Abraham Verghese - Cutting for Stone

Gray and shrunk to her bones, she was a shadow of the mother he once knew. Her playfulness was gone, but then so was the reciprocity it might have found in this gangly son of hers whose eyes were haunted and ringed by worry lines. They sat side by side on the porch of their cottage, their fingers intertwined like dried roots. In the early morning they watched the tea pickers float by on the footpath, their feet hidden in the mist, their lunch pails creaking with every step. During the day only the nurses interrupted their solitude to take their temperatures and to bring tiffin and medications. By dusk, when they saw the tea pickers head home, it was time for sleep.

Since Hilda had no wind, he read to her. She wept with pride at his precocious fluency. The cane-bottomed lounge chairs had large armrests and a writing palette made of the same teak. Here they penned letters to each other, put them into envelopes, and sealed them; after lunch they exchanged envelopes, tore them open, and read their letters. They prayed at least three times a day. In the most bitter cold they remained outside, bundled up.

At first Thomas was light-headed from the altitude. He grew stronger. His cough lessened. But nothing—not fresh air, or milk, meat, or eggs or the tonics that were forced on her—helped Hilda. Her cough was different. It was a honking, bleating sound. He noticed that she had an exquisitely painful swelling at her breastbone, pushing up under her blouse. He was embarrassed to ask about it, and careful not to let his head rest there. Once, when she was undressing, he caught a glimpse. It was as big as a robin's egg but of a darker color. He assumed it was the consumption, the phthisis, the tubercle bacillus, the Koch's agent, TB, the mycobacterium—whatever name it had, it was a treacherous enemy ripening within her.

ONE EVENING as they lay next to each other, their beds pulled together, and as he read to her from the daily worship book, she exclaimed in surprise. He looked back at the sentence to see if he had missed a word. He looked up to see blood staining her white nightgown and spreading out as if she had been shot.

As long as he lived he would remember that in the awful moment when she realized she was dying, and when her eyes sought his, her first thought, her only thought, was about abandoning her son.

For a second Thomas was paralyzed. Then he jumped up and pulled aside the soggy blouse. A red geyser shot up from her chest and arced to the ceiling, then fell to earth. In the next instant it did it again. And again. A pulsing obscene blood fountain, timed to every beat of her heart, kept striking the ceiling, showering him, the bed, and her face with blood, soaking the pages of the open book.

He recoiled from the monstrous sight, this eruption from his mother's chest which painted everything around it red. When it occurred to him to try to staunch it with the bedsheet, the jet was already dropping in height, as if the tank were empty. Hilda lay soaked in her blood, her face white as porcelain and flecked with scarlet. She was gone.

Thomas cradled her soggy head, his tears falling on her face. When Dr. Ross arrived, a white coat thrown over his pajamas, he said to Thomas, “It was inevitable. That aneurysm has been ticking in her chest for over a year. It was just a matter of time.” He reassured Thomas that the blood was not infective—the thought had not crossed the boy's mind.

ALONE, TRULY ALONE, Thomas developed fever, and a cough. He refused to be moved from the cottage to the infirmary; the cottage was the last thing on earth to connect him to his mother. He let them take him for an X-ray. Later he watched Muthukrishnan, the compounder, arrive with a pushcart carrying the bulky pneumothorax apparatus in its polished wooden case. Muthu squatted on the balcony and, after wiping his face with a towel, he opened the wings of the fancy box and began unpacking the large bottles, manometers, and tubing. Dr. Ross, himself once a consumptive, soon cycled up. “The X-ray was no good, lad. No good at all,” Ross said.

It is just a matter of time, Thomas thought. He looked forward to joining his mother.

He didn't flinch as the needle went between his ribs posteriorly and into the pleural space that lined the lung, a space that was normally a vacuum, Ross explained. “Now we measure pressures.” He maneuvered the needle while Muthu fiddled with the two bottles, raising and lowering them on Ross's command. “This is ‘artificial pneumothorax.’ Fancy way of saying we put air in that vacuum that lines your chest to collapse the infected part of the lung, lad. Those Koch bacteria need their oxygen to thrive, and we won't give it to them, will we?”

Facedown, from the depths of his illness, Thomas thought this reasoning was illogical: What about my oxygen, Dr. Ross? But he said nothing.

For twenty-four hours Thomas had to lie prone, propped in position by sandbags. Muthu came by many times a day to check on him. Muthu noted the sudden fever and the chills. The artificial pneumothorax had introduced other bacteria into the pleural space around the lung. He heard Ross's voice from afar. “Empyema, my boy. That's what we call pus collecting around the lung. Doesn't happen that often in my hands, but it does happen. I am so sorry. Alas, the pus is too thick to come out with a needle,” Ross said.

For the operation they took him to a tiled room with high windows. It seemed bare but for a narrow raised table in the middle, over which was suspended a giant dish light resembling the compound eye of an insect. The place left a strong impression on the boy. It was otherworldly, hallowed ground, but still secular. The name “theater” was fitting.

Ross cut into the skin, under local anesthesia, just to the outside of the left nipple, then exposed three adjacent ribs and cut out short segments from them, thereby unroofing, or “saucerizing,” the empyema cavity. The pus had no place to collect. Despite the anesthesia, Thomas had moments of excruciating pain.

When he could speak, Thomas asked, “Won't an opening like that destroy the vacuum in the pleural space? Won't it cause air to rush in and the whole lung to collapse?”

“Brilliant question, lad,” Ross said, delighted. “It would collapse in anybody else. But the infection, the empyema, has stiffened the lining of your lung, made it thick and inflexible, like a scab. So in your case, the lung won't collapse back.”

For a week, pus oozed out onto gauze padding strapped over the hole. When it slowed to a trickle, Ross stuffed the wound with gauze tape, to cause it to “heal by secondary intention.” During dressing changes, Thomas studied his crater with a mirror, taking perverse pride in what it produced and the day-to-day changes as his body made repairs.

Ross was a short, cheerful man with the roundest and most forgettable of faces and the bow legs of a jockey. He always warmed the chest piece of his stethoscope in his chubby hands before letting the metal touch Thomas's skin. He percussed Thomas's chest, sounding it out skillfully. Ross pulled out the gauze and they peered into the crater. “You see the red, pebbly-looking base, Thomas? We call that granulation tissue. It will slowly fill up the wound and allow skin to form over it.” And that was exactly what happened. At one point the granulation tissue grew excessively, pouching out like a strawberry. “Proud flesh,” Ross called it. Holding a crystal of copper sulfate in his forceps, he rubbed it over the proud flesh, burning it back.

One day Ross brought him Metchnikoff s Immunity in Infectious Diseases along with Osler's Principles and Practice of Medicine. Metchnikoff was hard going, but Thomas liked the drawings of white cells eating bacteria. Osler was surprisingly readable.