The Covenant of Water

1934, Madras

In the morning as Digby turns into the native ward, a giant goiter leaps up in front of him. It bulges from collarbone to chin, swallowing all the landmarks of the neck. The face above it sits like a pea atop a toadstool. Aavudainayaki is a thin woman with a broad smile that makes up for the rudeness of her goiter. Palms clasped, she greets him with “Vanakkam, Doctor!” When she first arrived, her overactive goiter caused her palpitations and tremors and made her intolerant of heat. Two weeks of oral saturated solution of potassium iodide drops—SSKI—have reversed her symptoms, and she’s thrilled. But SSKI has done nothing for the enormous, lumpy swelling that stretches taut the skin of her neck, revealing the lattice of engorged blood vessels on the goiter’s surface.

“Vanakkam, Aavudainayaki!” He feels bad that he’s unable—or isn’t foolhardy enough—to tackle her goiter, but he’s taken pains to master her formidable name. To remove her goiter he needs a skilled surgeon to teach him. The same is true if he is to tackle the exceedingly common cancers of the tongue or of the larynx that are related to the unsightly habit of chewing paan. He referred Aavudainayaki to the Madras Medical College, but she refused. No one but “Jigiby Doctor,” who gave her the miraculous drops, may operate. Krishnan translated her thoughts: “She says she has faith only in you, and she’ll wait until you agree.”

“Honorine,” Digby says when he enters the ward, “stop feeding that goiter. I swear it’s grown overnight.”

“It won’t get smaller with yer complaining. I’ve canceled your clinic on Tuesday. We’re meeting Ravi. Dr. V. V. Ravichandran at General Hospital. He’s brilliant . . . The first Indian full professor in surgery at the Madras Medical College. When the governor needed surgery, his wife quietly sent for Ravi. Everyone knows he’s the best, but on top of that he’s a lovely man and a good teacher. I knew him when we were posted together in Tanjore.”

“Well, well! What’s this?” An Indian in white slacks and a white short-sleeved shirt breezes into his own office, three junior doctors in tow, his high-pitched laughter preceding him as he exclaims, “Claude Arnold’s assistant wants to learn? A miracle! Most want to flee Claude only!” His excited demeanor is that of a man perpetually on the verge of hysterical laughter, his eyes buried in round, smiling cheeks. Digby finds himself grinning. Dr. Ravichandran grasps Honorine’s and Digby’s hands at the same time. His prematurely gray hair is slicked back and receding. On his convex forehead his namam is a vertical, three-pronged fork, the center stripe red and the flanking two white. It signals he’s a Vaishnavite, holding Vishnu to be the supreme god in the pantheon.

Ravichandran releases Digby’s hand but not Honorine’s; his full lips are pulled back into a disarming grin that Digby soon understands is a permanent state. “Dr. Digby, but for this remarkable lady I would have collapsed and been cremated in Tanjore, such was my busy-busyness, daily, from morning to night.” His lilting speech reminds Digby of the Carnatic music teacher next door to his bungalow, who drills his students in the army of intermediate notes between the Western do-re-mi. “But Madam Honorine stepped in, no discussion. She made a schedule. Including tea together each day, no matter what, at four thirty. Then I was to go home. Private practice could only begin at seven pee yem. Not only that, she decreed that practice must be away from my house, so I’d have some sleep!”

“Fat lot of good that did, Ravi, when you kept giving patients your home address.”

Ravi guffaws at his own helplessness. “Ayo, Honorine, those Tanjore patients are still coming two hundred and fifteen miles to see me, though I try to dissuade them!” His professional vanity is strangely charming.

The bearer sets down tea and butter biscuits; the stenographer pushes a stack of forms before Ravi and he signs without looking down. A limping barefoot man in a blue uniform, who Digby learns later is Veerappan, Ravi’s former patient and driver, sets a colossal six-tiered silver tiffin carrier on Ravi’s cluttered desk. He unlocks the frame by sliding the long spoon-bolt out of its rings, then unstacks and displays each dish for Ravi to peer at and sniff before Veerappan reassembles it all and departs, having filled the room with the scent of coriander, cumin, and lentils.

“Some things haven’t changed, I see,” Honorine says. “How’s yer muther, then?”

“My mother is well, thanks be to the Divine,” Ravi says. “Digby, no other hand but my mother’s prepares my food, as I am her one and only issue.” He giggles mischievously. “If she knew that I am giving it away to patients in the septic ward, she would have to destroy the cooking vessels, bathe in the temple thrice a day, and live on barley and ghee for five days. But she is suspicious. When I get home, she’ll ask, ‘How was the bitter gourd?’ knowing fully well there was no bitter gourd! Veerappan has a second tiffin carrier in the car whose existence is unknown to Mother. I eat when I go later for house calls. I give in to my weakness for mutton korma with paratha. Beloved Matron Honorine only was my temptress and corrupter. Her pease pudding with ham—that was how my flesh-eating life began. One day, I will atone by giving away all my possessions—wear saffron robes, go to Benares, and pass from the world.”

All this while, an audience of junior doctors looks on, and an office boy hands Ravi a stack of chits, each of which he manages to scan without losing his train of thought.

“Glasgow, is it? Oh, Digby, so much I wanted to visit. Glasgow! Edinburgh! Hallowed names for surgeons, are they not? How wonderful it would have been to sit for the exams. To put the magical FRCS behind my name . . . Fellow of the Royal College of Surgeons! Ayo, I even had my steamer ticket!”

“What stopped you?” Digby asks hesitantly.

“Three thousand years of history,” Ravi says gravely. “We Brahmins believe the ocean is polluted, and in crossing to a foreign land over water the soul putrefies; one is damned for all time—”

“Tell him the truth, Ravi,” Honorine says. “It was your mother.”

He bursts out laughing. “Correctly only Honorine is telling. Ayo, my saintly mother . . . it would kill her. If I went overseas that would be matricide. Supposing she survived, her only issue would return so polluted that even if he stood out of sight, she could not speak to him ever again. Thus only, I stayed. But tell me, Digby, what made you risk eternal damnation and cross the water? What are you running from? Or to?”

Blood surges around Digby’s scar. Ravichandran’s grinning gaze settles there with curiosity and compassion. Digby searches for words.

“A blushing surgeon is better than the other kind,” Ravi says to Honorine. “I won’t add to the discomfort of a man who is already having Claude Arnold as his superior. Digby, did you know a Rolls-Royce sits in front of Claude’s house? Why he bought it? Because I have one! My Rolls was the first in Madras and has been a splinter under the dermis of your countrymen! ‘The impertinence of this babu!’ ” Ravi says, trying to mimic a posh English accent. His laughter interrupts his narrative. “The governor had to get one. Much later, Claude Arnold too. But Claude’s doesn’t move. It decorates the house like the pottu on my mother’s forehead. Digby, I am unmarried. I work very hard. For the profession I am giving up the necessities, but should I give up the luxuries? In my own land, am I not to come and go as I please?”

Ravi suddenly shouts over Digby’s shoulder at someone in what sounds like coarse and vulgar Tamil, his smile fading. “Impatient people!” he says, the smile slowly returning. “Always rushing. I am so behind that yesterday catches up with tomorrow. Anyway, Digby, if saintly Honorine likes you, then I am liking too. Come. My first case is a stomach resection for a likely gastric cancer. If it’s not too far gone.”

In the theater, Digby assists, anticipating Ravichandran’s movements, yet careful not to get in the way. There’s a rock-hard mass in the antrum, just above the pylorus where the stomach empties, a location where even a small tumor comes quickly to a patient’s attention because they feel full after a few bites. Ravi runs his hand over the surface of the liver, then pulls out the small bowel, all twenty feet of it, feeding it through his hands, looking for metastasis. Then he inspects the pelvis. “No spread. We’ll do a distal gastrectomy. Switch sides. I will be your humble servant.” Digby cuts out half of the stomach. Having Ravichandran as his skilled assistant, subtly improving his view and access, makes Digby feel like a far better surgeon than he really is. When he’s done, they’re left with a stump of the duodenum—into which bile and pancreatic juice pour—and the stump of the stomach remnant.

“What now, my young friend?”

“I’ll sew off the duodenum, leaving a blind stump. Then I’ll connect a loop of jejunum to the remnant of the stomach.” It’s the same familiar procedure he does for peptic ulcers at Longmere.

“A gastrojejunostomy, is it? Why not join the stomach directly to the duodenum? A Billroth One? Why not keeping the normal continuity? And then no duodenal stump to leave behind that might leak.”

Digby clasps his hands together, his gloves bloody past the knuckles, the open belly awaiting his decision. “To be honest,” he stammers, “I’ve done many more gastrojejunostomies at Longmere. For me it would be trickier to connect what’s left of the stomach to the scarred duodenum than to do what I am familiar with and know I can do safely. Yes, it would leave behind a blind duodenal stump, but that has less chance of leaking than if I tried to connect the stomach to the duodenum. In my hands.”

“Good answer! The best possible operation is not the same as the best operation possible! Of course, if the cancer returns, all this is moot. Go ahead.”

Operating weekly with Ravichandran at General Hospital is precisely the surgical education Digby sought when he came to India. He sops up every pearl the brilliant surgeon offers, and lingers to watch Ravi as he operates with others. Meanwhile, Aavudainayaki waits, unwavering in her determination that “Jigiby Doctor” take out her goiter. She earns her keep on the wards by being a willing helper to Matron and the nurses, and a support to new patients. She has become family.

Five weeks after first meeting Ravichandran, Digby takes Aavudainayaki to General Hospital in the early morning in a rickshaw. Ravi greets her graciously in Tamil. After palpating her goiter, he has her raise her arms and keep them up, her biceps bracketing her cheeks. Soon, her face gets dusky colored and congested, and she becomes breathless. “See that, Digby? Call it ‘Ravi’s sign.’ It means this goiter extends into her chest. If we can’t get at it from the top, we’ll be sawing through the sternum. Nothing routine about this, I assure you.”

The anxious patient is eager to convey something in Tamil to Ravi, who reassures her. He says drily to Digby, “I’ve assured her that the white man only is performing the surgery. I am merely assisting the great Jigiby Doctor.”

Ravi fusses after the patient is under anesthesia, asking first for a bigger sandbag between the shoulder blades to throw her neck forward, and for the foot of the table to be lowered further to help the engorged neck veins drain better. “Small things make a big difference, Digby. God is in the small things.”

Soon after they start, the operative field is cluttered with hemostats and they pause to tie off all the bleeders. As Ravi predicted, Aavudainayaki’s goiter extends down into the chest; not even his long fingers can retrieve it. “Ravichandran’s Spoon, please,” he says, turning to the scrub nurse. The long instrument she produces is new to Digby. Ravi eases it under the breastbone. Blind, by feel alone, he levers the lower pole of the goiter out of the chest. “You recognize my instrument, Digby? It’s the spoon that slides through the side slots of my tiffin carrier and bolts the stacked dishes together. My mother blames the driver for losing our spoons. Truly it is multi-purposeful, is it not? Eating fish curry or fishing out goiter!” When they’re done, Ravi is concerned. “The first night is the most dangerous. Essential to have a tracheostomy tray and a nurse at the bedside, please.” There’s reason to worry: the cartilage rings of the trachea normally prop the airway open, but Aavudainayaki’s are thinned out from long-standing pressure from her goiter. Postoperative swelling presents a real danger of the rings collapsing.

Digby has a full day of clinic and rounds at Longmere. But after dinner, he cycles to General Hospital again. Aavudainayaki’s smile has greeted him each morning for weeks now. For all her faith in Jigiby Doctor, he’s terrified of it ending badly.

At night all hospitals become hushed, sepulchral, the silence punctuated by a few coughs or moans. Digby’s footsteps echo in the hallways as he passes the open wards. A nurse sitting under a dim lamp looks up, surprised; she smiles shyly. Her smile stays with him. He feels a longing to be close to a woman.

Aavudainayaki sleeps comfortably, a tracheostomy kit at her bedside, but no nurse is to be seen. A sluggish, slovenly probationer returns after an hour, startled to see Digby. He dismisses her. He’ll keep vigil himself. To pass time he tries to depict the stages of the operation in his sketchbook.

Digby wakes to a high-pitched mewling noise and the sight of a desperate Aavudainayaki laboring to pull in air. That frightening sound—stridor—signals airway obstruction. He leaps to her side, ashamed that he fell asleep. Her terror-stricken face shows no joy at seeing Jigiby Doctor; she senses her imminent death. Digby tears open the tracheostomy tray while yelling for help. This is his worst nightmare: a tracheostomy in bad lighting with a struggling patient. He slashes through her dressings and is stunned to find her neck no longer flaccid as it had been after surgery—but swollen as though the goiter has returned with a vengeance! He cuts away three skin sutures and a huge blood clot slithers out past his fingers onto the bedsheet, a leering, jellylike blob. Aavudainayaki’s distress eases at once. Others arrive and flashlights shine onto the wound, which shows no active bleeding. The trachea is exposed and he could easily do a tracheostomy. But he sees no fresh bleeding and Aavudainayaki’s breathing is steady, her face calm. She even tries to smile.

He should take her back to the theater and under anesthesia explore the wound, find the bleeder if it’s still oozing. But it’s four in the morning. For an outsider to get the theater up at that hour will require an act of God. He’s loath to phone Ravi. He lets the skin flap back down without suturing it, just covering it loosely with gauze. If there’s the slightest sign of fresh blood, I’ll take her back.

In the morning, the surgical team arrives for rounds, Ravi at its head. He eyes the large liquefying clot in the basin. Aavudainayaki’s smile is back, but Dr. V. V. Ravichandran is unsmiling. He examines the wound. The entourage of interns and assistant surgeons shift their feet nervously. “Which one of you checked this patient in the night?” Silence. “Good thing you were here, Digby. But when that clot came out, she belonged in the theater. You should have called me at once.”

“Her breathing improved. If—”

“No ifs, buts, and baingan bhartas!” Ravi says sharply, cutting him off. “In the interest of a patient you may wake me and Jesus Christ himself. To wake the anesthetist, you will need divine assistance. But take patient to theater. No discussion!” He glowers at Digby for a few seconds, then his expression softens. He picks up Digby’s open sketchbook. “Aah, nice only. Those surgical atlases never bleed, do they?”

As Ravi and the surgical crew are about to exit the ward, he stops and turns around so suddenly, his retinue pile into one another. His voice fills the ward. “Dr. Kilgour. Good surgeons can do any operation. Great surgeons take care of their own complications.”

Digby colors with the praise.