This was published in 2009, and it's Abraham Verghese's first novel (his two earlier works were memoirs). It weighed in last year at No. 28 on the New York Times' readers' list of best books of the first quarter-century, and at No. 77 on Becca Freeman's privately sourced equivalent.

Verghese later went on to write The Covenant of Water, which I read last year. He's a doctor as well as an author, and my experience with that book was repeated here: You need a strong stomach for all the medical detail...



Its geographic scope is broad. The bulk of the action is set in Addis Ababa, at a Catholic hospital called Missing (a corruption of the word Mission). But we go back to India for the origins of two key characters: Sister Mary Joseph Praise (who was born in what was then known as Cochin, Kerala, and followed her vocation to the city then known as Madras); and Thomas Stone (born in Madras, the son of a syphilitic British official and a mother who died when the boy was young). Praise and Stone first meet in 1947, on a ship bound for Aden. There's a terrible outbreak of typhoid aboard, and Sister Mary saves Stone's life. Then, as doctor and nurse, they're required to work together to treat other sufferers. But once the ship is out of quarantine, they go their separate ways. Stone goes to Missing, where he suggests she too might have a future, but her brief is to stay in Aden.

At this point, we're already heading into spoiler territory, so proceed with caution if you don't want to be deprived of the considerable element of tension and mystery that Verghese builds into his plot. One undeniable plus about this novel is its capacity to keep you turning the pages (even if you have more than a few questions by the end).

Anyway, Sister Mary and Stone are reunited when she turns up at Missing. Something bad has obviously happened to her in Aden. But she's a good nurse, and has much to contribute. A strong professional bond develops between her and the emotionally repressed Stone, who's a brilliant surgeon but very occasionally goes off on terrible alcohol-fuelled benders.

The massive drama of the novel's first section is Sister Mary's death in childbirth... The babies, twin boys who will be named Marion and Shiva, were apparently fathered by Stone, who -- completely unable to come to terms with this terrible event he does not seem to really understand, and the resultant death of a woman he now realizes he deeply loved -- bolts. The boys are brought up by Hema and Ghosh, who both work as doctors at Missing. They prove to be excellent substitute parents, and are two of the most admirable characters in the book.

There's a lot about this birth that remains mysterious until almost the end. You keep wondering whether the father could have been someone else... But no, everyone's clear that Stone is the only candidate. Eventually, we learn that the fateful act took place during one of those alcoholic stupors, which were apparently driven by attacks of acute depression. Sister Mary takes care of him, and well... There's no suggestion that he forced himself on her, but by the time he emerges from this period of craziness, he seems to have little recollection of what happened. She tries to tell him, but leaves it too late, and there's a muddle with letters, and -- well, the upshot is that he walks into the operating theatre to find her dying.


Kochi, Sister Mary's birthplace. The famous fishing nets get a mention

The rest of the narrative follows the careers of the two boys. Both become doctors. Neuro-divergent Shiva learns easily, but cannot adapt to formal instruction. Guided by Hema, he becomes an expert in fistula surgery. (And this is the first of my queries. As Aida Edemariam points out, there were actual people, Catherine and Reginald Hamlin, who did pioneering work in Ethiopia in this field, so it seems a little odd to co-opt their achievements, and attribute them to a fictional character...)

Marion, meanwhile, whose point of view dominates the book, takes the conventional path through medical school, and eventually ends up (not entirely by choice, but we'll come back to that) in the US. He does a surgical residency at a hospital in the Bronx called Our Lady of Perpetual Succour.

It's in this context that Marion encounters his father, now a renowned surgeon. Initially, the son is angry. You would be. But when he learns a little about his father's terrible upbringing, which at least partly explains his utter inability to really relate to other people, let alone give and receive love, he at least starts to understand the bigger picture.

Now, I need to tell you about Genet, because she's at the vortex of what I really DIDN'T like about this novel. About the same age as the twins, Genet is the illegimate daughter of one of the hospital servants, and she has been brought up alongside Marion and Shiva. There comes a point when Marion realizes he sees her as much more than a sister, and starts to dream, very idealistically, of their future life together. Genet is portrayed as sexually very upfront, and while Marion wants to save a sexual relationship for the context of marriage, Genet is curious, and finds the sexually experienced Shiva all too ready to satisfy her curiosity. Marion is now mortally offended with both of them, especially as Shiva keeps quiet, and allows his brother to take the blame once the action is discovered. But actually both boys get off pretty much scot-free. Shiva walks away unaffected; Marion has his pride hurt, and has to deal with being misunderstood. Genet, on the other hand, is now destined for genital cutting...

Eventually, she becomes involved with the Eritrean People's Liberation Front, and by force of association, Marion also ends up on the government's wanted list. Which is why he flees to the US.

That's where he comes across Genet again (and yes, there is a little too much coincidence at work in Cutting for Stone...) This is the bit that really makes you feel differently towards Marion. Up to now, he has seemed a little priggish, and whiny at times perhaps, but basically an OK guy. But Genet is ill, and has been traumatized by a number of bad experiences -- and it's hard to construe what Marion does to her as anything other than rape...


Chennai, birthplace not only of Stone but of Hema and Ghosh. This is the Cathedral of St George

Quick side note, because I want to come back to this women thing: Marion contracts Genet's hepatitis. Big time. It looks as though he will die. To the rescue, however, rides Shiva, who urges Thomas Stone to use part of his healthy liver to save the life of his sick brother. It's path-breaking surgery. And it saves Marion. Shiva, however, dies of post-operative complications.

Back to the book's women. The context is a traditional society in the 1950s and onwards, and the primary narrator is a child of that time. So it's unreasonable to expect impeccably modern and liberal views. On the other hand... As Edemariam comments: "Of course the narrator arises from a patriarchal society, but it is difficult not to feel discomfited by the fact that the virgin/whore/mother/passive sufferer roles of the women (particularly the Ethiopian women, who are prostitutes, or servants, or simply available and, if not, righteously punished for their wilfulness) are so unquestioned... There is surprisingly little imaginative projection of what Genet might feel." It's true: She never gets a chance to speak for herself in any meaningful way. And Verghese definitely assigns hard fates to unconventional women. Sister Mary dies in bloody chaos, and Genet gets into all kinds of trouble (ultimately also dying). I also found it slightly creepy that not one but two of the older women who knew Marion as a child now want him as a sexual partner. Seriously??

***

Other points of note:

1.

We learn quite a lot about Ethiopia. And this is first-hand stuff: "Abraham Verghese was born in Ethiopia in 1955. His Indian parents were working as teachers in Ethiopia then. Verghese began his medical training near Addis Ababa. He later joined his parents in the United States to continue his studies after Emperor Haile Selassie was ousted from power in Ethiopia. Being a foreign medical graduate at the end of his studies, he only found internships in less popular hospitals and communities." All this experience finds its way into Cutting for Stone.

Edemariam confirms: "I know the streets and shops he evokes, the hospitals; I know that his setting, seemingly so rich and strange, is real."

Over the course of the narratively, we glimpse the problems of Haile Selassie's government; the attempted coup (bizarrely delayed by five years in the book); the arrival of Mengistu and "an Albanian style of Marxism"; and Ethiopia's complex ethnic history (still making waves today).

We're also reminded of the Italians' misdemeanours in Ethiopia (also portrayed in The Shadow King, by Maaza Mengiste). The rout of the Italians in the battle of Adowa in 1896, Verghese tells us, saw 10,000 colonial soldiers "defeated by Emperor Menelik's barefoot Ethiopian fighters... No European army had ever been so thoroughly thrashed in Africa." So, the Italians wanted revenge. Hence Mussolini's instruction: "Qualsiasi mezzo!" Fight using any means, however dirty (and they really were)...


Milano Centrale: "Delayed by World War I, the plans were revised under Mussolini. The result was a mixture of Art Nouveau, Art Deco and fascism"

2.

Both in Ethiopia and in the US, we learn a lot about the "haves" and "have nots" of medicine. Quite early in the narrative, we see Matron telling a donor: "We need medicine and food. But we get Bibles... Our patients are illiterate... What we're fighting isn't godlessness -- this is the most godly country on earth. We aren't even fighting disease. It's poverty."

But the US is also not exempt from the hierarchies decreed by divergent wealth. In the eyes of the establishment where Marion works, the great teaching hospitals are the equivalent of Mecca... Our Lady does crucial work in a deprived and violent area, but it's constantly underfunded, and can exist only because it's staffed by international medical graduates who can't afford to go elsewhere.

There's also a cultural divergence that doctors from outside Ethiopia need to get used to (and much of the novel, after all, brings us the perspective of the outsider): "My head... my heart... and my stomach... This was how stress, anxiety, marital strife, and depression were expressed in Ethiopia... Psychic distress was projected onto a body part, because culturally it was the way to express that kind of suffering."

3.

St Teresa of Avila -- and particularly Gian Lorenzo Bernini's representation of her (to be found in the Church of Santa Maria della Vittoria, Rome) -- runs like a leitmotif throughout the novel.



Marion tells us: "Years later, I learned that St. Teresa's recurrent vision of the angel was called the transverberation, which the dictionary said was the soul 'inflamed' by the love of God, and the heart 'pierced' by divine love; the metaphors of her faith were also the metaphors of medicine. At four years of age, I didn't need words like 'transverberation' to feel reverence for that image. Without photographs of her to go by, I couldn't help but imagine that the woman in the picture was my mother, threatened and about to be ravished by the spear-wielding boy-angel." There's lots more about Teresa -- a fascinating figure -- here, and in the entries that follow.

4.

The book's title deserves a comment. Father and sons are surnamed Stone. And they're surgeons. Cutters. So that's one aspect of the title's meaning.

But the idea also comes from a line in the Hippocratic Oath: "I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art." What does this mean? "Verghese has said that this line comes from ancient times, when bladder stones were epidemic and painful: 'There were itinerant stone cutters -- lithologists -- who could cut into either the bladder or the perineum and get the stone out, but because they cleaned the knife by wiping it on their blood-stiffened surgical aprons, patients usually died of infection the next day.'" In this sense, cutting for stone denotes a kind of arrogance, an unholy egotism that's the opposite of humility.

At some point, we're told, Stone performed an operation on himself, to remove a finger. Reading about this, says Marion, someone might imagine that he "excised a part of himself as blithely as if he were cutting for stone on the body of another. What neither the reader nor Stone would accept was that his self-amputation was as much an act of conceit as it was an act of heroism."

And there are many warnings, including from Stone himself, that the surgeon needs to be modest. Examples: "The operation with the best outcome is the one you decide not to do"; and the 11th Commandment: "Thou shalt not operate on the day of a patient's death." The message seems to be that if you CAN cut, often you do cut. But maybe you shouldn't...

***

In sum, I read this with interest and enjoyment, but ultimately, I'd agree with Kirkus: "A bold but flawed debut novel."