Inbal: Ringer of the Bell
Esther Y Lee
May 14, 1990. 1:18 PM.
Labor and Delivery. Room 7.
A 19 y/o primigravida at 39 weeks 5 days estimated gestational age, presents with contractions of 9 hours. Rupture of membranes occurred 1 hour ago. Patient reports good fetal movement, denies vaginal bleeding. Admitted for progression of labor.
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If language was birthed like children I’d be: Multiple Gestation, Preterm Contractions, and Postpartum Hemorrhage. Belly round and bumpy with life wrestling itself. An inverted moon crater. A heel, a piece of buttock. A curled fist. Jacob grabbed his twin brother’s ankle and didn’t let go. I clung to English at school. It was the language of authority, heated debates. It was how I proved myself. I could argue apologetics in English, but couldn’t pray in Hebrew. My mother tongue detached from me prematurely. The language of the Tanakh benched for my childhood season, content to let English take the field. I should be completely bilingual, but early losses stunted growth. Hebrew was reserved for early morning murmurs to my parents, nightmares, and asking why only tears were seen at the Wailing Wall.
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The tongue may be the strongest muscle group of the body. What we see and feel is the mere tip of the Herculean structure. Supported by an army of slender muscles in the neck and pharynx it supports the 10 cm appendage. It can be silenced with the slip of the knife during parathyroidectomies, paralyzing fragile motor fibers of the twelfth cranial nerve. Sensation is determined by an offshoot of the mandibular branch of the trigeminal nerve. Taste, by the slinking chorda tympani branch of the facial nerve. Small buds—the filiform, fungiform, foliate papillae—cover the tongue like a map at the wheel. What does it mean that we must borrow from the natural world around us—filamentous, mushroom-like, leafy, nipple-like—to describe one of the most sensitive methods of discovering the world? We don’t divide the tongue anymore according to the location of its taste sensors. But if this was true—if geography determined identity and purpose—is there something to note that sweetness was detected at the tip of the tongue, the first foray of love? That bitterness begins at the final curtain call, near the uvula, the hanging bell before the throat?
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Blood drips to the floor in languid motion. Their hands are down there, in the deep recess. A gaping wound exists where there was nothing before. Ex nihilo. They are putting in stitches, closing up the black hole, returning it to its former shape and functionality. The mother is done. She’s entered a delirious moment postpartum where nothing matters anymore. Not when she cried out, her mouth accusing: Who did this to me? Not the whimpering babe, not the husband’s shaking lips. Not the midwives’ hands performing spells. She only cares that it’s finished. She can’t see how she must repeat this. She weeps silently, cautious about interrupting the work around her.
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May 15, 1990. 12:40 AM.
Labor and delivery.
Summary: normal spontaneous vaginal of a live female, 2900g, Apgar score 9/10. Delivered LOA1, no nuchal cord, no meconium. Nose and mouth bulb suctioned at perineum; body delivered without difficulty. Cord clamped and cut. Baby handed to nurse. Placenta delivered spontaneously, intact. Fundus firm, minimal bleeding. Placenta appears intact with 3 vessel cord. Perineum and vagina inspected – small 1st degree perineal laceration repaired under local anesthesia. EBL2 350cc. Patient tolerated procedure well, recovering in LDR3. Infant to WBN4.
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People tell me that my English is great. You definitely don’t have an accent! (What they mean is that I sound like they do.) They congratulate me for something I’ve never worked hard for, or felt like I’ve earned. All my education has been in English. It was only natural I learned to fit in. My tongue quickly molded to it with joy. But I never felt good when they—English teachers, lab partners, first-time acquaintances, mentors—told me this. They would say, good job for making us think you were American. You nearly pulled one over me! You’re exotic without flaunting it. How would you feel if someone congratulated you for having grey eyes, the perfect shade of blonde hair? The words escaping my mouth feel the same way. Misplaced.
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May 16, 1990. 8:15 AM.
LDR ward.
Second day post-partum. Patient is planning on breastfeeding. Infant is unable to latch on. Contraceptive plans remain to be decided, but she wants to achieve pregnancy in a year. Lochia presents with 2-3 pads per day. Mild perineal pain persists, treated with PO Ibuprofen. Patient wants to return home.
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In Hebrew, the word for uvula is inbal, which also means clapper, or ringer, of the bell. A sort of gatekeeper for the rest of the intestinal tube. It is also a common name in the country. Inbal, protector of the throat, ringer of the bell. The voice of an angel in the desert.
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I betray myself every time I use the power of the exotic for my own gain. Apart from saying words wrong because I’ve never heard them spoken out loud—only read in books—I still make those mistakes like any other lazy tongue. When my mouth slips up, I catch myself by assuring everyone that “English is my second language.” I still get a pat on the back for trying. I told my boyfriend in grad school this white lie as a joke during our first months of living together. Apparently my face didn’t betray it. He walked around for a month afterwards under the pretense of my language prowess, to study medieval literature in a second language. How much harder must Inbal work for the same gain. Later on in bed when I told him what I actually meant, we laughed about it, about how funny I was. I nonchalantly play the same trick over and over again.
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I’m pregnant. She keeps telling herself this, as if saying it again would take away the edge. She is happy, and strangely tearful. She thought it couldn’t be possible, but here she was. At some point, overdue becomes undeniable. It’s been eleven months since the twins were born and she swore she’s never going to do that again. The doctors told her to wait longer because the last one was very difficult on her body. Severe unanticipated blood loss, they said. The doctors had hovered over her split abdomen for so many strained minutes. The nurses threw green sterile drapes on the floor so that no one would slip on the blood. She couldn’t see past the drapes that separated her and everyone else. Silenced by blindness. Only 22 and already feeling too tired. Everyone says it gets better with age because muscle memory kicks in. The rest of the children would slip right out. But she’s already forgotten how to braid Inbal’s hair. The little one is tying it up by herself, albeit messily, a stubborn child. And she’s only started gan5 just this year. The teacher said she likes to sing to the other children, to make them happy. My Inbal, my daughter. Be tall and happy for me.
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Middle English, late 1300s: Lingual is defined as ‘a tongue-shaped surgical instrument.’ From the word in Medieval Latin, lingualis, meaning of, or related to, the tongue. Now the word lingua or lingual is rarely used in common speech. According to an online dictionary, it sits at the bottom 30% of least used words.
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I’m more than my tongue, my lingual identity. Tongue is the the tip of personhood. What is under this American accent, those drawn out ah’s and fickle rules? What is hiding under these features, the unruly eyebrows, and frantic tongue? My predilection for talking and arguing? Of deeply loving and deeply hating in the same cry? Language shapes our thoughts and dreams, our attitudes towards each other. I know my identity runs deeper than the tongue I speak, but so often I’m caught between two parallel worlds. I lose myself in the chaos. When I was young, I used my words to prove my existence and fight for my place. The right to exist ceased for the silent and unnamed. If I don’t speak, how can I prove I’m real?
The tongue often knows before the heart does. That morning I knew things had changed when I didn’t fight him anymore. The silences began slowly, and then formed one long sigh. It filled up the space between us, creating nothing out of something. Reverse creation. He accused me of never choosing him, and my tongue couldn’t respond. No words. I was gone.
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May 11, 1997. 3:43 AM.
Emergency department.
26 y/o G4P3 at 27 weeks, 3 days presents with painful contractions and vaginal bleeding for 4 hours. Contractions occur every four minutes. Patient reports decreased fetal movement since contraction onset and uterine tenderness. Rupture of membranes occurred 1 hour before arrival. Increased uterine tone and normal ultrasonogram. Patient is anxious and pale. Suspected placental abruption. Admitted for emergent caesarean section.
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Of the forty-three confessions that are recited on Yom Kippur every year, eleven of the sins are committed through speech. This means that a quarter of all annual sins are attributed to the tongue. The tool that hides behind double locked doors—innocent lips, casual teeth—confident of its façade. A Jewish proverb6 notes that the tongue is the pen of a ready writer. Deftly used, easily misused. The power to love, to tear black holes and stitch them up with painstaking care. Christians tell the story of how Jesus healed a deaf man who couldn’t speak, by touching his ears and tongue. The masses begged for healing, for a miracle they could talk about. But Jesus took the poor man aside, away from the crowd. He quietly touched his ears. He spat and touched his tongue. Be opened. Ephaphatha! Immediately the bolts were opened and the string of his tongue was loosened. Praises were lifted. The eleven were added to his lot. The confessional monologue became available to his tongue. Physician, heal thy own limp.
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May 11, 1997. 8 AM.
North operating room.
Preoperative diagnoses:
*****1. Preterm labor
*****2. Intrauterine pregnancy at 27-3/7 weeks gestation
*****3. Placental abruption, sudden onset heavy vaginal bleeding
Postoperative diagnoses:
*****1. Placental abruption
*****2. Postpartum hemorrhage
*****3. Emergent hysterectomy
Title of surgery: Repeat lower-segment transverse uterine incision
Anesthesia: Spinal, GET7
Estimated blood loss: 2500 cc
Findings: Stillborn male infant, vertex, right occipitotransverse position, weight 860g.
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And when they raised their eyes from afar, and did not recognize him, they lifted their voices and wept; and each one tore his robe and sprinkled dust on his head toward heaven. So they sat down with him on the ground seven days and seven nights, and no one spoke a word to him, for they say that his grief was very great.
(Job 12:11-12)
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May 11, 1997. 11:05 AM.
North operating room.
Description of the procedure: The patient was brought into the operating room from the emergency room where she received an epidural for an emergent suspected placental rupture with preterm labor. Foley was also performed. A repeat low-abdominal incision was made and the fascia was separated. Bleeders were clamped and coagulated. Rectus muscles were cut with a scalpel and separated. The peritoneum was entered and the bladder was moved posteriorly.
A living male infant was delivered from the occipitotransverse position. The nose and mouth were suctioned. Breathing did not begin spontaneously with tactile stimulation. The cord was clamped twice and cut with scissors. The infant was transferred to the pediatric team.
The placenta was delivered manually. Maternal side of placenta showed dark clots. The uterine incision was sutured inside the pelvis. There was marked bleeding from the uterus. Suspected postpartum hemorrhage – protocol enacted. Bimanual uterine massage was performed. Second IV placed and fluid resuscitation was continued. The patient was put under general anesthesia with endotracheal intubation. Blood loss could not be controlled with coagulation and hemostats. Blood bank was notified. Oxytocin IM 10 units was given. Vigorous fundal massage continued. Prolonged hypotension, tachycardia, tachypnea occurred. Uterine artery was ligated. 2 units of PRBCs were transfused and Hemabate IM 250 mcg.
Vaginal bleeding continued. The decision for curative hysterectomy was made by Dr –. The uterus was removed per standard of care. The pelvic and abdominal cavity were rinsed with saline solution. The skin was closed with prolene sutures and a dressing placed over the incision.
EBL is 2100cc. Transferred to ICU for stabilization and blood transfusions.
~
After the burial the immediate family sits shiva, a week of mourning. Shiva, from the word sheva8. A designated shiva house keeps the family together and provides a communal place to sit on low stools, cry, and receive comfort from others. Mourners refrain from leaving the shiva house. Errands, civic duties, social responsibilities, and academic work are put on hold. Being seen in public may force the mourners to pretend, to put on social graces, which wouldn’t be appropriate, so mourners remain inside. Better to ache truthfully at home than to pretend in public. The laws of mourning require the family to focus on the soul and refrain from physical attention. For thirty days, including the shiva days, beards are grown, hair is left uncut, and new clothes are scorned. Mirrors are covered. Clothing is torn. This shloshim9 period concludes the designated time for mourning for close relatives, including children. To grieve the most traumatic loss such as a parents’ death, this continues for a year after the burial. Mourners refrain from anything enjoyable, because to mourn is to abstain from what makes the heart soar.
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Because these wings are no longer wings to fly
But merely vans to beat the air
The air which is now thoroughly small and dry
Smaller and dryer than the will
Teach us to care and not to care
Teach us to sit still.
(from ‘Ash Wednesday’, T. S. Eliot)
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I finally answered my mother’s prayers and returned home. I bought my ticket, packed up my books and cacti in Cambridge, and left without telling anyone. Back to the desert and the green falafel stand across my house. The bitter lemon trees still guarded the front door, looking like light bulbs in the bright summer afternoon. Ima welcomed me with warm hands still covered in flour for the evening meal challah. Her eyes asked me why I came so late—did I not care it was almost sundown, almost shabbat? It has been seven years since I left and two years since I graduated. I defended my thesis with honors then started teaching at the University. I stood alone at the ceremony. The rest of my family was just emerging from the one year mourning period after Aba passed away. The first shiva in the family was a mistake that I barely registered at seven. Ima lost her youngest, and her capability for more little ones. I was too young to register what a devastating blow it was to her, our family, the community. Because I had removed myself, the second shiva in the family was unaccessible. I didn’t ask and they didn’t apologize. Moving continents had both added more distance and eased the pain of separation I had with my family.
Did I want to return home? To slip back into the tongue of wailing? The mourner’s Kaddish circled my heart for those thirty days, slow dancing with Maimonide’s obscure text. It curled up beside me in bed when I tried to sleep. I counted the thirty days, marking them in my calendar. The irony was very complete. The lost daughter of a rabbi who ran away, only to end up studying the texts of her roots. A daily reminder of the home she left constant at her fingertips. Wrestling, turning the reasons for this ache over and over again. The point of the leaving. And now, the point of coming home.
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The lonely man’s dry tongue was raised back to life. Was it not enough to just pronounce, to perform an oral deliverance? What authority of the tongue—but what humility of the hand! Reciting seventy times seven confessions for the days of my life couldn’t erase the regret of what I’d done, and not done. To touch, to enter into someone’s pain, and leave unchanged is a miracle taken for granted. Losing parts of yourself—blood, organs, a child—to losing words or languages is circular mourning. To sit low, remember, and enter in again. My tongue, heal yourself.
~
Esther Y Lee was born in South Korea, but spent most of her childhood wandering SE Asia. She’s currently a fourth year medical student and recently moved to the US to finish up her studies. For now you can find her in a hospital somewhere in NYC. She recently published a narrative about an unexpected cross-cultural connection in a hospital (‘Migrations‘, Intima Spring 2016 issue). She is eager to continue combining her passions in narrative medicine and cultural humility as a global physician. She sees herself working somewhere diverse, underserved, and warm. Send her a note at estherylee7@gmail.com.
Andrea Pacheco is Honduran currently living and studying in Costa Rica. She holds a BA in Art/Photography, but is somehow now an M.Sc. candidate in Forest Management and Conservation, working on topics of climate change, governance, and forests in Central America. You can find her behind her computer trying to finish her thesis, or on better days, hiking through the tropical forest with a camera strapped to her back. Reach her at pacheco.gracia@gmail.com to talk either art, her research, or both.
