The Covenant of Water

1974, Madras

Mariamma writes to let Uma Ramasamy know the date of her return. Uma replies by telegram: Bring the genealogy you mentioned. I have something to show you.

Two weeks after the funeral, Mariamma boards the overnight train from Punalur—not the route her father took. In her berth, she cannot sleep. She finds the suspense unbearable. Why didn’t Uma just say what she’d found?

She arrives in Madras in the early morning and freshens up in the hostel. By eleven o’clock she’s in the gloomy and unnerving Pathology Specimen Room, waiting for Uma. The hundreds of preserved specimens on the shelves, used by examiners to quiz students in the viva voce in anatomy, pathology, and every clinical specialty, stare at her.

Uma arrives, hugs Mariamma, then holds her at arm’s length to study her, ensure she’s in one piece while she struggles for the right words. She gives up and just hugs Mariamma once more. “Is that it?” Uma says at last, wiping her eyes, looking at the poster-sized sheet rolled into a tube.

“That’s a copy. The original is falling apart. And it’s in Malayalam. I translated all the writing that I could decipher.”

Like keepers of the faith, they pore over the lives of Parambil. Mariamma summarizes what she knows: the crucifix over wavy lines is for those who drowned; wavy lines without a crucifix indicate an aversion to water. The annotations suggest that in the fifth or sixth decade of life some of those with the Condition staggered or had dizziness. There are several references to deafness. And three mentions of weakness of one side of the face, including in her grandfather.

Uma says, “I don’t see a simple Mendelian pattern of inheritance. Striking that it affects men more than women!”

“Well . . . maybe not. Since women marry and move away, there’s little record of them after that. They belong to another family from then on. It’s as though marriage makes them disappear.” Like my mother, she thinks.

“Thank you for bringing it. Immensely helpful.” Uma sits back. “So . . . Mariamma, on the general autopsy, there were no injuries sufficient to have caused your father’s death . . . He drowned.” She waits for Mariamma to absorb this. But for the Condition her father might have swum to safety.

After a while, Mariamma nods for Uma to go on. “Before I performed the brain autopsy, I spoke with Dr. Das from neurology, told him what I knew. He was with me when I removed the brain. We saw something. The truth is I almost missed the crucial finding. It was subtle, and it helped to have your story and to have Das there. Let’s go to the Brain Room and I’ll show you,” she says, rising.

As they walk down the hall, Uma says, “The brain needs at least two weeks to harden in formalin, preferably more. I just pulled it out before I came here, and it’s safe to handle but not ready for sectioning.” Sectioning is the pathology ritual carried out with a bread knife and breadboard, slicing the brain much like a loaf. “Dr. Das will meet us in the Brain Room by the way. Are you ready?”

The Brain Room looks like a deep, rectangular storeroom, with shelves lining two sides and a floor-to-ceiling window at the far end. The shelves are crammed with plastic buckets, like paint in a hardware store, except these buckets hold brains, waiting to harden. A fresh brain when removed is soft and will mold itself to whatever container it is in. For it to retain its proper shape while it hardens, a string is passed through the blood vessels on its underside, then the inverted brain is suspended in formalin by tying the string to a crossbar over the top of the bucket.

Dr. Das is already there, a stooped, unobtrusive man, waiting patiently. On a tray on the table by the window, and covered by a green cloth, like dough being allowed to rise, sits her father’s brain.

After introductions, Uma glances at Mariamma, then removes the cloth. Her father’s brain is slightly bigger than a shelled coconut. On the underside, like the stalk below the florets of a cauliflower, is the brain stem. Dangling from it like untied shoelaces are the cranial nerves, severed by Uma in order to remove the brain from the skull. Those nerves carried signals from her father’s eyes, ears, nose, and throat, allowing him to see, smell, taste, swallow, and hear. Mushrooming above the brain stem and dwarfing it are the two cerebral hemispheres. Her father’s brain looks like any other brain. But it isn’t. It held his unique memories, every story he wrote, and the ones he might have written; it held the love he had for her. It holds the mystery of why he came to Madras.

Uma says, “As I said, I didn’t see anything abnormal at first, but then . . .” She hands a magnifying glass to Mariamma and points with a probe. “Look here, where the facial nerve and the acoustic nerve are about to enter the brain stem. Can you see this little yellow bump on the acoustic nerve? On any other brain and without Dr. Das with me, I might have thought it was nothing, especially because I saw the same thing on the other side. But given your family history, it seemed significant. I took a tiny sample of one bump before putting the brain in formalin. I did a frozen section and yesterday a more permanent stain on that sample. I saw spindle cells, stacked in palisades. It’s an acoustic neuroma.”

“That explains his hearing loss,” Mariamma says.

Dr. Das clears his throat, and says, “Yes.” The soft-spoken neurologist’s body floats within his half-sleeved white coat. “Acoustic neuromas aren’t malignant in the usual sense. They don’t spread. They just grow very, very slowly. But, in that tight cleft between the inside of the skull and the outside of the brain stem, something the size of a peanut is like an elephant squeezed into a closet, isn’t it? The tumor begins in those acoustic nerve fibers that receive balance signals from the inner ear, from the labyrinth. But as it grows, it presses on the fibers that affect hearing, as you noted. As it gets even bigger, it presses on the facial nerve sitting right next to it and causes weakness of one side of the face . . .” He pauses, to ensure Mariamma is following.

“Most patients that I diagnose in life with acoustic neuroma have them on just one side. But given that your father had them on both sides, and with your family history, your father probably had a variant of neurofibromatosis, or von Recklinghausen’s disease. Do you know it?”

She does. The old woman who sold jasmine outside Mariamma’s hostel had von Recklinghausen’s. The profusion of bumps under her skin originated in the cutaneous nerves. The visible parts of the woman’s body were completely cloaked in mushroom-like growths, though they didn’t seem to trouble her.

“But my father had no skin bumps, nothing.”

“Yes, I know,” Dr. Das says. “But you see there is a variant of neurofibromatosis that has few or no skin lesions, and it causes acoustic neuromas on both sides. Sometimes it has characteristic benign tumors elsewhere. I actually think it may be a quite separate disease from von Recklinghausen’s, but for now they are lumped together. There aren’t very many reports of it running in families. Your family is unique.”

Half an hour later, Doctors Ramasamy and Das are gone. Mariamma had asked if she could be alone in the Brain Room for a bit.

The buckets on the shelves look on like spectators. She closes her eyes. With her feet planted firmly on the floor, she doesn’t sway. Her father would not have been able to do that; he might have fallen over. But she can stand, eyes closed, thanks to the labyrinths, the organs of balance buried in her bony skull—one on each side. Inside each labyrinth, three fluid-filled circular canals, like interlocking rings at angles to each other, register the movement of the fluid within, and thereby register her position in space; they send that information to the brain through the acoustic nerve. In her father’s case the signals were interrupted by these tumors.

Das spoke of the labyrinths as “proof of God.” As a child, when Mariamma spun herself around like a dervish, she’d become dizzy when she stopped. That was because the fluid in the labyrinth, in those circular canals, was still swirling, telling her brain that she was turning, even though her eyes said she wasn’t. The conflicting signals made her stagger like a drunkard and even want to throw up. Spinning like a dervish wasn’t a game Lenin or her father could ever be persuaded to play. They already lived with conflicting signals.

Since her father got unreliable signals or no signals from his labyrinths, he must have compensated for this deficiency quite unconsciously by relying heavily on his eyes to see the ground, to find the horizon. He also relied on sensation in his feet, telling him his feet were on the ground. In the dark when he couldn’t see well, couldn’t see the horizon, or whenever his feet were in water and had nothing to push against, he was lost.

Dr. Das said that a new advance, not yet routine—computed axial tomography, or CAT scan—allowed incredible cross-sectional images of the brain. Acoustic neuromas as small as her father’s could be diagnosed early in life. But, he said, even if her father’s tumor had been diagnosed in the last year, unless it was causing him major symptoms like facial paralysis, or headache and vomiting from raised pressure in the brain, no one would consider surgery. That’s because the operation is formidable and risky, and reserved for bigger tumors. For the latter, neurosurgeons would make an envelope-sized opening at the back of the skull, just above the hairline, pulling aside the cerebellum to get at the tumor, which sat buried in a minefield of critical structures—large venous sinuses, vital cranial ­arteries—and with other cranial nerves draped over the tumor, and with the brainstem close by.

She senses Big Ammachi with her, peering down, shocked at the sight of her son’s brain on the table. Can her grandmother see past the terrible violation of his body, and rejoice at this new understanding? The Condition now has a medical name and an anatomic location, which explain its strange symptoms: deafness, an aversion to water, and drowning. They’ve found the enemy, but the victory feels hollow. So what if they have a name for it? What use is that unless science and surgery can advance to where a child with this disorder can live a normal life without the risk of drowning, or hearing loss, or worse symptoms as they get older?

Three generations of us are here in the Brain Room, Mariamma thinks. When Big Ammachi lit the seven-tiered lamp the night her namesake was born, she’d said to the kaniyan, “There’ll never be another like my Mariamma, and you can’t begin to imagine what she’s going to do.” As a child, whenever her grandmother recounted that tale, she’d always say they lit the lamp so it might show Mariamma the way for whatever she might choose to do in life. “What will I do, Big Ammachi?” Mariamma asks aloud now, just as she did so long ago, her voice echoing in the Brain Room. She hears her grandmother’s reply: “Whatever you imagine.”

Ammachi, I imagine taking on this enemy that drowned my father, drowned him when a train wreck couldn’t kill him. I imagine conquering this cramped territory at the base of the brain, making it my battlefield, and giving myself to better understanding these tumors. It will take years of training, but this is what I imagine, Ammachi, and I’ve never been more certain—I’ll be a scientist and a neurosurgeon.

Mariamma spends two more years in Madras after graduation, the first of which is her required internship, rotating through all the specialties. For her second year, she’s a “senior house surgeon”—a glorified intern—but on the general surgery service alone. Only when she completes the two years is she qualified to apply for a training spot in neurosurgery.

Deciding to be a neurosurgeon is far easier than getting a spot in one of the few neurosurgical training programs in the country. She has excellent grades, a prize medal in anatomy, strong letters of recommendation, and by this time she has two published papers with Uma (one on leprosy, and the other a case report on her father’s acoustic neuroma and its presentation in one family over generations). But, even if no one says this outright, many centers don’t think women should be in neurosurgery.

At the eleventh hour, she’s accepted to the oldest and best-known neurosurgery program in the country: the Christian Medical College in Vellore, just two and a half hours west of Madras by train. Founded by Ida Scudder, an American missionary physician, it was first a women’s clinic and then a women’s medical school before becoming coeducational. It has become an outstanding referral center, staffed by dedicated physicians. Church missions of every denomination support the medical school by sponsoring students.

Mariamma’s admission has a caveat. Since she applied for a “sponsored” training slot supported by her diocese in Kerala, she must fulfill a two-year service obligation at a mission hospital before she begins her training. Then, after becoming a fully-fledged neurosurgeon, she must serve for two more years in a mission hospital to complete her bond.

Seven years after she first stepped into the Red Fort, she leaves Madras, with tearful goodbyes to Anita, Chinnah, Uma, and so many others. She will begin her two-year bond in a brand-new, but unfurnished, four-story mission hospital that is to have the absolute best equipment. She’ll be its first, and for now its only, physician.

The location of this mission hospital is a stone’s throw from where her grandmother lit the lamp on the occasion of her birth: the district village of Parambil.