On the evening of March 31, 1991, in the house on St. Ronan Terrace, I sat writing in the room I call my scriptorium. Usually, in Connecticut, March is winter hanging by a thread, but this year it had turned hot without any transitional period of moderation; the leaves were already half-size. For most of the month I had been on an extended lecture tour that took me from the island of Kauai to Nova Scotia, then on to Delaware, California, and Texas. Around nine o'clock I left my desk and went to stand at the open window. The branches had begun to stir in a sudden breeze. There was the muffled sound of thunder. Jagged nerves of lightning leaped. In the sultry air the pattern of the wallpaper turned from green to gold; the figures in it grew wavy, they vibrated like heat rising from a pavement. All at once my legs buckled. From downstairs Janet heard the thud and came running.
"What?" she said.
"I can't think why . . . , " I replied.
"Can you get up?" I tried but could not.
"You'd better call . . . " But she had already dialed. Within minutes two young men in uniform stood over me. I remember being bundled up, the stretcher sliding home aboard the ambulance. One of the men took my pulse and blood pressure, then relayed the information to someone over the phone. I heard the sirens.
"For goodness' sake, don't use the sirens," I told him. "It will disturb the neighbors. Besides, it isn't that serious."
"Take it easy, Pops," said the young man. "It's sporty this way." I remember nothing else until 23 days later, when I woke up on a ship, I thought; somewhere off the coast of Texas, I thought. Oh yes, there was this: at the emergency room I was placed on a stretcher. All around and above me, a flock of white birds--stooping to peck at my arms, groins, beaking my mouth, rectum, everywhere. Then nothing . . . save for whispers crowding around, leading me deeper and deeper into the darkness. Then they too vanished.
Coma is the state into which he is tumbling. Moment by moment there is a turning inward of the senses. The sounds, smells, sights, perceptions of the outside world are disappearing. The Milky Way roars across the sky like an army of light. At last his fall is broken by a soft cushion and he is suspended in a viscous, pearly matrix that is itself both time and space; his vertebrae have melted; he lies here strewn, submerged.
I feel ashamed to pounce upon the page with a narrative that is so open, explicit, so personal. In one sense it is a vivisection, the cutting up of a living creature to see how it works, rummaging among the still-quivering flesh for its soul. As you can see, I am warming up before making a start, rubbing my hands together to summon up courage. If I have written much of it in the third person, well, that is because such an obsessive account of an illness forces one, like Dorian Gray, to confront his own "devilish, furtive, ingrown" self-portrait. The pronoun he gives a blessed bit of distance between myself and a too fresh ordeal in which the use of I would be rather like picking off a scab only to find that the wound had not completely healed. Still, I, the author, will be present throughout, looking on, translating for him, the patient.
In writing this journal I had no overriding wish to educate myself in the subject of Legionnaires' disease, the diagnosis ultimately given to my ailment. Once I had learned that it is caused by the bacterium Legionella pneumophila, which thrives in the mist sprayed from air- conditioning ducts, that a building or an airplane having been infested, travelers are especially vulnerable, that it is quite often a massive pneumonia associated with collapse of the respiratory function and therefore fatal; once I had glanced at a few colored photographs of autopsy specimens of lungs and liver and kidney, my curiosity about the disease was exhausted. A writer, like an old-time doctor, prefers impressions to facts. Impressions are what last. Facts, such as the data read from the screen of the computer, have a tendency to change from day to day. But I think it is time to get on with the chronicle of an illness told afterward.
Let us look in upon that cubicle of the emergency room. The stretcher upon which he lies is engulfed in nurses and doctors, each of whom is ministering to him at the same time. In a moment, his clothing is stripped from him. Because he is flailing about, his wrists and ankles have been restrained. From veins in his arms and groins endless ribbons of blood, dark from the cyanosis, are pulled into tubes. His head is steadied, his neck extended by mighty hands; the mouth of the man is pried open and an attempt is made to insert a tube into his trachea. But his agitation is extreme, like that of a man drowning. Or rather, that of a man playing the role of someone drowning in an old-fashioned melodrama. It has that jerky, staccato rhythm. Because of this, the intubation cannot be carried out. Medication is injected into a vein and the doctor at the head of the stretcher tries again.
There. Now the tube is in his trachea, the cuff inflated to keep it from slipping out. Still not fully narcotized, the man shakes his frantic head from side to side, refusing what has been thrust in. He coughs, strains, his neck is a contraption of taut tendons and engorged veins. To the uninitiated it might seem a kind of molestation. At last the morphine reaches his brain; he subsides into flaccidity. His chest lifts, recedes, lifts again at the insistence of the rhythmic, squeezing fist of a perfect stranger. Ointment is squeezed from a tube into his eyes, and his lids are taped shut to protect the corneas. It is the beginning of a long sleep. In the meantime, a catheter has been slid into his bladder, another plastic tube into one of his nostrils to gain access to his stomach. Already, long strings of blackish bile are staining the sheet on which he lies. The cardiogram shows the rhythm of his heart to be precarious-- ventricular tachycardia. Drugs are administered, electrodes readied to apply to the chest. An X-ray is taken; one of the doctors remarks that the chest is not expanding symmetrically. The diagnosis is massive bilateral pneumonia with toxic shock. How strange that he had no earlier warning. Despite the administration of pure oxygen, his lips and fingernails remain blue. His temperature, they say, is very high. His pulse too, his blood pressure almost unobtainable. Is he going to die? No one knows. But there is more than a hint of death here.
Within minutes, then, he is a preparation, something they have made and whose every flicker and seepage can be measured precisely. In addition to the doctors, nurses, and technicians, I, the author, am also there, standing, or rather, hovering bodiless above and to the side, out of the way yet able to see, to hear, now and then able to reach down if I wish and touch him, the one lying there on the stretcher who seems to be a small bird perched on an arrow that has been shot from the bow and is flying somewhere. If ever the man wakes up and can speak for himself, I shall have to change pronouns.
The martyrdom of the intensive care unit has begun. It has a certain relentless monotony that would render any such narrative boring. So I shall not proceed day by day through the pestering and goading of the flesh that go by the name intensive care. Suffice it to say that for the next 23 days the man in the bed is to be ventilated, dosed, defibrillated, probed, suctioned, and infused. Most of his bodily functions will be taken over. No longer need he swallow, chew, inhale or exhale, cough, urinate, defecate, clear his throat, maintain acid-base balance, cogitate, remember, sigh, weep, laugh, desire. Even the need for making tears has been taken over by the ophthalmic ointment that protects his corneas. For those who will tend him, he is at once the raison d'être and the predicament from which they long to extricate themselves. The doctors are earnest and tireless. They remind me of poor farmers who, year in and year out, turn with their hoes the same exhausted patch of soil, planting and replanting, flogging it, cherishing it. But there will come the day when the pathetic patch of dust will no longer yield. Only then will they let it be. In other words, this man is half dead, although not quite at the point of no return. For him death would certainly be much easier to achieve than life. The prospect of life regained is like sitting down to a gourmet lunch without the blessing of appetite.
The intensive care unit suggests a blockhouse, a building made of concrete, designed to withstand attack during wartime. Even the patient who is conscious exists here in a kind of reverie. Within the blockhouse 20 respirators, each inhaling and exhaling at its own pace, make a steady, wet noise like the fall from a fountain. Such a sound goes unnoticed in an intensive care unit beneath the clatter and thump, the footfalls, the calling out, the moaning. So cleverly has the noise of these respirators been woven into the larger fabric of sound that within minutes it cannot be dissected and analyzed for itself. Absolute silence could not be deeper. All the while, in the chimney of his brain, thoughts fly up and, a moment later, waft away, irretrievable.
Dreamer that he is, even in the blockhouse, even from the depths of his coma, he invites the IV pole, the respirator, the whole massive bank of machinery to suggest the background for a story: the hanging bottles of saline become a crystal chandelier; the moans of his sick neighbor are the sound of an oboe being played in another part of the house; the cooing of pigeons on the window ledge becomes the rapturous cries of lovers. Those who enter and leave his room will be characters in a story--there is a nurse, Maureen, with a long, slender neck at the hollow of which rests a tiny gold cross. A chambermaid performs her futile acts of domesticity, fitting her mop in and around the legs of the others. Now and then she will cast a glance at the wreckage in the bed and sigh. Even to death and beyond, he will be the teller of tales, collecting impressions, defying forgetfulness, and meeting gods all along the road, the way you do when reading Homer or Virgil. He can do all that? In coma? Oh yes, he can. Dream, imagination--these are the chariots that the comatose body rides. It is by these that the flesh extends itself to encompass the whole world.
He had always been thin--a parcel of bones, really, stitched together with ligament, strung with nerves and tendons, and with a cap of aluminum hair; his eyes are of that indeterminate color called hazel. But now it is the sixth day. He is swollen like a toad, his flesh cold and soggy, his edematous eyelids at half-mast. You wonder how they could have overhydrated him so. In their zeal to combat his state of shock, they have given him 50 pounds of excess glucose and saline solution. There is the sadness of a toad in his hazel eyes. The familiar landmarks by which he could once be identified are no longer to be seen: the zygomatic arches surmounting the cheeks, the iliac crests, the tapered phalanges. Where is the squarish mandible that (he has been told) gave his head the look of a Roman senator? Where, the graceful hollow above each clavicle? And all the while, beneath the deceptive fullness of edema, the wasting of his muscles goes on, the congestion of his internal organs. He has become something that even I would not want to touch. Not so the nurses--Maureen, Linda, Heather. Beautifully serene, they continue to stroke and massage him, to wipe away all stains, to bathe and dress him in clean linen. To look at him today you would never guess that he is the same man brought to the emergency room six days ago and set loose at supersonic speed into the void and traveling on remote control.
At last, by the tenth day, the diuretic has succeeded in drying him out. Succeeded beyond anyone's expectations. All day and all night, the nurses have emptied the plastic collecting bags suspended from the side rail of the bed, exclaiming. The output of urine is nothing short of heroic. Within four days he has become little more than a skeleton, every bone visible and palpable--the skeleton of a child whose puberty has been delayed. At the same time he looks ancient enough to have been mentioned in the Old Testament. Oh, let me confess it! Sometimes he seems brave and beautiful to me, although I know that I am the only one who would think so. Look at him! A sprig of chicory blooming between paving stones, indomitable.
Day fourteen All the blood that is still in a liquid state has been drawn from his veins; syringe after syringe has glittered with it. The rest is clotted or extravasated into the tissues. Huge purpura, ecchymoses, and hematomas cover the sticks that were his arms. There is a moist rattle in the endotracheal tube. Now and then a nurse detaches the tube from the respirator long enough to suction it clear, and then the rattle disappears for a while.
I have spent the entire day observing him. The poverty of his body, the way he shivers like a wet dog. The draining away of his flesh and blood. He is like an abandoned cottage in ruins, the eaves of his ribs overhanging the scaphoid belly. His umbilicus, that mute evidence of his ancestry, seems set directly upon the vertebral column. When the narcosis is allowed to lift, he curls up, stretches out slowly like a larva, signaling with the only sound he can make--the faint borborygmi of his bowel. At last I understand the term embedded, the way a fly trapped in a chunk of amber must apprehend its plight.
Beneath the sheet he is naked save for his feet, which are encased in brand-new high-top running shoes. His wife has shopped for them at the suggestion of Maureen, who is worried about foot drop. These massive sneakers hold the feet at right angles to the legs. It is ludicrous, and even the anguished members of his family--his children--cannot keep from smiling at the small boy who has taken his new shoes to bed with him.
Day eighteen He has been in coma for almost three weeks. What is it like? It is like being encased in a layer of wax that separates him from the rest of mankind. The outer air is a foreign element into which he is unable to break through. Nor should he try, for he could no longer breathe it in. An immense weight holds down his thin bluish eyelids. He could not have raised them. Nor does he want to. He has no need for eyes. Here there is nothing for him to do but wait and listen to the silences rubbing against each other. Now and then there is a small shifting in the air as if far away, on another continent, a boa constrictor were slowly unwinding from a branch. Could this place have a name? Is it on any map of the world? A decision has been made to wean him from the respirator.
The narcotics and paralyzing agents have been given in lower doses throughout the night. Toward dawn he is lying in the upper berth of a sleeping car; there is no room to sit up or turn over. The train is hurtling across an endless prairie where it is always night. Once in a while the eternal darkness outside the train window is punctuated by something--a forest of bare white birch trees, a herd of cattle, only their white faces showing. A few silvery birds fly. Or are they fish streaming?
There are times when his face seems to contort into weeping; his eyes open and show themselves brimming with a molten sorrow. When it passes, the spasm, there is a relief about the diaphragm as when vomiting or sobbing stops and you can let go of yourself. This morning he even made a gesture as if to reach up and claw from him the skin of wax that is his coma. It is the same gesture made by Lazarus in the painting (School of Rembrandt) when he sits up in the tomb and begins to unwrap his cerements. But unlike Lazarus, the man in bed cannot manage it. By afternoon his arms and legs are once again flailing about, resisting. In the chart his behavior is noted as "combative." Nothing could be further from the truth. What makes him struggle so is not aggressiveness; it is desperation.
The man now is about the size of a small deer lying starved and exhausted in snow. See how he lifts his head, turns it slowly, on his face a look of puzzlement, uncertainty, as he sees me hovering in the corner of the room where wall and ceiling meet. Something passes between us--not quite speech. He opens his mouth as if to eject the tube but cannot. Then with a purposefulness that I did not think he could muster, he reaches one hand up and pulls it, coughing, choking, from his throat with the cuff still inflated. He seems surprised at what he has done, the sounds he is making.
"That was very naughty!" The nurse attaches nasal prongs to deliver oxygen to his nostrils until the doctor can come to replace the tube. Meanwhile he is rid of the tube and struggles to extrude vowels and consonants from his larynx. Even his eyebrows take part in the effort to speak, the way they arch, lifting as if to encourage his lips and tongue. It gives his face a look of boyish earnestness. But there is no voice, only a thick, gelatinous rasp, as the vocal cords no longer approximate. Minutes later the anesthesiologist arrives. Just in time, for the cyanosis has darkened. The wrists and ankles of the patient have been secured to the bed. The nurse holds his head as if it were the head of a statue whose sightless eyes have no pupils. The hands that grip him are hard as tongs. In the end he yields to them as though yielding to a strangler's thumbs. The endotracheal tube is replaced, its cuff inflated. The dose of morphine is increased. Immediately his empty sockets return a gray, stony stare. He must remain paralyzed and unconscious until such time as he no longer needs the respirator. And so he sleeps on.
He is like a gardener digging in the earth who makes a decision to lower himself to the underworld. Down and down he goes, swinging from root to root. On either side, worms, rocks, gulches, darkness, eyes like panthers caught in a net of lashes, moisture dripping. Just so does he follow the mushroom scent of hell, and with each fathom grows paler, less opaque, his flesh melting--solid to liquid, until at last there will be only the vagueness of vapor. Once or twice he looks back up to see how far he has come, but the path behind has closed up, leaving no trace. He would not be able to find his way back. The thick, twisted roots have tapered into fine, hairlike rhizomes that he parts with his hand the way one parts a curtain of beads. His cheeks and arms are coated with cold moisture, more like rot than sweat. The odor of mushrooms grows heavier. Solid ropes of it slide in and out of his mouth, fill his throat. After a long time the path widens and ends abruptly at the edge of a black river. Here he lies down, not to sleep--in this place there is no need for sleep or wakefulness. Nor is there any need to move.
Day twenty The sight of his hands is particularly sad. Those fine muscles between the metacarpal bones and in the web spaces--the interossei and the lumbricals--have atrophied; the mounds of flesh have given way to gullies. The skin is dry and as chaste and beautiful as old paper. But I remember the passion inspired by those fingers, their gifted, sly, infinitely provocative caresses and gestures. No sign of that now.
A doctor turns over first one hand, then the other, searching perhaps for a usable vein. Then he sees the elevated, dimpled scar tissue in each palm that begins to contract and draw down the ring finger. That is the Dupuytren's contracture of which the man has been inordinately proud. He never lost the chance to tell the gullible that these were the stigmata of the Crucifixion. The examining doctor makes a note to show the Dupuytren's contracture to the medical students.
Day twenty-one A gray dawn slides through the ill-fitting slats of the venetian blind. From the glum faces of the nurses, it is clear that in the blockhouse things are looking worse. Whatever fragile equilibrium between acid and base, between oxygen and carbon dioxide, between positive and negative that the doctors have managed somehow to piece together has come unraveled. All the vital signs have taken a turn for the worse. Fever. If it goes any higher, he will burst into flames. A pair of gills would work better than his solidified, liverish lungs. Daedalus! You can make anything! How about it? A pair of gills for the man!
"Let him not die," someone murmurs. The possibility itself lowers the temperature in the room; the patient shivers. With the sheet pulled down, he looks more and more like a winter-starved deer, stricken. Don't go! Not yet! Who is that calling out? Then I see that it is I calling out in pursuit of myself. The sheet is drawn smooth up to the armpits (as though he could move) and tucked in under the mattress. When the nurse lets his head down, the pillow is scarcely dented by the weight of it. If someone had asked him at that moment what was his dearest wish, it would have been to lie on his stomach with his arms bracketing his head.
Day twenty-two All day and night, silt has settled in his veins, turning them solid. Only the bubbles of saliva on his teeth continue to wink bravely in the light. A slow slide of clot advances through his body. It began in the venules of the arms and legs, filled the larger veins, the iliac, the inferior vena cava, flowing slowly toward the heart. By morning it will have achieved the right auricle. A single muffled thump, and it will be hurled to the lungs. And there it will stay, hardening into a cast of the pulmonary circulation. Should he die, will I too feel the cold mud in the marrow of my bones?
Day twenty-three And now it is my sad duty to report to you his death. It occurs at precisely 1:38 P.M. on April 23. He has been in the intensive care unit for three weeks and two days. From far away there comes a drumming so faint and rapid as to be unrecordable by even the most sensitive device in the room. Could it be rain? No, the sound lurches and staggers as though the drummer had slipped and lost his beat.
"Ventricular tachycardia," says the nurse and calls for the doctor. The drumming grows louder and louder until it fills the room. Then all at once it stops as though an arrow had been shot through the throat of the drummer boy. The pace of activity in the room quickens. Maureen pounds vehemently upon his chest, turns up the oxygen flow. Injections are given into the tubing, then directly into his heart (or where she surmises his heart to be), syringes full of calcium and adrenaline. Electrodes are clapped to his chest and a series of jolts delivered that cause the body of the man to jounce hideously in the bed. His lips and fingernails are a deep blue. Minutes go by. The doctor arrives.
"How long has the ECG been flat?"
"Four and a half minutes." For a while they continue their efforts, which are like a pantomime. To no avail. No amount of resuscitation has the least effect. The heartbeat is not restored. At last the efforts are discontinued. There he lies, the sheet having been thrown off in the struggle, his slight body pale, emaciated, childlike were it not for that head like a Roman senator's and his aluminum hair.
"This man is dead."
Maureen, she who had pounced upon him like a cat, jolted him with currents of electricity, seen to the injections into his very heart, sags against a wall. She has given up trying to catch his ghost, which was running away from her. He was already out of her reach and she could not pursue him further. Sorrowfully, Maureen sits by the bed recording the events in the chart, her usually strong, bold handwriting gone shaky. See how she pleats her forehead, draws in her lips, for in spite of all that she has witnessed over the years she cannot bear to be present at this. Time of death, she writes, 1:38 P.M.
It is strange, this painless death. Like stepping through a door held politely open for him. It doesn't seem right, somehow; a trivialization of the event. Death ought to be harder to achieve. Better to be hunted down, rooted out, hurting and bloody. Then death would come as a relief. It would be welcome.
It is now ten minutes since the doctor's pronouncement of death. Already the man has taken on that look of dignity that the newly dead have because of their possession of secrets. Or is it that they travel in a beyond that must be entered formally? Maureen is still writing an account of the last minutes of his life, her efforts to resuscitate him--the intracardiac injections of calcium and adrenaline, the jolts of electricity delivered to his chest, the failure of the electrocardiogram to respond. Glancing up, she has noted the characteristic "settling" of his body, the fixity that is incontrovertible; she has seen that so many times. Alone in the room, Maureen pauses in her charting to wipe her eyes with the back of her hand. Bleary with tears, she does not see what I see, that a subtle change is taking place in the contents of the bed, that the utter stillness of the body has been replaced by a calmness of the flesh, that beneath the closed eyelids his eyeballs roll slowly from side to side, then dart the way fish will move in a pond. Look! He shudders as if to shake off something that threatens to cling, and tightens those eyelids; minnows of light rising in the shallows. Then he hears a wingbeat, and feels something fugitive, immaterial, a beige veil being drawn from his face, slowly at first then faster, until the final whisk is like a slap. A moment later he draws the first breath. It is a deep sigh that might be interpreted as one either of sorrow or of satisfaction, as though one precious thing were being relinquished and another embraced. The nurse's incredulous stare! Her galvanic leap to his side! He, blinking in the explosion of light. When he opens his eyes, their color has gone from the ambivalence of hazel to the jubilation of blue.
Again a breath is drawn, and another and another. A tracing has returned to the electrocardiograph, which the nurse had not yet detached from his arms and legs. The room, which had descended into a subaqueous silence emanating from the corpse, is now fiercely active. All the machinery is back in place, chugging, vibrating, clicking, ringing. Nurses scurry, calling out to one another. They bend over the bed, coaxing, noting and recording each sign of revivification. The intravenous chandelier sends light streaming through his body until he is something radiant and glowing in the bed. From time to time the nurses turn to look at each other, their faces swept with wild surmise. It is true! After ten minutes of certified death, this man has . . . risen. Risen! Such a word does not belong in an intensive care unit.
Now the man is coughing against the endotracheal tube, he wrinkles his forehead, tears stream from his eyes, he shakes his head slowly from side to side. It is painful to observe the resurrection of a man, to behold a log of inert flesh trying to raise itself. But the pain is all ours. He feels nothing as yet. He is like the bulb of a tulip probing the earth in which it has lain all winter unaware of its potential, without memory or hope. As we do not ascribe pain to the tulip in its rebirth so ought we not to imagine that he, the man, is torn loose and abraded.
Then he who has performed no purposeful movement in three weeks reaches up one hand and pulls the tube from his throat and mouth. And that is not all: a smile breaks upon his face, but such a smile as has never been seen on the continent of North America. And in a hoarse whisper, but plainly enough, he utters the single word: Yes.
"Did he say yes?"
"What do you suppose he means?"
"I couldn't say. Perhaps he was just answering a question someone asked him weeks ago before he went into coma."
"Does that happen?"
"More likely it is some odd form of seizure activity."
What he means, what the nurses cannot know, is that everything begins with a yes. That is how the first two bits of energy in the universe greeted each other, collided. Boom! And yes! there was life. So it is with the resurrected. Once again his throat fills with the word until the pressure of it is unbearable and he cries out in the hoarse voice that sticks to his jaws . . . Yes! Saying yes to life, accepting once again the burden and thrill of it.
It is the next day. He lies on his back, arms and legs splayed out so as not to disengage any of the needles or tubes. Now and then he is propped on one side or the other. What he really wants is to curl up so as to give himself a hug, to accept his own warmth. Still, on his face is a strange, far-off look, as if to say, death is easy; it is the return to life that requires courage. When a nurse comes to take his temperature, he follows her solemnly with his eyes that seem to say: I have been to the land of the dead. Do not touch me. From that moment on, his vital signs-- pulse, blood pressure, temperature--are normal. His oxygen saturation, 100 percent. There is no longer any doubt that he will recover.
About the consternation of the entire medical staff there is little to be said. The joy at his reawakening is general, but in each person it is colored