Class Notes Winter 2009
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THE BOOK THAT CHANGED MY LIFE
It has seemed for all these years almost too pat, a cliché, that I had wanted to be a neurosurgeon ever since I was in seventh grade and read Death Be Not Proud by John Gunther, an account of the illness of his teenage son, Johnny, who died of a brain tumor. I went back recently to Death Be Not Proud, as I had on occasion before, only this time I discovered something more about the book and about myself.
The foreword advises the reader that what follows is “the story about what happened to Johnny’s brain.” But with this latest read I was transported back to the first and saw again Johnny Gunther not as a patient, but as a peer. More than the surgical exploits of Tracy Putnam or the imperious consult of Wilder Penfield, legendary pioneers in the then-fledgling specialty of neurological surgery, the journalistic courage of John Gunther changed my life. The narrative was always about Johnny, about how, despite our afflictions, we may somehow prevail.
Death Be Not Proud ends with a contribution from Frances Fineman Gunther, Johnny’s mother. “I greeted him each morning as if he were newly born to me.” I am sure I had no conscious recollection of these words when I wrote about a mother caring for her dying son, in a book I was privileged to have published in 1997, “The boy is sleeping his child’s sleep with his face buried in his mother’s arms. The back of his hairless scalp, the only respondent to his therapy, seems newborn.” —MARC FLITTER ’65
Marc Flitter has practiced neurosurgery in Miami Beach, Erie, Pa., and, since 2001, Farmington, N.M., where he is affiliated with San Juan Regional Medical Center. A native of Easton, he is the author of Judith’s Pavilion: The Haunting Memories of a Neurosurgeon, published first by Steerforth Press and available from Grand Central Publishing.
JUDITH
The Patient Would Not Survive.
It is to Judith’s Pavilion that I have admitted, confined, and confessed my failures, and not just my own, but all the patients who might otherwise haunt me, refuse to be buried or rationalized or forgotten.
Sterile drapes were placed over her head and back so that the only part of Judith Halpern that could still be seen was her shaved scalp and the upper part of her neck. It was as if the rest of her had been excused. I would call her back when it was all over. I didn’t want to be forcing my attentions with scalpel and drill on a wife and mother. It was a tumor I was after. . . .
I made what was called a hockey-stick incision. The scalpel traced upward through her skin like a flare at sea, lighting her scalp with its trail of blood. It began at the level of her earlobe and reached its apogee in the midline, its ascent no higher than the occipital protuberance, that bony outcrop on the back of her skull. From there it fell, inscribing the shaft of that pointed constellation to the handle resting in the nape of her neck.
Her scalp was thick. A few of the arteries that had been cut sprayed on my gown, and one reached the right lens of my glasses as if I were on the Odessa steps in The Battleship Potemkin. Most of the bleeding stopped when I spread the wound edges with a self-retaining retractor, the claw-like ends of that instrument burying themselves in the yellowish subcutaneous tissue. A few vascular holdouts, persistent fireboat celebrants, were extinguished with electric cautery. Then all was still. Her head remained motionless in a three-pinned embrace. There were no veins gulping air.
The part of her skull that lay gleaming under the operating room lights seemed to be taunting, “Get inside if you can.” That challenge had been more formidable when neurosurgeons had no power tools, when arm-numbing exertion was required just to drill the first burr hole. I imagined that bone stunned to hear the whine of the pneumatic bit. I enlarged the nickel-sized hole it had produced with biting instruments called rongeurs. Their dinosaur-like jaws tore away at the margins of the skull. I covered the vascular channels in the bone with an occlusive wax, keeping them free of air and the anesthesiologist content. Gradually, as if I were uncovering some buried vase, the rounded outline of the dura, the membranous covering of the brain, appeared. Then it was precision time, the paradox of the exposure. After having broken through the equivalent of a vault, what would be required of me now was the delicacy of repairing a watch or inscribing the Lord’s Prayer on a grain of rice.
I changed what I was seeing then, positioned the operating microscope. Its two eyepieces and the objective lens were covered with a transparent sterile drape, all suspended on the end of a three-jointed arm supported on a pedestal. It would be the key to gaining entry to her world. It magnified the wound so that my entire visual field was no wider than the word “eye.” Each individual blood vessel, each single fiber of tissue became the object of attention, determining sequential efforts. Distance was traversed in millimeters rather than inches. Even the sounds in the operating room were muted by that view, as if hearing were partly visual.
I began to open the dura, using a more delicate scalpel than the one that had violated her skin. It was the transition from dinosaur jaws to jeweler’s forceps, from rending to teasing. I held either side of the taut membrane open with a suture that almost whispered its fragile tension, “five-0 nylon.” It wasn’t the smallest suture available, but fine enough to seem as if its strand might easily float away. . . .
My view was as breathless as if I had reached the summit of Kilimanjaro, or K2, or wherever I had hoped to find an answer. It was brain tissue, the reason why I had kept at it for all those years. . . . In neurosurgery it was always the same. It was Stanley coming upon Livingston, and Holmes declaring, “Watson, have a look at this.” It was the brain and there was nothing like it. Nothing could replace it. It didn’t regenerate. It couldn’t be sutured or glued, anastomosed or fused. It was the palpable paradox of Eurydice. To touch it was to lose it in almost all circumstances. The only saving grace of a brain operation was that what remained had such extraordinary potential. That is what I saw through the microscope; magnified, illuminated and waiting. . . .
I had divined from the CAT scan that two inches below the surface of her brain lay the root of her dysfunction. I inserted the cup-like ends of a biopsy forceps through the cortical incision. The instrument was pistol gripped. Squeezing the trigger closed the tissue-gathering ends within the brain. I fired then and watched the approximated tip’s retreat. There was no sense of tearing as if some tenacious artery had become enraged. I saw no angry surge of blood that welled behind the silver instrument. . . .
As I watched, the exposed portion of the brain began to undergo a transformation. . . . Brain tissue was being forced through the confines of the exposure. The implication was that there was bleeding at the biopsy site, that a clot was forming, pushing tissue ahead of it. . . . There was no clot that I could see and yet the tissue kept coming, extruding like lava without apparent end.
It was one of those moments that can occur during an operation that is defined by alarm. There was a visceral sense of being swept away, as if the malevolent force unleashed upon Judith had reached out and taken hold of me as well. Any hope of regaining mastery lay first in conceptual insight. What was the problem? Since I had not encountered blood along that biopsy track, only the concept of malignant brain edema offered a possible explanation. It was an alternative that begged exoneration. It wasn’t I, not the surgeon who brought her into that room, placed her in the semi-sitting position, opened the base of her skull, and cut into her brain for a bit of tissue. It was someone or something else, inside.
Whether it was true or not, at least I had an enemy I could engage. Medication was called for, a drug that might spirit away the edema fluid that was causing the tissue to expand to twice its normal size. But that remedy had no effect on her, not that afternoon turning into night.
I took a different tack then, thinking there had to be bleeding. I just wasn’t seeing it. I began to look beyond the site of the biopsy, deeper within the tumor. It was a mission of search and destroy. There was no environmentally safe journey into that forest. I might just as well have gone in with heavy equipment. There was bleeding then, and from more than one site. I was drawn further into the magnified world of the microscope. The blood might just as well have been descending upon a sleeping town, avalanche or mud slide, it made no difference. It carried the familiar and the recognizable with it, but somehow all wrong. Fragments of brain, cortex and white matter, welled up in that bleeding like victims being swept past in a
torrent. . . .
Finally her body’s coagulation abilities, the counter-pressure of cotton paddies, and her falling blood pressure stemmed the flow. By then it was too late. Underneath those paddies lay a quiet pool of ruin and devastation that could not be undone. There was no need to wait until the morning to assess the damage. The patient would not survive. I had seen this before, in my own cases and those of my colleagues and professors.
Then, almost unannounced—I certainly hadn’t sent for her—Judith returned to the room. It wasn’t just a small opening in sterile drapes through which brain tissue had herniated that was my charge. A human being lay there, now irreversibly lost. . . . And it wasn’t just the silver-haired retiree who had asked, “When can you schedule it?” who had returned. A handsome woman who was president of her Temple sisterhood was there . . . the sweatered bride, the wife of the boss who filled in as secretary . . . the aproned mother. . . . I was outnumbered, even before I had completed the closure and made my way to her waiting family.
It was ten o’clock and quiet outside the hospital that night as Judith lay in her post-op
coma. . . . I turned back to look at the hospital and at the lights coming from the windows of the ICU.
That view of where Judith lay dying has never left me. The perspective itself is part of an indelible image. I am below in the night solitude looking up at those windows, at the silhouettes of the nurses, and of Judith’s family ushered to the bedside. They approach her with the impossible hope that she will squeeze their hands. They convince themselves that she has, although it is imagined and cannot be confirmed. And I seem to be in two places at once, turning in that fatigued afterlook, and somehow still at Judith’s bedside, remote stranger to myself, the causative agent for her terminal state, isolated by the rueful conclusion to the anticipated surgery of that day. Sometimes the lone figure, forever hesitating by that car to glance at the hospital and the light-filled windows above, assumes yet another identity. He is the narrator in Frost’s “Acquainted with the Night,” having heard an “interrupted cry” from another street and unsure of who it was for, himself or the lost patient.
A doctor drawn to his patient by a vision of light and loneliness. It is an image that haunts the promenade of a gallery, my pictures at an exhibition, acquired over years of practice and remembered loss. It has defied time and my attempts at resolution and yet it has changed. The years since that night have peopled that futile intensive care unit and the floors above with other patients and colleagues who have died before their time. . . . They are the casualties of fate and technology who shared the terribly fragile nature that is our existence.
None of the images fade. . . . Judith and her fellow patients are never discharged. The nurses never go home. I have never driven away in my car to my family and rest. And Judith’s family never collect themselves, resolved to the unthinkable, but wait for their ten minutes every four hours, to beseech the unhearing.