Brain surgery, or at least anything more complex than drilling burr holes, was out of the question at Haydom Lutheran Hospital in Tanzania. The theaters had no operating microscope. The suckers barely worked. The operating light was too dim. Patients under anesthesia were ventilated by squeezing an oxygen bag with your hands. Instruments were scattered across a storeroom that looked like a teenager’s closet. Here, Dr. Dilan Ellegala would be limited to the most basic forms of neurosurgery, which was fine with him. Just a few easy cases in the morning to keep his surgical skills sharp, and then maybe a nap or a book or a run, whatever. He would let his mind wander.
As he neared the wards, people nodded and smiled. Word had gotten around quickly that he was a neurosurgeon. As far as he knew, he was the first brain surgeon to visit Haydom for any length of time, perhaps ever. Prior to his arrival, Tanzania had just three practicing neurosurgeons. Three for an entire country of forty million people. And all three were in Dar es Salaam, the country’s biggest city, five hundred miles away.
The United States had 3,700 neurosurgeons — not enough to keep up with the demand in either country. He didn’t know it at the time, but twelve countries in sub-Saharan Africa had no neurosurgeons at all.
* * *
The morning radiology meeting broke with the sounds of moving chairs. A clinician he’d met earlier approached. His name was Emmanuel Mayegga.
Mayegga had a round face, almond skin, a wisp of a mustache, and a high hairline that made his forehead stand out. He’d been on call during the night when a patient with a head injury arrived. The man was barely conscious. Mayegga wasn’t sure if the injury was a subdural or epidural. Either way, the man was in a bad way.
“Dr. Dilan, please, is there something you can do for this man?”
“Sure, let’s go,” Dilan said.
Dilan followed Mayegga through Radiology outside to a breezeway between the hospital’s buildings. To their right, patients waited next to a window to pay their bills. The surgical ward was on their left, and they entered through a heavy wooden door. Inside, patients spilled out of rooms lining both sides of a dark hallway. They found the farmer in a room with a window view of the hospital’s dirt driveway. Like the other rooms, it had about twenty beds and at least as many patients. Family members stood and sat nearby. The salty and slightly metallic smell of blood mixed with the scents of soiled sheets. An open window let in dust and flies. Dilan squeezed past other patients to reach the man, who lay motionless under a maroon blanket.
He was a farmer in his early fifties. The circumstances of his injury were vague. Mayegga had heard that he’d fallen while in a stupor and bashed his head. Dilan leaned toward the man, who appeared to be unconscious. He would need to do some quick tests to calculate the farmer’s Glasgow Coma Scale, a rough way of measuring the severity of a brain injury. To do that, he would need to inflict a bit of pain. He looked at Mayegga.
“Please tell him that I’m sorry.”
Mayegga said a few words in Iraqw, the farmer’s language and Mayegga’s. Dilan clenched his fist and placed it on the farmer’s sternum. Quickly, he rubbed hard, knuckles to bone. If the farmer reached for Dilan’s hands to stop the pain, then his brain was in reasonably good shape. But the farmer moaned and barely moved his arms. Dilan checked his eyes. Nothing. The Glasgow Coma Scale’s range is three to fifteen, with three being the worst. The farmer was a four.
“This means he’s in a deep state of unconsciousness,” Dilan said.
He leaned closer to the farmer’s head and noticed cerebrospinal fluid dripping from one ear, another bad sign. The brain is sealed tight in the skull, and cerebrospinal fluid is part of the protective buffer between hard bone and soft brain. A leak was a life-threatening condition in itself, a vector for infections. But the drips revealed a bigger drama playing out inside the farmer’s cranium. The blow to his head had breached the meninges — the brain’s outer defenses — and blood and fluid had begun to pool. He could see it in his mind: the dura would be hard, stretched tight from the pressure, and purplish, like a bruise on a pale person’s skin. The brain itself would have an angry red tint, like a bloodshot eyeball. Under this assault, the farmer’s brain was saving energy by shutting down less vital functions: speech, movement, consciousness. His brain was probably burning glucose like crazy in a last-ditch attempt to buy more time.
“Time is brain.” Dilan said this often to his surgical teams. Every minute counts when someone’s brain is damaged. Fix it quickly and you might save the memory of a first bicycle ride or a family camping trip; you might save the ability to move the legs, urinate, or breathe. He could save this man. It was a simple operation. He just had to get inside his head and stop the bleeding. Except for one problem. He had no way of opening the guy’s skull.
A brain weighs about three pounds. Its undulating lobes look similar to the inside of a cut-open cauliflower, but brain tissue has the consistency of brie. People sometimes describe its coloring as gray, but that’s only half true. A dead brain is gray, but a live one is pinkish yellow, flush with blood. It has roughly eighty-six billion neurons, all connected in ever-changing networks. The potential combinations of these networks are the number ten followed by a million zeros. For all practical purposes, no two brains will ever be alike.
The skull is the densest bone in the body, roughly as strong as oak. The skull is thicker in some areas, such as the forehead. But near the temple in a place called the pterion, it’s as thin as a cracker—no match for a smack with a stick, or a baseball, which is why baseball helmets have special flanges that extend down on the side facing the pitcher. A big artery, the middle meningeal, runs right underneath the bone. Some doctors call the pterion “God’s little joke.”
But any spot is vulnerable when enough force is applied to it. Even minor falls and blows could create eggshell fractures. In such cases, the skull bone bends inward from the blow but then pops back, pulled by muscles and tissue of the scalp. To the untrained eye, it might look as if nothing is amiss. But underneath the skull all sorts of mayhem can happen. If you strike your head hard enough, your brain sloshes back and forth like a sponge in a bucket. A brain has a forest of blood vessels, some as thick as cocktail straws, others finer than a strand of hair. When these blood vessels stretch and break, blood and other fluids build up inside the skull. With nowhere to go, the fluid compresses the brain, neural pathways are cut, circuits go down like a failing electrical grid.
Head injuries are as old as humanity, and so are attempts to fix them. Prehistoric healers used flints, obsidian, and other hard stones to make holes to relieve pressure, a process known as trepanation. In the 1800s doctors used chisels and mallets, often doing more harm than good. When suddenly exposed, swelling brains have a tendency to ooze out of the open skull like overbaked soufflés. Through the early 1900s, patients had a fifty-fifty chance of surviving even minor brain surgery. Because of this, the skull was sometimes called the closed box.
Harvey Cushing changed all that. Cushing was Harvard’s brilliant surgeon in chief, an accomplished artist who used both hands to write on chalkboards during lectures. Instead of chisels and mallets to open a skull, Cushing carefully drilled holes with a hand trephine, a cousin of the wooden-handle corkscrew. Then he grabbed a Gigli saw, a wire with serrated edges that doctors used for amputations.
He inserted one end of the saw into the first burr hole and guided it to the second hole. He fished out the saw from the second hole and then attached T-shaped handles to both ends. He moved the saw back and forth, as if flossing a tooth. When the wires met, he’d cut a line in the skull. Doing this in a circle, he could pop off a patch of skull like the top of a jack-o’-lantern.
The procedure was called a craniotomy, and with this technique, Cushing was able to expose the brain without turning it into a bloody pulp — he opened the closed box.
Gigli saws were still available, low tech, and cheap — twenty bucks in the United States. Some neurosurgeons used them even when they had electric or pneumatic saws at their disposal; they liked the feel of the wires and the back-and-forth rhythm. Dilan had an unproven theory: if given a choice, most neurosurgeons would choose manual transmissions over automatics.
Because Gigli saws were used for amputations, Dilan had thought the hospital might have one socked away in a storeroom and had gone looking for one as soon as he arrived. He opened cabinets and drawers, rifled through closets and boxes stuffed with secondhand supplies. He found suction tubes, clamps, retractors, dissectors, scalpels, and a Hudson Brace, a hand drill that looked like an eggbeater, all of which could be used in neurosurgery. But no Gigli saw.
Then, while searching a storage room, he discovered an old wooden case. The wood was honey-colored with long, dark grains, burnished by use and time, probably brought by a European doctor decades ago. The case had two brass hinges and a brass clasp. He opened it, and there it was: a Gigli saw, coiled in a circle and held in place by four wood blocks.
It looked like a museum exhibit, as if the nineteenth-century doctor Leonardo Gigli had made it himself. Dilan picked it up. It was rusty and broken into several pieces. How cool is this to find something so old? He studied it more closely.
You could use it if it was rusty — just clean and sterilize it — but not if it was broken or so weakened by rust that it might break inside a patient’s skull. This was both rusty and broken. He had put the saw away and closed the box. Awesome. But no use at all. Beyond repair.
* * *
Dilan couldn’t help the farmer, so he decided to go for a run — keep the work-life balance in check. Back at the cottage, he slipped into his shorts and put on his brown Nikes. He followed the long driveway to the gates. To the right, a small building sold gospel music and Bibles. Ahead, a steady stream of people moved through the swinging gates. In any given hour, six hundred might pass through: tall men with spines as straight as their staffs; children in green-and-maroon school uniforms; nursing students in pink uniforms and black shoes. People wore sandals made from old tire treads, yellow flip-flops, rubber wading boots, formal black-leather shoes. Dilan nodded to the gate guards, and then he was outside.
Across the road was a stall with a sign that said Junction Shop. Next to it was a cobbler sitting on a plank beside a sign that said Dr. Shoes. An uneven line of shops and huts ran up the hill, with empty spots here and there, like a mouthful of bad teeth. The road had been baked so hard that its surface had split into jagged fissures. He noticed again the slow pace of people around him and the exhausted lopes of the dogs. Everything and everyone seemed to be waiting for the rain to return, except perhaps the children.
He reached the top of the hill and turned right, passing between the thornbushes that guarded the airstrip. High, flat, and open, the airstrip felt like a stage. The midday sun was a powerful spotlight. He felt as if his eyes had gained extra contrast.
That farmer? He would die soon. Nothing I can do. Let it go. A stiff wind blew. He felt the dust on his pores. What a relief it was to have no responsibilities for a change. He took off down the airstrip, light steps, then faster.
Midway, something caught his eye. A bush. It was shaking in a violent way. Couldn’t be the wind. Nothing else was around. Hyenas? You could see their chalky white turds around the airstrip. Then he saw two arms coming out of the bush, moving back and forth like pistons.
Closer, and he saw the full figure of a man cutting a tree limb with a wire saw.
The man was tall and had a shuka blanket draped over his shoulder.
“Jambo,” Dilan said, still wishing he knew more Swahili. He used hand signals and a few other Swahili words to ask where the man had bought the saw.
“Mbulu,” the man said.
It might take a day or two to figure out how to get there and back.
Dilan asked if he could look at the saw.
The man handed it to him. It was about two-and-half feet long with three thin strands twisted around each other to create a jagged cutting edge.
“Can I buy this?”
The man looked puzzled.
More hand movements followed as Dilan offered the man twenty thousand shillings, about fourteen dollars, close to what he would pay for a saw online in the States, about two weeks of income for the average person around Haydom.
The man handed over his saw, his face a mix of bemusement and triumph.
Dilan coiled it and turned back toward the hospital. Time is brain.
* * *
The farmer was on a table in Theater One. Dilan had sorted through a bin of green scrubs, trying to find an extra large. The pants he found rode high on his ankles. His scrub top felt tight around his armpits. He scrubbed his hands in one of the three sinks outside the theater. Masks dangled from a shelf to the right. He shook the water droplets off his hands and walked through a double door.
The theater’s floor was concrete — gray and polished. The equipment was old, but the room was remarkably clean. The walls were white, and the ceiling had two bare fluorescent tubes. Four chains dangled from the ceiling with wire cages for glass IV bottles. Two screen windows let in the breeze. A black plastic clock tilted on the wall, ticking.
Since the theater’s lights were so dim, Dilan strapped his camper’s headlamp around his forehead. He worked with a nurse to put a tray together. He gave instruments simple names: “big biter” for the Leksell and Adson rongeurs and “nibbler” for the smaller Lempert rongeurs. He had the tree saw sterilized in an autoclave across the hall. The wire lay coiled next to the other instruments like a dark snake.
Victor, a Tanzanian anesthesiologist with a thin mustache and sleepy eyes, manned an oxygen bag. He squeezed it gently, ventilating the farmer’s lungs. Standing behind Dilan was Emmanuel Mayegga, there to observe. A nurse stood by with an orange flyswatter.
“Is the suction working?” Dilan asked the nurse.
The nurse nodded yes, but not in a confident way. No problem.
If the suckers failed, he’d sop it all up with gauze.
He rolled a stiff green towel into a tube and shaped it into a loop. He placed the loop under the farmer’s head to make a cradle. He didn’t want the man’s head to move when he drilled.
A nurse shaved the farmer’s head and smeared grain alcohol on the incision site. Normally, Dilan used a black pen to outline where he would make his first cuts. But he didn’t have a pen so he used a needle. He scratched a reverse question mark in the farmer’s scalp. The needle tip made a thin white line. He took a No. 10 scalpel and made a quick inch-long cut, following the line’s curve. Then another. He retracted the skin and scraped away a layer of muscle, revealing bone.
Now the Hudson drill. His left hand held the handle, his right found the crank. He moved the bit over the bone, pressed, and cranked; the gears squeaked; white bone dust piled up around the hole. He made another hole an inch away, then inserted a thin metal strip called a brain protector between them. The strip would shield the brain from the tree saw’s edges; he’d found it in the garage next to other ambulance parts. Good, he thought. The mechanics did a nice job cutting it to size.
Leaving the brain protector in place, he inserted the wire saw at an angle, making sure it went between the brain protector and the skull. When the end appeared by the second hole, he pulled it through. Then, Harvey Cushing style, he lifted both ends and moved the wire back and forth, cutting the bone.
Cool, it’s working.
He drilled more holes, sawed back and forth, until he could open the farmer’s hood.
Just in time. The brain was badly swollen. It had that angry red and purple coloring and was full of blood and cerebrospinal fluid.
Dilan found the damage and used an electric cauterizing tool to stop the bleeding. The tool zapped and sizzled and sent up wisps of smoke. The smoke smelled like burned hair. He flushed the wound with saline. He watched the farmer’s bruised brain pulse. With Emmanuel Mayegga still watching, he reversed what he’d done, closed the box.
“Nothing to it,” he said, and walked out the door.
Victor, the anesthesiologist, continued to squeeze and release the ventilating bag. He’d seen hundreds of patients with head injuries die because no one could help them. As he watched Dilan leave, he said under his mask, but loud enough for Mayegga to hear, “We have a neurosurgeon.”
Dilan ditched his green scrubs in the changing room and followed the breezeway back to the hospital’s entrance. “Wow,” he kept telling himself. “I just used a tree saw to open someone’s skull.”
Adrenaline coursed like electricity through his bloodstream, that familiar jolt from doing something new, of solving a problem that others hadn’t. He felt his feet scrape the dirt, felt the clean, dry air in his lungs. After a surgery like this, his senses came alive. Sometimes it even felt like joy.
With a CT scanner and a wire saw, he had opened the closed box. That meant he could repair subdural hematomas, drain abscesses, remove meningiomas and other tumors. Suddenly he had a caseload of patients who otherwise would have died. More patients than one neurosurgeon could ever handle.