Brain

Chapter 4

"Lisa Marino?" asked a voice, causing Lisa to open her eyes. Leaning over her was a nurse named Carol Bigelow, whose dark brown eyes were the only portion of her face visible. A flower-print hat contained her hair. Her nose and mouth were covered by a surgical mask.

Lisa felt her arm lifted and rotated so the nurse could read her identification bracelet. The arm was replaced and patted. "Are you ready for us to fix you up, Lisa Marino?" asked Carol, releasing the break mechanism on the gurney with her foot, and pulling the bed out from the wall.

"I don't know," admitted Lisa, trying to see up into the nurse's face. But Carol had turned away saying, "Sure you are," as she pushed the bed past the white Formica desk.

The automatic doors closed behind them as Lisa began her fateful journey down the corridor to OR #21. Neurosurgery was usually done in one of four rooms: Number 20, 21, 22, or 23. These rooms were fitted out with the special needs of brain surgery in mind. They had overhead mounted Zeiss operating microscopes, closed-circuit video systems with recording capabilities, and special OR tables. OR #21 also had a viewing gallery and was the favorite of Dr. Curt Mannerheim, Chief of Neurosurgery, and Chairman of the Department for the medical school.

Lisa had hoped that she'd be sleeping at this point, but such was not the case. If anything, she seemed particularly aware and all her senses sharp. Even the sterile chemical smell seemed exceptionally pungent to her. There was still time, she thought. She could get out of the bed and run. She didn't want to be operated on, especially not her head. In fact, anything but her head.

The movement stopped. Turning her gaze, she saw the nurse disappear around a corner. Lisa had been parked like a car at the side of a busy thoroughfare. A group of people passed her, transporting another patient who was retching. His chin was being held back by one of the orderlies pushing the bed, and his head was a bandaged nightmare.

Tears began to run down Lisa's cheeks. The patient reminded her of her own upcoming ordeal. Her central being was going to be rudely cracked open and violated. Not just a peripheral part of her, like a foot or an arm, but her head… where her personality and very soul resided. Would she be the same person afterward?

When Lisa had been eleven she'd had acute appendicitis. The operation had certainly seemed scary at the time, but nothing like what she was experiencing now. She was convinced that she was going to lose her identity if not her life. In either case, she was fragmenting, and the pieces were there for people to pick up and examine.

Carol Bigelow reappeared.

"Okay, Lisa, we're ready for you."

"Please," whispered Lisa.

"Come now, Lisa," said Carol Bigelow. "You wouldn't want Dr. Mannerheim to see you crying."

Lisa didn't want anyone to see her crying. She shook her head in response to Carol Bigelow's question, but her emotion switched to anger. Why was this happening to her? It wasn't fair. A year ago she'd been a normal college girl. She'd decided to major in English, hopefully to prepare for law school. She loved her literature courses and had been a superior student, at least until she'd met Jim Conway. She knew she'd let her studies go, but it had only been a month or so. Before meeting Jim she'd had sex on several occasions, but it had never been satisfying and she'd questioned why there was so much fuss about it. But with Jim it had been different. She knew immediately that with Jim, sex was the way it was supposed to be. And she hadn't been irresponsible. She did not believe in the Pill, but she'd made the effort to be fitted with a diaphragm. She could remember very distinctly how hard it had been for her to find the courage to make that first GYN clinic visit and go back when it was necessary.

The gurney moved into the operating room. It was completely square, about twenty-five feet on a side. The walls were constructed of gray ceramic tile up to the glass-faced gallery above. The ceiling was dominated by two large stainless steel operating room lights shaped like inverted kettle drums. In the center of the room stood the operating table. It was a narrow, ugly piece of equipment, reminding Lisa of an altar for some pagan rite. At one end of the table was a round piece of padding with a hole in the center, which Lisa instinctively knew was to hold her head. Totally out of keeping with the environment, the Bee Gees crooned from a small transistor radio in the corner.

"There now," said Carol Bigelow. "What I want you to do is slide over here onto the table."

"Okay," said Lisa. "Thank you." She was annoyed at her response. Thank you was the farthest thing from her mind. Yet she wanted the people to like her because she knew she depended on them to take care of her. Moving from the gurney to the operating table, Lisa held on to the sheet in a vain attempt to retain a modicum of dignity. Once on the table she lay still, staring up at the operating lights. Just to the side of the lights she recognized the glass partitions. Because of reflections, it was difficult to see through the glass, but then she saw the faces staring down at her. Lisa closed her eyes. She was a spectacle.

Her life had become a nightmare. Everything had been wonderful until that fateful evening. She had been with Jim and they both had been studying. Progressively, she had become aware that she was having difficulty reading, particularly when she came to a specific sentence beginning with the word "Ever." She was certain she knew the word but her mind refused to give it to her. She had to ask Jim. His response was a smile, thinking she was teasing. After she persisted, he told her "ever." Even after Jim had told her the word, when she looked at its printed form, it wouldn't come to her. She remembered feeling a powerful sense of frustration and fear. Then she began to smell the strange odor. It was a bad smell, and although she sensed she'd smelled it before, she could not say what it was. Jim denied smelling anything and that was the last thing Lisa remembered. What had followed was her first seizure. Apparently it had been awful, and Jim was shaking when she regained consciousness. She had struck him several times and scratched his face.

"Good morning, Lisa," said a pleasant male voice with an English accent. Looking up behind her, Lisa met the dark eyes of Dr. Bal Ranade, an Indian doctor who had trained at the university. "You remember what I told you last night?"

Lisa nodded. "No coughing or sudden movements," said Lisa, eager to please. She remembered Dr. Ranade's visit vividly. He'd appeared after her dinner, announcing himself as the anesthesiologist who was going to take care of her during her operation. He had proceeded to ask her the same questions about her health she'd answered many times before. The difference was that Dr. Ranade did not seem to be interested in the answers. His mahogany face did not change its expression, except when Lisa described her appendectomy at age eleven. Dr. Ranade nodded when Lisa said she'd had no trouble with the anesthesia. The only other information that interested him was her lack of allergic reaction. He nodded then too.

Usually Lisa preferred outgoing people. Dr. Ranade was the opposite. He expressed no emotion, just a quiet intensity. But for Lisa, under the circumstances this cool affectation was appropriate. She was glad to find someone for whom her ordeal was routine. But then Dr. Ranade had shocked her. In the same precise Oxford accent he said: "I presume that Dr. Mannerheim has discussed with you the anesthetic technique which will be used."

"No," said Lisa.

"That's odd," said Dr. Ranade at length.

"Why?" asked Lisa, sensing trouble. The idea that there could be any breakdown in communication was alarming. "Why is that odd?"

"We usually use a general anesthesia for craniotomy," said Dr. Ranade. "But Dr. Mannerheim has informed us that he wants local anesthesia."

Lisa had not heard her operation described as a craniotomy. Dr. Mannerheim had said that he was going to "turn a flap" and make a small window in her head so that he could remove the damaged part of her right temporal lobe. He'd told Lisa that somehow, a part of Lisa's brain had been damaged, and it was that section that was causing her seizures. If he could take just the damaged part out the seizures would stop. He'd done almost a hundred such operations with wonderful results. At the time Lisa had been ecstatic because up until Dr. Mannerheim all she could get from her doctors was compassionate head shaking.

And the seizures were horrible. Usually she knew when they were coming because she would smell the strangely familiar odor. But sometimes they came without warning, descending on her like an avalanche. Once in a movie theater, after she'd been given a long course of heavy medication and assurances that the problem was under control, she smelled the horrid odor. In a panic she'd jumped up, stumbled to the aisle, and ran back toward the lobby. At that point she became unaware of her actions. Later she "came to" propped up against the lobby wall by the candy machine, with her hand between her legs. Her clothes were partially off, and like a cat in heat, she'd been masturbating. A group of people was staring at her as if she were a freak, including Jim, whom she'd punched and kicked. Later she learned she'd assaulted two girls, injuring one enough to be hospitalized. At the time she'd "come to" all she could do was close her eyes and cry. Everyone was afraid to come near her. In the distance she remembered hearing the sound of the ambulance. She thought that she was going insane.

Lisa's life had come to a standstill. She wasn't insane, but no medication controlled her seizures. So when Dr. Mannerheim appeared, he seemed like a savior. It wasn't until Dr. Ranade's visit that she began to comprehend the reality of what was going to happen to her. After Dr. Ranade, an orderly had arrived to shave her head. From that moment on, Lisa had been frightened.

"Is there some reason why he wants local anesthesia?" asked Lisa. Her hands had begun to tremble. Dr. Ranade had thought carefully about his answer.

"Yes," he said finally, "he wants to locate the diseased part of your brain. He needs your help."

"You mean, I'll be awake when…" Lisa didn't finish her sentence. Her voice had trailed off. The idea seemed preposterous.

"That's correct," said Dr. Ranade.

"But he knows where the diseased part of my brain is," protested Lisa.

"Not well enough. But don't worry. I'll be there. There'll be no pain. All you have to remember is no coughing and no sudden movements."

Lisa's reverie was cut short by a feeling of pain in her left forearm. Looking up she could see tiny bubbles rising up in a bottle over her head. Dr. Ranade had started the IV. He did the same thing in her right forearm, threading into her a long thin plastic tube. Then he adjusted the table so that it tilted slightly downward.

"Lisa," said Carol Bigelow. "I'm going to catheterize you."

Picking up her head, Lisa looked down. Carol was busy unwrapping a plastic covered box. Nancy Donovan, another scrub nurse, pulled back Lisa's sheet exposing her from the waist down.

"Catheterize?" questioned Lisa.

"Yes," said Carol Bigelow, pulling on loose rubber gloves. "I'm going to put a tube into your bladder."

Lisa allowed her head to fall back. Nancy Donovan grasped Lisa's legs and positioned them so that the soles of her feet were together while her knees were widely apart. She lay exposed for the world to see.

"I'm going to be giving you a medicine called mannitol," explained Dr. Ranade. "It causes you to make a lot of urine."

Lisa nodded as if she understood while she felt Carol Bigelow begin to scrub her genitals.

"Hi, Lisa, I'm doctor George Newman. Do you remember me?"

Opening her eyes, Lisa gazed into another masked face. These eyes were blue. On the other side of her was another face with brown eyes.

"I'm the Chief Resident in Neurosurgery," said Dr. Newman, "and this is Dr. Ralph Lowry, one of our Junior Residents. We'll be helping Dr. Mannerheim as I explained to you yesterday."

Before Lisa could respond she felt a sudden sharp pain between her legs, followed by a curious fullness in her bladder. She took a breath. She felt tape being placed on the inner part of her thigh.

"Just relax now," said Dr. Newman without waiting for her to respond. "We'll have you fixed up in no time." The two doctors directed their interest to the series of X rays that lined the back walls.

The pace in the OR quickened. Nancy Donovan appeared with a steaming stainless steel tray of instruments, and with a bud crash she heaved it on top of a nearby table. Darlene Cooper, another scrub nurse, who was already gowned and gloved, reached into the sterile instruments and began to arrange them on a tray. Lisa turned her head when she saw Darlene Cooper lift out a large drill.

Doctor Ranade wrapped a blood pressure cuff around Lisa's right upper arm. Carol Bigelow exposed Lisa's chest and taped on EKG leads. Soon the sonar-like beeps from the cardiac monitor competed with John Denver on the transistor.

Dr. Newman came back from studying the X rays and positioned Lisa's shaved head. With his pinky on her nose and his thumb on the top of her head, he drew a line with a marking pen. The first line went from ear to ear over the top of her head. The second line bisected this one, starting at the middle of the forehead and extending back to the occipital area. "Now, Lisa, turn your head to the left," said Dr. Newman. Lisa kept her eyes closed. She felt a finger palpate the ridge of bone that ran back from her right eye toward her right ear. Then she felt the marking pen trace a looping line that began at her right temple and arched upward and backward ending behind her ears. The line defined a horseshoe-shaped area with Lisa's ear at its base. This was to be the flap that Dr. Mannerheim had described.

An unexpected drowsiness coursed through Lisa's body. It felt like the air in the room had become viscous and her extremities leaden. It took great effort for her to open her eyelids. Dr. Ranade smiled down at her. In one hand was her IV line; in the other hand a syringe.

"Something to relax you," said Dr. Ranade. Time became discontinuous. Sounds drifted in and out of her consciousness. She wanted to fall asleep but her body involuntarily fought against it. She felt herself being turned half on her side with her right shoulder elevated and supported by a pillow. With a sense of detachment she felt both wrists bound to a board that stuck out at right angles from the operating table. Her arms felt so heavy she couldn't have moved them anyway. A leather cinch went around her waist securing her body. She felt her head scrubbed and painted. There were several sharp needles accompanied by fleeting pain before her head was clamped in some sort of vise. Despite herself, Lisa fell asleep.

Sudden intense pain awoke her with a start. She had no idea how much time had passed. The pain was located above her right ear. It occurred again. A cry issued from her mouth and she tried to move. Except for a tunnel of cloth directly in front of her face. Lisa was covered with layers of surgical drapes. At the end of the tunnel, she could see Dr. Ranade's face.

"Everything is fine, Lisa," said Dr. Ranade. "Don't move now. They are injecting the local anesthetic. You'll only feel it for a moment."

The pain occurred again and again. Lisa felt like her scalp was going to explode. She tried to lift her arms only to feel the cloth restraints. "Please," she shouted, but her voice was feeble.

"Everything is fine, Lisa. Try to relax."

The pain stopped. Lisa could hear the doctors breathing. They were directly over her right ear.

"Knife," said Dr. Newman.

Lisa cringed. She felt pressure, like a finger being pressed against her scalp and rotated around the line drawn by the marking pen. She could feel warm fluid on her neck through the drapes.

"Hemostats," said Dr. Newman. Lisa could hear sharp metallic snaps.

"Raney clips," said Dr. Newman. "And call Mannerheim. Tell him we'll be ready for him in thirty minutes."

Lisa tried not to think about what was happening to her head. Instead she thought about the discomfort in her bladder.'

She called to Dr. Ranade and told him she had to urinate.

"You have a catheter in your bladder," said Dr. Ranade.

"But I have to urinate," said Lisa.

"Just relax, Lisa," said Dr. Ranade. "I'll give you a little more sleep medicine."

The next thing Lisa was conscious of was the high-pitched whine of a gas-powered motor combined with a sense of pressure and vibration on her head. The noise was frightening because she knew what it meant. Her skull was being opened by a saw; she didn't know it was called a craniotome. Thankfully there was no pain, although Lisa braced for it to occur at any moment. The smell of scorched bone penetrated the gauze drapes over her face. She felt Dr. Ranade's hand take hers, and she was thankful for it. She pressed it as if it were her only hope of survival.

The sound of the craniotome died. The rhythmic beeping of the cardiac monitor emerged from sudden stillness. Then Lisa felt pain again, this time more like the discomfort of a localized headache. Dr. Ranade's face appeared at the end of her tunnel of vision. He watched her as she felt the blood pressure cuff inflate.

"Bone forceps," said Dr. Newman.

Lisa heard and felt bone crunching. It sounded very close to her right ear.

"Elevators," said Dr. Newman.

Lisa felt several more twinges, followed by what seemed to her a loud snap. She knew her head was open.

"Damp gauze," said Dr. Newman, in a matter-of-fact voice.

While still scrubbing his hands, Dr. Curt Mannerheim leaned over to look through the door into OR #21 and see the clock on the far wall. It was almost nine o'clock. At that moment, he saw his chief resident, Dr. Newman, step back from the table. The resident crossed his gloved hands on his chest, and walked over to study the X rays arranged on the view box. That could mean only one thing. The craniotomy was done and they were ready for the Chief. Dr. Mannerheim knew he didn't have much time to spare. The investigation committee from the N.I.H. was due to arrive at noon. What was at stake was a twelve-million-dollar research grant that would support his research activities for the next five years. He had to get that grant. If he didn't, he might lose his entire animal lab, and with it, the results of four years of work. Mannerheim was certain he was on the brink of finding the exact spot in the brain responsible for aggression and rage.

Rinsing the suds, Mannerheim caught sight of Lori Mclnter, the Assistant Director of the OR. He shouted her name and she stopped in her tracks.

"Lori, dear! I've got two Jap doctors here from Tokyo.

Could you send someone into the lounge to make sure they find scrub clothes and all that?"

Lori McInter nodded, although she indicated she wasn't pleased at the request. Mannerheim's shouting in the corridor irritated her.

Mannerheim caught the silent rebuke and cursed the nurse under his breath. "Women," he muttered. To Mannerheim, nurses were becoming more and more a pain in the ass.

Mannerheim burst into the OR like a bull into the ring. The congenial atmosphere changed instantly. Darlene Cooper handed him a sterile towel. Drying one hand, then the other, and working down his forearms, Mannerheim bent over to look at the opening in Lisa Marino's skull.

"God damn it, Newman," snarled Mannerheim, "when are you going to learn to do a decent craniotomy? If I've told you once, I've told you a thousand times to bevel the edges more. Christ! This is a mess."

Under the drapes Lisa felt a new surge of fear. Something had gone wrong with her operation.

"I…" began Newman.

"I don't want to hear a single excuse. Either you do it properly or you'll be looking for another job. I got some Japs coming in here and what are they going to think when they see this?"

Nancy Donovan was standing at his side to take the towel, but Mannerheim preferred to throw it on the floor. He liked to create havoc and, like a child, demanded total attention where-ever he was. And he got it. He was considered technically one of the best neurosurgeons in the country, if not the fastest. In his own terms he said, "Once you get into the head, there's no time to pussyfoot around." And with his encyclopedic knowledge of the intricacies of human neuroanatomy, he was superbly efficient.

Darlene Cooper held open the special brown rubber gloves that Mannerheim demanded. As he thrust in his hands, he looked into her eyes.

"Ahhh," he cooed, as if he were experiencing orgastic pleasure from inserting his hands. "Baby, you're fabulous."

Darlene Cooper avoided looking into Mannerheim's gray blue eyes, as she handed him a damp towel to wipe off the powder on the gloves. She was accustomed to his comments, and from experience she knew that the best defense was to ignore him.

Positioning himself at the head of the table with Newman on his right and Lowry on his left, Mannerheim looked down on the semi-transparent dura covering Lisa's brain. Newman had carefully placed sutures through partial thickness of the dura and had anchored them to the edge of the craniotomy site. These sutures held the dura tightly up to the inner surface of the skull.

"All right, let's get this show on the road," said Mannerheim. "Dural hook and scalpel." The instruments were slapped into Mannerheim's hand.

"Easy, baby," said Mannerheim. "We're not on TV. I don't want to feel pain each time I ask for an instrument."

He bent over and deftly tented up the dura with the hook. With the knife he made a small opening. A pinkish gray mound of naked brain could be seen through the hole.

Once under way, Mannerheim became completely professional. His relatively small hands moved with economical deliberation, his prominent eyes never wavering from his patient. He was a physical person with extraordinary eye-hand control. The fact that he was short, five-foot-seven-inches, was a constant source of irritation to him. He felt he'd been cheated of the extra five inches to match his intellectual height, but he kept in excellent condition and looked much younger than his sixty-one years.

With small scissors and cottonoid strips, which he inserted between the dura and the brain for protection, Mannerheim opened up the covering over Lisa's brain to the extent of the bony window. Using his index finger he gently palpated Lisa's temporal lobe. With his experience the slightest abnormality could be detected. For Mannerheim, this intimate interaction between himself and a live pulsating human brain was the apotheosis of his existence. During many operations, the sheer excitement made him sexually erect. "Now let's have the stimulator and the EEG leads," he said.

Dr. Newman and Dr. Lowry wrestled with the profusion of tiny wires. Nancy Donovan, as his circulating nurse, took the appropriate leads when the doctors handed them to her and plugged them into the nearby electrical consoles. Dr. Newman carefully placed the wick electrodes in two parallel rows. One along the middle of the temporal lobe and the other above the Sylvian vein. The flexible electrodes with the silver balls went under the brain. Nancy Donovan threw a switch and an EEG screen next to the cardiac monitor came alive with fluorescent blips tracing erratic lines.

Dr. Harata and Dr. Nagamoto entered the OR. Mannerheim was pleased not so much because the visitors might learn something, but because he loved an audience.

"Now look," said Mannerheim, gesturing, "there's a lot of bullshit in the literature about whether you should take the superior part of the temporal lobe out during a temporal lobectomy. Some doctors fear it might affect the patient's speech. The answer is, test it."

With an electrical stimulator in his hand like an orchestral baton, Mannerheim motioned to Dr. Ranade, who bent down and lifted up the drape. "Lisa," he called.

Lisa opened her eyes. They reflected the bewilderment from the conversation she'd been overhearing.

"Lisa," said Dr. Ranade. "I want you to recite as many nursery rhymes as you can."

Lisa complied, hoping that by helping the whole affair would soon be over. She started to speak, but as she did so Dr. Mannerheim touched the surface of her brain with the stimulator. In mid-word her speech stopped. She knew what she wanted to say, but couldn't. At the same time she had a mental image of a person walking through a door.

Noting the interruption in Lisa's speech, Mannerheim said, "There's your answer! We don't take the superior temporal gyrus on this patient."

The heads of the Japanese visitors bobbed in understanding.

"Now for the more interesting part of this exercise," said Mannerheim, taking one of the two depth electrodes he'd gotten from Gibson Memorial Hospital. "By the way, somebody call X ray. I want a shot of these electrodes so we'll know later where they were."

The rigid needle electrodes were both recording and stimulating instruments. Prior to having them sterilized, Mannerheim had marked off a point on the electrodes four centimeters from the needle tip. With a small metal ruler he measured four centimeters from the front edge of the temporal lobe. Holding the electrode at right angles to the surface of the brain, Mannerheim pushed it in blindly and easily to the four-centimeter mark. The brain tissues afforded minimal resistance. He took the second electrode and inserted it two centimeters posterior to the first. Each electrode stuck out about five centimeters from the surface of the brain.

Fortunately, Kenneth Robbins, the Chief Neuroradiology X-ray technician, arrived at that moment. If he had been late Mannerheim would have thrown one of his celebrated fits. Since the operating room was outfitted to facilitate X ray, the chief technician needed only a few minutes to take the two shots.

"Now," said Mannerheim, glancing up at the clock and realizing he was going to have to speed things up. "Let's stimulate the depth electrodes and see if we can generate some epileptic brain waves. It's been my experience that if we can, then the chances of the lobectomy helping the seizure disorder are just about one hundred percent."

The doctors regrouped around the patient. "Dr. Ranade," said Mannerheim. "I want you to ask the patient to describe what she feels and thinks after the stimulus."

Dr. Ranade nodded, then disappeared under the edge of the drapes. When he reappeared he indicated to Mannerheim to proceed.

For Lisa the stimulus was like a bomb blast without sound or pain. After a blank period that could have been a fraction of a second or an hour, a kaleidoscope of images merged into the face of Dr. Ranade at the end of a long tunnel. She didn't recognize Dr. Ranade nor did she know where she was. All she was aware of was the terrible smell that heralded her seizures. It terrified her.

"What did you feel?" asked Dr. Ranade.

"Help me," cried Lisa. She tried to move but felt the restraints. She knew the seizure was coming. "Help me."

"Lisa," said Dr. Ranade, becoming alarmed, "Lisa, everything is all right. Just relax."

"Help me," cried Lisa as she lost control of her mind. The fixation of her head held, as did the leather strap at her waist. All her strength concentrated into her right arm, which she pulled with enormous force and suddenness. The wrist restraint snapped and her free arm arched up through the drapes.

Mannerheim was mesmerized by the abnormal recordings on the EEG when he saw Lisa's hand out of the corner of his eye. If he had only reacted faster he might have been able to avoid the incident. As it was, he was so startled that for a moment he was incapable of reacting. Lisa's hand, flailing wildly to free her body imprisoned by the OR table, hit the protruding electrodes and drove them straight into her brain.

Philips was on the phone with a pediatrician named George Rees when Robbins knocked and opened the door. Philips waved the technician into his office while he finished his conversation. Rees was inquiring about a skull X ray on a two-year-old male child who was supposed to have fallen down stairs. Martin had to tell the pediatrician that he suspected child abuse because of the old rib fractures he'd seen on the patient's chest X ray. It was sticky business, and Philips was glad to hang up.

"What have you got?" Philips asked Robbins, swinging around on his seat. Robbins was the Chief Neuroradiology technician whom Philips had recruited, and there was a special rapport between the two men.

"Just the localization films you asked me to do for Mannerheim."

Philips nodded as Robbins snapped them up on Philips' viewer. Normally the chief technician didn't leave the department to take X rays, but Philips had asked him to attend personally to Mannerheim just to avoid any trouble.

Lisa Marino's operative X rays lit up on the screen. The lateral film showed a polyhedral lucency where the bone flap had been cut. Within this sharply defined area were the bright white silhouettes of the numerous electrodes. The long needle-like depth electrodes Mannerheim had pushed into Lisa Marino's temporal lobe were the most apparent, and it was the position of these instruments that interested Philips. With his foot, Philips activated the motor on a wall-sized X ray viewer called an alternator. As long as he held his foot on the pedal, the screen in front of him changed. The unit could be loaded with any number of films for him to read. Philips kept the machine running until he found the screen containing Lisa Marino's previous X rays.

By comparing the new films with the old, Philips could determine the exact location of the deep electrodes.

"Gees," said Philips. "You take beautiful X rays. If I could clone you, half of my problems would be over."

Robbins shrugged as if he didn't care, but the compliment pleased him. Philips was a demanding but appreciative boss.

Martin used a finely calibrated ruler to measure distances associated with minute blood vessels on the older X rays. With his knowledge of the anatomy of the brain and the usual location of these blood vessels, he could form in his mind a three-dimensional image of the area he was interested in. Translating this information to the new films gave him the position of the tips of the electrodes.

"Amazing," said Philips, leaning back. "Those electrodes are positioned perfectly. Mannerheim is fantastic. If only his judgment equaled his technical skill."

"Do you want me to take these films back to the OR?" asked Robbins.

Philips shook his head. "No, I'll take them myself. I want to talk to Mannerheim. I'm going to take some of these older films as well. The position of this posterior cerebral artery bothers me a little." Philips picked up the X rays and headed for the door.

Although the situation in OR #21 had returned to a semblance of normality, Mannerheim was furious about the accident. Even the presence of the foreign visitors did not temper his anger. Newman and Lowry suffered the greatest abuse. It was as if Mannerheim felt they had deliberately schemed to cause the problem.

He had started the temporal lobectomy as soon as Ranade had inducted Lisa under general endotracheal anesthesia. There had been a panic immediately after Lisa's seizure although everyone acted superbly. Mannerheim had succeeded in grabbing Lisa's flailing hand before any more damage had been done. Ranade, the real hero, had reacted instantly, injecting a sleep dose of one hundred and fifty milligrams of thiopental IV, followed by a muscle paralyzer called d-tubocurarine. These drugs had not only put Lisa to sleep, but had also terminated the seizure. Within only a few minutes Ranade had placed the endotracheal tube, started the nitrous oxide, and positioned his monitoring devices.

Meanwhile, Newman had extracted the two inadvertently deeply embedded electrodes while Lowry removed the other surface electrodes. Lowry also had placed moist cottonoid over the exposed brain before covering the site with a sterile towel. The patient had been redraped and the doctors regowned and gloved. Everything had returned to normal except Manner-beim's mood.

"Shit," said Mannerheim, straightening up to relieve the tension in his back. "Lowry, if you'd rather do something else when you grow up, tell me. Otherwise hold the retractors so I can see." From Lowry's position the resident could not see what he was doing.

The door to the OR opened, and Philips entered, carrying the X rays.

"Watch out," whispered Nancy Donovan. "Napoleon is in a foul mood."

"Thanks for the warning," said an exasperated Philips. It irritated him that everyone tolerated Mannerheim's adolescent personality, no matter how good a surgeon he was. He put the X rays up on the viewer, aware that Mannerheim had seen him. Five minutes passed before Philips realized that Mannerheim was deliberately ignoring him.

"Dr. Mannerheim," Martin called over the sound of the cardiac monitor.

All eyes turned as Mannerheim straightened up, shifting his head so that the beam of his miner-like head lamp fell directly on the radiologist's face.

"Perhaps you don't realize that we are doing brain surgery here and maybe you shouldn't interrupt," Mannerheim said with controlled fury.

"You ordered localization X rays," said Philips calmly, "and I feel it is my duty to provide the information."

"Consider your duty done," said Mannerheim, looking back into his expanding incision.

Philips' real concern was not the electrodes' positions, because he knew they were perfect. It was the orientation of the posterior or hippocampal electrode in relation to the formidable posterior cerebral artery. "There's something else," said Martin.

Mannerheim's head shot up. The beam of light from his head strafed the wall, then the ceiling, while his voice lashed out like a whip. "Dr. Philips, would you mind taking yourself and your X rays out of here so that we can finish the operation? When we need your help, we'll ask for it."

Then in a normal voice, he asked the scrub nurse for some bayonet forceps and went back to work.

Martin calmly took his X rays down and left the OR. Changing back to his street clothes in the locker room, he tried not to think too much; it was easier on his mood. Heading back to Radiology, he allowed himself to ponder about the conflict in his sense of responsibility that the incident evoked. Dealing with Mannerheim called on resources he never imagined he'd need as a radiologist. He hadn't resolved anything when he arrived back at the department.

"They are ready for you in the angiography room," said Helen Walker when he reached his office. She stood up and followed him inside. Helen was an extremely gracious thirty-eight-year-old black woman from Queens who had been Philips' secretary for five years. They had a wonderful working relationship. It terrorized Philips to think of her ever leaving, because like any good secretary she was instrumental in running Philips' day-to-day life. Even Philips' current wardrobe was the result of her efforts. He would have still been wearing the same boxy clothes he'd worn in college if Helen hadn't teased him into meeting her in Bloomingdale's one Saturday afternoon. The result had been a new Philips, and the contemporary fitted clothes suited his athletic body. "

Philips tossed Mannerheim's X rays onto his desk, where they merged with the other X rays, papers, journals and books. It was one place Philips forbade Helen to touch. No matter what his desk looked like he knew where everything was.

Helen stood behind him reading a steady stream of messages she felt obligated to tell him. Dr. Rees had called asking about the CAT scan on his patient, the X ray unit in the second angiography room had been fixed and was functioning normally, the emergency room called saying that they were expecting a severe head injury that was going to need an emergency CAT scan. It was endless and it was routine. Philips told her to handle everything, which was what she'd planned to do anyway, and she disappeared back to her desk.

Philips removed his white coat and put on the lead apron he wore during certain X-ray procedures to protect himself from the radiation. The bib of the apron was distinguished by a faded Superman monogram, which had resisted all attempts at removal. It had been drawn there in jest two years previously by the neuroradiology fellows. Knowing the gesture had been made out of respect, Martin had not been annoyed.

As he was about to leave, his eyes swept across the surface of his desk for a reassuring glimpse of the program cassette, just to make certain he hadn't fantasized Michaels' news. Not seeing it, Martin walked over to shuffle through the more recent layers of debris. He found the cassette under Mannerheim's X rays. Philips started to leave, but again stopped. He picked up the cassette and Lisa Marino's latest lateral skull X ray. Yelling through the open door for Helen to tell the angio room he'd be right there, he walked over to his worktable.

He took off his lead apron and draped it over a chair. He stared at the computed prototype, wondering if it would really work. Then he held up Lisa Marino's operative X ray to the light that came from the banks of viewing screens. He wasn't interested in the electrode silhouettes and his mind eliminated them. What interested Philips was what the computer would say about the craniotomy. Philips knew they had not included the procedure in the program.

He flipped the switch on the central processor. A red light came on and he slowly inserted the cassette. He got it three-quarters of the way in, when the machine swallowed it like a hungry dog. Immediately the typewriter unit came alive. Philips moved over so he could read the output.

Hi! I am Radread, Skull I. Please enter patient name.

Philips pecked out "Lisa Marino" with his two index fingers and entered it.

Thank you. Please enter presenting complaint.

Philips typed: "seizure disorder," and entered that.

Thank you. Please enter relevant clinical information.

Philips typed: "21-year female, one year history of temporal lobe epilepsy."

Thank you. Please insert film in laser scanner.

Philips went over to the scanner. The rollers within the lips of the insertion slot were moving. Carefully Philips lined up the X ray with its emulsion side down. The machine grabbed it and pulled it inside. The output typewriter activated. Philips walked over. It said: Thank you. Have a cup of coffee. Philips smiled. Michaels' sense of humor emerged when least expected.

The scanner emitted a slight electrical buzz; the output device stayed silent. Philips grabbed his lead apron and left the office.

There was silence in OR #21 as Mannerheim mobilized Lisa's right temporal lobe and slowly lifted it from its base. A few small veins could be seen linking the specimen to the venous sinuses, and Newman skillfully coagulated and divided them. At last it was free, and Mannerheim lifted the piece of the brain out of Lisa's skull and dropped it into a stainless steel dish held by Darlene Cooper, the scrub nurse. Mannerheim looked up at the dock. He was doing fine. As the operation had progressed, Mannerheim's mood had changed again. Now he was euphoric and justly pleased with his performance. He'd done the procedure in half the usual time. He was certain he'd be in his office at noon.

"We're not quite finished," said Mannerheim, taking the metal sucker in his left hand and forceps in his right. Carefully he worked over the site where the temporal lobe had been, sucking out more brain tissue. He was removing what he called the deeper nuclei. This was probably the riskiest part of the procedure, but it was the part Mannerheim liked the best. With supreme confidence he guided the sucker, avoiding vital structures.

At one point a large globule of brain tissue momentarily blocked the opening of the sucker. There was a slight whistling noise, before the piece of tissue whooshed up the tube. "There go the music lessons," said Mannerheim. It was a common neurosurgical quip, but coming from Mannerheim after all the tension he'd caused, it was funnier than usual. Everyone laughed, even the two Japanese doctors.

As soon as Mannerheim had finished removing brain tissue, Ranade slowed the ventilation of the patient. He wanted to let Lisa's blood pressure rise a little while Mannerheim inspected the cavity for any bleeding. After a careful check Mannerheim was satisfied the operative site was dry. Taking a needle holder he began to close the dura, the tough covering over the brain. At that point, Ranade began carefully to lighten Lisa's anesthesia. When the case was over he wanted to be able to remove the tube in Lisa's trachea without her coughing, or straining. This required a delicate orchestration of all the drugs he'd been using. It was imperative that Lisa's blood pressure not go up.

The dural closure went swiftly and with a deft rotation of his wrist, Mannerheim placed the last interrupted stitch. Lisa's brain was again covered, although the dura dipped down and was darker where Lisa's temporal lobe had been. Mannerheim cocked his head as he admired his handiwork, then stepping back, he snapped off his rubber gloves. The sound echoed in the room.

"All right," said Mannerheim, "close her up. But let's not make it your life's work."

Motioning for the two Japanese doctors to come with him, Mannerheim left the room.

Newman took Mannerheim's position at Lisa's head. "Okay, Lowry," said Newman, echoing his boss, "let's see if you can help me rather than hinder me."

After dropping the bone flap into place like the top of a Halloween pumpkin and tying the sutures, Newman was ready to close. With a pair of rugged tooth forceps, he grabbed hold of the edge of Lisa Marino's wound and partially everted it. Then he plunged the needle deep into the skin of the scalp, making sure he picked up pericranium, and brought the needle out in the wound. Detaching the needle holder from its original position on the shank of the needle, he used the instrument to grab the needle tip, bringing the suture out into the wound; With essentially the same technique, he put the silk through the other side of the wound, trailing the suture off into Dr. Lowry's waiting hand so he could tie the stitch. They repeated this procedure until the wound was closed with black sutures, giving the impression of a large zipper on the side of Lisa's head.

During this part of the procedure, Dr. Ranade was still ventilating Lisa by compressing a breath bag. As soon as the last stitch was to be placed, he planned to give Lisa one hundred percent oxygen and reverse the remaining muscle paralyzer her body hadn't metabolized. On schedule his hand again compressed the breathing bag, but this time his experienced fingers detected a subtle change from the previous compression. Over the last few minutes Lisa had begun to make initial efforts to breathe on her own. Those efforts had provided a certain resistance to ventilating her. That resistance had been gone on the last compression. Watching the breathing bag and listening with his esophageal stethoscope, Ranade determined that Lisa had suddenly stopped trying to breathe. He checked the peripheral nerve stimulator. It told him the muscle paralyzer was wearing off on schedule. But why wasn't she breathing? Ranade's pulse increased. For him anesthesia was like standing on a secure but narrow ledge on the side of a precipice.

Quickly, Ranade determined Lisa's blood pressure. It had risen to 150 over 90. During the operation it had been stable at 105 over 60. Something was wrong!

"Hold up," he said to Dr. Newman, his eyes darting to the cardiac monitor. The beats were regular but slowing with longer pauses between the spikes.

"What's wrong?" asked Dr. Newman, sensing the anxiety in Dr. Ranade's voice.

"I don't know." Dr. Ranade checked Lisa's venous pressure while preparing to inject a drug called nitroprusside to bring down her blood pressure. Up to this point Dr. Ranade believed the variation in Lisa's vital signs was a reflection of her brain responding to the insult of surgery. But now he began to fear hemorrhage! Lisa could be bleeding and the pressure in her head could be going up. That would explain the sequence of signs. He took the blood pressure again. It had risen to 170 over 100. Immediately he injected the nitroprusside. As he did so, he felt that unpleasant sinking feeling in his abdomen associated with terror.

"She might be hemorrhaging," he said, bending down to lift Lisa's eyelids. What he saw was what he'd feared. The pupils were dilating. "I'm sure she's hemorrhaging," he yelled.

The two residents stared at each other over the patient. Their thoughts were the same. "Mannerheim's going to be furious," said Dr. Newman. "We better call him. Go ahead," he said to Nancy Donovan. "Tell him it's an emergency."

Nancy Donovan dashed over to the intercom and called out to the front desk.

"Should we open her back up?" asked Dr. Lowry.

"I don't know," said Newman nervously. "If she's hemorrhaging inside her brain it would be better to get an emergency CAT scan. If she's bleeding into the operative site, then we have to open her up."

"Blood pressure still rising," said Dr. Ranade with disbelief as he watched his gauge. He prepared to give her more medication to bring the blood pressure down.

The two residents remained motionless.

"Blood pressure still rising," shouted Dr. Ranade. "Do something, for Christ sake!"

"Scissors," barked Dr. Newman. They were slapped into his hand and he cut the sutures he'd just finished placing. The wound spontaneously gaped open as he got to the end of the incision. As he pulled the scalp flap back, the section of skull they'd removed for the craniotomy pushed up at them. It seemed to be pulsating.

"Let me have the four units of blood that's on call," shouted Dr. Ranade.

Dr. Newman cut the two hitch sutures holding the bone flap in place. The piece of bone fell to the side before Dr. Newman picked it up. The dura was bulging out with an ominous dark shadow.

The OR door burst open and Dr. Mannerheim came flying in, his scrub shirt was unbuttoned save for the bottom two.

"What the hell's going on?" he shouted. Then he caught sight of the pulsating and bulging dura. "Jesus Christ! Gloves! Let me have gloves!"

Nancy Donovan started to open a new pair of gloves, but Mannerheim snatched them away from her and pulled them on without scrubbing.

As soon as a few sutures were cut, the dura burst open, and bright red blood squirted out over Mannerheim's chest. It soaked him as he blindly cut the rest of the sutures. He knew he had to find the source of the bleeding.

"Sucker," yelled Mannerheim. With a rude sound, the machine began to draw off the blood. Immediately it became apparent that the brain had shifted or swelled because Mannerheim quickly encountered the brain itself.

"The blood pressure is falling," said Ranade.

Mannerheim yelled for a brain retractor to help him try to see the base of the operative site, but blood welled up the moment he took the sucker away.

"Blood pressure…" said Dr. Ranade, pausing. "Blood pressure unobtainable."

The sound of the cardiac monitor, which had been so constant during the operation, slowed to a painful pulse, then stopped.

"Cardiac arrest!" shouted Dr. Ranade.

The residents whipped up the heavy surgical drapes, exposing Lisa's body and covering her head. Newman climbed up on the stool next to the OR table and began cardiac resuscitation by compressing Lisa's sternum. Dr. Ranade, having obtained the blood, hung it up. He'd opened all his IV lines, running fluid into Lisa as fast as possible.

"Stop," yelled Mannerheim, who'd stepped back from the OR table when Dr. Ranade had shouted cardiac arrest. With a feeling of utter frustration, Mannerheim threw the brain retractor to the floor.

He stood there for a moment, his arms at his sides with blood and bits of brain dripping from his fingers. "No more! It's no use," he said finally. "Obviously some major artery gave way. It must have been from the God-damned patient pushing in those electrodes. Probably transected an artery and put it into spasm, which was camouflaged by the seizure. When the spasm relaxed it blew. There's no way you can resuscitate this patient."

Grabbing his scrub pants before they fell, Mannerheim turned to leave. At the door he looked back at the two residents. "I want you to close her up again as if she were still alive. Understand?"