Daniel L. Barrow sits on a chair that is wrapped in blue, sterilized plastic and rests his elbows on the armrests to steady his hands. He stares straight ahead into the eyepiece of a microscope, watching his surgical instruments move in a valley of brain tissue below the lens. The brain he is working on, with almost reverent care, belongs to an anesthetized 50- year-old woman, whose head is clamped to the operating table.
Dr. Barrow, the chairman of the neurosurgery department at Emory University's medical school, is in the middle of his first operation on what he calls a slow day. He showed up at his office at 5:30 a.m. and will wind up leaving at 7:00 tonight. As a department chairman, he views himself as the head of a business that generates $75-million a year in revenues. But he believes he has to perform in order to lead, and he will operate about 350 times this year.
His specialty within neurosurgery is fixing the flaws, known as cerebral aneurysms, that can bubble out from the walls of arteries in the brain. A ruptured aneurysm can kill someone or cause a stroke. Dr. Barrow's reputation for repairing aneurysms has earned him referrals from doctors throughout the South and put him in a book called The Best Doctors in America (Woodward-White, 1996).
Early this morning in his office, dressed in blue scrubs and sneakers, he reflects on being drawn into neurosurgery by a fascination with the brain's complex anatomy. He remembers going home from medical school to tell his father, a country doctor in Pittsfield, Ill., that he wanted to be a neurosurgeon. He told his father about his decision shortly after dawn, over coffee on the patio of the family home. "I can't imagine why anyone would want to do that," his father responded.
For the first half of the century, being a neurosurgeon meant you were a loser, Dr. Barrow says. The winners were almost inevitably the neurological conditions -- tumors, strokes, paralysis, back pain, spinal injuries. Advances such as microsurgery and new forms of medical imaging, Dr. Barrow says, have given neurosurgeons more victories in recent years.
In the operating room, Dr. Barrow acts as the conductor of a small orchestra of fellow doctors, nurses, and technicians. An anesthesiologist stands on the opposite side of the table from the surgeons, watching a rack of monitors that display the patient's vital signs.
The chief neurosurgical resident at Emory University Hospital, Cargill Alleyne, begins the operation. He slices the skin on the skull to make a semi-circular flap that can be pushed aside. He drills holes along the top of the skull, then down toward the ear and back up along the temple. He cuts between the holes with a special burr, then pulls off a section of bone and sets it aside.
After Dr. Alleyne has carved open a window on the brain, Dr. Barrow puts on a dark green sterile gown and gloves. He dons glasses with magnifying lenses set into them and a headset with fiber optic cables that release a dull blue glow. The cables conduct light from a box behind Dr. Barrow, then wrap over his hair and plug into a spotlight that shines out from his forehead.
Dr. Barrow pushes down in a fissure in the brain, moving toward an aneurysm so he can put a metal clip on it. When he is ready to work under the microscope, a nurse strips off his head gear. He sits in the microscope chair and rolls up to the patient so that his knees are under the table. His feet operate pedals that control the microscope, the drill, and an electrocautery device, which uses electrical current to cut tissue. He holds the electrocautery probe in his right hand and a suction tube to draw away blood in his left.
One of the spectators in the operating room is Walter Johnson, a neurosurgeon with strong, puffy hands, a calm manner, and collar-length gray hair. Dr. Johnson is a member of the neurosurgery department at Emory, but he practices about 130 miles away, in Dalton, Ga., a manufacturing town that bills itself as the carpet capital of the country.
Dr. Johnson inspects a row of images clipped to a light box that is hanging on the tiled operating room wall. Known as angiograms, the images were taken of the patient's head before the operation, and are made by filling the arteries with a dye that blocks X-rays. The arteries show up looking like gnarled black trees on the gray background of the X-ray film.
After Dr. Barrow clips the aneurysm, a new angiogram indicates that an important artery isn't filling up with blood. If the blood flow is blocked, Dr. Johnson says, the patient would have a stroke on the dominant side of her brain. "She couldn't speak," he says. "She'd lose the use of her legs."
Dr. Barrow gets back into his microscope chair to search for trouble, such as an artery that has gone into a constricting spasm. But all the visible arteries seem to be fat with blood, and so he asks the radiologist for another angiogram. A second image indicates that all arteries are functioning, and Dr. Alleyne starts the job of closing up the patient's skull.
Dr. Johnson and Dr. Barrow leave the operating room, and as they head down the corridor, Dr. Johnson asks what was wrong with the angiogram. "Amateurs?" he asks, referring to the radiology team. Dr. Barrow nods.
Dr. Barrow and Dr. Johnson order turkey club sandwiches in the doctors' dining room and talk about other cases. Dr. Barrow tells of a man who had a stroke and then rolled down a hill. When he was taken unconscious to a hospital, the doctors who saw him assumed that his condition was due to injuries suffered during the fall. By the time a consulting neurosurgeon detected a ruptured aneurysm in the man's brain, he was dead.
In patients who are conscious, aneurysms can cause symptoms, such as headaches, that are often wrongly diagnosed as migraine headaches, says Dr. Barrow. When a patient reports "the worst headache of my life," that is a tip off that it is time to check for an aneurysm, he says.
The two men take their sandwiches back to Dr. Barrow's office and continue to talk shop. The Dalton hospital where Dr. Johnson works wants another neurosurgeon, but Dr. Johnson doubts that enough work exists to support two. Dr. Barrow agrees. "It's not a two-neurosurgeon town," he says.
Dr. Johnson steps out to talk to another physician. Bob Davies, the neurosurgery department's business manager, brings in some numbers for Dr. Barrow to review. Each member of the department gets a quarterly profit-and-loss statement, and is eligible for a bonus based on performance. "Whether Dan liked it or not," says Mr. Davies later, "he knew he became a businessman from the moment he finished his medical training."
If Dr. Barrow isn't afraid to quantify performance, including his own, he is also aware of the emotional extremes that his profession induces. One hour he is exhilarated by finishing a complicated surgical maneuver that saves a patient's life, and the next he may have to tell a patient whom he has come to like that a tumor is malignant, and spreading fast.
Dr. Barrow's day of surgery is followed by a morning at the Emory Clinic. One of the first patients he examines is Ginger Monroe, whom he operated on in July to fix an abnormal tangle of blood vessels in her brain.
"Any problems?" asks Dr. Barrow.
"No," she says. "Other than the itching."
Dr. Barrow looks over the scar on her head. "Among other things, I'm good at picking scabs," he quips, as his fingers explore her scalp.
Then he delivers the doctor's version of a benediction. "You're cured. You don't need to worry about this anymore. Put it behind you."