Abraham Verghese: Cutting for Stone

In the ensuing seven years that she lived and worked at Missing Hospital, Sister Mary Joseph Praise rarely spoke about her voyage and never about her time in Aden. “Whenever I brought up Aden,” Matron said, “your mother would glance over her shoulder, as if Aden or whatever it was she left behind had caught up with her. The dread and terror on her face made me loath to ask again. But it scared me, I'll tell you. All she said was, ‘It was God's will that I come here, Matron. His reasons are unknowable to us.’ There was nothing disrespectful about that answer, mind you. She believed that her job was to make her life something beautiful for God. He had led her to Missing.”

Such a crucial gap in the history, especially that of a short life, calls attention to itself. A biographer, or a son, must dig deep. Perhaps she knew that the side effect of such a quest was that I'd learn medicine, or that I would find Thomas Stone.

SISTER MARY JOSEPH PRAISE began the task of the rest of her days when she entered Operating Theater 3. She scrubbed and gloved and gowned and stood across the table from Dr. Stone as his first assistant, pulling on the small retractor when he needed exposure, cutting the suture when he presented the ends to her, and anticipating his need for irrigation or suction. A few weeks later, when the scrub nurse couldn't be there, my mother filled in as scrub nurse and first assistant. Who knew better than a first assistant when Stone wanted a scalpel for sharp dissection, or when gauze wrapped around his finger would do. It was as if she had a bicameral mind, allowing one half to be scrub nurse, shuttling instruments from the tray to his fingers, while the other side served as Stone's third arm, lifting up the liver, or holding aside the omentum, the fatty apron that protected the bowels, or with a fingertip pushing down edematous tissue just enough for Stone to see where his needle was to take a bite.

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.

THOMAS 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.