The Covenant of Water

1977, Saint Bridget’s

Digby watches Mariamma take in the grounds of Saint Bridget’s as they pull past the gates. What must she think of his home of a quarter century, this quiet oasis to itself, whose high walls don’t even let sounds from the outside world reach their ears? Suja, one of Digby’s “nurses,” brings her left palm to the stump of her right hand. Mariamma responds automatically, barely registering that Suja’s “namaste” must be imagined to be complete.

The room in which they have Lenin is private and secluded from the rest of the leprosarium. Mariamma hesitates at the threshold, then follows Digby, moving like a sleepwalker. Thank goodness he’s still breathing, Digby thinks. He watches her fingers tremble as they rise to touch Lenin’s cheek. The unconscious figure on the bed has dark stubble on his face and scalp, like a devotee returning from a pilgrimage to Tirupati or Rameswaram. The sinuous veins on his thin arms stand out because of the complete absence of subcutaneous fat. His scalloped belly and the prominence of his rib cage make him look like a man on the brink of starvation, not a guerilla fighter.

Digby quietly straps the blood pressure cuff on Lenin’s floppy arm. His action brings Mariamma out of her trance. Her fingers seek Lenin’s pulse. “A hundred and seventy over seventy,” Digby says eventually, removing the cuff. “About what it was before.”

“Pulse is forty-six,” she says. “The Cushing response.”

When was the last time Digby heard that phrase? A half century ago in a Glasgow operating theater? He’s had few occasions to remember the pioneering neurosurgeon’s triad. Cushing observed that if a bleed or a tumor raised the pressure within the rigid confines of the skull, it caused the systolic blood pressure to rise, the pulse to slow, and the breathing to become irregular.

“We should sit him up,” Mariamma says. “It helps lower intracranial pressure.” It isn’t an admonishment, but Digby knows he should have thought of it. With Cromwell’s help and using a folded mattress from the other empty bed in the room, they prop Lenin up, his head lolling forward like a rag doll’s.

“May I examine?” she asks.

“He’s all yours!”

She looks at Digby strangely. Then she shakes Lenin’s shoulders. “LENIN!” Earlier, Lenin had tried to open his eyes when Digby called his name. He’d even spoken. Now his eyes are glazed over. A patient who doesn’t flinch when firecrackers go off under the bed is worse off than one who does. Mariamma grinds her knuckles into Lenin’s sternum—a painful stimulus for a conscious patient. Lenin stirs, a faint furrowing of his face.

“See that?” she says. “Just the right side of his face moved.” Digby missed it. She does it again, and now he sees. “A left facial nerve paralysis,” she says. “The tumor on his left acoustic nerve is the issue. It must be big enough to involve the facial nerve.”

She props Lenin’s upper eyelids open and then rocks his head from side to side, checking for doll’s-eye movements, then for a gag reflex. With a tendon hammer she compares his reflexes on both sides. She pulls an ophthalmoscope out of her bag and looks into Lenin’s pupils. “Papilledema, both sides,” she says. Another sign of raised pressure in the brain.

Digby watches her, seeing all the things he might have done. The body before her is the text. Soon, like a biblical scholar, she will perform her exegesis. It makes him conscious of his age—she is two generations his junior. But Digby’s expertise is now in nerves that can never recover. All the book knowledge he no longer uses has vanished. In the field of tendon transfers, he’s an expert, publishing a few papers on his innovations, building on Rune’s work. But this patient brings him into unfamiliar territory.

Mariamma puts away her tools, her brow creased.

Digby says, “I thought we might need to make a burr hole in his skull. That’s why I asked you to bring the trephine. That might relieve pressure—”

She shakes her head. “It won’t help. Lenin’s tumor is down near the brain stem. It’s blocking the flow of cerebrospinal fluid. He has hydrocephalus. That’s why he’s unconscious. A burr hole is good for blood collecting under the skull, but in Lenin it would just cause the brain to herniate.”

Digby digests what Mariamma has just said. He pictures the slit-like hollows—the ventricles—that sit deep within the right and left hemispheres of Lenin’s brain. Cerebrospinal fluid is normally manufactured in the two ventricles, then passes down a central canal that runs like a drainpipe through the brain stem, emptying out at the base of the brain so as to bathe and cushion the outside of the brain and the spinal cord. But with the drain blocked by the tumor, fluid has backed up in the ventricles, converting them from slits to tense balloons. In infants the unfused skull would simply expand as the ventricles enlarge. But in Lenin, the enlarging ventricles are slowly squishing the brain tissue surrounding them against his unyielding skull, rendering him first drowsy and then comatose.

“But what we could do,” Mariamma says, “is tap one of the ventricles. We would pass a needle through brain until we hit one swollen ventricle and then drain the cerebrospinal fluid. We’d have to make a tiny hole here in the skull.” She points to the top of Lenin’s head, off the midline. “Not a regular burr hole but just big enough to pass the needle.”

“You mean you do it blind?”

“There are anatomical landmarks to follow. But it’s blind, yes. But his ventricles should be so distended that the needle has a good chance of hitting a ventricle.” She waits, as though she hopes Digby will talk her out if it. “I’ve seen it done. It’s not a cure. But it might buy us time. Time is brain, they say in neurosurgery. If he improves, then if we can get him to Vellore, to the Christian Medical College, that’s if he agrees to surgery . . .” She trails off, silenced by all the “ifs.”

“It’s the best plan,” Digby says firmly.

In Digby’s small theater, they prop Lenin up and bind his head to padded orthopedic frames that slot into the operating table. With a skin-marking pen, Mariamma draws a vertical line from the root of Lenin’s nose straight up to the center of his skull. With a tape measure she marks a point eleven centimeters along the line. From there she draws a second line, perpendicular to the first, heading to Lenin’s right ear. She marks an X three centimeters along this second line.

“Removing fluid from one ventricle will empty both, since they’re connected. I chose the right to avoid the speech center in the left hemisphere. In case you’re wondering.”

“I should have been,” Digby says.

The trephine Mariamma brought will make too big a hole. After conferring, Digby brings out the twist drill he uses for long bones. She injects local anesthetic into the skin and down to the skull at the X. With a scalpel she makes a small but deep cut down to the bone. Since he’s familiar with the instrument, Digby operates the twist drill. When he feels it punch through the outer table of skull, Mariamma takes over with a rongeur to nibble at the bone till they can see the glistening membrane that covers the brain. Even through that tiny hole, the membrane bulges out, the brain seeking relief from the pressure. Digby sees Mariamma flinch: this brain belongs to someone she cares for.

She picks up the spinal tap needle. It is long and hollow with a removable inner stylet. Earlier, she’d marked the shaft seven centimeters back from the needle tip. She clamps a hemostat to the needle hub and hands Digby the hemostat. “Stand directly in front of him, Digby, and hold the hemostat. I’ll be standing at his side. You must keep me pointing at the inside of the eye from your perspective. I’ll be aiming for the tragus of his ear on my view. Even if I tilt the needle in the front-to-back plane, your job is to not let me deviate in the side-to-side plane, keep me pointing to the inner canthus of the eye.”

God help us, this is crude, he thinks. She advances the needle into the brain. At five centimeters, she stops and pulls out the inner stylet. Nothing comes out of the hub. She reinserts and pushes the needle in another centimeter before withdrawing the stylet.

Clear fluid, like spring water, comes spurting out.

“Oh, my!” Digby exclaims. Theories are nice, but the proof is the fluid dripping steadily onto the towels.

“I can see the surface of the brain sinking back!” Mariamma says, excitedly.

When the dripping finally ceases, she slides the stylet back into the inner hollow and removes the needle, then plugs the bone with sterile bone wax. Just as she ties a knot in the single stitch she used to close the scalp wound, they feel the table shake. An ungloved hand emerges. “Hold on there,” Digby shouts, whipping off the drapes.

A groggy Lenin stares out of the drapes bunched over his forehead, like a mole emerging from its burrow, squinting at the light.

“Take your mask off,” Digby says quietly to Mariamma, removing his own.

Lenin’s head can’t move, but his eyes swivel from Digby to Mariamma. They settle on Mariamma. Digby cannot say which of them—Mariamma or Lenin—is more astonished. The theater becomes utterly still as the two stare at each other. All sounds outside vanish.

“Mariamma,” says the recently comatose patient, his voice weak and hoarse. “I am so happy to see you.”