Saturday (2 page)

By means of balancing and doubling, he was able to perform major surgery in one theatre, supervise a senior registrar in another, and perform minor procedures in a third. He has two neurosurgical registrars in his firm at present - Sally Madden who is almost qualified and entirely reliable, and a year-two registrar, Rodney Browne from Guyana, gifted, hardworking, but still unsure of himself. Perowne's consultant anaesthetist, Jay Strauss, has his own registrar, Gita Syal. For three days, keeping Rodney at his side, Perowne moved between the three suites - the sound of his own clogs on the corridor's polished floors and the various squeaks and groans of the theatre swing doors sounded like orchestral accompaniments. Friday's list was typical. While Sally closed up a patient Perowne went next door to relieve an elderly lady of her trigeminal neuralgia, her tic douloureux. These minor operations can still give him pleasure - he likes to be fast and accurate. He slipped a gloved forefinger into the back of her mouth to feel the route, then, with barely a glance at the image intensifier, slid a long needle through the outside of her cheek, all the way up to the trigeminal ganglion. Jay came in from next door to watch Gita bringing the lady to brief consciousness. Electrical stimulation of the needle's tip caused a tingling in her face, and once she'd drowsily confirmed the position was correct - Perowne had it right first time - she was put down again while the nerve was 'cooked' by radiofrequency thermocoagulation. The delicate trick was to eliminate her pain while leaving her an awareness of light touch - all done in fifteen minutes; three years' misery, of sharp, stabbing pain, ended. Ian McEwan

He clipped the neck of a middle cerebral artery aneurysm

- he's something of a master in the art - and performed a biopsy for a tumour in the thalamus, a region where it's not possible to operate. The patient was a 28-year-old professional tennis player, already suffering acute memory loss. As Perowne drew the needle clear from the depths of the brain he could see at a glance that the tissue was abnormal. He held out little hope for radio- or chemotherapy. Confirmation came in a verbal report from the lab, and that afternoon he broke the news to the young man's elderly parents.

The next case was a craniotomy for a meningioma in a 53 year-old woman, a primary school headmistress. The tumour sat above the motor strip and was sharply defined, rolling away neatly before the probing of his Rhoton dissector - an entirely curative process. Sally closed that one up while Perowne went next door to carry out a multi-level lumbar laminectomy on an obese 44-year-old man, a gardener who worked in Hyde Park. He cut through four inches of subcutaneous fat before the vertebrae were exposed, and the man wobbled unhelpfully on the table whenever Perowne exerted downwards pressure to clip away at the bone.

For an old friend, a specialist in Ear, Nose and Throat, Perowne opened up an acoustic in a seventeen-year-old boy

- it's odd how these ENT people shy away from making their own difficult routes in. Perowne made a large, rectangular bone flap behind the ear, which took well over an hour, irritating Jay Strauss who was wanting to get on with the firm's own list. Finally the tumour lay exposed to the operating microscope - a small vestibular schwannoma lying barely three millimetres from the cochlea. Leaving his specialist friend to perform the excision, Perowne hurried out to a second minor procedure which in turn caused him some irritation - a loud young woman with an habitually aggrieved manner wanted her spinal stimulator moved from back to front. Only the month before he had shifted it round after she complained that it was uncomfortable to sit down. Now Saturday

she was saying the stimulator made it impossible to lie in bed. He made a long incision across her abdomen and wasted valuable time, up to his elbows inside her, searching for the battery wire. He was sure she'd be back before long.

For lunch he had a factory-wrapped tuna and cucumber sandwich with a bottle of mineral water. In the cramped coffee room whose toast and microwaved pasta always remind him of the odours of major surgery, he sat next to Heather, the much-loved Cockney lady who helps clean the theatres between procedures. She gave him an account of her son-in law's arrest for armed robbery after being mistakenly picked out of a police line-up. But his alibi was perfect - at the time of the crime he was at the dentist's having a wisdom tooth removed. Elsewhere in the room, the talk was of the flu epidemic - one of the scrub nurses and a trainee Operating Department Practitioner working for Jay Strauss were sent home that morning. After fifteen minutes Perowne took his firm back to work. While Sally was next door drilling a hole in the skull of an old man, a retired traffic warden, to relieve the pressure of his internal bleeding - a chronic subdural haematoma - Perowne used the theatre's latest piece of equipment, a computerised image-guidance system, to help him with a craniotomy for a resection of a right posterior frontal glioma. Then he let Rodney take the lead in another burr hole for a chronic subdural.

The culmination of today's list was the removal of a pilocytic astrocytoma from a fourteen-year-old Nigerian girl who lives in Brixton with her aunt and uncle, a Church of England vicar. The tumour was best reached through the back of the head, by an infratentorial supracerebellar route, with the anaesthetised patient in a sitting position. This in turn created special problems for Jay Strauss, for there was a possibility of air entering a vein and causing an embolism. Andrea Chapman was a problem patient, a problem niece. She arrived in England at the age of twelve - the dismayed vicar and his wife showed Perowne the photograph - a Ian McEwan

scrubbed girl in a frock and tight ribbons with a shy smile. Something in her that village life in rural north Nigeria kept buttoned down was released once she started at her local Brixton comprehensive. She took to the music, the clothes, the talk, the values - the street. She had attitude, the vicar confided while his wife was trying to settle Andrea on the ward. His niece took drugs, got drunk, shoplifted, bunked off school, hated authority, and 'swore like a merchant seaman'. Could it be the tumour was pressing down on some part of her brain?

Perowne could offer no such comfort. The tumour was remote from the frontal lobes. It was deep in the superior cerebellar vermis. She'd already suffered early-morning headaches, blind spots and ataxia - unsteadiness. These symptoms failed to dispel her suspicion that her condition was part of a plot - the hospital, in league with her guardians, the school, the police - to curb her nights in the clubs. Within hours of being admitted she was in conflict with the nurses, the ward sister and an elderly patient who said she wouldn't tolerate the obscene language. Perowne had his own difficulties talking her through the ordeals that lay ahead. Even when Andrea wasn't aroused, she affected to talk like a rapper on MTV, swaying her upper body as she sat up in bed, making circular movements with her palms downwards, soothing the air in front of her, in preparation for one of her own storms. But he admired her spirit, and the fierce dark eyes, the perfect teeth, and the clean pink tongue lashing itself round the words it formed. She smiled joyously, even when she was shouting in apparent fury, as though she was tickled by just how much she could get away with. It took Jay Strauss, an American with the warmth and directness that no one else in this English hospital could muster, to bring her into line.

Andrea's operation lasted five hours and went well. She was placed in a sitting position, with her head-clamp bolted to a frame in front of her. Opening up the back of the head

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needed great care because of the vessels running close under the bone. Rodney leaned in at Perowne's side to irrigate the drilling and cauterise the bleeding with the bipolar. Finally it lay exposed, the tentorium - the tent - a pale delicate structure of beauty, like the little whirl of a veiled dancer, where the dura is gathered and parted again. Below it lay the cerebellum. By cutting away carefully, Perowne allowed gravity itself to draw the cerebellum down - no need for retractors - and it was possible to see deep into the region where the pineal lay, with the tumour extending in a vast red mass right in front of it. The astrocytoma was well defined and had only partially infiltrated surrounding tissue. Perowne was able to excise almost all of it without damaging any eloquent region.

He allowed Rodney several minutes with the microscope and the sucker, and let him do the closing up. Perowne did the head dressing himself, and when he finally came away from the theatres, he wasn't feeling tired at all. Operating never wearies him - once busy within the enclosed world of his firm, the theatre and its ordered procedures, and absorbed by the vivid foreshortening of the operating microscope as he follows a corridor to a desired site, he experiences a superhuman capacity, more like a craving, for work.

As for the rest of the week, the two morning clinics made no more demand than usual. He's too experienced to be touched by the varieties of distress he encounters - his obligation is to be useful. Nor did the ward rounds or the various weekly committees tire him. It was the paperwork on Friday afternoon that brought him down, the backlog of referrals, and responses to referrals, abstracts for two conferences, letters to colleagues and editors, an unfinished peer review, contributions to management initiatives, and government changes to the structure of the Trust, and yet more revisions to teaching practices. There's to be a new look - there's always a new look - at the hospital's Emergency Plan. Simple train crashes are no longer all that are envisaged, and

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words like 'catastrophe' and 'mass fatalities', 'chemical and biological warfare' and 'major attack' have recently become bland through repetition. In the past year he's become aware of new committees and subcommittees spawning, and lines of command that stretch up and out of the hospital, beyond the medical hierarchies, up through the distant reaches of the Civil Service to the Home Secretary's office.

Perowne dictated monotonously, and long after his secretary went home he typed in his overheated box of an office on the hospital's third floor. What dragged him back was an unfamiliar lack of fluency. He prides himself on speed and a sleek, wry style. It never needs much forethought - typing and composing are one. Now he was stumbling. And though the professional jargon didn't desert him - it's second nature - his prose accumulated awkwardly. Individual words brought to mind unwieldy objects - bicycles, deckchairs, coat hangers - strewn across his path. He composed a sentence in his head, then lost it on the page, or typed himself into a grammatical cul-de-sac and had to sweat his way out. Whether this debility was the cause or the consequence of fatigue he didn't pause to consider. He was stubborn and he pushed himself to the end. At eight in the evening he concluded the last in a series of e-mails, and stood up from his desk where he had been hunched since four. On his way out he looked in at his patients in the ICU. There were no problems, and Andrea was doing fine - she was sleeping and all her signs were good. Less than half an hour later he was back home, in his bath, and soon after, he too was asleep.

Two figures in dark overcoats are crossing the square diagonally, walking away from him towards Cleveland Street, their high heels ticking in awkward counterpoint - nurses surely, heading home, though this is a strange time to be coming off shift. They aren't speaking, and though their steps don't match, they walk close, shoulders almost touching in an intimate, sisterly way. They pass right beneath him, and

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make a quarter-circular route around the gardens before striking off. There's something touching about the way their breath rises behind them in single clouds of vapour as they go, as though they're playing a children's game, imitating steam trains. They cross towards the far corner of the square, and with his advantage of height and in his curious mood, he not only watches them, but watches over them, supervising their progress with the remote possessiveness of a god. In the lifeless cold, they pass through the night, hot little biological engines with bipedal skills suited to any terrain, endowed with innumerable branching neural networks sunk deep in a knob of bone casing, buried fibres, warm filaments with their invisible glow of consciousness - these engines devise their own tracks.

He's been at the window several minutes, the elation is passing, and he's beginning to shiver. In the gardens, which are enclosed within a circle of high railings, a light frost lies on the landscaped hollows and rises of the lawn beyond the border of plane trees. He watches an ambulance, siren off, blue lights flashing, turn into Charlotte Street and accelerate hard southwards, heading perhaps for Soho. He turns from the window to reach behind him for a thick woollen dressing gown where it lies draped over a chair. Even as he turns, he's aware of some new element outside, in the square or in the trees, bright but colourless, smeared across his peripheral vision by the movement of his head. But he doesn't look back immediately. He's cold and he wants the dressing gown. He picks it up, threads one arm through a sleeve, and only steps back towards the window as he's finding the second sleeve and looping the belt around his waist.

He doesn't immediately understand what he sees, though he thinks he does. In this first moment, in his eagerness and curiosity, he assumes proportions on a planetary scale: it's a meteor burning out in the London sky, traversing left to right, low on the horizon, though well clear of the taller buildings. But surely meteors have a darting, needle-like quality. You

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see them in a flash before their heat consumes them. This is moving slowly, majestically even. In an instant, he revises his perspective outward to the scale of the solar system: this object is not hundreds but millions of miles distant, far out in space swinging in timeless orbit around the sun. It's a comet, tinged with yellow, with the familiar bright core trailing its fiery envelope. He watched Hale-Bopp with Rosalind and the children from a grassy hillock in the Lake District and he feels again the same leap of gratitude for a glimpse, beyond the earthly frame, of the truly impersonal. And this is better, brighter, faster, all the more impressive for being unexpected. They must have missed the media coverage. Working too hard. He's about to wake Rosalind - he knows she'll be thrilled by the sight - but he wonders if she'd get to the window before the comet disappears. Then he'll miss it too. But it's too extraordinary not to share.