Cutting for Stone

DR. COOPER ARRIVED promptly at eight that evening in an embassy staff car, just as the patient, a Polish gentlemen, pulled up in his Kombi.

Ghosh had learned the technique of vasectomy as an intern, and he'd learned directly from Jhaver in India, whom he spoke of as “the maestro of male nut clipping who is personally responsible for millions of people not being here.” The operation was a novelty in Ethiopia, and now expatriate men, particularly Catholics, came to Ghosh in increasing numbers for an operation that was uncommon or unavailable in their countries.

“I have a proposition for you Dr. Cooper. I shall teach you the vasectomy, and once you are proficient, you can pay me back by doing a vasectomy on a VIP patient.”

“Do I know him?” Cooper asked.

“You are talking to him,” Ghosh said. “So you see I have a vested interest in seeing you are superbly trained. My assistant, Marion, will help me judge your skills. Marion, not a word to Hema—you either, Cooper—about my plans, please.”

Cooper had a stiff brush cut and overlapping square teeth that looked like Chiclets. His American accent was sharp, jarring to the ear, but offset by the way he drawled out his words, by his relaxed, affable manner, as if he'd never had an unpleasant moment in his life and did not expect to.

“See one, do one, teach one. Raaaiyt, old buddy?” Cooper said.

“Indeed, yes,” Ghosh said. “It is easy to do, but harder than it looks. Some preliminaries, Dr. Cooper. I tell the patient to use an enema the night before, because nothing makes them more tense than being constipated. Warm milk and honey mixed together and put into an enema bag held shoulder high is what I recommend.”

“Does it work?”

“Does it work? Let me put it this way: if the patient happens to be drinking a whiskey and soda, it'll suck the glass right out of his hand.”

“Gotcha,” said Cooper.

“I also ask the patient to take a warm bath beforehand. It relaxes him.” He added sotto voce, “And it improves my olfactory experience, you know?”

The patient hadn't said a word thus far. He was, Ghosh had told me, a consultant to the Economic Commission for Africa, an expert on population control who happened to be the father of five girls. He didn't mind all the attention.

“We can't finish if we don't start, so we better start, yes? Marion, the heater please?” I'd already turned on the electric heater under the table. “Here is the first caveat. If you don't want the scrotum to shrivel up, and the balls to retract to the armpit, the room has to be really warm. Now, the second caveat is relaxation. Very important. A barbiturate or narcotic might help. I recommend an ounce of Johnny Walker Red or Black. I'm not particular. A wonderful relaxant. And yes, you might give one to the patient, too.”

Cooper's laugh rolled leisurely out of his mouth, like the great banks of clouds that spilled over the Entoto Mountains.

I hoped Cooper was paying attention. I'd seen it before: when the patient's private parts were first exposed, even when the room was warm, the scrotal skin—the dartos muscle—would wrinkle and shrink, and the cremaster muscle would tug the testis up. Then, after a good swallow of whiskey (by the patient), which was served only at this point and not before, the sac unfurled.

Both surgeons were gloved, and Ghosh cleaned the area thoroughly and then draped sterile towels to frame the field. “Another tip, Dr. Cooper. Even though it's a simple operation, mustn't allow any bleeding. Do you know what a brinjal looks like, Dr. Cooper?”

“I don't believe I do, no sir,” Cooper said.

“Aubergine? … Melanzana?…Eggplant?”

Cooper recognized the last word.

“Well, if you don't meticulously control bleeding, you'll have an eggplant. Or two. And you know what we call that complication, Cooper. We call it the bloody-brinjal-and-bugger-all. Which is also what they fed us for five years in my medical-school hostel.”

I served the patient his Johnny Walker, which he downed in one gulp.

I loved assisting Ghosh. Ever since he treated me as if I were old enough to learn and understand, I took my role very seriously. I was thrilled to have Cooper there watching.

Ghosh, on the patient's right, rooted with his thumb and index finger at the top right of the scrotum, just where it joined the body. “You feel all the wiry things—lymph vessels, arteries, nerves, and whatnot? Well, the vas deferens is in that lot, and with practice you can tell it apart from all the other wires. It has the largest wall-to- lumen ratio of any tubular structure in the body, believe it or not. Here it is. A whiplike structure. Put your finger behind mine.”

Cooper rooted around, and said, “Got it. The vas. Yup.”

“Now, push the vas forward from the back with the tip of your index finger, fix it like this against the pulp of your finger so that it doesn't slip away.”

Ghosh's instructions to Cooper were similar to what he said to me when I assisted him. He loved to teach, and in Cooper, he had the kind of student he deserved. If he dazzled Cooper with his polished delivery, it was because he'd practiced it on me. Practicing medicine and teaching medicine were completely connected for Ghosh. When there was no one to instruct, he suffered. But that was rare. He would happily teach a probationer, or even a family member—whoever happened to be around.

“I use Adrenalin with my local anesthetic to keep the bleeding minimal. And don't be stingy.” He emptied a five-cc syringe of local into the tissue that his index finger pushed forward. “Any less than that and he'll have pain and the balls will go to the armpit. You'll have to call a chest surgeon to bring them down. Now … see how my index finger still has the vas stretched over it? I make a tiny cut in the scrotal skin. I keep pushing on the vas, pushing it forward … and … there! When I can see it in the wound, I use an Allis to grab the vas.”

He pulled out a short length of pale, white, wormlike tissue. “I put a mosquito clip here and here … and then I cut between the clips. I remove a two-centimeter segment. Ideally you'd send it to pathology. That way if his wife gets pregnant a year from now, you can show the patient the pathology report and he'll know it's not because you didn't do your job but because a third party did his job better. I don't send it to pathology for the simple reason that we don't have a pathologist. But for a while, there was a pathologist at the American Embassy clinic in Beirut. I'd do the vasectomies for the American staff and send him these little pieces I cut out. The man did the pathology for all the American embassies in East and West Africa. He kept sending back reports that my specimens were inadequate: though he thought he saw some uroepi -thelial tissue, he couldn't be certain it was the vas. ‘It's the vas,’ I wrote to him each time. ‘What other uroepithelial tissue could I have cut out? Call it the vas.’ But he kept complaining: ‘Cannot be certain. Not enough tissue.’ It was starting to annoy me, you know? So finally, I sent him a pair of sheep's balls. I put them in formalin and sent them off in the same diplomatic pouch. With a note: ‘Is this enough tissue?’ Never had a problem with him after that.”

Cooper hee-hawed, his mask sucking in and out.

“Now, I tie off the cut ends with catgut. And then I tell the patient, ‘No communication with wife allowed for the next ninety days.’ “

Ghosh turned to face the patient, and repeated the sentence. The patient nodded. “Okay, you can communicate, say ‘Good morning, darling,’ and all that, but no sex for three months.” The patient grinned. “Okay, you can have sex, but you must wear a condom.”

“I use interruptus,” the patient said, speaking for the first time in a heavy East European accent.

“You use what? Interruptus? Pull and pray? Good God, man! No wonder you have five kids! It's noble of you to try to get off the train at an earlier station, but it's unreliable. No sir. Interrupt the interruptus, man, unless you want to reach your half dozen this year.” The patient looked embarrassed. “You know what we call young men who use coitus interruptus?” Ghosh said.

The population expert shook his head.

“We call them Father! Daddy. Pater. Pappa. Pere. No sir, I have done the interrupting for you. Give me three months and you can tell your missus that she is not to worry because you will be shooting blanks, and there will be no more interruptions and you will be staying for dessert, coffee, and cigars.”