “You knew, huh? Two. But they did nothing.”

He wasn't just constipated but obstipated—not even gas could pass. The bowel was completely obstructed.

Outside the cubicle the men seemed to be arguing.

Mebratu's tongue was dry, brown, and furred. He was dehydrated, but not anemic. Ghosh exposed the grotesquely distended abdomen. The belly didn't push out when Mebratu took a breath. In fact it moved hardly at all. This is my work, Ghosh thought to himself as he pulled out his stethoscope. This is my grave-digging equivalent. Day in and day out. Bellies, chests, flesh.

In place of the normal gurgling bowel sounds, what he heard with his stethoscope was a cascade of high-pitched notes, like water dripping onto a zinc plate. In the background he heard the steady drum of the heartbeat. Astonishing how well fluid-filled loops of bowel transmitted heart sounds. It was an observation he'd never seen in a textbook.

“You have a volvulus,” Ghosh said, pulling his stethoscope off his ears. His voice came from a distance, and it didn't sound like it belonged to him. “A loop of the large bowel, the colon, twists on itself like this—” He used the tubing of his stethoscope to demonstrate first the formation of a loop, then the twist forming at the base. “It's common here. Ethiopians have long and mobile colons. That and something about the diet predisposes to volvulus, we think.”

Mebratu tried to reconcile his symptoms with Ghosh's explanation. His mouth turned up; he was laughing.

“You knew what I had as soon as I told you, right, Doctor? Before you did all these … other things.”

“I suppose I did.”

“So … will this twist untwist by itself?”

“No. It has to be untwisted. Surgically.”

“It's common, you say. My countrymen who get this … what happens to them?”

At that moment, Ghosh connected the face with a scene he wished he could forget.

“Without surgery? They die. You see, the blood supply at the base of the loop of bowel is also twisted off. It's doubly dangerous. There's no blood going in or out. The bowel will turn gangrenous.”

“Look, Doctor. This is a terrible time for this to happen.”

“Yes, it is a terrible time,” Ghosh burst out, startling Mebratu. “Why here, if I may ask? Why Missing? Why not the military hospital?”

“What else have you understood about me?”

“I know you're an officer.”

“Those clowns,” he said, nodding his chin in the direction of his friends outside. “We don't do a good job of dressing as civilians,” Mebratu said, wryly. “If their shoes aren't spit polished they feel naked.”

“It's more than that, actually. Years ago, shortly after I arrived here, I saw you conduct an execution. I'll never forget that.”

“Eight years and two months ago. July the fifth. I remember it, too. You were there?”

“Not intentionally.” A simple drive into the city had turned into something else when a large crowd on the road had forced him and Hema into being spectators.

“Please understand, it was the most painful order I ever carried out,” Mebratu said. “Those were my friends.”

“I sensed that,” Ghosh said, recalling the strange dignity of both the executioner and the condemned.

Another wave of pain traveled over Mebratu's face and they both waited till it passed. “This is a different kind of pain,” he said, trying to smile.

“You should know,” Ghosh said, “that earlier today the palace called. They asked Matron to inform them if a military person came here for treatment.”

“What?” Mebratu swore and tried to sit up, but the movement made him yell in pain. His companions rushed in. “Did Matron tell the palace?” he managed to ask.

“No. Matron told me she wouldn't turn you away knowing that you had nowhere else to go.”

The patient relaxed now. His friends had a quick discussion, and then they remained in the room.

“Thank you. Thank Matron for me. I am Colonel Mebratu, of the Imperial Bodyguard. You see we had plans, a few of us, to meet on this date in Addis. I came from Gondar. When I got here I found the meeting had to be called off. We feared we were … compromised. But I didn't get the message till I was already here. Before I left Gondar, yesterday, my pain began. I saw a physician there. Like you, he must have known what I had, but he told me nothing. He told me to come back and see him in the morning and that he wanted to check me again. He must have told the palace, or else why would they call the hospitals in Addis? Hanging will also be my fate if I am discovered in Addis. You must treat me. I can't be seen at the military hospital today.”

“There is another problem,” Ghosh said. “Our surgeon has … he has left.”

“We heard about your … loss. I am sorry. If Dr. Stone can't do it, then you have to.”

“But I can't—”

“Doctor, I have no other options. If you don't do it, I die.”

One of the men stepped forward. With his light beard, he looked more like an academic than a military man. “What if your life depended on it? Could you do it?”

Colonel Mebratu put his hand on Ghosh's sleeve. “Forgive my brother,” he said, then smiled at Ghosh as if to say, You see what I have to do to keep peace? Out loud he said: “If something should happen, you can say in good faith that you knew nothing about me, Dr. Ghosh. It's true. All you know about me are all the things you guessed.”

GHOSH DIALED Hema's quarters. It occurred to him that Colonel Mebratu and his men must have been plotting some kind of a coup. What else could the secret meeting in Addis have been about? Ghosh was faced with a conundrum: How did one treat a soldier, an executioner, who now was engaged in treason against the Emperor? But of course, as a physician, his obligation was to the patient. He felt no dislike for the Colonel, though he could do without the brother. It was difficult to dislike a man who bravely suffered physical pain and managed to retain his manners.

Over the hum of the receiver, Ghosh could hear the blood rushing into his ear with every heartbeat.