Cutting for Stone

by Abraham Verghese

  He went through the motions at school. She exhorted him to pray, told him that she prayed every hour and that God listened and prayer never failed. He prayed constantly, convinced that at the very least the prayers kept her alive.

  I know God did not mean to keep us apart, and soon he will bring us back together.

  ONE DAY, Thomas woke to find his pillow moist. When Sebestie lit the lamp, there was the mark of the beast: a fine red spray on his pillow, a strangely beautiful pattern. Sebestie wept, but he was overjoyed. He knew this meant he would see his mother again. Why didn't he think of this sooner?

  Two barefoot stretcher bearers in crisp white drill met his train in Ooty. They took him directly to Hilda's cottage. He climbed into her narrow cot, into her arms. He was eleven years old. “Your coming is the best and worst present I could ever have,” she said.

  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 Disea
ses 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.

  In a life that was merely a prelude to death, Thomas found he looked forward to Ross's visit, to the short man's daily rituals. And yet he held back his affection for the doctor, because that was a recipe for loss. “I'm not going away, lad,” Ross said one day. “And since you are staying, why don't you join us on rounds.” Ross turned and left, not waiting for an answer.

  WHEN ROSS PRONOUNCED him healed, Thomas had been at the sanatorium for a year and a half. During that time he never saw his father. Fothergill came twice, saying Justifus Stone was too ill to travel. Thomas asked Ross about the illness from which his father suffered. Ross said, “It's not tuberculosis, but something else.”

  “To do with his legs?”

  Ross tousled Thomas's hair. “Something punky, lad. Unfortunate, it is. He is bedridden. You'll learn in medical school,” he said.

  It was the first time Ross had ever uttered the words “medical school” to Thomas. Thomas couldn't control the fluttering in his heart, as if a door had cracked open in his coal cellar, bringing in light, promising a future when he had visualized none.

  ROSS, NOW OFFICIALLY THOMAS'S GUARDIAN, decided Thomas should go to boarding school in England. Thomas didn't even consider going to see his father in the infirmary in Madras before he sailed.

  Two terms had gone by when Ross wrote to say that Justifus had died. A modest inheritance under Ross's guardianship would allow him to finish schooling and go to university.

  Ross had led Thomas in the direction of medical school as if it were inevitable. Thomas had no reason to resist. Life thus far had convinced him of his aptitude for two things: sickness and suffering.

  In medical school in Edinburgh, he lost himself in his studies, finding a stability and a sanctity missing before. He had no need to lift his head from his books, no desire to go anywhere but for classes or demonstrations. When his eyes tired, he went diffidently to the infirmary, hoping no one would throw him out. He got to know a house officer here, a senior student there, and before long, and well before his class had reached the clinical years, he was being pointed to interesting patients.

  The hospital porter nicknamed him “the Lurker,” and Thomas didn't mind. In the organized chaos of the hospital, in the labyrinth of corridors, in the stink and confinement of its walls, he found both order and refuge; he found home. Misery and suffering were his closest kin.

  A drunk named Jones looked eerily like his father; Thomas realized it was the waxy complexion, the swollen parotids, the loss of the outer third of the eyebrows, and the puffy eyelids of alcoholism that gave both men a leonine appearance. Now that he was trained to see, he put together the other clues he recalled: red palms, the starburst of capillaries on cheek and neck, the womanly breasts, and the absence of armpit hair. His father had cirrhosis. Perhaps that was the “punky” thing that Ross had been too polite to mention.

  IT WAS SLEETING on a bitter cold evening in the Founders’ Library when the final piece came together, and when it did, Thomas slammed his book shut, alarming Mrs. Pincus, the librarian. The young man, who practically lived in the study carrel farthest from the fireplace, suddenly ran out into the spitting snow, hatless and distraught.

  Thomas negotiated the long corridor leading to his room in the pitch-dark. Walking in the dark was something his father could not have done. The signals coming up from Thomas's toe and ankle and knee told him where he was in space, but in Justifus Stone those messages had been blocked in his spinal cord. His father's stamping, crashing gait, always worse at night when he no longer could see where his feet were planted—that was from syphilis of the spinal cord, or tabes dorsalis. No child should possess such knowledge of a parent.

  The meandering conversation, the boastful tales at the dinner table, the delusions of grandeur—that was syphilis of the brain, not just the spinal cord.

  Once in his room, Thomas stripped before the wardrobe mirror. With a second handheld mirror he examined every inch of his skin. No syphilids. No gumma on his skin. He listened to his heart but heard nothing unusual. He'd been spared congenital syphilis. But then he realized that his fear was absurd because congenital syphilis had to come through the placenta to him, it had to come from his mother. Absurd for him to worry. What his mother had was tuberculosis. Pure as the Virgin, his mother could never have had….

  He cried out suddenly, the anguish of a child whose final illusion is stripped away. He understood at last.

  It had been under his nose all this time. Tuberculosis didn't cause aneurysms like the one that killed her, but syphilis did. “Mother. Poor Mother,” he cried, grieving for her all over again. His father had murdered Hilda with his unbridled lust. She might have recovered from her TB, but she probably never knew she had syphilis until that aneurysm blossomed and began eroding painfully through the breastbone when she was at the sanatorium. Ross would have told her what it was. She knew. By that point neither salvarsan nor even penicillin, had it been available, would have been of any use.

  WHEN THOMAS STONE BOUGHT his own cadaver in his final year of medical school, it was unheard-of, but did not surprise anyone. He was planning a second complete dissection, searching for mastery of the human body.

  “Is Stone around?” was a common question in the casualty room, because he was the medical student who was more constant than Hogan or the other porters, always willing to stitch up a laceration, or pass a stomach tube, or run to the blood bank. He was the happiest of students when asked to scrub in and hold a retractor during emergency surgery.

  One night, Dr. Braithwaite, Senior Consultant Surgeon and Chief Examiner for the Royal College of Surgeons, came in to see a patient with a high stab wound to the abdomen. Braithwaite was a legend for having pioneered a new operation for esophageal cancer, a notoriously difficult condition to cure. The patient, already inebriated, was terrified, abusive, and combative. Braithwaite, a compact man with silver hair, wore a blue three-piece suit that was the same shade as his blue eyes; he dismissed the porters restraining the patient and he put his hand gently on the man's shoulder and said, “Don't worry. It is going to be all right.” He kept his hand there, and the patient, staring at the elegant doctor, quieted down and stayed that way during the brief interview. Then Braithwaite examined him quickly and efficiently. When he was done, Braithwaite addressed his patient as if he were a peer, someone he might see later in the day at his club. “I'm glad to tell you that the knife spared your big blood vessels. I am confident you are going to do very well, so I want you not to worry. I'll operate, to repair whatever is cut or torn. We are going to take you to the operating theater now. Everything is going to be fine.” The docile patient extended a grubby hand of thanks.

  When they were out of earshot of the patient, Braithwaite asked the entourage of registrars and house-officers, “What treatment is offered by ear in an emergency?”

  This was an old saw, particularly in Edinburgh. Still, the old saws were not well known anymore, a matter that distressed Braithwaite greatly. He saw it as emblematic of a slackness in the new generation of trainees, and it was sad that only one person knew the answer. And that too a medical student, of all people.

  “Words of comfort, sir.”

  “Very good. You can come and assist me in surgery if you like, Mr. …”

  “Stone, sir. Thomas Stone.”

  During the surgery Braithwaite found Thomas knew how to stay out of the way. When Braithwaite asked him to cut a ligature, Stone slid his scissors down to the knot and then turned the scissors at a forty-five-degree angle and cut, so there was no danger to the knot. Indeed, Stone so clearly understood his role that when the senior registrar showed up to assist, Braithwaite waved him off.

  Braithwaite pointed to a vein coursing over the pylorus. He asked Thomas what it was.

  “The pyloric vein of Mayo, sir …,” Thomas said, and appea
red about to add something. Braithwaite waited, but Thomas was done.

  “Yes, that's what it's called, though I think that vein was there long before Mayo spotted it, don't you think? Why do you think he took the trouble to name it?”

  “I believe it was as a useful landmark to identify the prepyloric from the pyloric area when operating on an infant with pyloric stenosis.”

  “That's right,” Braithwaite said. “They should really call it the pre -pyloric vein.”

  “That would be better, sir. Because the right gastric vein is also referred to in some books as the ‘pyloric vein.’ Which is very confusing.”

  “Indeed, it is, Stone,” Braithwaite said, surprised that this student had picked up on something that even surgeons with a special interest in the stomach might not know. “If we have to give it an eponym, maybe call it the vein of Mayo if we must, or even the vein of Laterjet, which seems to me much the same thing. Just don't call it pyloric.”

  Braithwaite's questions became more difficult, but he found the young man's knowledge of surgical anatomy to be shockingly good.

  He let Thomas close the skin, and he was gratified to see him use both hands and take his time. There was room for improvement, but this was clearly a student who'd spent many waking hours tying knots one-handed and two-handed. Stone had the good sense to stick to a two-handed knot, tied well and with care, rather than showing off to Braithwaite with one-handed knots.

  The next morning, when Braithwaite returned, he found Stone asleep in a chair at the bedside in the recovery room, having kept an all-night vigil on the patient. He did not wake him.

  At year's end, after passing his final exams, when Thomas was appointed to the coveted position of Braithwaite's house officer, Shawn Grogan, a bright and well-connected medical student, found the courage to ask Braithwaite what he might have done to be selected instead of Stone.