Contents
Title Page
Dedication
Epigraph
Chapter One
Chapter Two
Chapter Three
Chapter Four
Chapter Five
Acknowledgments
About the Author
Also by Ian McEwan
Copyright Page
TO WILL AND GREG MCEWAN
For instance? Well, for instance, what it means to be a man. In a city. In a century. In transition. In a mass. Transformed by science. Under organised power. Subject to tremendous controls. In a condition caused by mechanization. After the late failure of radical hopes. In a society that was no community and devalued the person. Owing to the multiplied power of numbers which made the self negligible. Which spent military billions against foreign enemies but would not pay for order at home. Which permitted savagery and barbarism in its own great cities. At the same time, the pressure of human millions who have discovered what concerted efforts and thoughts can do. As megatons of water shape organisms on the ocean floor. As tides polish stones. As winds hollow cliffs. The beautiful supermachinery opening a new life for innumerable mankind. Would you deny them the right to exist? Would you ask them to labor and go hungry while you yourself enjoyed old-fashioned Values? You—you yourself are a child of this mass and a brother to all the rest. Or else an ingrate, dilettante, idiot. There, Herzog, thought Herzog, since you ask for the instance, is the way it runs.
Herzog, Saul Bellow, 1964
One
Some hours before dawn Henry Perowne, a neurosurgeon, wakes to find himself already in motion, pushing back the covers from a sitting position, and then rising to his feet. It's not clear to him when exactly he became conscious, nor does it seem relevant. He's never done such a thing before, but he isn't alarmed or even faintly surprised, for the movement is easy, and pleasurable in his limbs, and his back and legs feel unusually strong. He stands there, naked by the bed—he always sleeps naked—feeling his full height, aware of his wife's patient breathing and of the wintry bedroom air on his skin. That too is a pleasurable sensation. His bedside clock shows three forty. He has no idea what he's doing out of bed: he has no need to relieve himself, nor is he disturbed by a dream or some element of the day before, or even by the state of the world. It's as if, standing there in the darkness, he's materialised out of nothing, fully formed, unencumbered. He doesn't feel tired, despite the hour or his recent labours, nor is his conscience troubled by any recent case. In fact, he's alert and empty-headed and inexplicably elated. With no decision made, no motivation at all, he begins to move towards the nearest of the three bedroom windows and experiences such ease and lightness in his tread that he suspects at once he's dreaming or sleepwalking. If it is the case, he'll be disappointed. Dreams don't interest him; that this should be real is a richer possibility. And he's entirely himself, he is certain of it, and he knows that sleep is behind him: to know the difference between it and waking, to know the boundaries, is the essence of sanity.
The bedroom is large and uncluttered. As he glides across it with almost comic facility, the prospect of the experience ending saddens him briefly, then the thought is gone. He is by the centre window, pulling back the tall folding wooden shutters with care so as not to wake Rosalind. In this he's selfish as well as solicitous. He doesn't wish to be asked what he's about—what answer could he give, and why relinquish this moment in the attempt? He opens the second shutter, letting it concertina into the casement, and quietly raises the sash window. It is many feet taller than him, but it slides easily upwards, hoisted by its concealed lead counterweight. His skin tightens as the February air pours in around him, but he isn't troubled by the cold. From the second floor he faces the night, the city in its icy white light, the skeletal trees in the square, and thirty feet below, the black arrowhead railings like a row of spears. There's a degree or two of frost and the air is clear. The streetlamp glare hasn't quite obliterated all the stars; above the Regency façade on the other side of the square hang remnants of constellations in the southern sky. That particular façade is a reconstruction, a pastiche—wartime Fitzrovia took some hits from the Luftwaffe—and right behind is the Post Office Tower, municipal and seedy by day, but at night, half-concealed and decently illuminated, a valiant memorial to more optimistic days.
And now, what days are these? Baffled and fearful, he mostly thinks when he takes time from his weekly round to consider. But he doesn't feel that now. He leans forwards, pressing his weight onto his palms against the sill, exulting in the emptiness and clarity of the scene. His vision—always good—seems to have sharpened. He sees the paving stone mica glistening in the pedestrianised square, pigeon excrement hardened by distance and cold into something almost beautiful, like a scattering of snow. He likes the symmetry of black cast-iron posts and their even darker shadows, and the lattice of cobbled gutters. The overfull litter baskets suggest abundance rather than squalor; the vacant benches set around the circular gardens look benignly expectant of their daily traffic—cheerful lunchtime office crowds, the solemn, studious boys from the Indian hostel, lovers in quiet raptures or crisis, the crepuscular drug dealers, the ruined old lady with her wild, haunting calls. Go away! she'll shout for hours at a time, and squawk harshly, sounding like some marsh bird or zoo creature.
Standing here, as immune to the cold as a marble statue, gazing towards Charlotte Street, towards a foreshortened jumble of façades, scaffolding and pitched roofs, Henry thinks the city is a success, a brilliant invention, a biological masterpiece—millions teeming around the accumulated and layered achievements of the centuries, as though around a coral reef, sleeping, working, entertaining themselves, harmonious for the most part, nearly everyone wanting it to work. And the Perownes' own corner, a triumph of congruent proportion; the perfect square laid out by Robert Adam enclosing a perfect circle of garden—an eighteenth-century dream bathed and embraced by modernity, by street light from above, and from below by fibre-optic cables, and cool fresh water coursing down pipes, and sewage borne away in an instant of forgetting.
An habitual observer of his own moods, he wonders about this sustained, distorting euphoria. Perhaps down at the molecular level there's been a chemical accident while he slept—something like a spilled tray of drinks, prompting dopamine-like receptors to initiate a kindly cascade of intracellular events; or it's the prospect of a Saturday, or the paradoxical consequence of extreme tiredness. It's true, he finished the week in a state of unusual depletion. He came home to an empty house, and lay in the bath with a book, content to be talking to no one. It was his literate, too literate daughter, Daisy, who sent the biography of Darwin which in turn has something to do with a Conrad novel she wants him to read and which he has yet to start—seafaring, however morally fraught, doesn't much interest him. For some years now she's been addressing what she believes is his astounding ignorance, guiding his literary education, scolding him for poor taste and insensitivity. She has a point—straight from school to medical school to the slavish hours of a junior doctor, then the total absorption of neurosurgery training spliced with committed fatherhood—for fifteen years he barely touched a non-medical book at all. On the other hand, he thinks he's seen enough death, fear, courage and suffering to supply half a dozen literatures. Still, he submits to her reading lists—they're his means of remaining in touch as she grows away from her family into unknowable womanhood in a suburb of Paris; tonight she'll be home for the first time in six months—another cause for euphoria.
He was behind with his assignments from Daisy. With one toe occasionally controlling a fresh input of hot water, he blearily read an account of Darwin's dash to complete The Origin of Species, and a summary of the concluding pages, amended in later editions. At the same time he was
listening to the radio news. The stolid Mr. Blix has been addressing the UN again—there's a general impression that he's rather undermined the case for war. Then, certain he'd taken in nothing at all, Perowne switched the radio off, turned back the pages and read again. At times this biography made him comfortably nostalgic for a verdant, horse-drawn, affectionate England; at others he was faintly depressed by the way a whole life could be contained by a few hundred pages—bottled, like homemade chutney. And by how easily an existence, its ambitions, networks of family and friends, all its cherished stuff, solidly possessed, could so entirely vanish. Afterwards, he stretched out on the bed to consider his supper, and remembered nothing more. Rosalind must have drawn the covers over him when she came in from work. She would have kissed him. Forty-eight years old, profoundly asleep at nine thirty on a Friday night—this is modern professional life. He works hard, everyone around him works hard, and this week he's been pushed harder by a flu outbreak among the hospital staff—his operating list has been twice the usual length.
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.
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 twenty-eight-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 fifty-three-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 forty-four-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 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 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 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 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.