The Deadly Target in His Brain
By LAWRENCE SHAINGBERG
The following account of a young man’s critical operation is based
largely on several months that Lawrence Sheinberg spend with the chief of
neurosurgery and his associates in a major eastern teaching hospital. The names of all persons have been changed
and the locations disguises.
Perhaps Charlie White’s tumor
was present at his birth, but his trip to neurosurgery did not begin until two
weeks after his 31st birthday, when he stood up from his desk to go
to lunch and dropped to the floor with an epileptic seizure. No illness or warning preceded that
attack. For 50 seconds he felt as
though his heart had stopped, and for three minutes his left leg shook gently,
as if keeping time to music.
Six days after the seizure,
on a cold March afternoon, Charlie White come to Osler Memorial Hospital to
meet with neurosurgeon James Brockman, the man they called the Boss around the
ward. For all the weakness in his knees,
Charlie was inexplicably excited. Since
his seizure, life had been intense. He
saw everything, took nothing for granted.
In some ways he had never felt better.
Charlie had had computerized
X-ray sacs of his cerebral tissue and X rays [angiograms] of his cerebral
circulatory system, and they indicated the presence of a tumor called
meningioma just above the motor strip on the left-hand side of his brain. While such brain tumors are seldom
malignant, the deadly thing about them is that they have no room for
expansion. Once they attain a certain
size they can cause paralysis, muteness, amnesia—or death in a very short time.
They were sitting around a
conference table: the Boss, two resident surgeons and an intern on one side,
Charlie, his sister and their mother on the other. The angiograms were mounted on a screen, and Charlie saw tangles
of hack on white that shacked around a central mass like the roots of an oak
stretched out from its trunk.
Brokman read X rays the way
most people read newspapers. He drew a
circle with his fountain pen. “The
tumor is just above the motor strip,” he said.
“That’s why it gave you a leg seizure.”
With a flourish that was knotless comic for being compassionate, he
touched his own head with his fountain pen, describing a circle just behind the
crown. “I’d say that the tumor is just
about here.”
“Damn,” said Charlie,
“that’s just where I felt it.” He was a
short, stocky fellow with hyperactive eyes.
He was more composed than his family.
“What’s the danger?” he asked.
“What happens if you don’t operate?”
Brockman was used to this
question, and he got to the bottom line so fast that no toom was left for
anticipation or imagination. “Sooner or
later it will kill you.”
The next question, although
it was less serious, was a lot more awkward: “What sort of incision do you
make.”
Brockman indicated a
U-shaped line in his head, a horseshoe that began behind his left ear and ended
in front of it and reached the midline of the skull at its apex. “We make a cut here, them another here; then
we make a sort of trapdoor through the skull.
It’s a simple procedure.”
What Brockman was describing
was a craniotomy. Of all stages in
neurosurgery it is probably the last dangerous, but it is also the most
shocking, the supreme violation of identity.
Mrs. White began to sob, and
Brockman took her hand. “Come on, come
on. It’s not as bad as that. Think about it for a while and let me know
what you decide.”
“Why should we think about
it?” Charley said. “It’s my decision ad I want it out. I don’t want it growing in my head. When can you do it?”
“How about next Thursday?”
The Boss and Charlie stood
and shook hands.
Brockman’s work was a family
tradition. Both his father and his
grandfather had been surgeons, professors of surgery, and chiefs of their
departments. Operations were his
theater, his prayer meeting, and the consummation of the romance that energized
his life. A short (five-foot-three) man
of 65, he claimed that when he entered the OR there was no time in the room, no
distraction, and no hunger. “There’s no
field so challenging as brain surgery,” he said, “none that lays down such
responsibility ad anxiety or imposes so many life-or-death decisions.”
Whenever Brockman discussed
surgery, two themes appeared and intertwined: primitivism and sexuality on the
one hand, and “management power” on the other.
“Surgeons are interventionists, activists by nature, people who seek
solutions. We’re dealing with danger,
blood, power, conquering the man or woman on the table. No wonder wives of patients fall in love
with surgeons. Aren’t we the male who
conquers her male?”
Charlie White’s night nurse
had just left when Brockman stopped by for evening rounds.
“You scared?”
“Yeah, a little.”
“You are afraid of
dying. Don’t be. We know what we’re doing.”
“Okay,” Charlie laughed.
Brockman squeezed his hand
and said, “As long as you keep laughing, kid, you will do all right.”
Charlie tried to watch the
ball game of TV, but it was no use.
Terror rose in him; grotesque images of his head split open, Brokman’s
hands wrist-deep inside his skull. At 9
p.m., they gave him a Valium, and at 9:30 resident surgeon Benny Richmond came
to shave his head.
The Valium helped; Charlie
slept soundly until he was awakened for pre-operative preparation for the
following morning. There was much to do
to get him on steroids to decrees his intracranial pressure. Orally, he got Dilantin and Phenobarbital
for seizures, Nembutal for terror. Then
the operating-room attendant wheeled Charlie’s bed into the hall.
It was 7:30 and the
operating room was ready. Scrub nurses
Millie Yeats and Esther Woolf had arrived at seven to put the machines in place
and lay out the instruments—150 of them, rolled in blue towels on the stand
that straddled the operating table.
Charlie’s bed was pushed
through the door and stopped parallel to the operating table. Millie asked Charlie if he could lift
himself and slide across. “Why not?” he
said, and then, as if they had done him favor, “Thank you very much.”
The nurses and resident Jose
Rivera removed his dressing gown, covered him with a sheet and buckled leather
straps across his chest and thighs. His
face white and his mouth locked in a contorted smile, in turn Charlie looked
terrified, helpless and oblivious. The
pace of the room had quickened: Benny Richmond and nurse Lisa King arrived, and
now there were five people plugging him into machines, moving his legs, tilting
the table, applying leads for the EKG to his chest and a blood pressure strap
to his arm.
There was no way to avoid
the knowledge of what was about to happen and no way, with the patient awake,
to acknowledge it. The result was a
sort of mindless chatter among the staff, but it ceased abruptly with the
arrival of Terry Schreiber, the anesthesiologist. He brought a sense of danger to the room, as though this were
about to take a turn that no one could control.
“How you doing, sport?” he
asked.
“Okay, I guess.”
Schreiber broke open an I.V.
kit and quickly found the vein he wanted in Charlie’s wrist. “You’re goanna have the sweetest sleep you
ever knew. Good night, sport.” Before half the syringe was empty, Charlie’s
head had keeled to the right.
With his loss of
consciousness, the room abruptly increased its velocity, like a satellite
shifting orbit. No appearance to
maintain now, no need to screen the violence.
Benny took a purple marking pen and –centering himself by putting his
little finger on Charlie’s nose and his thumb on the peak of his skull—he drew
a free-hand line along the midline of his skull, then another from ear to ear,
bisecting it.
Schreiber administered
nitrous oxide through a mask and finally halothane, the principal anesthetic
agent. Carla Fredericks, Schreiber’s
assistant, inserted a long plastic tongue depressor with a light on the end
obit, and then, aiming an eight inch needle down Charlie’s throat, gave him a
short of lidocaine, to anesthetize his vocal cords and prevent them from going
into Spam from the general anesthetic.
Withdrawing the syringe, she clamped a bite-block over his tongue and
turned on the central IV line so that pancuronium, the paralytic agent
administers along with halothane, would immobilize every muscle except the
heart, protecting Charlie from bucking during surgery and moving his tumor
around. Because Charlie was now
incapable of breathing for himself, she turned on the respirator.
Jose slid a greased catheter
into Charlie’s urethra, taped plastic covers over his eyes, inserted a needle
and then a catheter in the femoral artery in his right thigh (to track his
blood pressure), and installed a line in his hand through which, if required,
he’d be given blood.
It was 7:50. Jose and Benny checked the angiograms, and
then positioned Charlie’s head on a black rubber cushion with a hole in the
center that looked like a huge chocolate doughnut. Using the lines that Benny had drawn as guides, they drew a flap
on Charlie’s skull; five tiny circles and then a pentagon connecting them.
That was as far as they
could before scrubbing, so they retired to the washroom for the elaborate
cleansing ritual prescribed for all who would touch the patient. When they returned, dripping hands held
high, Millie helped them into surgical gowns, masks and skin-tight rubber
gloves. Finally, nothing showed but
their eyes. Millie clamped Benny’s
headlight on his forehead and adjusted it, as he faced Charlie’s head, so that
it shone on the flap he’d drawn.
He took a syringe from the
instrument stand and injected Charlie’s scalp in a half-dozen places with
saline solution to reduce its vascularity before incision. Since each injection caused a swelling like
a large hive, the scalp looked like the belly of a pregnant dog.
By now the steady beep of
the oscilloscope could be heard, its beautiful jagged lines—read outs of pulse
and blood pressure—marching across the screen above Charlie’s feet. Every 30 seconds Carla would make what she
called eye rounds, checking vital signs through gauges on the anesthetic
machine and listening—through earphones that trailed under the bed sheet. Since her work kept her close to his face,
she was, of all those in the room, most aware of Charlie as a person. “Cute, isn’t he?” she said to Millie.
Benny made the first
incision, a quick slice with the scalpel along the forward line of the flap, at
8:40, and the scalp was peeled away from the muscle beneath it about 15 minutes
later. Three layers of tissue—scalp,
muscle and the membrane called the galea—had to be severed before bone was
reached and drilling begun. Charley’s
scalp was about a half-inch thick and the bone about a quarter-inch thick. Altogether, it would take 55 minutes to
complete the flap.
Bleeding was heavy along the
incision, and after the blood was suctioned and sponged, white plastic clips
were installed to seal off the vessels.
When the lime of the flap had been incised, the tissue beneath it was
sliced with a very sharp knife. The
flap was peeled back gently like the skin of an orange and wrapped with a
mesh-like material.
“Call the Boss,” Benny
said. “Tell him 30 minutes.”
When the Boss was exposed,
six large holes, about the size of those in a bowling ball, were drilled along
the line of the flap with a craniotomy, a stainless-steel cylinder that looked
like a space gun and whined like a baby pig when activated. The craniotomy’s great feature was that,
being air-powered, it responded negatively to pressure. The harder the tissue it encountered, the
more power it generated. Thus, the
drill bit turned with maximum speed through bone and stopped altogether when it
met the soft tissue lay beneath it.
Benny had to get all his
weight behind the craniotomy to make it penetrate Charlie’s skull. He leaned forward until his body was nearly
20 degrees of the vertical. Clearly,
the brain was not meant to be violated.
When the holes were finished, he then sawed out the line between the
holes. The saw moved almost
imperceptibly, sending up trials of bone dust and generating so much heat that
it required constant irrigation. Now
Benny threaded a flexible instrument called a dural protector between the holes
and slid it back and forth several times to separate the bone from the brain
beneath it. He rolled his head in a
circle as if to stretch his neck, then looked up at Millie on the stand.
“Chisels, please.”
She handed him two
stainless-steel instruments with blunt one-inch blades, slapping them between
his thumb and forefinger. After working
them around the edges of the flap, Benny elevated it gently until he was
certain it was coming off the durra and then lifted it clear. For the first time, Charlie’s brain was
visible, framed by the flap and covered by the silky film of the durra like an
embryo in its sac.
Brockman had arrived in the
locker room just about when Benny was calling for the chisels. As always, he took a scrub sponge into the
OR and continued to scrub, dripping suds on the floor, while he inspected the
flap that Benny had turned.
‘Looks good,” he said.
“You’re getting better all the time.”
Brockman examined the
angiograms while Millie pulled on his gloves, and finally stepped up and probed
the durra with his finger. Then he quickly
opened it. Taut and resilient, it
snapped out of the way and the brain pushed through the opening like a tiny
fist. It was 9:35
After marking a small
incision, the Boss began cutting out a piece of durra that more or less
followed the flap. Finally, the durra
flap was raised, wrapped in moistened gauze and clamped out of the way. In all its convolutions, oyster-gray and
pink on its surface and almost black at the folds the cortex was visible at
last. It was 9:45.
At the bottom of the
exposure lay the tumor. Striated with
blood vessels like the brain around it but still sharply distinct from it,
darker and smoother, it was clearly alien.
“Okay,” said the Boss, when a good view had been exposed. “There’s no reason from what I see that we
shouldn’t get it all.”
The first target with
meningiomas is their blood supply.
Since they’re highly vascular tumors, they can hemorrhage if interred
directly, but once their principal sources have been legated, they can be
manageable. In search of the feeding vessels,
Brockman worked his way around the tumor.
With that entire cutting,
the doctors were using the suction tubes a lot, and suddenly a piece of normal
brain got caught and sucked—whoosh! —Up the tube, gone forever into the central
garbage receptacle. The normal tissue
had come far from anything crucial and would not be missed. To say the least, Brockman took its
departure in stride. “Damn,” he said. “There go the music lessons.”
Everyone cracked up. But the pleasure was short-lived because
Jose got his suction tube entangled with the Boss’s. “Hey, Jose, are you sleeping?
Move it out of the way!”
By ten o’clock Brockman had
the tumor legated and separated with Cottonoids from the brain around it. His anger had settled, and the conversation
at the table hade becomes friendly, almost intimate.
The sounds of the OR became
musical and hypnotic. The sizzle of the
cautery, the flute-like beep of the oscilloscope, the sighs of the respirator,
the conversation, the suction, the clink of instruments against each other like
knives and forks at the dinner table.
It was all repetitive, monotonous, as constant in its rhythm as a fugue.
By 10:15 they were
extracting tumor. Using a scalpel first
and then a copper spoon, Brockman broke through the tumor’s capsule and dug it
out in small, bloody silvers, which he placed in the specimen glass on the
instrument stand. Inside, the tumor’s
texture looked a lot like Cream of Wheat.
By 10:40 half the tumor was in the specimen glass, the rest had snaked
up the suction tube and the Boss was packing the empty cavity with Gel foam, a
Styrofoam-like material that promotes clotting. A few minutes later, he said, “All right, let’s get out of here.”
By the time Brockman had
showered, dressed and made his way to the ninth floor, where, to use his words
for it, he played a bit of God for the White family, Charlie was almost
reassembled.
At seven that evening
Charlie was talking to his mother. Tow
days later, he was released from the intensive-care unit and returned to the
ward. He would need no radiation of
chemotherapy because the tumor, as Brokman had predicted, had turned out
benign, but Charlie would be on Dilating indefinitely, to protect him from
seizures, and he would have to consider himself, for the rest of his life, prone
to meningioma.
His skin healed in a week,
muscle and bone in 70 days. According
to Brockman, all traces of surgery were gone from his brain within a year. Nothing was said or postulated about its
traces in his mind, but then, as they say, nothing was done to his mind anyway.
