Cutting for Stone

compounder, bent over the patient, and with one swift move made the diagnosis.

Years later Ghosh showed me the correspondence he had with the editor of the New England Journal of Medicine, who was about to publish Ghosh's seminal series of cases of relapsing fever. The editor felt “Adam's sign” was pretentious. Ghosh defended the honor of his uneducated compounder at the risk of not being published in that prestigious journal.

Dear Dr. Giles,

… in Ethiopia we classify hernias as “below the knee” and “above the knee,” not “direct” or “indirect.” It's another order of magnitude, sir. Our casualty room often has as many as five patients prostrate on the floor with fever. The clinician asks: Is this malaria? Is it typhoid? Or is it relapsing fever? There is no rash to help sort this out (the “rose spots” of typhoid are invisible in our population), though I will grant you that typhoid causes a bronchitis and a slow pulse, and people with malaria often have giant spleens. I would be remiss in publishing a paper on relapsing fever without providing the clinician a practical way to make the diagnosis, particularly in settings where blood and serum tests are hard to come by. The clinician has only to grab the patient's thigh, squeeze the quadriceps muscle, squeeze it hard: Patients with relapsing fever will jump up because of the otherwise silent muscle inflammation and tenderness that is part of this disease. Not only is this a good diagnostic sign, but it can raise Lazarus. This sign was first noted by Adam, and is deserving of the eponym “Adam's sign.”

I could testify to Adam's sign—Saleem yelled and leaped to his feet when Adam mashed. The editor wrote back. He was pleased with all the other revisions but Adam's sign remained a sticking point. Ghosh held his ground.

Dear Dr. Giles,

… there is a Chvostek's sign, a Boas's sign, a Courvoisier's sign, a Quincke's sign—no limit it seems to white men naming things after themselves. Surely, the world is ready for an eponym honoring a humble compounder who has seen more relapsing fever with one eye than you or I will ever see with two.

Ghosh, working in an obscure African hospital, far from the academic mainstream, had his way. The paper was published in the prestigious journal, and no doubt led to his being invited to write a chapter in Harrison's Principles of Internal Medicine, the bible of senior medical students. Now, here he was, a professor. Hema bought our new professor two beautiful pin-striped suits, one black and the other blue. Also a tweed coat with leather elbow patches, as if to put “Professor” in quotes. The bow tie was his idea. In all things, especially when it cost little and did no harm to others, Ghosh was his own man. The bow tie told the world how pleased he was to be alive and how much he celebrated his profession, which he called “my romantic and passionate pursuit.” The way Ghosh practiced his profession, the way he lived his life, it was all that.

36. Prognostic Signs

LIFE IS FULL OF SIGNS. The trick is to know how to read them. Ghosh called this heuristics, a method for solving a problem for which no formula exists.

Red sky in the morning, sailors take warning.

Pus somewhere and Pus nowhere means Pus in the belly.

Low platelets in a woman is lupus until proven otherwise.

Beware of a man with a glass eye and a big liver …

Across the outpatient department, Ghosh would spot a breathless young woman, her cheeks flushed, contradicting her general pallor. Hed suspect narrowing of the mitral valve of the heart, though he'd be hard- pressed to explain exactly why. It would make him listen carefully for the soft, rumbling murmur of mitral stenosis, a devilish murmur which, as he said, “you'll only hear if you know it's there,” and then it was only audible with the bell of the stethoscope lightly applied over the apex of the heart after exercise.

I'd developed my own heuristics, my mix of reason, intuition, facial appearance, and scent. These were things not in any book. The army soldier who'd tried to steal the motorcycle had an odor at the moment of his demise, and so, too, had Rosina, and the two odors were identical—they spoke of sudden death.

But I didn't trust my nose when I should have, when it picked up signals from Ghosh that put my nerves on edge. I wrote it off as being a function of his new job as a professor, a side effect of his new suits and new environment. When I was around him it was easy to be reassured. He'd always been upbeat, a happy soul. But now he was even more jovial. He'd found his best self. For a man who prided himself on “the three Ls: Loving, Learning, and Legacy,” he'd excelled in all three.

On the anniversary of Hema and Ghosh's marriage, I woke myself at 4:00 a.m. to study. Two hours later, I walked over from Ghosh's old bungalow to the main house. Shiva had moved back to our boyhood room. It was still dark outside. I planned to creep into Shiva's room to see if a shirt I was missing had been laundered and hung in his closet. I came in as Almaz arrived. I hugged her and then waited as she made the sign of the cross on my forehead and murmured a prayer.

Hema was still sleeping. The hallway bathroom door stood open, steam coming out. Ghosh stood in front of the washbasin, a towel around his waist, leaning heavily on the sink. It was early for him. I wondered why he was using this bathroom. So as not to wake Hema? I could hear his labored breathing before I saw him and, certainly, before he saw me. The effort of bathing had winded him. In his reflection in the mirror, I saw his unguarded self. I saw terrible fatigue; I saw sadness and apprehension. Then he saw me. By the time he'd turned around, the mask of joviality which had fallen into the sink had been slapped back on, not a seam showing.

“What's wrong?” I asked. I felt my stomach flutter. The scent was there. It had to be connected to what I just saw.

“Not a thing. Scary, isn't it?” He paused to take a breath. “My beautiful wife is sleeping like an angel. My sons make me so proud … Tonight I'm going to take my wife dancing and I'll ask her to extend our marriage contract for another year. The only thing wrong is that a sinner like me doesn't deserve such blessings.”

Hema came out to the hallway, shaking sleep from her hair. Ghosh flashed me an anxious look.

He turned back to the mirror, whistling as he slapped on cologne. His eyes pleaded with me not to alarm Hema. The effort of holding his arms up made his “Saints Come Marching In” full of staccato notes and pauses. I got my shirt and left.

I had an early morning class, an important one. But I followed my instinct, my intuition—my nose. I dressed and then hid myself behind Shiva's toolshed. Soon, the Volkswagen appeared out of the mist, with just Ghosh in it. I followed on foot.

I got to Casualty in time to see him enter Matron's office. Not only was Matron there at this early hour, she was waiting. I stood there considering what this meant, when Adam appeared carrying a bottle of blood. Matron's door opened for him. Adam emerged moments later empty-handed. He was startled to see me, and he tried to close the door behind him, but I had a foot there.

Ghosh was on a lounge chair, his feet up, a pillow behind his head, smiling. Bach's “Gloria” chorus sounded on Matron's ancient phonograph. Matron bent over his arm, taping the needle that carried blood into his vein in place. They looked up, thinking perhaps it was Adam returning for something.

Ghosh's lips moved.

“Son, you know I—”

“Don't bother to lie to me,” I said.

He looked to Matron, as if for a cue. She sighed. “This is fate, Ghosh. I always thought Marion should know.”

I'll never forget the stillness, the hesitation, and a trace of something I'd never before seen on Ghosh's face: cunning. Then it gave in to resignation and a faraway look. For a moment I saw the world through his eyes, his intellect, his sweeping vision that took in Hippocrates, Pavlov, Freud, and Marie Curie, the discovery of streptomycin and penicillin, Landsteiner's blood groups; a vision that recalled the septic ward where he wooed Hema, and Theater 3 where he was the reluctant surgeon; a vision that recapitulated our birth and looked to the future, looked past his life to the end of mine and beyond. And then and only then did it settle, gather, and focus, on the now, on a