Cutting for Stone - Abraham Verghese [182]
Fistulas have been described since antiquity. But it wasn't till 1849 in Montgomery, Alabama, that Dr. Marion Sims, my namesake, first succeeded in repairing a vaginal fistula. His first patients were Anarcha, Betsy, and Lucy, three slave women who had been cast out by their families and their owners because of this condition. Sims operated on them—willing subjects we are told—in an attempt to cure the fistula. Ether had just been discovered but wasn't in widespread use, so his patients were wide awake. Sims closed the gaping hole between bladder and vagina with silk and thought he had cured them. But a week later, he found pinhole openings along the line of his repair through which urine was leaking. He kept trying. He operated on Anarcha some thirty times. He learned from each failure, modified his technique until he ultimately got it right.
When Hema operated on the girl wed seen, she used the principles of repair established by Marion Sims. She first put a catheter through the urethra into the bladder to divert the urine away from the fistula to allow the wet, macerated tissues to dry and heal. A week later, Hema operated vaginally using the bent pewter spoon the Alabama surgeon had fashioned—the Sims speculum, we now call it—which allowed for good exposure and made vaginal surgery possible. She had to carefully dissect out the edges of the fistula, trying to find what had once been discrete layers of bladder lining, bladder wall, then vaginal wall and vaginal lining. Once she had trimmed the edges, she made her repair, layer by layer. Sims, after many failures, had a jeweler fashion a thin silver wire which he used to close the surgical wound. Silver elicited the least inflammatory reaction from the tissues, inflammation being the reason a repair would break down. Hema used chromic catgut.
At dinner, a month after Id learned of Ghosh's blood disorder, Hema shared with us that she and Shiva had operated on fifteen successive fistula patients with not one recurrence. “I owe this to Shiva,” she said. “He convinced me to take more time preparing the women for surgery. So now, we admit the patients and feed them eggs, meat, milk, and vitamins for two weeks. We treat with antibiotics till the urine is clear and use zinc oxide paste on their thighs and vulva. It was Shiva's idea to deworm them and correct iron deficiency anemia before surgery. We work on strengthening their legs, getting them moving.” She looked at Shiva with pride. “I am embarrassed to say, he's seen and understood their needs better than I have after all these years. Like the idea of physical therapy—”
“Can't get them to walk after surgery if they won't walk before,” Shiva said.
On four of their patients the hole into the bladder was so large, so scarred down and shrunk back, that it was impossible to pull the edges together. In these patients, Hema and Shiva had learned to expose a narrow but thick “steak” of flesh under the labia and, while keeping it connected at one end to its blood supply, tunnel its free end up and pull it into the vagina and use it as a live patch in the fistula.
“Matron has a donor who wants to support nothing but fistula surgery,” Shiva said. “We're getting one thousand American dollars every month.” I found it difficult to look at him, let alone congratulate him.
I STOPPED FRETTING over Genet. When she failed two of the four courses the first year and had to repeat both semesters, I was too distracted by Ghosh's illness