Gordon had an odd smile on his face. It was the first thing I noticed when we were introduced.
The smile seemed unrelated to his underlying emotional state. It flickered on and off like a faulty porch light. The smile was his first response when spoken to, as if signaling his return to the secular world from an all-consuming private reality.
Though he was emaciated, pale, and his breathing labored, he was calm and resigned—quite the opposite of Essie who was overwrought, filling the space around her with nervous energy. Her gaze went back and forth between Gordon and me.
“I tell you what,” Essie said, I’m going to wait outside.”
When Essie left, I began to take Gordon’s history. As I interviewed him, I instinctively sized him up, trying to pick out as many clues as possible to who he was and to his condition. The patient encounter is traditionally divided into the history and the physical. But in actual fact, the examination begins the moment patients enter the room. One is alert to whether their hands are cold or warm and sweaty (which could indicate hypothyroidism or hyperthyroidism). One notes whether they are dressed shabbily or with glaring mistakes such as mismatched socks or clothing inappropriate for the season, a sign of dementia or delirium. Do they have the normal inflections in their speech or is it a dry monotone, as in Parkinson’s disease? Is their facial expression or “affect” appropriate to their emotional state? A discrepancy between the sadness the patient expresses in speech and the hearty smile on their face is a clue to schizophrenia.
To me the history and the physical are the epitome of the internist’s skill, our equivalent of the surgeon’s operating room. Like Sherlock Holmes—a character based on a superb clinician, Dr. Bell—the good internist should miss no clue, and should make the correct inference from the clues provided.
It was with this sort of scrutiny that I approached Gordon: He was clear-eyed and clean-shaven—he had found the energy to shave before he came to Essie’s house. His light brown hair was cut in two tiers: on top, the hair was longish, slightly down over his forehead in a wet, spiky look. The roots were a darker brown shade than the tips. Below an equatorial line at the level of his ear tops the hair was cut short, ending neatly well above his collar. He had cut his hair recently but it had been three weeks or more since he colored it. He wore blue cords and a blue cotton shirt with the collar buttoned. He had clearly lost weight: his belt bunched his pants around his waist.
The carotid artery in his neck was pulsating away, and there was a slight sheen to his skin, which, just to the side of his Adam’s apple and above the carotid pulse, showed a gentle undulation that was not normal: probably an enlarged lymph node. There would be more enlarged nodes in the armpit and groin.
The ER clipboard showed Gordon’s weight, blood pressure and the usual soundings. His temperature was 103 degrees Fahrenheit, his pulse was rapid and his blood pressure on the low side. His breathing was rapid, about forty breaths per minute.
Peeping out of his shirt pocket was a much crumpled carbon copy of a lab slip from the Dade County Health Department which he pulled out for me: “HIV positive by ELISA.” The test was dated October 1985, about the time the test first became freely available.
“When do you think you contracted the virus?”
“What do you mean?”
“Well, your test says October 1985. But did you suspect you might be infected before that? Did you have any lovers who died of AIDS?”
“I’ve had one—no two—lovers. Who died of AIDS. I guess I must have got the virus in ’80 or ’81.”
“How long have you been feeling poorly?”
He laughed a short, sharp laugh. “Months—no, years.” A smile remained on his face. “I was tired for so long. And losing weight. Even before I came home.” Now, I was certain that Gordon was the prodigal son, once given up for lost.
“What have you been feeling since you got home?”
He smiled again. “Tired. And feverish.”
“Do you have fever every day?”
“Not too bad. I stay cold all the time. I can barely shower. Or wet my head, ‘cause I freeze to death. And then I’ll suddenly break a sweat.”
“And what else?”
“Otherwise I’m doing pretty well.”
“Any shortness of breath?” He was speaking in clipped sentences because he was so short of breath. And yet he did not volunteer this symptom.
“I guess.”
Gordon was being a reluctant patient. Passive, as if he recognized the fever and other symptoms, but was only marginally conscious that it was happening to him. As if he had already separated from his body in some way.
“How bad is it?”
“What?”
“The shortness of breath.”
“Not too bad. Only if I try to walk or do something strenuous.”
I waited.
“—and I guess it has been getting worse. The last day or two. Sometimes”—and here he flashed a conspiratorial smile again, a smile that was quite inappropriate in the context of what he was saying—“sometimes it’s all I can do. To get my breath. Even as I just lay here.”
When I asked him about prior medical problems he told me he had contracted syphilis two years before and taken a series of injections for it.
As we helped Gordon undress so that I could examine him, I already had strong suspicions as to what was going on. The wan face and the flickering smile aroused my suspicion that the virus had made headway in the brain: he had early HIV dementia. I looked into his pupils with my ophthalmoscope for the big white splotches that indicated cytomegalovirus infection—the commonest cause of blindness with AIDS. There were none.
In his mouth, in addition to the white plaques of Candida, I saw a purple spot the size of a quarter tucked next to his last molar, between cheek and gum. It was more than a discoloration. It was a boggy swelling, almost certainly a Kaposi’s sarcoma lesion—“KS.” I touched it with the tip of the tongue depressor. “Does that hurt?” Gordon shook his head. I decided not to mention it to him for now. Most KS lesions, particularly if there were only a few on the skin and in the mouth, tended to not cause problems. If Gordon were to die, it would probably be from a cause other than the KS. I examined the rest of his skin carefully but found no more lesions.
I percussed over his lungs. The normal thoom-thoom of resonance that one should hear from air vibrating in the tiny air sacs of the lung was missing in the bases of both Gordon’s lungs. With my stethoscope I could hear fine Velcro-like crackling sounds in his lungs when he took a deep breath. In his armpits and groin were more lymph nodes of the same size as in his neck.
His x-ray showed a lacelike pattern in both lungs that was consistent with Pneumocystis carinii pneumonia. His blood exam confirmed that he was very anemic and would need a transfusion. I wrote out the orders to admit him to the hospital. I went out and spoke to Essie and we both returned to tell Gordon.
“Gordon, I think you need to be in the hospital. You have a pneumonia.”
“I don’t want to be in the hospital. Can’t you give me some medicine and send me home?”
“It’s not that simple. You need blood. You need antibiotics by vein.”
He smiled and shook his head.
Essie stepped in: “Now, Gordo, you are going to do what the doctor says and there ain’t no two ways about it.” Her tone was gentle, but brooked no argument.
I was puzzled by Gordon’s attitude. On the one hand, he seemed to have given up. Yet he had gone to Essie’s house that night. He had told her he was sick and had let her drive him all the way down to me. But he had no real interest in why I wanted to admit him and in what might be going on with his body.
Gordon was placed on the fifth floor and assigned that first night to a nurse called Mary—a stroke of luck for both Gordon and me. Mary seemed so comfortable with Gordon and his ailment that I was in awe. It was as if she had worked in a big-city hospital and had taken care of countless HIV patients. All the nursing staff had been “in
-serviced” on AIDS, but that alone could not account for her attitude.
Over the next three weeks, Mary and then Eleanor and then several other nurses on the fifth floor became friendly with Gordon. There were, I would find out later, other nurses who wanted nothing to do with him. But those who were willing closely tended Gordon as his mysterious fevers and pneumonia waxed and waned. They assigned themselves back to him every day as if he was a prize patient.
Every time I visited there was some new twist: Chinese food one night when they found out he had a passion for it; Elton John tapes and a boom box because of a song on TV that had stirred some other kind of nostalgia. Later, when Gordon was discharged, Mary and another nurse traveled up to Virginia to make a surprise visit to Gordon. While there, they helped bathe and feed him and cheered the family on in their efforts.
AS I TOLD ESSIE when she first called, I was scheduled to give a talk in Norton, Virginia, a few days after Gordon’s admission to the hospital. My drive would take me near Essie’s home outside of Blackwood, a few miles south of Norton. Essie, who had stayed with Gordon the first two nights before heading back for a change of clothing, suggested that I visit with her and look around the area on my way to Norton. I agreed. Gordon remained an enigma to me. Two days in the hospital and I didn’t know him any better than when I first met him. Perhaps by visiting his country home, meeting his family, I might get a clearer picture of the strange man who lay quietly between the sheets of his hospital bed.
Gordon’s parents had been down to see him each day, but their visits had not coincided with my rounds. Essie, who was my link to them, said my visit would be the ideal opportunity to explain to them what Gordon had. It was clear that Essie, whether because of her medical background or for reasons that I did not as yet know, had taken charge of Gordon’s care.
I set out for Virginia at about ten in the morning. Summer was over and fall colors were appearing on the tips of trees. The day was warm, but I was able to manage without the air conditioner, keeping the windows down and letting the air whip through my car.
It had been a while since I had driven this route. I had forgotten how much the green, undulating pastureland just outside of Johnson City looked like Ireland. It was hypnotic; it made you want to stop and inquire about purchasing the lone house that sat on a hill and all the land around it.
The tobacco allotments in the corner of these estates stood out from the rest of the fields. The big floppy tobacco leaves looked yellow and turgid, ready to pluck. In some fields the plants had been harvested and propped up against tobacco stakes in orderly stacks that looked like miniature wigwams.
The barns of Tennessee had always fascinated me. They came in all shapes; they were as individual as people. I passed several where the corrugated tin roof had one long sloping section and a short angular section, the final size and shape of the building determined entirely, it seemed, by what was available to make the roof. Another barn was little more than a lean-to. Some were painted red with Gothic roofs and shiny silos next to them. But the majority looked abandoned and only when you drew close was it apparent that they were being put to some use. The knotty pinewood had weathered to a slate gray color and looked brittle. I imagined if I touched it, it would break off in my hand like a wafer. In place of doors on hinges there were square openings cut into the walls through which I could glimpse a wagon or the back tires of a tractor, or tobacco leaves hanging from the rafters.
As I approached Kingsport and drove past the giant Eastman-Kodak plant, the acrid scent that came from this plant reached my nose. Eastman-Kodak was the town of Kingsport. Perhaps that was why the town was so willing to live with this daily reminder of the plant’s existence and pass it off with comments like, “It’s not really that bad,” and “It doesn’t always reach where we live.”
Now the undulating pastureland gave way to hills and deep valleys. The soil was so rich that foliage and undergrowth clogged every inch of space, blanketing the land as far as I could see like a rain forest. At the top of a hill I could see a thin clearing like a hair-parting where a power line cut through the trees.
I was passing the outskirts of Kingsport and entering Weber City: the border with Virginia. The highway gave way to Route 23, which would take me all the way to Norton and on to Kentucky if I chose. Now Route 23 ran through Weber City, parallel and very close to the railway tracks. There were traffic lights every block and my pace was reduced to a crawl. A coal train traveled slowly in the opposite direction to my car. To look at it gave me vertigo.
I passed a garden of eternal rest built on an embankment and stretching right down to the highway. The neat granite and marble headstones carried familiar Tennessee and southwest Virginia names: Tipton, Caldwell, Morris, Greer. Churches abounded in this town, crowding both sides of the road like used-car dealers. Spires rose from them like the horns of unicorns. Two of the churches were giant brick edifices with ample parking lots while others were simple rectangular buildings with aluminum siding, painted white, only the spire indicating the building’s purpose.
Outside Weber City, my pace picked up. And now on my left, for the first time, was a mountain range. Its presence and proximity gave a whole different feel to my drive. The mountain was an even ridge that had few peaks; it stretched into the distance, parallel to the highway. This was the Cumberland chain. I was passing through Cumberland Gap. The side of the road here was sheer rock-face.
Now, mile after mile and I was mostly in shade. The road dipped down into valleys and then rose to cross a mountain pass. Trees with dense foliage extended to the very top of the mountain.
Every few miles a roadside market—a plain rectangular building—offered gas and sodas. I passed a few houses on the side of the highway. They were really trailers that had been bricked in and a porch added. Flower pots hanging on the porch displayed a profusion of colors. When I saw a satellite dish it was always with one of these well-tended trailers.
Occasionally, I could sight down a dirt lane leading off Route 23 and see a shack with junk cars in front and a rotting roof on top.
An hour and a half after I set out I reached the turn-off for the town of Big Stone Gap. I passed through Big Stone and came out the other end into the town of Appalachia. As you drive into the town of Appalachia, you are greeted by a giant terraced rock wall where the face of the mountain has been brutally savaged. Nothing moves on this rock face; the mines took what they needed and moved on. The main street of Appalachia had old, two- and three-story office buildings interspersed with newer bank buildings, mine offices and, of course, a few churches. Downtown was barely a block or two long and then I was out of Appalachia, driving out into country again, heading to Blackwood. A few miles down the road I came to a fork: one fork led on to Possum Trot Hollow and the coal camp of Stonega. The other fork wound farther up the mountain to Sawmill Hollow, to the coal camps of Osaka and Roda. Beyond Roda, in the distance, were the Black Mountains of Kentucky and “bloody” Harlan.
Essie’s directions involved taking a left turn at a house with a lawn jockey (an “artificial nigger,” as Essie termed it) in the yard and driving till I came to Preacher’s Creek. The house sat ten miles from the fork and Essie was standing on her porch, waiting for me. She looked tired. She was apologetic about her humble abode, though I assured her she should not be.
The house was a one-story, square-shaped, cinder-block house. It was raised three feet off the ground so that you had to climb up six steps to get to the porch. The open porch was narrow and held a swing, the lawn mower and a dog’s kennel. The house was in essence a modified shotgun house—the front door was aligned with the back door and the two rooms in between constituted the living and dining rooms. A bedroom led off from each of these rooms. Essie’s parents lived across the road in a similar house; cousins and relatives were scattered up and down the hollow. Not a car passed whose occupants Essie did not know.
Essie saw me looking at the mountain that rose steeply behind the house.
; “This here is what you call a hollow. Most everybody lives in a hollow—there’s not too many that live on the mountain.”
Essie’s hollow had been spared the fate of many others. When underground mining had given way to strip mining, the loggers had cleared the trees and then the bulldozers went to work cutting, gouging, burrowing into the side of the mountain as they had done at the entrance to the town of Appalachia, until they found the seam. When the rains came, the first spoil bank had often collapsed and fallen on to the next spoil bank until the mountain slid into the creek, plugging it, overflowing the yards, causing slag to seep into the wells.
Essie’s living and dining rooms were paneled in a dark wood. The lights were on though it was early afternoon. Above the babble of the TV, I heard the staccato eruptions of a police scanner from Essie’s bedroom. Later, I heard scanner chatter in Essie’s cousin’s house and every other house I visited. The police, fire and ambulance squawks were like a collective subconscious that played in the minds of a whole county and kept them aware of anything that affected their neighbors.
On the living room wall, Elvis, wreathed in a golden halo, smiled from a knobby walnut frame. A chubby Gordon, whom I barely recognized, looked at me from the back row of a family photograph. On top of the TV was a framed photograph of a young girl with moon eyes, a large mouth, even teeth, huge dimples and wearing a beehive hairdo.
“That was me, believe it or not,” Essie said. “Lord, I was a firecracker then!” This triggered off her laughter. Sabatha, Essie’s older daughter, who was in her last year of high school, brought the frame over to me. (The children had stayed home from school to meet me and to hear word of their Uncle Gordon.) Essie was heavier now than in the photograph. I saw in Essie’s daughter, Sabatha, some of the young Essie—a big-boned comeliness that would have to exercise great discipline to keep from getting stout. In the photograph, the set of Essie’s chin suggested no reluctance—even then—to speak her mind. And the dimples and the smile were unchanged.