Appo moved slightly across to Hulla’s head. His ear brushed against a hold cut through the side of the blanket, providing space that ran to the back of his scalp. The boy had been clean shaven only a few days prior, showing only smooth skin just past the periphery of his bruise. Appo pointed to an area a few centimeters behind and above the ear.

“This is where I’m going to make the incision. We’ll make a small circular cut with the scalpel and pull back the skin and muscle. Then I’m going to cut a smaller, rectangular hole within the space. This will take some time, as I’m going to be doing the procedure with another scalpel.” Appo wished he had Parbast’s drill, as it would’ve made the procedure significantly faster. But he doubted the Yalds would have let him carry such a barbaric-looking instrument anywhere near their child.

With confirmation from Tomi that Hulla was still stable, Appo began the incision. He positioned his body over Hulla’s side, forming a C-shaped cut just slightly larger than his ear. It was an awkward angle, but it was a smooth and quick cut. Appo wanted to show confidence early. It seemed to work; the family squirmed but continued doing their duty. Uten particularly impressed Appo, holding his young brother’s head in a steady grip. Appo retraced over the cut several times with a variety of thinner scalpels, slicing through fascia and muscle before he felt his hand reach bone. Erish dutifully followed his incisions, soaking Hulla’s minimal blood loss with a spirit-soaked rag.

As Appo maneuvered to remove the connective tissue from the skull, a horrifying realization hit him: he had forgotten to consider that he was now one-handed. In all the rush of preparation, he had overlooked such a blatant and obvious fact. He inspected the cut briefly, knowing that he needed his other hand to keep the skin taut as he peeled tissue away from the skull.

Instead of admitting such a foolish mistake, Appo gestured at Erish. “This is you, pay attention,” he lied under a veil of annoyance, as if he were waiting for her to move into position.

“Ati’s dirt, I wasn’t paying attention. I’m sorry.” As Erish pulled back the skin, Appo repressed the twinge of guilt he felt. He needed to stay assured, and loudly announcing he forgot how many hands he had wouldn’t inspire confidence.

But this was a major problem. How could he have overlooked such a simple obstacle? He wouldn’t be able to tie sutures, or even hold his position upright.

“Of course I wasn’t thinking about it. If I stopped to think, the boy would have died.” Appo chalked it up to lack of sleep and moved on, though that didn’t reassure him. He would have to adjust to it all on the fly.

Appo took his time removing the skin from the scalp, taking care to avoid nicking any major blood vessels. Fortunately, the scalp came off with ease, hence one reason Appo chose the spot in particular. By this point, the Yalds had settled into a rhythm. Erish kept a strong grip on Hulla’s scalp with one hand, and alternated between soaking blood into sterilized cloth and cauterizing smaller bleeds. Tomi dutifully recited Hulla’s stable vitals, and Uten kept Hulla’s head sturdy and in place. Garabi bounced between them all, handing rods and rags and scalpels and whatever else they needed.

After ten minutes, Appo pulled a skin flap half the size of a palm over Hulla’s ear, and pinned a finger’s width of it behind his brow. Appo had done such a clean job that the bone had kept its yellowish white color. Appo could see that above the ear, Hulla indeed had a small divot in his skull, a very vulnerable spot as far as the skull was concerned. The crack itself was barely noticeable. Considering how long Hulla had walked before falling unconscious and how well he had tolerated the surgery thus far, Appo was getting his hopes up. Hulla could indeed survive.

At Appo’s suggestion, Garabi reheated the opium pipe and handed it back to Tomi, this time letting the boy inhale its fumes in brief bursts. With the occasional smoke rising, Appo was concerned Tomi was letting some fumes get to her. The last thing he needed was for her to pass out. Fortunately, Tomi snuffed the flame and handed it back to her grandfather.

“His breathing is stable again. His heart rate is coming down, but not as fast as the first time.”

If you come across this story on Amazon, it's taken without permission from the author. Report it.

“Very good.”

Now was the most critical part: the incision into the skull. Appo had chosen three of his sharpest knives to have on standby at the juncture. Appo was well aware of the skull’s thickness, and although he wouldn’t have the same speed as if he had Parbast’s crank drill, in due time he could file through.

Or at least he would, if he had the extra foundation from having two hands.

As Appo began filing, it became more and more apparent how difficult the challenge in front of him would become. He tried to stabilize himself with his missing hand but kept retracting it in pain. He couldn’t get a firm grip. Appo’s slices on the skull were uneven and shallow. Realizing how awkward it looked, he maneuvered his body around to create a shallow border, outlining the piece of bone he planned to remove. Hulla struggled slightly, but Uten’s grip kept his head in place.

After several tedious minutes, Appo finished carving the borders. But his progress was too slow, and he kept experimenting with carving methods. He pressed his left arm onto the boy’s body, or ontop of his own carving hand with minimal success. If the Yalds had any concerns, they kept their mouths shut. Appo had to figure something out, fast.

Without warning, Hulla convulsed. His head arched forward as he spat up vomit, most of which landed on Tomi’s arm. She stood briefly in shock before grabbing onto Hulla. He vomited again before launching into a series of coughs. Uten kept most of his grip throughout, but his eyes betrayed how horrified he was.

Appo backed away with his knife. It was possible someone spoonfed the boy porridge in the interim, another possibility Appo had not considered. Before he could move to stabilize the boy’s head, however, Garabi beat him to Uten’s position.

“Help your sister,” Garabi said. Uten nodded and released his grip, moving closer to Hulla’s mouth. The boy’s maw was open, allowing Uten to look inside for any remaining vomit. As Garabi pressed his hands against Hulla’s skull, Appo noticed he was missing all of his fingers. Or rather, they had atrophied down to stubs. It must have been another long-term effect of the leprosy. Appo realized why Garabi had kept his hands under his robe. Yet here he was, assisting with a surgery, handing over metal tools and providing help without concern or complaint.

As Hulla’s vomiting ceased, Appo looked down at the boy’s skull. He had carved the rectangle, but it was a crooked and uneven outline. He wasn’t even sure he could fix it, at least in the time he had. Appo was now fully appreciating the impressive thickness of the human skull.

Appo had to come to the brutal terms. Where he was now, he wouldn’t be able to finish the surgery. Not the way he was.

Appo looked to Garabi again. He held onto his boy’s son with a firm grip, simply pressing his stubbed hands against the side of his temple. He had an idea.

“Erish, you have been watching what I’ve been doing, right?”

Erish nodded.

“Are you okay switching places? You may be better suited for this.”

Erish paused before moving into position. “Show me again where you cut.” There was no hesitation in her voice.

After a brief demonstration, Erish swapped positions with Appo. He stood over her side, guiding her cutting motion as she sawed through the skull. After a minute or two of gathering her bearings, Erish moved at a very capable speed, cutting through the bone in a steady and competent line. Appo wondered whether she had even comprehended that she was operating on her son.

Within twenty minutes, they had reached the base of the skull. Everyone switched places again, with Uten moving to Erish’s spot. Appo placed a bent metal rod into the incision of the cut directly behind Hulla’s ear. With a strong tug, Uten pulled the plate of skull away. The bone jutted out with a loud crack, and blood gently poured out the side of the wound. Appo instructed Garabi to adjust Hulla’s head, facing it upwards. The blood rippled out of the side of his cheek down the camel blanket. After adjusting his head a few more times, the flow slowed to a trickle before ceasing entirely. Appo briefly visualized the grayish-pink color of the boy’s brain before unpinning the boy’s scalp-flap and pressing it back into his skull.

“We got it,” Appo announced. He looked around at the Yalds, expecting to see cold faces from his reluctance to finish the cutting. Instead, they looked at him in awe. If there was any judgement they had for him, they did not show it. The other lepers clasped their hands together in silent prayer.

Without pausing, Erish swapped her bone cutting tools for Appo’s suture kit. She moved fast, even faster than Appo when he had two hands. “When will he know if he’s okay?” she asked.

Appo shrugged. He didn’t know. Hulla’s fate was now in Ati’s hands, as far as the Yalds were concerned.

Halfway through the stitching, Appo’s lack of sleep finally caught up to him. Confident in Erish, Appo allowed her to finish closing the wound as he stepped away. Two lepers greeted Appo, who offered him both of their meager cots. At first, Appo declined, but the lepers insisted, and he eventually found himself lying supine before he fell into a deep and satisfied sleep.

After Erish finished tying the suture knot, Tomi volunteered to watch Hulla through the rest of the night. She never left his side, watching the slow rhythms of his chest until long after the sun faded over the horizon.