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Into India

It was as Manohar had said. The father had tried to nip his son's romance in the bud, and so Shivaji had tried to commit suicide by swallowing a railroad spike. It was about six inches long, more flat than square, and loomed enormously large and white on the x-ray film. It had lodged just above the boy's diaphragm and behind his heart. He was drooling excessively, since he was unable to get even his own saliva past the obstruction, and he looked miserable. I tried to cheer him up, but it was cumbersome through an interpreter, so I soon gave up. Instead, I set about getting a look at the object from within as quickly as possible.

When at last I saw the spike through the esophagoscope—a long tube with a tiny light at its end, which I'd passed down the boy's throat—the object filled the entire visual field. Miraculously, his esophagus appeared to be uninjured. However, I couldn't budge the mass from where it had lodged. Clearly, a thoracotomy—surgery through the chest wall—would be necessary to remove it.

I summoned Drs. Archie Fletcher and Jim Donaldson, colleagues at the hospital in Miraj, by sending a chit—a note by bicycle-messenger, there being no phones. Together, we opened the boy's chest, made an incision in his esophagus, lifted out the spike, and, after irrigating the area thoroughly, sewed up the soft, muscular tube. Mercifully, there were no complications. Shivaji recovered and the spike became a paperweight on my desk. I soon forgot about him, for other crises were brewing.

Marilyn, who is a nurse; our two small children; and I had arrived in India two years earlier, in 1954. We were motivated not so much by the conventional missionary zeal to proselytize, but by a sense of adventure and by humanitarian impulses more characteristic of the Peace Corps, though that organization had not yet come into existence. The Presbyterian Board of Foreign Missions, needing a thoracic surgeon in India, had agreed to overlook Marilyn's and my "Unitarian leanings," as they put it, and had appointed me to the post of director of surgery at the Wanless San. My primary charge was to establish a thoracic surgery training program.

I soon realized achieving that goal would be complicated by the fact that Dr. M. Paul, the medical superintendent of the

Author Tim Takaro, second from the left, and several of his colleagues—including Manohar Mane, center—at the beach.

By the mid-1950s, pulmonary resection—the excision of a portion of the lung—had begun to displace thoracoplasty. My charge was to teach Indian surgeons the newer procedure, which was much more complicated for the surgeon and much riskier for the patient, but also more definitively curative.

India's vice president during his 1957 visit to the Wanless TB Sanatorium.

sanatorium, was not a happy man. (Although I worked with Dr. Paul for several years, I never knew his first name. As did most Indians then, he used just an initial rather than his full first

name.) A beefy, dour, dark Dravidian in his mid-fifties, Dr. Paul was from the Tamil region in the south of India, where English instead of the national language, Hindi, predominated. He and his wife lived on the other side of the grounds and, in part because of their linguistic isolation from the rest of the Indian staff, kept to themselves. He had been appointed because of the Mission Board's policy to staff the sanatorium exclusively with Christians; Dr. Paul had been the only such candidate available.

Dr. Wilfred Jones, my predecessor as director of surgery, had taught Dr. Paul how to perform thoracoplasties. In the era before antimicrobial therapy, this operation was the standard surgical treatment for pulmonary tuberculosis. It involved the removal of several ribs from the upper third of the rib cage; this allowed the muscles of the chest wall, once they were no longer supported by the ribs, to collapse the upper part of the lung, where the disease was often more prevalent. The interior of the chest cavity was not entered at all.

It was a relatively bloody and crude procedure, but simple enough that most physicians without surgical training could perform it. And patients usually survived, if painfully, and improved. For those who were fleshy enough, and conscientious about exercising their shoulder muscles, the deformity of the chest wall was often minimal. Not many Indian TB patients could be described as fleshy, however; the asymmetry in the shoulders of most patients who'd undergone a thoracoplasty, even many years earlier, was usually very apparent.

But by the time I arrived in India, in the mid-1950s, pulmonary resection—the excision of a portion of the lung—had begun to displace thoracoplasty as the operation of choice. My charge was to teach Indian surgeons the newer procedure, which entailed entering the chest cavity to remove the diseased portion of the lung (or sometimes an entire lung). This was much more complicated for the surgeon and much riskier for the patient, but also more definitively curative. In the U.S., learning to do lung resections required a grounding in general surgery plus two additional years of training in thoracic surgery.

Herein lay my dilemma—the root of the dispute between Dr. Paul and me. None of the staff physicians at Wanless had

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