Working on Happiness: how would you cope with post-operative regret?

In 1953, while living in Germany, my mother began creating a remarkable book. She called it Happiness. It is a deeply personal, carefully assembled collection of poems, biblical passages, prayers, prose and pictures through which she explored love, faith, beauty, belonging and the life she hoped to lead. Now, as my mother enters her 91st year, we are transcribing and preparing it for publication. We hope to preserve it not only for the generations of her family who will follow, but are mindful that the act of preservation opens up many dilemmas.

The book is in a state of considerable disrepair. Its spine is failing, its edges are frayed and its pages are becoming increasingly fragile. We are trying to save it through digitisation and duplication, perhaps by rebinding it, and by whatever other means we can devise. Inevitably, I find myself thinking about my prostate cancer, and about the body more generally. It too becomes frayed at the edges. Its structures weaken, its mechanisms begin to fail, and we look for ways to repair what can be repaired while preserving as much as possible of the original.

Perhaps both undertakings are a hiding to nothing. The book cannot be made young again, any more than I can. Preservation is not immortality, and every repair carries the possibility of loss. But all is not lost yet.

Bodies disappear. Books fall apart. Yet the stories they contain can prove remarkably resilient. Poems, pictures, memories and fragments of love have an extraordinary ability to linger, sometimes long after their supposed expiry date. By saving this book and allowing its contents to travel beyond its fragile covers, we may give Happiness a life that neither its maker nor its materials could ever have anticipated.

That final idea is especially moving: the original object remains precious precisely because it is vulnerable, while digitisation and publication allow what it contains to escape the limits of the object and, ultimately, of the body that made it. There is something wonderfully defiant in that – something I know my mother appreciates.

Mindful of my recent journey through the NHS, I’ve been consulting with a consultant about what’s to be done. Previously he diagnosed the problem and suggested three solutions. Here, he discusses his preferred option and the possible outcomes.

Proposed operative procedure

The patient would be admitted to the bindery and placed under controlled workshop conditions. A bespoke cradle would support the volume throughout the procedure. Using a minimally invasive, robotic-assisted approach (or, more accurately, extremely steady hands while imagining the presence of a robot) the damaged spine would be approached through the existing line of failure.

The deteriorated external spinal tissue would be carefully mobilised. Original covering fragments would be preserved wherever viable. A radical excision of loose adhesive and irreversibly degraded lining material would then be undertaken, with particular care to avoid positive margins of instability. The sewing structure would be inspected. Broken supports would be repaired and loose leaves reattached. Tears would be reinforced using Japanese tissue and reversible conservation adhesive.

Nerve-sparing considerations

Every effort would be made to preserve the structures responsible for the patient’s future function and quality of life. In bookbinding terms, these include:

• the original sewing;
• the ability of the pages to open naturally;
• the flexibility of the spine;
• the connection between the text block and boards;
• and the patient’s recognisable outward appearance.

A bilateral nerve-sparing procedure would be attempted where the original materials remain sufficiently healthy. If deterioration extends too far into the joints or sewing supports, wider excision may be required on one or both sides to achieve structural security. The owner should understand that nerve sparing cannot be guaranteed until the spine has been directly examined.

Margin status

The aim would be to remove all actively failing material while preserving the maximum possible amount of original fabric. A “positive margin”, in which deteriorated adhesive, cloth or lining remains at the edge of the repair, could increase the risk of recurrent structural failure. However, excessively wide excision might unnecessarily sacrifice historic material. The operative judgement therefore lies in achieving the narrowest safe conservation margin.

Lymph-node dissection

There is no current indication for removal of neighbouring books, shelves, bookends or associated archival material. If evidence of active mould or insect activity is discovered, adjacent volumes may require examination and temporary isolation. Routine removal of otherwise healthy surrounding material would not be recommended.

Expected functional outcomes

The principal objectives are restoration of:

• structural continence, so that pages remain securely within the volume;
• controlled opening without excessive strain;
• improved spinal stability;
• the ability to stand with appropriate support;
• and satisfactory long-term archival function.

Some early leakage of loose fibres or adhesive residue may occur, but this should settle following rehabilitation. The patient is unlikely to regain the unrestricted flexibility of youth. The expected outcome is safe, dignified and supported function – not vigorous opening to 180 degrees.

Risks and complications

Potential complications include:

• damage to brittle paper during mobilisation;
• separation of images from failing adhesive;
• incomplete preservation of the original spine covering;
• positive structural margins;
• recurrent joint failure;
• loss of spinal flexibility;
• cosmetic asymmetry;
• and the discovery of more extensive disease than imaging has suggested.

There is also a small risk of postoperative regret if the patient emerges looking conspicuously “restored.” For that reason, all new materials should be sympathetic but identifiable, and no attempt should be made to erase the signs of a long and meaningful life.

So, what would you do, dear reader, particularly about any postoperative regret?

We’ll be continuing to consult with our consultant about what happens next and will keep you posted!