BMJ  2005;330:368 (12 February), doi:10.1136/bmj.330.7487.368

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Saturday

Hey, Saturday—get up late and it's okay, but not for Henry Perowne, consultant neurosurgeon. Although he is usually "thoughtlessly content" at the weekend, today just happens to coincide with the anti-war demonstration on 15 February 2003. His day starts and ends with a bang.

Perowne is a rationalist, with a boyish enthusiasm for modern science and at odds with the cynicism of these "baffled and fearful" days. Reflecting on trans-sphenoidal hypophysectomy, he considers the procedure "humane and daring—the spirit of benevolence enlivened by the boldness of a high-wire circus act." A true descendant of US neurosurgeon Harvey Cushing and something of an Everyman, he is Joyce's Leopold Bloom as FRCS. His stream of consciousness can eddy within seconds from contemplating the fate of his urinary waste to the ongoing debate on Iraq. Like Bloom he is uplifted by music and cooking, has a difficult daughter, and clashes with the damaged and angry, as in his road rage incident with one Baxter, who has Huntington's disease. Perowne thinks, even as Baxter threatens him, "this is how the brilliant machinery of being is undone by the tiniest of faulty cogs, the insidious whisper of ruin, a single bad idea lodged in every cell, on every chromosome four."

Our man is working too hard—"on his rounds he hits the corridors with an impatient stride his retinue struggles to match." Doing excessive sessions trying to tidy up the turbid ebb and flow of human misery is proving tough. He "knows himself to be incapable of pity. Clinical experience wrung that from him long ago." Envious of the simple joys of others he thinks "there has to be more to life than merely saving lives." He needs a sabbatical; instead he gets Baxter.

The writer researched this novel by observing operations over a two year period. The result is a masterly marshalling of detail combined with a probing narrative drive that chisels expertly to a neat conclusion. McEwan's heavy appropriation of medical jargon reflects his tipsy delight in adapting these words for a literary purpose. Here he is on the tentorium cerebelli: "a pale delicate structure of beauty, like the little whirl of a veiled dancer." With stereotactic precision McEwan wields his pen like a gamma knife to dissect out the essential practice of a surgeon. Readers may find themselves titubating wearily in woeful recognition of the trials that daily face Perowne—"forty-eight years old, profoundly asleep at nine thirty on a Friday night—this is modern professional life."

Ambiguity and doubt on how to deal with the threats of a post September 11 world contrast with the "safe and simple profession" of neurosurgery. How Perowne copes with Baxter—"cruel, weak, meaningless, demanding to be confronted"—chimes with the dilemma posed by Saddam. Actions have consequences, the age old question is posed—what is the morally correct way forward? McEwan seems to diagnose that in both politics and surgery "the difference between good and bad care is near-infinite."

One minor gripe: it's difficult to believe that a neurosurgeon doesn't have an on-call rota these days, making every glass of wine on a Saturday an unnecessary gamble.

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Royal Sussex County Hospital, Brighton John.Quin{at}bsuh.nhs.uk

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