A Natural History of Love (50 page)

But these twentieth-century Honduran children want only to look
normal
according to our western ideal, set in part by pictures in magazines and on television, and in part by the faces of their families and neighbors. That translates into features with a simple, rounded symmetry.

By 6:00
P.M
. the waiting room holds only a few adults, the clinic rooms have grown dimmer. The fans continue mixing the thick, hot air. Tongue depressors lie on the floor. A long crack in the wall of Room 9 meanders like a healing scar. The single fluorescent light casts a glare over the room, in one corner of which sit two empty Coca-Cola bottles. In this room alone, Ruth and Dean have examined eighty patients. “It’s a bottomless well,” Ruth says, leaning wearily against the wall.

Wrung out and sweaty, we gather up our belongings and head across the courtyard and down an alley to the parking lot, where a mustachioed driver waits to ferry us home. We are all lodging with upper-class San Pedro Sula families, at houses walled in and splendid, patroled by men with rifles, and most nights there will be dinner waiting for us and the oasis of an air-conditioned bedroom in which to sleep.

   Operations begin the next morning, so I head straight for the “break room,” a tiny place dominated by a large red Coca-Cola refrigerator and dozens of boxes of patients’ charts. In a dim narrow corridor, I slip on a lavender scrub dress, blue-and-white shoe covers, shower cap, and mask. I walk down a long hallway. Swinging doors open onto a small room, glared over by exposed fluorescent lights, where two operating tables stand parallel, about ten feet apart. The blue tile walls give way to green paint at shoulder level, and the olive-green tiled floors look ready for a track meet. Waves of people wearing identical masks and scrubs bustle through the room.

Then the surgeons go into the hallway to wash at two white porcelain sinks, which stand beneath two large barrels of water, methodically soaping and scrubbing their hands, fingernails, and arms up to the elbows. Ten minutes later they return and enter the operating room with their hands held high, as if ready to cast a spell in unison. A nurse holds a glove open. Dave Thomas, a tall, stately surgeon in his late thirties from Salt Lake City, makes a purse of his fingers and slides the hand into the glove. Pursing the other hand, he slides it into the second glove. Then he works the latex down snug around the fingers with small tugging snaps. The three operating rooms are over eighty years old, and one of them has an opaque wall of glass bricks. A few years ago, when the electricity failed during an evening operation, Luis Bueso ran outside and pointed his car’s headlights at the glass wall, and nurses held flashlights above the operating tables. Two tables will be in use simultaneously, something that is strictly forbidden in the United States because of the possibility of cross-contamination. But in Honduras, operating rooms are scarce, and there are no malpractice suits to worry about. The absence of malpractice laws also means that I can serve as a circulating nurse, bridging the sterile and nonsterile worlds of the operating room, a privilege impossible for a nonmedical person in the States. In any case, most of today’s operations will be on mouths, and the mouth is full of germs to begin with. In this twin-tabled room, doctors float from one operation to the other, advising and observing, and the experience is doubled, condensed.

A small, part-Indian boy is carried in and laid on the near table. His skin looks waxy in the lamplight, and he sleeps in a blue turban like a miniature prince. A shiny aluminum clamp, holding the wrap closed, dangles over the top of his head like a jewel. An anesthesiologist tapes his eyes closed and an air tube into his mouth. Then she clamps a plastic clothespinlike device onto one of his toes, to measure pulse, blood pressure, and the amount of oxygen in the blood. Nurses arrange shiny, color-coded instruments in the correct order on a “back table,” grouping them according to size and species. Dave Thomas bends his gloved fingers and holds them up as if praying. It is an old habit, not letting his hands drop lest they become contaminated. At last he settles himself on a stool at the head of the operating table, and Dean, sitting down on a stool at one side, gets ready to assist, and I join them.

“Teinte”
Dave Thomas says to a nurse, and she hands him a small gleaming inkwell. Drawing the blue-tipped stick from it, he dots blue along the nose and mouth, diagramming the future “Cupid’s bow.” With small calipers, he measures the philtrum on the right, then computes where the left side of the nose and mouth should be, and discusses with Dean how best to assemble it. Taking a needle, he burrows under the skin, injecting norepinephrine-laced lidocaine all around the areas where he’ll be working. Then he puts on a headlamp attached to a wide black band around his forehead, at the front of which a small halogen lightbulb sits above his line of sight. An electrical cord running down his back connects the lamp to a battery pack worn on a white belt at his waist. He tilts the lamp’s mirrorlike dish to the correct angle. Then he calls for a scalpel.

Holding the blade steady, as if it were a single-haired paintbrush, he traces his blue diagram with movements fine, light, and feathery. In fact, he doesn’t seem to be making contact with the skin at all, and for a moment I wonder if perhaps he is just rehearsing his first incision. A thin line of blood wells behind his strokes, the blue ink turns to red as if by magic. With a tweezers, he lifts a flap of skin and cuts its edges loose with small gnawings of the scalpel. My eyes zoom in on the open flesh shining in the light, as I watch Dave begin to cut free one side of the nose, which is fused to the cheek. His wrists arch and pivot. His long fingers pick up an instrument, bend at several joints, assume acute angles as they work inside the mouth. At times they flex and pose like a praying mantis. He removes a large bolus of extra flesh from under the nose. Peering into the mouth, I can see where the pink, soft, emery-boardlike skin stops and the white, glossy lining of the nose begins. As he cuts, blood wells and he pinches the spot with tweezers, and Dean zaps the tweezers with a cautery gun which carries the current down to the flesh. A spark sizzles at the spot, then turns it black. Dave carves free the fused part of the nose so that he can pull it back where it belongs, more than an inch away. A red crescent appears, then a deeper red canyon. With a tweezer, he stretches the nose, now freed from the bone, to where it should be. “Going to be tight,” he says, more as a sigh than a statement. The chart says this is Rigoberto, a four-month-old boy from Santa Barbara. I remember seeing him with his father in the clinic. A Peace Corps worker, a twenty-seven-year-old woman from Michigan who found them in the mountains, told them of Luis Bueso’s program, and accompanied them on their bus journey. The trip had cost his father six lempiras, a full day’s wages.

Seeing blood and gore, in the absence of brutality, is not upsetting, but beautiful, fascinating, inspiring. It is when malice accompanies it that blood quickly becomes unbearable. I cannot glimpse a slasher movie without turning my head away in horror and disgust; but to watch an operation is to be enthralled by the red-and-white estuaries of the human body, and the finesse of surgeons who sail into them. There is no vicarious bridge, no sense that this could be me on the table as, hypnotic and beautiful, the body reveals its colors and textures. True, at first, there is a mild shock at seeing someone’s insides exposed to the light. But that is swiftly followed by a jolt of privilege, as you peer into the many levels of what is usually a closed crypt. The body is just a collection of hide, flesh, and fluid. But when you consider that from it come all-weather thinkers like Montaigne or artists like La Tour, that on a pedestal of flesh sits a mind, discomfort evaporates. Instead, you find yourself thinking: how amazing that mere matter should lead to this. How amazing that a dialect of fluid and bone can produce acts of mercy, heroism, and love.

At last, nearly two hours later, Dave begins stitching, piercing the skin with a curved needle and pulling the catgut slowly through. Then he loops the suture around a clamp, grabs the other end of the suture, and slides the loop down the clamp, making quick, intricate knots between the instruments and his fingers. The motion is like a spider arranging its web. He draws the threads taut, and a nurse snips them. Then he pushes the needle through for another stitch. In the background, Linda Ronstadt croons a bluesy “What’ll I do, when you are far away, and I’m so blue … what’ll I do?” When she finishes, silence falls like a cleaver. Then, a few moments later, Patsy Cline begins swoonfully singing “I’m crazy …”

Meanwhile, on another table across the room, Isabel lies showered in light. Luis Bueso and Dave Fogarty face each other across her mouth, which they have opened up like an unfolded origami crane. Their glances meet at the crossroads of her skewed lips. A nurse seated low at the head of the table waits for their requests, her gloved hands folded. There is a certain kitchen intimacy to the group—two people sitting on worn stools at a table under a central light, with others standing close by and leaning forward; everyone’s attention is focused on the same spot. A painter, a Dutch master, would make much of this scene—the luster of concentration in the eyes of the surgeons, the overhead lamp rinsing the child’s face with white and casting the doctors in stark shadows. Light cascades over the hills, planes, and valleys of their faces, over Dave Fogarty’s prominent brows and Luis’s large glasses. Together they break open the mansion of her flesh, and roam through it with their hands. All their knowledge, training, and history run like voltage down their arms. To have hands as steady and probing as theirs is to touch life where it lives, in the cell, blood, and bone, in the pastures of yellow fat that bloom like wildflowers above the soft tissues. Their mouths are masked, and what they say is of no consequence, but their hands speak a silent, fluent Esperanto. Exchanging instruments, touching one another and the child, their hands are relentlessly eloquent, lyrical, and profound as they converse in an argot of tendon and nerve. Hours later, after orating inside the girl’s body, their hands will at last have argued persuasively with her flesh; and when they leave they will stitch up the entrance with a small trail of stars.

Back at table one, a little girl lies swaddled in sheets. The child looks so peaceful, she might be sleeping normally and dreaming. But I know that isn’t possible. Anesthesiologists prefer to give children drugs that will render their brains electrically silent. The brain’s metabolism, its requirement for oxygen for nutrition, then drops to a very low level. This is protective in various situations, but especially when a doctor is operating in a way that could interrupt the brain’s blood supply—on a blood vessel that supplies part of the brain, for example, or during a face or heart operation. Indeed, any time there’s a risk to the brain, it’s often desirable to have an anesthetic that will silence the brain. As a result, the children don’t dream during the operations, and they remember nothing afterward; their brains are idling. But the children don’t look dead. Their skin glows with a soft candle-wax sheen, and they seem suspended in time and space, like small hibernating astronauts.

Ruth pauses a moment, lifts a triangle of skin with a pair of tweezers, arranges and rearranges it, trying out various syllogisms. Her face seems to be saying:
If I move this around, and that above, and this under, and that through, then those pieces of skin will fall there
. Hours pass, but eventually the small face follows her logic into a more orderly mouth and nose. She pushes the cleft together to make a whole. All the pieces now fit like a machine-tooled jigsaw puzzle. Ruth rolls her cramped shoulders and straightens her back a moment, then leans forward again and continues stitching.

All the surgeons are raunchy and funny in the operating room, which sometimes sounds like an episode of
M*A*S*H
. Although some American surgeons prefer a quiet operating room, most don’t. Flirtatious, joking, and crude banter happen there so often that it makes one wonder if there isn’t a deep psychological need at work. Surgeons perform an act of controlled violence—unmalicious violence, therapeutic violence, ritualized violence—but violence just the same. We have evolved with certain instinctive responses to horror. And it
is
horror to cut open the protective armor of someone’s body, and expose the thick porridges inside. Although we don’t like to think of ourselves in that way, we are a heap of bright fluids in a sac; and we’re taught never to break the sac open, because life can pour away so easily. Surgeons seem to defuse the horror in various ways—by blanking out any personal details about the patient, by draping the patient’s body so that it’s unrecognizably human, by allowing their hands to perform acts profound, solemn, and holy while their minds retreat into the opposite realm of the coarse, the casual, and the profane. “Is this a little girl or a little boy?” I sometimes ask Dave Thomas, and he always says, “I don’t know.” Only minutes before, he was looking at the patient’s chart, which includes personal details and a photograph, as well as evaluations made during clinic. How could he “forget” only minutes later if it’s a girl or a boy?

“When you’re operating, are you aware of the patient as a person?” I ask Dean Sorensen, while he’s stitching a cleft palate back together. He looks up at me, above the magnifying part of the loops. For a moment, his blue eyes fix me solidly. “If I did that I’d be petrified.”

It is what makes it possible for Ruth Carr, before an operation on a man who has been burned on almost every part of the front of his body except the penis, to say: “He must have been wearing his flameproof jockstrap that day.” It’s what prompts Luis Bueso, during an operation on a well-built teenage girl, to say: “A good pair of tits have more pulling power than an oxcart.” It is what allows David Fogarty, while he tries to thread a suture needle, whose eye he misses, to say with a smirk to a male Honduran doctor: “If that hole were surrounded by hair, I wouldn’t have missed.” The banter is the anesthetic for the surgeon.