"Lisa," said Dr. Ranade. "I want you to recite as many nursery rhymes as you can."
Lisa complied, hoping that by helping the whole affair would soon be over. She started to speak, but as she did so Dr. Mannerheim touched the surface of her brain with the stimulator. In mid-word her speech stopped. She knew what she wanted to say, but couldn't. At the same time she had a mental image of a person walking through a door.
Noting the interruption in Lisa's speech, Mannerheim said, "There's your answer! We don't take the superior temporal gyrus on this patient."
The heads of the Japanese visitors bobbed in understanding.
"Now for the more interesting part of this exercise," said Mannerheim, taking one of the two depth electrodes he'd gotten from Gibson Memorial Hospital. "By the way, somebody call X ray. I want a shot of these electrodes so we'll know later where they were."
The rigid needle electrodes were both recording and stimulating instruments. Prior to having them sterilized, Mannerheim had marked off a point on the electrodes four centimeters from the needle tip. With a small metal ruler he measured four centimeters from the front edge of the temporal lobe. Holding the electrode at right angles to the surface of the brain, Mannerheim pushed it in blindly and easily to the four-centimeter mark. The brain tissues afforded minimal resistance. He took the second electrode and inserted it two centimeters posterior to the first. Each electrode stuck out about five centimeters from the surface of the brain.
Fortunately, Kenneth Robbins, the Chief Neuroradiology X-ray technician, arrived at that moment. If he had been late Mannerheim would have thrown one of his celebrated fits. Since the operating room was outfitted to facilitate X ray, the chief technician needed only a few minutes to take the two shots.
"Now," said Mannerheim, glancing up at the clock and realizing he was going to have to speed things up. "Let's stimulate the depth electrodes and see if we can generate some epileptic brain waves. It's been my experience that if we can, then the chances of the lobectomy helping the seizure disorder are just about one hundred percent."
The doctors regrouped around the patient. "Dr. Ranade," said Mannerheim. "I want you to ask the patient to describe what she feels and thinks after the stimulus."
Dr. Ranade nodded, then disappeared under the edge of the drapes. When he reappeared he indicated to Mannerheim to proceed.
For Lisa the stimulus was like a bomb blast without sound or pain. After a blank period that could have been a fraction of a second or an hour, a kaleidoscope of images merged into the face of Dr. Ranade at the end of a long tunnel. She didn't recognize Dr. Ranade nor did she know where she was. All she was aware of was the terrible smell that heralded her seizures. It terrified her.
"What did you feel?" asked Dr. Ranade.
"Help me," cried Lisa. She tried to move but felt the restraints. She knew the seizure was coming. "Help me."
"Lisa," said Dr. Ranade, becoming alarmed, "Lisa, everything is all right. Just relax."
"Help me," cried Lisa as she lost control of her mind. The fixation of her head held, as did the leather strap at her waist. All her strength concentrated into her right arm, which she pulled with enormous force and suddenness. The wrist restraint snapped and her free arm arched up through the drapes.
Mannerheim was mesmerized by the abnormal recordings on the EEG when he saw Lisa's hand out of the corner of his eye. If he had only reacted faster he might have been able to avoid the incident. As it was, he was so startled that for a moment he was incapable of reacting. Lisa's hand, flailing wildly to free her body imprisoned by the OR table, hit the protruding electrodes and drove them straight into her brain.
Philips was on the phone with a pediatrician named George Rees when Robbins knocked and opened the door. Philips waved the technician into his office while he finished his conversation. Rees was inquiring about a skull X ray on a two-year-old male child who was supposed to have fallen down stairs. Martin had to tell the pediatrician that he suspected child abuse because of the old rib fractures he'd seen on the patient's chest X ray. It was sticky business, and Philips was glad to hang up.
"What have you got?" Philips asked Robbins, swinging around on his seat. Robbins was the Chief Neuroradiology technician whom Philips had recruited, and there was a special rapport between the two men.
"Just the localization films you asked me to do for Mannerheim."
Philips nodded as Robbins snapped them up on Philips' viewer. Normally the chief technician didn't leave the department to take X rays, but Philips had asked him to attend personally to Mannerheim just to avoid any trouble.
Lisa Marino's operative X rays lit up on the screen. The lateral film showed a polyhedral lucency where the bone flap had been cut. Within this sharply defined area were the bright white silhouettes of the numerous electrodes. The long needle-like depth electrodes Mannerheim had pushed into Lisa Marino's temporal lobe were the most apparent, and it was the position of these instruments that interested Philips. With his foot, Philips activated the motor on a wall-sized X ray viewer called an alternator. As long as he held his foot on the pedal, the screen in front of him changed. The unit could be loaded with any number of films for him to read. Philips kept the machine running until he found the screen containing Lisa Marino's previous X rays.
By comparing the new films with the old, Philips could determine the exact location of the deep electrodes.
"Gees," said Philips. "You take beautiful X rays. If I could clone you, half of my problems would be over."
Robbins shrugged as if he didn't care, but the compliment pleased him. Philips was a demanding but appreciative boss.
Martin used a finely calibrated ruler to measure distances associated with minute blood vessels on the older X rays. With his knowledge of the anatomy of the brain and the usual location of these blood vessels, he could form in his mind a three-dimensional image of the area he was interested in. Translating this information to the new films gave him the position of the tips of the electrodes.
"Amazing," said Philips, leaning back. "Those electrodes are positioned perfectly. Mannerheim is fantastic. If only his judgment equaled his technical skill."
"Do you want me to take these films back to the OR?" asked Robbins.
Philips shook his head. "No, I'll take them myself. I want to talk to Mannerheim. I'm going to take some of these older films as well. The position of this posterior cerebral artery bothers me a little." Philips picked up the X rays and headed for the door.
Although the situation in OR #21 had returned to a semblance of normality, Mannerheim was furious about the accident. Even the presence of the foreign visitors did not temper his anger. Newman and Lowry suffered the greatest abuse. It was as if Mannerheim felt they had deliberately schemed to cause the problem.
He had started the temporal lobectomy as soon as Ranade had inducted Lisa under general endotracheal anesthesia. There had been a panic immediately after Lisa's seizure although everyone acted superbly. Mannerheim had succeeded in grabbing Lisa's flailing hand before any more damage had been done. Ranade, the real hero, had reacted instantly, injecting a sleep dose of one hundred and fifty milligrams of thiopental IV, followed by a muscle paralyzer called d-tubocurarine. These drugs had not only put Lisa to sleep, but had also terminated the seizure. Within only a few minutes Ranade had placed the endotracheal tube, started the nitrous oxide, and positioned his monitoring devices.
Meanwhile, Newman had extracted the two inadvertently deeply embedded electrodes while Lowry removed the other surface electrodes. Lowry also had placed moist cottonoid over the exposed brain before covering the site with a sterile towel. The patient had been redraped and the doctors regowned and gloved. Everything had returned to normal except Manner-beim's mood.