Still without touching her, judging only by the way she lay limply curled on the gray sheet in the corner of the room, I concluded that the young woman’s clinical condition was not good and that she may, in Hishin’s words, have “managed to do herself real liver damage.” I had already noticed how she was hugging herself with both arms, and how with weak but incessant movement she kept scratching and rubbing herself, a classic symptom of accumulated bile salts penetrating the skin. But I smiled, trying not to reveal to her parents, who were standing right behind me, any sign of anxiety or panic. I knew too that there was no point in undressing her now, in front of her parents and the Japanese backpackers, and trying to auscultate her heart and lungs. Obviously I had to perform a blood count and sedimentation rate quickly and obtain the exact bilirubin and glucose levels and liver functions. I had to see the color of her urine and have it tested right away. In the meantime I bent over her on my knees and covered her forehead lightly with my hand to feel her temperature, which seemed worryingly high, and I put my other hand onto her cropped blond head, wondering momentarily whom she had inherited this blondness from, for both Lazar and his wife had dark hair. Then I slid my hand down to her nape and her neck, to feel if there was any swelling in the neck or the thyroid gland, and at the same time I asked her the kinds of meaningless routine questions I usually asked patients in order to gain their confidence and encourage them to reveal, even if unintentionally, additional truths about themselves.
I was glad to see that despite her weakness she seemed eager to cooperate with me, for my main fear when I had begun this trip had been that I would find her so far gone in that she would be completely apathetic, or even resist my efforts to arrive at an exact diagnosis of her condition and take the right steps to bring her home quickly. In contrast to the resistance she seemed to show toward her parents, she answered my questions willingly, if hesitantly, and recalled how it had all begun and what she had felt and where it had hurt most, and she was even able to describe the changing color of her urine since then, and of course what hurt her now, apart from this itchiness that was driving her crazy—for which I was prepared, because after Hishin had forgotten to bring me the articles he had promised, I had managed to read up on the disease in an old English medical encyclopedia I found in my parents’ house the night before we left, where the itch was particularly vividly described. “Apart from the itch, what is giving you pain?” I pressed her to go on complaining to her heart’s content, and she did so, and although I noticed that she was confusing symptoms associated with the disease with independent symptoms, such as pains in her legs and a heavy feeling in her back, I said nothing and just nodded my head in agreement with everything she said, still stroking her neck, where I felt a slight swelling in the trachea. Perhaps, I thought, the swelling was natural to her, and I dropped my hand in order not to confuse myself with superfluous speculations before I obtained the results of the crucial tests, which had to be given and rushed to the hospital in Gaya immediately. But I couldn’t forget the remark made by the Indian doctor in the train, about the unreliability of the laboratory in the Gaya hospital. It was a pity we’d met him, I reflected bitterly, because if we had to start checking up on how reliabile the Indian laboratories were, we would never finish. But I immediately suppressed this idle thought. Even if Hishin had exaggerated my qualities greatly, mainly in order to get his friends off his back, he was well acquainted with my scrupulous thoroughness, and he had trusted it to guide me without making any mistakes that might eventually be discovered in the hospital in Tel Aviv, where malicious professors and sycophantic doctors would lick their lips over them. I was only too familiar with the fact that in medicine everybody always has to have the last word: what should have been done, what shouldn’t have been done, and what did more harm than good.
But I knew that here I was in sole charge, and I had to make an immediate decision. Even though it seemed strange to me for a moment that the director of a big, modern hospital, with the best medical minds at his disposal, should be standing here anxiously with his wife in a dark little chamber in a Buddhist monastery at the end of the world, completely dependent on the professional opinion of an inexperienced young resident, who had not yet examined the patient properly but only touched her lightly on the forehead to feel her temperature and felt her neck a little, I stood up to announce my decision.
“We have to perform some essential tests immediately,” I explained, “so we’ll know where we are and where we’re going. Even though her condition’s not great, she can be moved. But before that we have to find out a few things, such as the bilirubin and glucose levels, in order to learn how much damage has already been done to the liver. But there’s no need to return her to the hospital; we can obtain the samples on the spot and take them to Gaya. In the meantime, I suggest we find a better room and move her into it. She shouldn’t be left in this squalor.”
A smile now hovered on Lazar’s wife’s face—not the familiar smile, which still confused me by its ready appearance, but a more inward and personal smile, as if she were wondering at the authoritative tone I had suddenly adopted (which, to tell the truth, originated with Professor Hishin, who always used the first-person plural when he came across a patient or the relative of a patient who appealed to him particularly). The two Japanese girls came out of their corner, bent over the gas burner, and offered us some of the pale tea they had brewed. Lazar’s wife hesitated, but Lazar declined the offer, in a hurry to rush off and obey my orders by finding a decent place for us to stay. “You can all wait for me here,” he announced. His wife seemed upset by his urge to depart, quickly stiffened, and said, “Just a minute,” and Lazar said, “What’s the matter?” and she replied, “Perhaps I should come with you.”
“But why?” asked Lazar. “There’s no need.”
But she insisted: “No, I think I should come along to help you.” She was already bending over her daughter to kiss her, and promising, “We’ll be back soon.” Then she turned to me and said, “You stay with her, and if possible start your tests, and we’ll be back right away.” So saying, she went off with her husband, evidently unable to remain alone not only with me but even with her daughter.
Einat was still lying hugging herself with both arms, scratching and rubbing, sending me a quiet look from eyes as yellow as a tiger’s or a hyena’s. But in spite of her obviously poor physical condition, I felt no pessimism, for I knew that I had already gained her confidence by the way I laid my hand on her head and felt her nape and neck. From the minute Hishin told me about her, I had harbored the suspicion that I was being sent to an apathetic patient who had lost the will to recover and might even resist my efforts to help her. But it didn’t look as if the young woman lying here would be able to mobilize any resistance; she was too absorbed in her frenzied scratching, and she was eager too for strange hands to touch her and even to take part indirectly in the frantic scratching. But I didn’t want to hurry to work yet, and although it was beginning to get dark, I first drank the bitter, scalding tea offered by the Japanese girls and asked them to tell me about themselves. They told me that they had arrived in Bodhgaya two days before, directly from Japan, to take an advanced course in meditation in the nearby Japanese monastery, and since there had been no room there they had come here and been given a place to sleep with the sick girl, on condition that they look after her a little. They had tried to take care of her needs without getting infected, and wore cloth masks when they touched her. Yesterday they had taken her into the inner garden of the monastery and fed her the rice gruel that they had cooked for her. But her itch was severe, and the ointments the monks had given her didn’t help, and had I brought some good medicine with me? they asked, as if I had come all the way from Israel to treat an itch. “Maybe,” I said, “we’ll see,” and I opened the knapsack and began emptying its contents onto the blanket they spread out for me, angry with Lazar’s wife for not staying to help me undress her daughter. But the Japanese girls were very helpful; t
hey brought me a big flashlight to supplement the dim light of the bulb, and then they sat Einat up and helped me take off her stained white robe, and supported her thin white back while I knelt and passed the stethoscope inch by inch over her back and chest to auscultate her lungs and see if they were clear and free of liquids, and of course to listen to her heartbeat, which was completely regular. The two girls watched my examination, pleased that somebody had come to relieve them of the responsibility for the patient, who had been entrusted to their charge maybe as a kind of religious test imposed by the monks. I nodded my head in satisfaction and said to my patient, “Everything sounds fine, Einati,” adopting the pet name used by her parents, and then I laid her slowly on her back to feel her abdomen, which was hard and covered with red marks from her incessant scratching. To my surprise, her inflamed liver, which should have been enlarged, appeared to have shrunk so much that it was difficult to palpate in the flat, hard abdomen, as if it had already begun to degenerate. At first I was alarmed, but I immediately said to myself that degeneration couldn’t possibly have occurred only two months after the outbreak of the disease. The gall bladder did seem enlarged, and was apparently also inflamed, for the slightest pressure from my fingers was enough to make Einat scream so loudly that the Japanese girls averted their faces. Footsteps were quickly audible in the corridor, and a shaven-headed monk in a robe the color of the setting sun came hurrying up to discover the cause of the scream, which had echoed through the quiet monastery. He spoke no English, and I asked the Japanese girls to explain that I was a doctor from Israel who had come with the girl’s parents to take her home.
But the monk remained standing in the doorway, as if he were unable to grasp the connection between my words and the scream of pain uttered by the woman lying half naked on the floor. I felt suddenly disheartened at the possibility of losing my patient’s confidence, and rage at Lazar’s wife’s desertion welled up in me for her. I decided to interrupt my clinical examination and postpone the palpation of the spleen and kidneys to another time. I would have plenty of opportunities later, I said to myself, and so I changed the dressing on the wound on Einat’s leg, which seemed to me infected but not serious. I put her stained white robe back on and tried to reassure her. “Don’t worry, it’s only an inflamed gall bladder, which is quite natural in hepatitis.” Among the medications I found a tube of cortisone ointment, which was supposed to relieve the itching, and allowed her to rub it on her arms and abdomen herself, warning her not to expect anything more than temporary relief, since the unexcreted bile salts accumulated under the skin and the itching could be relieved only from inside. But she thanked me gratefully. While she smeared herself with the ointment, assisted by the Japanese girls, I asked one of them to bring the flashlight closer and prepared to draw blood. I have to admit that it gave me a kick to see them all, including the Buddhist monk, frozen in their places as I tightened the rubber tube around Einat’s thin arm, looked for a vein, and gently and slowly extracted a syringe full of blood. Not content with one, I took another one and filled it too. As long as she’s lying here quietly, I thought to myself, I might as well get two—who knows, a test tube can break or become infected; the blood’s flowing now, and who can tell what might happen tomorrow?
Now we waited for the Lazars to return. The monk went away, and one of the Japanese girls took Einat to the toilet with two transparent sterile containers I gave her for a urine sample and if possible a stool as well. I remained with the other girl, and made no bones about asking her for a fresh cup of tea, which she was happy to give me, adding a little dry cake as well. Since she seemed intelligent, I asked her what she was looking for in Bodhgaya, and she told me about a local course in a kind of meditation called Vipassana, whose main feature was abstinence from speech for two weeks. “For that you have to come all the way from Japan?” I asked with a smile. “Couldn’t you keep quiet for two weeks at home?” But it transpired that silence next to the Buddha’s sacred bo tree had a significance that was different from silence anywhere else. Then I asked her to tell me something about the Buddha and what his teachings could mean to a rational, secular man like myself, who had no inclination to mysticism or belief in reincarnation. She tried to explain to me that Buddhism had nothing to do with mysticism but was an attempt to stop the suffering that came from birth, illness, old age, and death, or even the mental suffering incurred by the presence of a hated person or the absence of a loved one. And the way to stop the suffering was to try to become detached and free and thus to attain Nirvana, which was the end of the cycle of rebirths. “Is it really possible to stop the cycle of rebirths?” I inquired with an inner smile, in Hindu irony, and as I asked, Einat returned from the toilet supported by the Japanese girl, who was carefully carrying the two little receptacles, which contained a faintly pink fluid, the color of the tea I had just been drinking. And although my heart froze for a moment at the obviously pathological appearance of the urine, which suggested the presence of blood, I said nothing and betrayed no sign of anxiety. On the contrary, I congratulated Einat on the success of her efforts and took the two little containers and placed them with the test tubes of blood in a padded leather pouch which could be fastened to someone’s belt for safe conveyance during a trip. Good for our head pharmacist, I thought admiringly; I mustn’t forget to praise him for his foresight and ingenuity when I get back. I went on talking to the Japanese girl about the Buddha and his followers, drinking my third cup of tea while Einat dozed in the fetal position, as if the loud cry she had previously produced had calmed her. I was beginning to feel astonished at the procrastination of her parents, and thinking angrily of Lazar’s wife, who even at this difficult hour was no doubt looking for somewhere original to stay.
They finally returned, agitated but also proud of their achievements. Suddenly the room filled with a number of half-naked young Indians, who before our eyes put together two stretchers from bamboo poles and mats, like the ones on which dead bodies were transported to the river. One of them was quickly loaded with our luggage, while the sick girl was carefully lifted onto the other and covered with a floral cloth. In a soft, beautiful twilight hour, our little procession left the Thai monastery with two stretchers held shoulder-high and made its way through the tree-shaded streets of Bodhgaya, passing shacks made of cloth and wood, under the sympathetic gaze of locals and pilgrims. Our destination was a hotel not far from the local river, surrounded by lawns and flower beds, where the Lazars had found a bungalow consisting of three small rooms connected by a passage and a rather dirty kitchenette with a sink and a stove in one corner and a table in the middle, which someone had already heaped with fruit and vegetables, cheeses and chapatis in anticipation of our arrival. For a moment I stood amazed at the transformation of my simple request for a decent room into this massive domestication. Before even asking about the results of the examination I had carried out on their daughter in their absence, both the Lazars burst into a frenzy of organization. Einat was put to bed between clean white sheets in a little room of her own, and Lazar’s wife fussed over her and pampered her and went to fetch a vase of fresh flowers from the hotel manager, while Lazar himself attacked the clutter and disorder with a vengeance, opening the suitcases and putting the clothes away in the closets as if he had forgotten all about his hospital and his promise to conclude the trip in ten or twelve days. It was as if all he wanted was to settle down in this little bungalow in the charming Buddhist village, which in comparison to the Indian reality we had seen up to now was a veritable paradise on earth.
But I still hadn’t opened my suitcase, only put it on the bed in the little room set aside for me. I was uneasy, not only because of the color of Einat’s urine, and the blood, which at first sight looked diseased and saturated with bilirubin, or the enlarged gall bladder, which had made her scream with pain when I touched it, but mainly because of my failure to palpate the liver, as if it had shrunk or degenerated in an alarmingly accelerated process of cell destruction. In which case, I th
ought, there was a good chance that before long she might develop a sudden internal hemorrhage. The thought terrified me, because if that happened here, in this remote village, all we would be able to do was pray to Buddha. As Lazar stood in the doorway with a strange-looking apron tied around his waist and invited me to come into the kitchen, I pulled myself together and decided to return immediately to Gaya and hand the samples over to the hospital laboratory and at the same time have a look at their equipment, so I would know what would be available to us if we needed it. If, as I feared, the results were bad, it would make no sense to settle down in this funny little bungalow with its dirty little kitchen and big dining table—we should go straight to Calcutta and take her to the hospital recommended by the Indian doctor on the train, so I wouldn’t have to cope with any possible deterioration on my own. Strangely enough, the Lazars did not seem worried; perhaps they had expected to find her in worse condition, or perhaps they had put their faith in Hishin’s pronouncement that in the last analysis hepatitis was a self-limited disease, and accordingly, after collecting their daughter and transferring her to the bungalow, all they sought was rest. The holy village too appeared to have had a calming effect on them, and they seemed perfectly happy to putter about in their little kitchen with its knives and forks and plates and even a pot bubbling on the stove.
I decided to sow a few seeds of anxiety in the cozy domesticity that was taking over here, and, declining to sit down at the laid table, I announced without undue gravity that I felt obliged to go straight to the hospital at Gaya with the samples I had obtained. I placed the ointment to relieve Einat’s incessant itch on the table, between the fruit and the chapatis, and also a few Valium tablets and paracetamol to bring down her temperature, and warned the Lazars not to mask her symptoms by exaggerating the dosage. But I wasn’t sure that I had conveyed my anxiety to them, for Lazar greeted my announcement with astonishment. “Are you sure that it’s really necessary to go to the hospital now, in the dark?”
Open Heart Page 11
