Pus in Boots
Going under one's own knife in the Indian countryside.
I grew up in a two-doctor home strewn with medical curiosities. Among my childhood toys were plastic models of inner ears, femurs, and gastrointestinal tracts. Every day, our postman delivered a stack of medical journals dense with text broken up by gruesome clinical photographs. Every morning while eating my Cheerios, I used the magazines as placemats, read the articles absentmindedly, and stole glances at repulsive skin conditions.
When I left home to travel, the memory of those photographs kept me feeling healthy. When I got sick, I knew that no matter how persistent my wet cough, or how vertiginous the spinning of my fever-stricken head, things could always be much worse. Part of me even wished they would get a little worse, so that I could practice my secondhand medical knowledge. Career soldiers, I thought, must feel this way if they spend their entire professional lives in peacetime, preparing for a war that never comes. Whenever I traveled to lands untouched by modern medicine, I longed for a mild skirmish with disease. I figured that only in a doctorless place would I have license to do my own fighting, and my own healing.
On a sunny afternoon, snorkeling alone off an uninhabited Indian island in the Andaman Sea, the enemy came to me. I kicked a spike of coral with my bare right foot, puncturing my instep and sending what looked (underwater) like a little puff of brown smoke streaming out of the wound. I swore, swam back to shore, and hopped around while searching for toilet paper to staunch the bleeding. No boat would pick me up till the next day, so by the light of a campfire, I swatted flies away from the wound, then was kept awake half the night by the loud noise of dozens of tiny hermit crabs skittering across my tarp. The boat picked me up, and a week later I returned to mainland India, barely concerned that the little gash had not yet scabbed over and had already gone through two distinct shades of yellow.
India is not a doctorless land, although in back-country areas you might do better by following WebMD or applying leeches than by calling the local quack. Upon arriving in the modern metropolis of Calcutta, I should have asked my barefoot rickshaw-puller to trot straight to a professional. But I had had little cuts before, and this one didn't look like it would get worse. Instead, I took the first train to the Sunderbans — a delta of mangroves at the mouth of the Ganges, where I hoped to see the native Bengal tigers and investigate rumors that they still sometimes devoured fishermen.
To reach the Sunderbans by the route I had planned, I discovered that I would have to cross the river by foot. A drought had left the waterline too low for the ferry, so Indians walked single-file ahead of me, trudging across a river that upstream had been used for 1,500 miles as a toilet and cremation site by most of the Gangetic basin. Those Indians in the water who wore any footwear at all wore sandals, and most carried on their heads plastic and jute sacks destined for vehicles waiting across the river. As I took my foot out of its hiking boot, it started to throb, and I worried that if it wasn't infected already, it would be soon, after I dunked it in the mud and effectively let millions of Indians poop on it.
At the other shore, a few minutes later, I frantically rinsed the accumulated muck from my wound, emptying two large bottles of mineral water in the process. The next day, in a boat searching for tigers among the mangroves, I began fretting more, and caught myself staring down at my foot and not at the shoreline where I would most likely see the big cats. "That is a tiger," my guide said, motioning sagely at a speck in the distance. "Or a deer." I was too worried to look up and make my own assessment. He said the fishermen tried wearing masks on the backs of their heads to make themselves look more alert and harder to attack, but the tigers figured out the ruse and ate a few guys every year anyway. Fascinating, I thought. But will my foot rot off?
I traveled north for the next week, through West Bengal and Bihar, and I watched the gash carefully. It developed a gooey surface, still yellowish, and in the stuffy, hot weather, it never dried out. The margins of the wound had begun jagged, but the persistent moisture had softened the healthy flesh on the margins, macerating them and letting the frontiers of the infection expand beyond the initial puncture to a broad oval. Each night, usually under the orange glow of a single bare bulb in a hotel room, I watched the stages of infection and imagined my suppurating extremity on the cover of Archives of Dermatology.
I have often wondered why I didn't go back to Calcutta for proper care. A good cleaning and a course of antibiotics might have arrested the infection. But one of the things travelers do, often unconsciously, is to seek the lives they've left behind or traded away, and to check up on where the other fork in the road led. A talented young painter might, once she grows up to work in advertising, tour galleries on her holidays. The yuppified Bohemian who once flirted with a move to Paris might spend a week every few years — perhaps a regretful week — sipping cafes au lait on the Left Bank. I knew I would never be a doctor, but I also knew that my putrid foot was exactly the kind of problem that I, as a lifelong medical hobbyist, might have a shot at solving for myself.
When I finally decided that I needed to perform surgery on my own foot, I was deep in Bihar, an Indian heartland state known for its religious pilgrimage sites, dire poverty, crime, and unrelenting squalor. In many parts of India, men urinate and defecate frankly in the streets. But in the worst parts of Bihar, the sewage system was medieval at best, and young men splattered effluent on the street as if doing so were a sport. Keeping my wound clean proved impossible. In Gaya, a big city, mad traffic flung waste into the air, and I knew by smell alone that every breeze was septic, and that even the hotel room where I changed the wound's dressing was covered with a thin film of filth. The one positive note, I thought, was that if I wanted to use maggots to debride the wound, I probably wouldn't have to look far.
I left Gaya behind for the countryside town of Rajgir to the northeast, and a secluded Burmese monastery. Rajgir's valley, and really all of that part of Bihar, is dotted with religious sites, particularly Buddhist ones, so monks of many nationalities have established outposts. My favorite was a monastery built into a cliff outside Bodh Gaya. When I walked up, a pasty old Englishman in saffron robes intercepted me and said something incomprehensible. I looked at him dumbly. "You do speak Tibetan?" he asked. An odd assumption, I thought, considering that I was wearing Tevas to air out my foot and a T-shirt — a gift from my mother — that advertised the antibiotic Biaxin.
In Rajgir, I told the monks that I would be staying for a few days, doing nothing but reading and tending to my foot by changing the dressing, cutting away dead flesh, and disinfecting. They nodded in instant appreciation, perhaps because their lives were organized around exactly the same kind of vaguely masochistic monotony and studious attention that I had described. One even pointed me to the nearest pharmacy, which sold peroxide, alcohol, forceps, bandages, a scalpel, and fresh gauze.
At dawn, I sat on the monastery's roof and asked the abbot to boil water for tea and to sterilize the equipment. A younger monk came upstairs to watch. From the top of the monastery, we could see a valley that contained many of the sites from the life of the Buddha himself — his first monastery, places where he preached and slept. But the monk was looking not at the Buddha but at me, my ugly oozing foot, and my teapot of stainless steel tools.
I settled in for my debridal party. The gash, initially smaller than a dime, now larger than a quarter, had turned green; its expanding fringes looked gray and brown, headed toward black. I started by irrigating it again with squirts of water, this time while using the forceps to lift the edges of the wound to free up dirt and dead skin that had penetrated surprisingly far into the wound. I drizzled peroxide into it. The monk, silent till now, cooed in delight when it foamed up.
And then, finally, I took the forceps, lifted up the skirt of skin around the wound, and cut it all away with a few short and painful strokes, taking care to slice a millimeter or so into the live, healthily vasculated flesh so that no dead skin would remain to trap filth. Blood flowed — not copiously, but enough to require gauze drizzled with alcohol, which I applied firmly and tied in place with the bandage.
I sat with the monk in silence, enjoying the first breeze I had felt in Bihar that didn't smell as if it had wafted off the dung heap. Over the next few days, I parked myself on top of the monastery and changed the dressing every couple of hours, till a dry scab formed and the skin around the gash began puckering slightly. Over a month, the wound area shrank to almost nothing.
What's now on my foot is a dark scar with uneven borders. It's perhaps a little unsightly, which is fine, because anyone so unlucky as to be able to examine my foot will long since have succumbed to an olfactory assault many times worse than the visual one. For me, the scar is a favorite keepsake from India, a septic souvenir. Like most souvenirs it reminds me of where I've been, but this one also reminds me of where I haven't — of my actual past, but also of a life I never ended up being able to lead, except as surgeon for a day, in the badlands of Bihar. • 8 August 2008
Graeme Wood is a staff editor at The Atlantic.
Photo by nemone via Flickr (Creative Commons).