Beginning a painting was the hardest part. Each time, there was an anxious confrontation with the blank white canvas as he stood before the easel. The image was unstable and there were so many choices: who or what entered and who or what remained excluded. Gradually, out of uncertain mist, the charcoal drawing diverged forms from background with broken lines, cross hatchings, and shadings. With an eraser, chiaroscuro images were recovered from darkness. But the pattern was still tentative and required layers of color to establish meaning which was not yet knowable.
On the glass palette, he always arranged the oil paint colors in the same sequence. He squeezed out an inch of each color from the tubes. On the left, he neatly arranged a vertical column of warm colors: cadmium yellow and red, alizarin crimson, yellow ochre, and raw sienna. On the right, there were two blues, cerulean and ultramarine, and two greens, sap and viridian. Across the top center, he placed a thicker band of titanium white. He rarely used purple or black paint and then only for efficiency not effect. There were limitless possibilities in this palette.
His paintings often recalled childhood outings with his parents and two sisters. There were beach scenes in Mendocino and Carmel and picnics at the Russian River and the Napa Valley. His paintings sold for modest prices but he had not been able to retire early from his job as librarian at the high school. A modest inheritance allowed him to maintain the old Victorian house that he inherited from his parents. His mother’s grand piano still anchored the living room and his father’s ornate desk dominated the guest bedroom. Six years ago, his wife died suddenly after a ruptured aortic aneurysm. When he was not painting, Lucy’s absence still filled him with sadness, especially in the morning when he awakened and in the evening just before sleep. The vascular surgeon had declared that she did not feel pain and likely did not know what had happened.
That was a blessing, he thought. Perhaps it was a blessing as well that they did not have children. Children might bring only more of the sorrow of separation when they grew up and left.
On most days, the solitary call he received was from the police department which maintained a kindly service to check on elderly or housebound residents. The dispatcher called at 5 p.m. each day.
Attending to memories was the most pleasant way he could think of to occupy the days. With a few flicks of his wrist on a paintbrush he could recreate the sunlit patterns on the ocean or the bloom of the mustard fields. His current painting in progress was an autumn scene with an apple orchard and rows of grape vines stretching out over ochre hills streaked with purple shadows. He struggled with the line drawing. He wanted the strength of repeating vines without a monotonous impression. His colors were confined within the borders rather having a life of their own.
Why do I continue? he asked himself. Life’s ordeals were easier to bear if you could see beauty or God in every image.
Last week, he painted a purple undercoating for the grapevines, alizarin crimson and ultramarine blue mixed in equal parts. He could touch the purple now without any stickiness so with dry brushes, he applied thin layers of yellow and green with a light touch that let the undercoat show through. He was startled to realize that at this moment, he could not recall the name of this method of painting wet over dry.
The word began with an s.
He had become increasingly forgetful over the last few months. He could no longer easily recall the names for basic painterly techniques. Last week, he forgot the Italian word for partially scratching off a layer of paint with a knife to reveal a different color below. Yesterday, he could not remember the name for shading with dots and small circles.
They were all s words. I can still scribble and splatter, he thought wryly.
He got up for a light lunch. He could reheat the corn chowder and vegetable lasagna that had been delivered two days ago. He felt lightheaded walking downstairs to the kitchen and held on to the bannister. The first time that he stumbled, he managed to keep upright by gripping the railing with both hands and pushing up but with the second stagger, he toppled down. He felt a sharp blow to his head and then suddenly, he was in the apple orchard.
A cool breeze carried the smell of the fruit and the buzz of insects. He saw his mother unpacking a basket of wheat crackers, string cheese, and apple slices. She waved to him and his sisters and called them to come to the outdoor redwood table. The crescent moon came up over the now entirely purple hills. He saw Lucy beyond the fruit trees. She wore a yellow summer dress and the breeze unfurled and fluttered her long hair like a signal flag. Those were his last thoughts before a dark haze overcame him.
***
When he did not answer the 5 p.m. courtesy call, the dispatcher sent over a police officer. The name registered on the house list was Warren Partington. The officer looked through the kitchen window, saw Partington laid out on the floor, and summoned the paramedics. When they arrived and forced the door open, the old man was conscious but lethargic, mumbling something about a vineyard and a painting. His blood pressure was normal and his breathing was regular. Still, they drove him to the emergency room downtown for a complete medical evaluation.
The brain CT scan showed an ovoid tumor in the inferior left frontal lobe. On attending rounds the next morning, Dr. Gabriel Reed, a lean surgical intern, stood outside the new patient’s room and summarized the case for the neurosurgical team: “Warren Partington is an eighty year old man, a retired librarian, who presents with dysphasia and a left frontal mass on the scan.”
Reed knew that everyone on the team understood that the tumor involved Broca’s area. Introductory anatomy texts acknowledged the nineteenth century French physician who reported loss of speech in patients who suffered left frontal brain injuries.
Dr. Mathew Trujillo, the chief neurosurgical resident, opened the sliding door to Warren’s room. Sunrise across the eastern hills lit up the room. Partington sat up in his hospital bed when he saw the neurosurgical team. Dr. Sid Narayan, the attending neurosurgeon entered, leading the team who trailed behind and gathered around the bed. Trujillo and a senior resident wore long white coats and two interns had short coats. Two nurses wore powder blue scrub suits without coats. Narayan was the only one who wore a suit and tie. To Partington, Narayan looked like a celebrity surrounded by a flock of fans.
“How are you doing this morning?” Trujillo asked. Trujillo’s salt and pepper hair was slicked back neatly.
“Must finish,” Warren said. He clasped the top of his pale blue hospital robe with his frail hands. The white cloaked flock scrutinized him as if he withheld a valuable secret.
“Finish what?” Trujillo asked.
“Painting.”
“He’s been perseverating about a painting,” offered Reed.
“Perhaps painting is an important hobby for him,” Narayan suggested.
Partington looked into Narayan’s dark eyes and sensed that the physician tried to understand. He was grateful. But, it was not just a hobby.
“He is oriented to person and place but not date,” added Reed.
Trujillo pulled out a pen from his top pocket and held it in front of Partington. “Can you name this object?” He clicked the pen top back and forth.
“Brush.”
Trujillo held up two fingers. “How many?” he asked.
“Two brushes,” Warren said.
“Will you use cortical mapping?” asked the senior resident. Tortoise shell glasses framed her blue gray eyes and ash blonde hair.
“Yes,” Narayan said. “That has become standard of care.” He turned to Partington and said: “We are discussing the tumor that was detected on the scan. I assure you that the tumor can be removed safely.”
Partington took a deep breath and felt calmer. He gave the neurosurgeon a weak smile and Narayan nodded his head. With a glance toward the door, Narayan summoned the team to assemble outside.
“We can schedule your surgery for tomorrow afternoon,“ Trujillo added.
“I will return later to talk more about the risks and benefits,” said Reed.
Partington raised a spindly hand to wave. He watched the flock of white coats and their leader exit. He understood that he should follow their advice but still wondered if surgery was truly necessary at his age. He felt a swell of questions rising up but was at a loss for words. He had once possessed an infinite palette of colors to express his ideas but now he was reduced to black and white.
***
At the center of the brightly lit room, Partington lay motionless on the operating table. He was anesthetized with an endotracheal tube and two intravenous lines. Dr. Paula Nowak, the anesthesiologist, sat behind the patient’s head and the neurophysiologist who would assist with the brain mapping stood behind her. The surgical scrub nurse arranged the instruments on adjacent higher tables that were draped in seascape blue shades. Scalpels, probes, drills, punches, and scissors were precisely arranged and ready for work. The preoperative MRI scan had been registered in the computer and generated the target for surgery and the intraoperative navigation that worked like the global positioning system in a car.
After the circulating nurse cleaned Partington’s scalp, Trujillo donned the surgical gown and gloves. He asked for a sterile pen to mark the incision: a long arc over the temporal and frontal lobes centered over the tumor as determined by the navigation system. He asked for the scalpel by extending his right palm. Trujillo let Reed lengthen the incision above the left ear and forward to the hairline. Trujillo applied plastic clips to stop bleeding from the scalp and then retracted the flap to expose the cranium. They worked the power drill and saw to create a skull flap that they elevated with a gently curved probe to reveal the underlying dura mater. Trujillo signaled to Nowak to back off on the anesthesia. Narayan joined the case after Trujillo opened the dura mater to reveal the cream colored and gently pulsating brain. The central aspect of the brain was discolored grey where the tumor broke through the surface.
The neurophysiologist showed Partington pictures on a laptop computer. They did baseline tests and then repeated the trial as Narayan touched the brain or tumor surfaces with a slender electrical stimulating probe. They showed Partington simple drawings of animals, musical instruments, and household objects.
Along the back edge of the tumor, the patient said “tiger” for the image of a lion. Narayan placed a sterile tab on this area since it was eloquent, affecting speech.
Partington said “kit” instead of cat when Narayan stimulated three millimeterrs to the left side.
To an image of a belt, Partington said: “for holding pants up.”
Stimulation of the tumor itself did not alter Partingtons’s speech.
A few millimeters further back, Partington said nothing with brain stimulation when he was presented with images of a trumpet and then a baby carriage.
If the surgeons avoided retraction on eloquent areas, they could traverse a safe passage to remove the tumor. Narayan turned over the tumor resection to Trujillo. Under the microscope, Trujillo coagulated blood vessels at the tumor surface and entered the tumor with a suction tip and cup forceps. As he removed more tumor with the ultrasonic aspirator, he kept talking to Partington and stimulated the circumference of the tumor bed. There was no worsening in the patient’s speech. He handed off a specimen of the tumor to the circulating nurse so that she could send it to the pathologist for frozen section and analysis. When the entire tumor was removed, Trujillo instructed Nowak to put the patient back to sleep so that the closure could proceed routinely.
“Mr. Partington, you did great,” said Trujillo. “Now you can rest.”
“You should get an excellent result,” added Narayan.
The pathologist called into the room to inform Narayan and Trujillo that their patient had a primary tumor of the glial cells of the brain, not a metastatic tumor that had spread from another part of the body. The pathologist could not determine on the frozen section if the tumor was a low grade tumor like an oligodendroglioma or a high grade tumor like a glioblastoma multiforme. They would have to wait for the permanent section results that would be available in a few days.
“Great job to you as well, Matthew,“ Narayan said. He left Trujillo and Reed to replace the bone flap and close the scalp.
“Thank you,” Trujillo said. He eased into the warm flush of success. They had done good work today.
***
Next morning, Gabriel Reed checked on postoperative patients before neurosurgical team rounds. After ensuring symmetry of strength in the patient’s arms and legs, Reed asked Partington to count fingers. He held up one and then two and the patient had no problem.
“Before surgery, you said two brushes.”
“Scumbling,” said Partington.
Reed looked at Partington quizzically.
“Before surgery, I could not remember the word for lightly painting wet over dry.”
“I did not know that word.”
“Claude Monet used scumbling in the water lily paintings.”
Reed vaguely recalled the vibrant viridian green and cobalt blue impressionist paintings from a college art history class.
“Sgrafitto involves scratching off paint to reveal a prior layer below,” Partington continued. “Van Gogh often used sgrafitto, scratching through his thickly applied paint.”
“I did not know that word either.” Reed had not anticipated a tutorial on art history and techniques.
“Stippling involves shading with dots or small circles.”
“I like to learn something new each day.”
“Surgeons probably don’t need to know how to scumble, use sgrafitto, or stipple,” continued Partington with a broad smile.
“Surgery is different than painting.”
“They were all s words.”
“Scalpel starts with s also,” Reed offered. “So does slice.” Then, he realized that he might have missed the point.
“Artists use knives as well,” Partington said with stifled mirth. “To mix paint and apply thick layers but not to cut. Of course, they can correct their mistakes when the paint dries by scumbling or sgraffito. Not like surgeons.”
“Scumbling or sgrafitto would not work in surgery.” Reed smiled as well at the moment of harmony that developed between them. “You have done so well. I hope you can carry on with your painting.”
“I will paint to the end,” Partington said.
Hopefully, for many years if the tumor is benign but maybe only a few months if the tumor is malignant. They both thought the same thought.
“You are like a new person.”
“Thank you for taking such good care of me,” Partington added with warm smile and reached out to clasp Reed’s right hand.
As he left the room and walked down the gray tiled corridor, Reed reflected agreeably that there was more to Partington than he had initially imagined. Likely, he could find an unexpected story with each patient if he got beyond the diagnosis and indication for surgery.
As he eased back into the hospital bed, Partington thought of his unfinished painting. The gloom that engulfed him over the last three days lifted and he experienced a surprising euphoria. He wanted to finish scumbling yellow and green on the purple undercoat of the grapevines. He would use sgraffito and stippling to mold the distant hills. Then, he might search for a new subject for his next painting. Maybe the young doctors or even an imaginary scene. He might try abstraction or a least figurative abstraction. He doubted that he could let go of representation altogether. The possibilities were endless as the colors that he could mix on his palette and apply with a light touch to the prior layers.
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