My new ritual was to come on Saturday evenings to see Genet. She was just up the hill from the palace where General Mebratu (with Zemui at his side) took hostages and tried to bring about a new order.
Genet could have come home on weekends, but she said Missing evoked painful memories. She insisted she was happy at Empress Menen. The Indian teachers were strict but very good. Sheltered from society and from us, she worked very hard.
We entered university together for our premedical course, and the following year we entered medical school. Now out of uniform and in regular clothes, her dress and manner remained reserved and subdued. Each time I went to visit Genet in the Mekane Yesus Hostel opposite the university, I'd pray that this would be the day when the locked door to her heart opened and I might see traces of the old Genet. She was appreciative for the tiffin carrier of food Almaz and Hema sent for her, but the barrier she put up around herself remained.
I still loved her.
I wished I didn't.
We entered the Haile Selassie the First School of Medicine in 1974— only the third class to be admitted. Genet and I were paired as dissection partners on a cadaver, which was fortunate for her. Anyone else would have taken offense at her frequent absences and her failing to carry her load. I didn't think she was lazy. There was no good reason for this; something was brewing, and for once I had no clue.
OUR BASIC SCIENCE TEACHERS were very good, a mix of British and Swiss professors and a few Ethiopian physicians who graduated from the American University of Beirut and then took postgraduate training in England or America. There was one Indian: our own Ghosh. Ghosh had a title: not Assistant Professor, or Associate Professor, or Clinical Associate Professor (implying an honorary, unpaid designation), but Professor of Medicine and Adjunct Professor of Surgery.
I don't think any of us, not even Hema, realized the extent of Ghosh's scholarship during his twenty-eight years in Ethiopia. But Sir Ian Hill, dean of the new medical school, certainly did. Ghosh had forty-one published papers and a textbook chapter to his name. An initial interest in sexually transmitted illness had given way to major scholarship on relapsing fever, for which he was the world's expert, because the louse-borne variety of this disease was endemic to Ethiopia, and because no living person had observed the disease as closely.
I learned about relapsing fever as a schoolboy when Ali of the souk opposite Missing brought his brother, Saleem, to the hospital and asked me to intercede. Saleem burned with fever and was delirious. Ghosh said later that Saleem's story was typicaclass="underline" He'd arrived in Addis Ababa from his village with his life's belongings in a cloth strung over his shoulder. Ali found his brother a toehold in the seething, swarming docks of the Merkato, where, monsoon or not, he hauled sacks off the trucks and into the godowns. At night he slept cheek by jowl with ten others in a flophouse. In the rainy season, there was little opportunity to wash clothes because they would take days to dry. Saleem's living conditions were unfit for humans, but ideal for lice. While scratching his skin he must have crushed a louse, its blood entering his body through the scratch. Coming from the village, he had no immunity to this urban disease.
In Casualty, Saleem lay on the ground too weak to sit or stand, semiconscious. Adam, our one-eyed compounder, bent over the patient, and with one swift move made the diagnosis.
Years later Ghosh showed me the correspondence he had with the editor of the New England Journal of Medicine, who was about to publish Ghosh's seminal series of cases of relapsing fever. The editor felt “Adam's sign” was pretentious. Ghosh defended the honor of his uneducated compounder at the risk of not being published in that prestigious journal.
Dear Dr. Giles,
… in Ethiopia we classify hernias as “below the knee” and “above the knee,” not “direct” or “indirect.” It's another order of magnitude, sir. Our casualty room often has as many as five patients prostrate on the floor with fever. The clinician asks: Is this malaria? Is it typhoid? Or is it relapsing fever? There is no rash to help sort this out (the “rose spots” of typhoid are invisible in our population), though I will grant you that typhoid causes a bronchitis and a slow pulse, and people with malaria often have giant spleens. I would be remiss in publishing a paper on relapsing fever without providing the clinician a practical way to make the diagnosis, particularly in settings where blood and serum tests are hard to come by. The clinician has only to grab the patient's thigh, squeeze the quadriceps muscle, squeeze it hard: Patients with relapsing fever will jump up because of the otherwise silent muscle inflammation and tenderness that is part of this disease. Not only is this a good diagnostic sign, but it can raise Lazarus. This sign was first noted by Adam, and is deserving of the eponym “Adam's sign.”
I could testify to Adam's sign—Saleem yelled and leaped to his feet when Adam mashed. The editor wrote back. He was pleased with all the other revisions but Adam's sign remained a sticking point. Ghosh held his ground.
Dear Dr. Giles,
… there is a Chvostek's sign, a Boas's sign, a Courvoisier's sign, a Quincke's sign—no limit it seems to white men naming things after themselves. Surely, the world is ready for an eponym honoring a humble compounder who has seen more relapsing fever with one eye than you or I will ever see with two.
Ghosh, working in an obscure African hospital, far from the academic mainstream, had his way. The paper was published in the prestigious journal, and no doubt led to his being invited to write a chapter in Harrison's Principles of Internal Medicine, the bible of senior medical students. Now, here he was, a professor. Hema bought our new professor two beautiful pin-striped suits, one black and the other blue. Also a tweed coat with leather elbow patches, as if to put “Professor” in quotes. The bow tie was his idea. In all things, especially when it cost little and did no harm to others, Ghosh was his own man. The bow tie told the world how pleased he was to be alive and how much he celebrated his profession, which he called “my romantic and passionate pursuit.” The way Ghosh practiced his profession, the way he lived his life, it was all that.
36. Prognostic Signs
LIFE IS FULL OF SIGNS. The trick is to know how to read them. Ghosh called this heuristics, a method for solving a problem for which no formula exists.
Red sky in the morning, sailors take warning.
Pus somewhere and Pus nowhere means Pus in the belly.
Low platelets in a woman is lupus until proven otherwise.
Beware of a man with a glass eye and a big liver …
Across the outpatient department, Ghosh would spot a breathless young woman, her cheeks flushed, contradicting her general pallor. Hed suspect narrowing of the mitral valve of the heart, though he'd be hard-pressed to explain exactly why. It would make him listen carefully for the soft, rumbling murmur of mitral stenosis, a devilish murmur which, as he said, “you'll only hear if you know it's there,” and then it was only audible with the bell of the stethoscope lightly applied over the apex of the heart after exercise.
I'd developed my own heuristics, my mix of reason, intuition, facial appearance, and scent. These were things not in any book. The army soldier who'd tried to steal the motorcycle had an odor at the moment of his demise, and so, too, had Rosina, and the two odors were identical—they spoke of sudden death.