by Ian Mcewan
He enters the theatre by way of the anaesthetic room. Waiting for him, sitting by their machine, are Jay Strauss and his registrar, Gita Syal. Round the table are Emily, the scrub nurse, Joan, the runner, and Rodney—looking like a man about to be tortured. Perowne knows from experience how wretched a registrar feels when his consultant has to come out, even when it's an obvious necessity. In this case it hasn't even been Rodney's decision. Jay Strauss has pulled rank. Rodney's bound to feel that Jay has grassed him up. On the table, obscured by surgical drapes, is Baxter, lying face down. All that's visible of him is the wide area of his head shaved to the rear of the vertex, the crown. Once a patient is draped up, the sense of a personality, an individual in the theatre, disappears. Such is the power of the visual sense. All that remains is the little patch of head, the field of operation.
There's an air in the room of boredom, of small talk exhausted. Or perhaps Jay has been holding forth on the necessity of the coming war. Rodney will have been reluctant to voice his pacifist views for fear of being taken apart.
Jay says, “Twenty-five minutes. That's pretty good, chief.”
Henry raises a hand in greeting, then gestures at the young registrar to accompany him to the light box where Baxter's scans are on display. On one sheet, sixteen images, sixteen bacon slices through Baxter's brain. The clot, trapped between the skull and its tough membranous inner lining, the dura, sits across the midline, the division between the two hemispheres of the brain. It's two inches or so below the vertex and is large, almost perfectly round, and shows pure white on the scan, with telltale precise margins. The fracture is clearly visible too, seven inches long, running at right angles to the midline. In its centre, sitting right on that midline, is shattered bone, where the skull has partially caved in. Right below that depressed fracture, vulnerable to the sharp edges of displaced bone tilted like tectonic plates, runs a major blood vessel, the superior sagittal sinus. It extends along the fold—the falx—where the two hemispheres meet, and it's the major vein draining blood away from the brain. It sits snugly in the groove formed where the dura wraps separately round each hemisphere. Several hundred millilitres per minute flow through the sinus and it's possible for a surgeon to tear it while lifting the broken bone. So much blood escapes, you can't see to make a repair. This is when a year-two registrar can panic. And this is why Jay Strauss has called Henry.
While he's looking at the scans, Perowne says to Rodney, “Tell me about the patient.”
Rodney clears his throat. His tongue sounds thick and heavy. “Male, in his twenties, fell downstairs about three hours ago. He was drowsy in casualty, with a Glasgow Coma Score of thirteen dropping to eleven. Skull lacerations, no other injury recorded. Normal C-spine X-ray. They did a scan, ordered a crash induction and sent him straight up.”
Perowne glances over his shoulder at the monitors on the anaesthetic machine. Baxter's pulse shows eighty-five and blood pressure one hundred and thirty over ninety-four.
“And the scan?”
Rodney hesitates, perhaps wondering if there's a catch, something he didn't notice that could compound his humiliation. He's a big lad, occasionally and touchingly homesick for Guyana where he has ambitions to set up a head injury unit one day. He once had hopes of playing rugby for a serious team until medicine and neurosurgery took him over. He has a friendly, intelligent face, and the word is that women adore him and he puts himself about. Perowne suspects he'll turn out well.
“It's a midline depressed fracture, both extradural and”—Rodney points to an image higher up the sheet and a small white mass shaped like a comma—“subdural too.”
He's seen the only slightly unusual feature, a clot below the dura as well as the larger one above it.
“Good,” Perowne murmurs, and with that one word Rodney's evening is rescued. There is, however, a third abnormality the registrar will not have noticed. As medicine progresses, certain diagnostic tricks fall into disuse among the younger doctors. In a frame further up the sheet, Baxter's caudate on both sides of the brain lacks the usual convexity, the normal healthy bulge into the anterior horn of the lateral ventricles. Before DNA testing, this shrinking was a useful confirmation of Huntington's Disease. Henry never doubted he was right, but the physical evidence confers its own bleak satisfaction.
Henry says to Jay, “Is there blood around?”
Gita Syal answers, “Plenty in the fridge.”
“Is the patient haemodynamically stable?”
“Blood pressure and pulse are OK. And pre-op bloods are fine, airway pressure's fine,” Jay says. “We're ready to roll, boss.”
Perowne takes a look at Baxter's head to make sure Rodney has shaved him in exactly the right place. The laceration is straight and clean—a wall, a skirting board, a stone-floor landing rather than the grit and filth you see in wounds after a road traffic accident—and has been sewn up by A and E. Even without touching, he can see that the top of his patient's head has an area of boggy swelling—blood is collecting between the bone and the scalp.
Satisfied with the registrar's work, he says to him as he leaves, “Take the sutures out while I scrub up.” Henry pauses in the corner to choose some piano music. He decides on the “Goldberg” Variations. He has four recordings here, and selects not the showy unorthodoxies of Glenn Gould, but Angela Hewitt's wise and silky playing which includes all the repeats.
Less than five minutes later, in long disposable gown, gloves and mask, he's back at the table. He nods at Gita to start the CD player. From the stainless-steel trolley Emily has positioned at his side, he takes a sponge on a clamp and dips it in a bowl of Betadine solution. The tender, wistful Aria begins to unfold and spread, hesitantly it seems at first, and makes the theatre seem even more spacious. At the very first stroke of sunflower yellow on pale skin, a familiar contentedness settles on Henry; it's the pleasure of knowing precisely what he's doing, of seeing the instruments arrayed on the trolley, of being with his firm in the muffled quiet of the theatre, the murmur of the air filtration, the sharper hiss of oxygen passing into the mask taped to Baxter's face out of sight under the drapes, the clarity of the overhead lights. It's a reminder from childhood of the closed fascination of a board game.
He sets down the brush and says quietly, “Local.”
Emily passes him the hypodermic she has prepared. Quickly he injects in several places under skin, along the line of the laceration and beyond. It's not strictly necessary, but the adrenaline in the lignocaine helps reduce the bleeding. At each location the scalp immediately swells into bumps. He sets down the hypodermic and opens his hand. He doesn't have to ask—Emily places within his grasp the nicely weighted skin knife. With it he extends the laceration by several inches, and deepens it. Rodney is close at his side with the bipolar cauteriser, closing off the bleeding points in two or three places. At each contact there is a bleep, and a thin trail of greyish smoke rises with a sharp odour of singed flesh. Despite his bulk, Rodney cleverly avoids crowding his consultant's space and applies the small blue Raney clips that pinch tightly on the parted skin and close off the blood supply.
Perowne asks for the first of the big self-retaining retractors and sets it in place. He lets Rodney attach the second—and now the long incision is stretched apart like a wide-open mouth to reveal the skull and all the damage.
The fracture runs fairly straight. Blood, altered blood, is rising up through it. Once Rodney has washed out the area with saline and wiped it, they can see the crack in the bone is about two millimetres wide—it looks like an earthquake fissure seen from the air, or a crack in a dry riverbed. The depressed fracture in the centre has two segments of bone at a tilt with three other finer cracks radiating from them. There'll be no need to drill a burr hole. Perowne will be able to slip the cutting saw into the larger fissure.
Emily presents the craniotome, but he doesn't like the look of the footpiece—it seems a little skewed. Joan hurries into the prep room and comes back with another. It's satisfactory, and while she u
npacks it from the sterile wrapping and fits it, he says to Rodney, “We'll turn a free flap around the depressed fracture so that we've got full control of the sinus.”
It's said that no one opens up faster than Henry Perowne. Now he goes even more quickly than usual because there's no danger of damaging the dura—the clot is pressing down on it, pushing it away from the skull. Although Rodney leans in with a Dakin's syringe to douse the cutting edge with saline solution, the smell of singed bone fills the theatre. It's a smell Henry sometimes finds clinging to the folds of his clothes when he undresses at the end of a long day. It's impossible to speak over the high-pitched whine of the craniotome. With his eyes he indicates to Rodney that he should observe closely. Exceptional care is needed now as he guides the saw across the midline. He slows, and tilts the footpiece of the drill upwards—otherwise there's a danger that it will catch and tear the sinus. It's a wonder brains come to any harm at all outside an operating theatre when they're encased so thickly in bone. At last Perowne has cut round a complete oval shape behind the crown of Baxter's head. Before he lifts the flap he examines the fragments of the depressed fracture. He asks for a Watson Cheyne dissector and levers them gently up. They come away easily and he puts them into the kidney bowl of Betadine that Emily offers.
Now, using the same dissector, he lifts the whole free flap away from the skull, a large piece of bone like a segment of coconut, and lays it in the bowl with the other bits. The clot is in full view, red of such darkness it is almost black, and of the consistency of recently set jam. Or, as Perowne sometimes thinks, like a placenta. But round the edges of the clot, blood is flowing freely now that the pressure of the bone flap has been relieved. It pours from the back of Baxter's head, over the surgical drapes and onto the floor.
“Elevate the head of the table. Give me as much as you can,” Henry calls to Jay. If the bleed is higher than the heart, the blood will flow less copiously. The table rises, and Henry and Rodney step back in quickly through the blood at their feet and, working together, use a sucker and an Adson elevator to remove the clot. They irrigate the area with saline and at last get a glimpse of the tear, about a quarter of an inch long, in the sinus. The bone flap was well placed—the damage is right in the centre of the exposure. The welling blood immediately obscures their view again. An edge of bone from the depressed fragment must have pierced the vessel. While Rodney holds the sucker in place, Perowne takes a strip of Surgicel and lays it over the tear, places a swab on top and indicates to Rodney to press down with his finger.
Henry asks Jay, “How much blood have we lost?”
He hears Jay ask Joan how much irrigation has been used. Together they make the calculation.
“Two point five litres,” the anaesthetist says quietly.
Perowne is about to ask for the periostal elevator, but Emily is already placing it in his hands. He finds an area of exposed but undamaged skull, and with the elevator—a kind of scraper—harvests two long pieces of pericranium, the fibrous membrane that covers the bone. Rodney lifts the swab, and is about to lift also the Surgicel from the tear, but Perowne shakes his head. A clot might be already forming and he doesn't want to disturb it. He gently lays the strip of pericranium over the Surgicel, and adds a second layer of Surgicel and the second strip of pericranium, and places a new swab on top. Then Rodney's finger. Perowne rinses out the area again with saline and waits. The opaque milky bluish dura remains clear. The bleeding has stopped.
But they can't begin to close up yet. Perowne takes a scalpel and makes a small incision in the dura, parts it a little and peers inside. The surface of Baxter's brain is indeed covered with a clot, much smaller than the first. He extends the incision and Rodney tucks back the dura with stay sutures. Perowne is pleased with the speed of his junior registrar's work. Rodney uses the Adson to lift out the congealed blood. They wash out with saline, sucker the mix away and wait to see if the bleeding continues—Perowne suspects that one of the nearby arachnoid granulations could be a source. There's nothing, but he doesn't close up just yet. He prefers to wait a few minutes, just to be sure.
In this lull, Rodney goes over to a table by the prep room door and sits down to drink a bottle of water. Emily is busy with the instrument tray, Joan is dealing with the wide pool of blood on the floor.
Jay breaks off a murmured conversation with his registrar to say to Perowne, “We're fine over here.”
Henry remains at the head of the table. Though he's been conscious of the music, only now does he give it his full attention again. Well over an hour has passed, and Hewitt is already at the final Variation, the Quodlibet—uproarious and jokey, raunchy even, with its echoes of peasant songs of food and sex. The last exultant chords fade away, a few seconds' silence, then the Aria returns, identical on the page, but changed by all the variations that have come before, still tender, but resigned too, and sadder, the piano notes floating in from a distance, as though from another world, and only slowly swelling. He's looking down at a portion of Baxter's brain. He can easily convince himself that it's familiar territory, a kind of homeland, with its low hills and enfolded valleys of the sulci, each with a name and imputed function, as known to him as his own house. Just to the left of the midline, running laterally away out of sight under the bone, is the motor strip. Behind it, running parallel, is the sensory strip. So easy to damage, with such terrible, lifelong consequences. How much time he has spent making routes to avoid these areas, like bad neighbourhoods in an American city. And this familiarity numbs him daily to the extent of his ignorance, and of the general ignorance. For all the recent advances, it's still not known how this well-protected one kilogram or so of cells actually encodes information, how it holds experiences, memories, dreams and intentions. He doesn't doubt that in years to come, the coding mechanism will be known, though it might not be in his lifetime. Just like the digital codes of replicating life held within DNA, the brain's fundamental secret will be laid open one day. But even when it has, the wonder will remain, that mere wet stuff can make this bright inward cinema of thought, of sight and sound and touch bound into a vivid illusion of an instantaneous present, with a self, another brightly wrought illusion, hovering like a ghost at its centre. Could it ever be explained, how matter becomes conscious? He can't begin to imagine a satisfactory account, but he knows it will come, the secret will be revealed—over decades, as long as the scientists and the institutions remain in place, the explanations will refine themselves into an irrefutable truth about consciousness. It's already happening, the work is being done in laboratories not far from this theatre, and the journey will be completed, Henry's certain of it. That's the only kind of faith he has. There's grandeur in this view of life.
No one else in the theatre knows the hopeless condition of this particular brain. The motor strip he's looking at now is already compromised by disease, most likely by deterioration in the caudate and putamen, deep in the centre of the brain. Henry places his finger on the surface of Baxter's cortex. He sometimes touches a brain at the beginning of a tumour operation, testing the consistency. What a wonderful fairy tale, how understandable and human it was, the dream of the healing touch. If it could simply be achieved with the caress of a forefinger, he'd do it now. But the limits of the art, of neurosurgery as it stands today, are plain enough: faced with these unknown codes, this dense and brilliant circuitry, he and his colleagues offer only brilliant plumbing.
Baxter's unmendable brain, exposed under the bright theatre lights, has remained stainless for several minutes—there's no sign of any bleeding from the arachnoid granulation.
Perowne nods at Rodney. “It's looking fine. You can close up.”
Because he's pleased with him, and wants him to feel better about the evening, Perowne lets his registrar take the lead. Rodney sews up the dura with purple thread—3-o Vicryl—and inserts the extradural drain. He replaces the bone flap, along with the two broken pieces from the depressed fracture. Then he drills the skull to screw in place the titanium plates
that hold the bone secure. This part of Baxter's skull now resembles crazy paving, or a broken china doll's head clumsily repaired. Rodney inserts the subgaleal drain and then sets about sewing the skin of the scalp with 2-o Vicryl and punching in the skin staples. Perowne gets Gita to put on Barber's “Adagio for Strings.” It's been played to death on the radio these past years, but Henry sometimes likes it in the final stages of an operation. This languorous, meditative music suggests a long labour coming to an end at last.
Rodney puts chlorhexadine on and around the wound and applies a small dressing. It's at this point that Henry takes over—he prefers to do the head dressing himself. He releases one by one the pins of the head-clamp. He takes three opened-out large gauze swabs and places them flat on Baxter's head. Around the head he lays two gauze swabs left long. Holding the five swabs in place with his left hand, he begins to wind a long crêpe bandage around Baxter's head while supporting it against his waist. It's technically and physically difficult, avoiding the two drains and preventing the head from dropping down. When at last the head bandage is in place and secured, everyone in the theatre, the whole firm, converges on Baxter—this is the stage at which the patient's identity is restored, when a small area of violently revealed brain is returned to the possession of the entire person. This unwrapping of the patient marks a return to life, and if he hadn't seen it many hundred times before, Henry feels he could almost mistake it for tenderness. While Emily and Joan are carefully pulling away the surgical drapes from around Baxter's chest and legs, Rodney makes sure the tubes, leads and drains are not dislodged. Gita is removing the pads taped over the patient's eyes. Jay is detaching the inflatable warming blanket from around Baxter's legs. Henry stands at the end of the table, cradling the head in his hands. The helpless body is revealed in a hospital gown and looks small on the table. The meditative, falling line of the orchestral strings seems to be addressed to Baxter alone. Joan pulls a cover over him. Taking care not to tangle the extradural and subgaleal drains, they turn Baxter onto his back. Rodney slots a padded horseshoe into the end of the table and Henry rests Baxter's head on it.
