I N  T H E  B E G I N N I N G , the brain was singular, whole and undivided. That was the problem. Like the Earth of Genesis, the brain as an object of knowledge, and so of treatment and healing, was without form, its secrets hidden in a fog from which it seemed clarity would never emerge. The brain needed discrimination into all its structures and colorings, the enumerated chambers and scaffolds; it needed articulation that could account for the splendors of the universe it created within itself. It needed resolving into the millions of complex and subtle actions, apprehensions, sallies, dances and chants with which it could engage its universe.

Just over a century ago, the brain was like an image under a microscope that is beyond the instrument’s power of resolution, a spheroid blob that might really be one object of entirely different shape than appears, or a number of objects all of different shapes. No way of telling.

When you twist up the magnification of a microscope that is already beyond its power to resolve, in place of a tiny spheroid blob you see a large spheroid blob. It doesn’t matter how much the image is magnified; at Earth-size, an Earth-size blob comes up. It only improves if you also increase the resolution of the microscope.

Overwhelming though it had seemed, the quest to understand the brain at submicroscopic resolution succeeded, magnificently. By now, the time of this story, a century’s unrelenting effort to articulate the brain into its tiniest anatomical structures and most detailed physiological activities was in its final stages, a century that had seen the invention of the most dazzling technology in history and the bending of much of that technology to this purpose.

But as great an adventure is now under way, and that is what this story is about. A revolution is going on in neurosurgery and neurology that those in its midst believe will make the era before this seem like a dark age—like Europe as the cathedrals emerged with the millennium, as both evidence of monumental change coming and framework of that change. As then, the forms, designs and crafts that produced those stone works of highest art had existed before, on that same soil in ancient times, on Eastern soil at that time. But a new design had taken root.

The cathedrals that emerged were a product of their time and place and the minds of the men and women whose spirit they embodied, and of the force of their will directed in new ways, as though the spirit of the new millennium were to be felt in shaping space before it had any content.

This is as much a story of our time and place. Over a three-year period I spent hundreds of days and nights at Barrow Neurological Institute, in downtown Phoenix. The institute is part of St. Joseph’s Hospital and Medical Center and to the unsuspecting eye is indistinct from it. You have to be told that the halls of Barrow are polished dark stone, while those of St. Joe’s are carpeted, to realize you have made a transition. But sure as the cathedrals marked an unmistakable reach for heaven, there at Barrow is a giant structure within which everything and everyone focuses inward to the brain, from the neurosurgical suites on the fourth floor to the autopsy rooms and laboratories in the basement, to the giant toruses of CT and MRI scanners, intraoperative microscopes, three-dimensional television sets to view surgeries, all to bring the brain into focus.

A large part of the story involves the amassing of ever-more sophisticated technology, ever-more dazzling machinery to see the brain in dozens of different ways, to measure its every input and output and response to every imaginable drug.

But what has that technology brought us? The answers to that question are not unequivocal ones. This is a story of disasters as well as triumphs, and of stars to be sure—some of them on the receiving end of the knife.

The story is shaped by overarching, powerful personalities. They shaped Barrow Neurological Institute; they shaped neurosurgery. You don’t do that from the sidelines and you don’t get to the center of the action by waiting to be called. You know and go. What goes on inside brain surgeons’ brains? What makes them go? Monumental ego? Or, in the words of Peter Raudzens, chief of neuroanesthesia, big brass balls? To crack open a living human’s skull and put a razor to his brain. Make that his soul. What kind of people do this sort of thing for a living?

Robert Spetzler, director of BNI, is a man of supreme and unshakeable confidence. Spetzler is tall, with a handsome face, reddish brown hair, and mustache. A contrast with white-haired John Green, who created Barrow out of cowtown dust and who introduced us in Green’s office. In the elderly Green, a man of kindness and good humor, it is hard to see the virile medical giant. Spetzler remembers him that way.

Spetzler still has the rangy, powerful build of the varsity backstroker he was twenty years ago. Then swimmers were first being taught to push into the wall of pain as they overextend muscles and oxygen demand, to push until they broke through the pain barrier into a pure concentration of will on swimming. Appropriate for the neurosurgeon.

As medical legend has it, the cardiovascular and orthopedic surgeons are the power athletes; it takes a lot of physical strength to crack a chest and rearrange bones. But the pure concentration, hour after hour, the force of will that can carry an operating team from morning until night and then, in just the moment of repose, jump back into a sheer emergency at full mental force, that is the brain surgeon’s forte, physical power held together by strength of will as much as muscular coordination.

At the climax of this story, a moment as self-defined and unequivocal as its beginning, Spetzler and I were talking in Vienna, Austria, on an off day in the middle of what was already proving to be the most difficult surgery he had ever been through. We were talking about what a neurosurgeon does to prepare for a major case like this. “You go over the procedure, and over it again, and over it again,” he said. “You simply repeat every step you are going to do and go through every possible thing that can go wrong. And then you do it again.”

You go over the procedure so often that it cannot leave your mind; that’s the point. Then it is the night before surgery. “As you drift down to sleep, you are in the operating room, and you cut the wrong side. Or you see a vein or artery, and you cut right through it. Stupid things, all the things you prepared yourself never to do in your first day of residency, you’re doing them. And that wakes you up. And then you think about the procedure, and as you fall asleep, it comes again. On the night before a major case, of course, you never really sleep. You half-sleep. Running things through your mind.”

And then after a repose full of nightmares, you go in and do the procedure, calm and cool, truly the most confident human alive. Procedure is the key word to neurosurgery. A procedure has specified steps that can and must be choreographed and rehearsed; it has a beginning, a middle and an end. Most importantly, it must not have surprises.

Well and good, but where do I begin? For weeks I fumbled through stacks of notes, boxes of tapes, the bones of history, for omens, like some ancient hunter trying to guess where the game lies, but came up only with the same annoying, finally angering metaphor—a gray blob, as large as you choose it to be but a frustrating, enraging, indiscriminate blob no matter how large you magnify it, however powerful your vision. Then, as sometimes happens, the point came, and it came in precisely this way.

On April 16, I jolted awake for no reason at 4:20 a.m. and within a few minutes was running off the shivers in the dark, by far the earliest I’ve been out running in ten years. I started my stopwatch as always and heard the mounting roar of a motorcycle headed south, fast, beyond the wall ahead as I ran east, where the sky was still pitch dark. Then there was a scraping clash of cheap metal, like a hubcap clattering off. I figured it was just that and ran on as the motorcycle roared southward.

Seconds later someone shouted, yelling like an angry brawler; then came an undertone of pain. I turned out to the main road. In the dark I could just make out someone writhing, sitting up, lying down, shadow on shadow, then shouting again. He lay in the dirt of the broad shoulder, out of further danger. Farther down the road, illuminated by a street-light, the motorcycle lay on its side. I had nearly reached him, out-shouting him to lie still, when I picked out something much more alarming than his pain. Stretched across the fast lane, face down and arms outstretched and pointed like a diver’s, lay a second figure in clothing as dark as the road.

Running to the dark, blurry form I heard the easy breathing of someone deeply asleep, and stood in front of him facing the lights curving toward us in the dark, waving my arms. The pickup truck swerved and stopped. Call 911! He nodded and drove on. Now the breathing was of a troubled dreamer, halting, beginning again, only now with a sucking sound I had gotten to know over the past three years, following neurosurgery residents into the Emergency Room when such accident cases were brought in. I couldn’t make out his face; it was topped by unruly brown hair. No helmet. I thought, He’s dying and needs CPR, but I knew better than to try to move him with a likely neck injury. A mixture of dread and relief there. A man was dying at my feet, but there really wasn’t anything I could do but dance like a rodeo clown to keep the trucks off him.

The next pickup was luck, a railroader with flares we set out. And the next a charm, an emergency med tech on his way to work. The sucking was more pronounced now. Another motorist was kneeling by the second boy, twenty yards away off the side of the road. Here, the railroader and I slowly rolled the body while the paramedic turned the head in precise unison. A very young face appeared, not 20 yet and, I thought, maybe as old as he gets. Placing a plastic shield over the boy’s mouth, routine in the era of AIDS, the paramedic began mouth-to-mouth. The sucking sound went on. Somewhere inside the seemingly undamaged skull I guessed blood was leaking, probably throttling the brain stem, where breathing and heartbeat are regulated, the animal soul.

Cops were here now. The boy jolted and clear fluid poured out of his mouth, drained down the roadbed. The EMT stopped and pumped hard on the boy’s chest, three times, went back to the mouth-to-mouth. Was he dying? More police cars, finally ambulances. The boy was put on a respirator, his breathing steady and regular; now his heartbeat would sound fine, I knew. Statements for the police report: “He coded almost right away,” the EMT said; not much older than the boy and looking the most upset of anyone. Sure, he was the only one who had a prayer of saving him, so the only one who can wonder if everything will turn out all right and if he did everything right. It looked right.

I thought the other boy probably wasn’t hurt too bad, as aware of his pain and circumstances as he was, asking over and over how his friend was doing. He was hurt just bad enough to blurt it all.

Two pals drinking it up, roaring off into the night. Sucking down whiskey and springtime and life. Hit the guardrail at sixty and both got thrown off the bike, which roared on riderless for nearly a hundred yards before skidding off the road. That eerie image won’t go away, the riderless motorcycle roaring south, something I heard but never saw. Now I see it all the time but hear nothing, a little silent movie in my head. It was the driver at my feet, and, as it would occur to any spectator, it occurred to me. What will happen at the other end of the ambulance ride? Recovery? I doubted it. Dead on arrival? Yes and no, and the point turns on this. The respirator would mimic life to a T. Death would be a matter of decision. What had once been unequivocal and immediate would be debated over time. Was that all we had won with the glitzy chrome technology?

The newspaper said that the boy was eighteen and that he died later that April day in the hospital; so be it. Was death at 4:40, 4:50, or when the respirator was turned off? Had his parents had the finances or lacked the will, death might have been stamped days or weeks or months later. In the interim the staff on dawn rounds would have written, as I’d seen the neurosurgery residents write dozens of times, Patient remains in a vegetative state. Glasgow Coma Scale of 3. Does not respond to commands, does not respond to touch, pupils non-responsive and fully dilated, does not respond to pain....

I did not witness the hours between the accident and the pronouncement of death this time, but I had many times before. The incidents all have one quality in common, and one in particular now stood in sharp relief—an accident of over a year earlier that had faded from memory came back crystal clear.

Paul Francis, then a first-year neurosurgical resident, and I were having lunch in the cafeteria when the trauma bells rang. We rushed to the trauma room and waited. As Hollywood suspense is built by music, the tension in the ER is driven by the sound of sirens, faint then distinct, rising to crescendo, then stopping; that’s when you hold your breath. Then you hear the rumble of wheels and the rapid pumping of feet shoving the gurney like a battering ram first through the electric doors into the ER and then through the rubber curtain into the trauma room. I ducked out of the way as the trauma team rushed to hook up IVs, respirator, monitors, to take pulse, insert catheter, knowing Paul would call out if something instructive occurred once the patient was stabilized.

It always took a while before the rush of green scrubs cleared and revealed the patient. This one was a motorcycle crash on one of Arizona’s desert highways. A young man in his 20s, handsome as the devil with curly light brown hair and a reddish mustache, slumbering but otherwise appearing just fine. His breathing was regular and even, though you couldn’t tell if it was his own or only the respirator’s; his heart beat steady and true.

“No helmet?” Paul Francis asked.

“He had a helmet,” the paramedic said, pausing for effect, “hanging on his seat.”

Francis looked into one gray eye, saw its pupil dilated wide and called to me. “His right pupil is blown, he’s in bad shape. I don’t know what’s wrong. Everything else seems fine. And his left. Both pupils blown. What the hell is wrong.” Francis pinched the man’s nipple, which will bring a stir even from someone fairly comatose. Nothing.

One of the nurses, seeing a line of blood in the man’s hair rubbed it back with her glove, a gentle gesture, and suddenly everyone, leaning in so intently, sucked in a breath. A palm-size piece of his skull lifted up right at his hairline; his brain surface was splattered underneath. And the nurse said in one of those clear hard voices that speak years of this, “We’re looking right at his sinuses.” And so we were. Right down through the roof of the world.

The trauma surgeon looked in at him and barked, “Turn off the respirator.”

The chest fell still, eyes stared wide and vacant, and the heart monitor went off into that long inane peal when the beats no longer come, when the brain stem has ceased sending its pulses and the heart’s own signals fibrillate. He had looked so lifelike.

Where has this technology brought us, other than to the brink of bankruptcy? Sometimes it has brought us to a chronic vegetative state instead of a quick death. Sometimes all we get is a big gray blur where a moment of terror used to be.

There it is.

The line of death, razor sharp and sudden as a hammer blow, has been magnified and magnified and magnified yet again. The thin gray twilight line now can go on forever. Without resolution. And that, to be sure, is the darkness out of which this story emerges and into which its protagonists fight to prevent its sinking. New science often has a way of magnifying like that, boosting raw power by orders of magnitude without articulating it into useable pathways. It gives the power to see but does not give vision itself. It is not a gift outright.

The frustration of watching someone on a respirator for as long as the power is kept on is the same as the frustration when it seems the combined genius of the century has netted nuclear bombs. What is power without resolution? A great gray blob. How then do you bend the enormous powers of new science to your will? How do you articulate, discriminate, increase the resolution?

Focus, first. Concentrate every fiber at your command to this one thing. Neurosurgery is about winning resolution, in all the ways it can be won, for those are all the ways it can be lost; it is about harnessing technological power, bending it to one’s hand by one’s will. The story is about the articulation of consciousness, layer by painstaking layer, and that is the same as the articulation of death, layer by layer.

The razor line between life and death is crossed when you hit the rail at 60, no matter how you magnify the line. But the difference between that death and the “deaths” in standstill procedures in neurosurgery is the difference between hurling tons of metal into the ground and landing the space shuttle. There it is.

Articulate, discriminate, control, control more precisely. Focus to the maximum power of resolution, then focus on increasing the power of resolution. To win you must take each emergence of the gray blob as a challenge; you have reached the limit of your resolution, which must have no limit. On and on. Western science and medicine, it is argued, are about ever-increasing control over the unknown, over uncertainty and the unexpected. Neurosurgery is the paradigm, without apology.

You see what the gray blob is now, so tiny it is just beyond the limit of your straining eyes and it may be about to do something, now looming so large it fills the entirety of your vision and your mind with its grayness. No difference. It is the enemy.

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Copyright 1997 Edward J. Sylvester