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The tumour carved out of Don Townshend's arm looks not so much angry, as stubborn — half a fist of filet mignon, sitting up on a green sterile towel.

This is a bloom of cancer, the epidemic scourge.

You can't help but look at it, but you don't want to. It's too private — a rogue life form that was slowly trying to kill a man, after all. It looks malignant, and it is.

But the longer you look at the tumour, the more it tells you about the man it lived in, about the doctor who took it out, about the hospital where that happened, even about the medical system that paid for the operation, what it can do and what it never will.

The lump we all fear. The lump the surgeon loves to cut away. The incurable thing.

***

The pageant of surgery, the great writer-surgeon Richard Selzer called it — the holiest profession in the hospital. Still, if this is a pageant, it's less religion than backyard barbecue. This isn't a darkened operating theatre, hushed in contemplation of a human life lying in the balance.

In OR 11 at Mount Sinai Hospital in downtown Toronto, the lights are blazing and Bruce Springsteen's The Rising is wailing over the sound system. For Jay Wunder, 43, presiding orthopedic surgeon and all-round onco-genius, it's surgical party time.

Four nurses are unwrapping sterilized trays of surgical instruments and arranging them in a semi-circle around the operating slab like an all-you-can-eat banquet.

The anesthetist and his resident are camped out behind a makeshift sheet at the head of the table, gently pumping oxygen, morphine and isoflurane, an anesthetic, and rocuronium, a muscle relaxant, into the patient.

Oh, right: the patient. There in the middle of it all, naked and plain, lying on the table as though he had been dumped by a guy hurrying off on his break, is Don Townshend.

Mr. Townshend is out cold, but it's not like he's asleep: This is something deeper, "the monstrous silence of anesthesia" (Dr. Selzer again), his body surrendered, his soul — this is the weird thing — somehow on vacation.

Two corrugated hoses run into and out of the breathing tubes on his face. Dr. Wunder is arranging a side table especially for Mr. Townshend's crooked arm. It's 9:02 on a Wednesday morning.

"The tumour's relatively small," Dr. Wunder says — the previous week, he took one the size of a basketball out of a man's leg — "but it's in the worst possible position, around the nerve and the vein."

He'll let you touch it: It feels like concrete upholstered in skin, soft and hard at once. Today, he is going to cut it out, preferably without having to amputate Mr. Townshend's arm.

But once the three residents pull draping sheets around Don Townshend's body, he becomes less human. All that's visible of the man, poking out of the blue hill, is his arm and his two legs, orangey red with antiseptic and taped off tight where they join his body. They look like spare limbs someone forgot to take home. The human being has become the task. This is how surgeons like Dr. Wunder can do their jobs.

***

A month after his premature birth at 24 weeks and five days gestation, Zachary Bastead weighs 920 grams, a big gain from his initial 700. Parked on their backs and stomachs in their glass incubators, the mechanical mamas that keep them alive, immobilized between rolled-up flannelette blankets, the preemies look like fancy desserts under glass.

Zachary's not thriving. He is still on an oscillating ventilator (700 breaths a minute), has suffered a mild brain hemorrhage and had one transfusion, 10 per cent of his blood volume. But then, a baby his size has only 63 millilitres of blood, about one-80th the blood supply of an adult male.

In a conference room off one end of the ward, Karel O'Brien, a senior neonatologist in the intensive-care department, is bringing Will Delill and Lindsay Bastead, Zachary's parents, up to date. Zachary — tiny Zach — needs an operation. Someone needs to open his chest through an incision in his side, slip though his pipsqueak ribs, dart under his thumb-sized lungs, and tie off an extra blood vessel between his aorta and his pulmonary artery. The child seems barely big enough to hold, much less operate on.

"He's still quite sick," Dr. O'Brien says in her eight-ounce Irish accent. This is the word Mount Sinai's doctors use, talking to laypeople — not ill, not some technical explanation, just sick. "He's being kept alive by a respirator, but the respirator also endangers the lungs."

"That's the first time we've heard all that," Mr. Delill says when she's gone.

***

Eleven-thirty at night on 12 south: Mostly geriatric patients up here, plus four orthopedic recovery beds. Last weekend, three patients died on this unit. A tiny birdlike woman under a thin blanket launches straight at the nurse when she enters on rounds. "You speak Hungarian!"

"Nah," Kawah says. There is no way Kawah would speak Hungarian. Kawah, the nurse, is Liberian, a west African with an accent like a gorgeous carved ebony banister.

"But you speak English."

When Kawah touches her shoulder, the old woman pulls away, flapping her arms. "How ah you?" Kawah says.

"How am I?"

"How ah you?"

"I don't know," the old lady answers.

Sometimes there are four to a room. The nurses turn out the lights and tell them to go to sleep, but the old birds yak through the night, watching the lights blink on and off on the buildings downtown, not unlike their memories. Why sleep? There will be plenty of that soon enough.

***

Don Townshend complained about the pain in his right elbow for 10 years. His family doctor in Charlottetown, where he is an auto mechanic, always said the same thing: "It's tendinitis." Whereupon the doctor would give him some medication. "And as long as I took it, I'd have no pain. But I'm not much for taking pills. So I'd take them for as long as the prescription lasted, and then I'd just put up with the pain."

The pain stuck around. A year ago this past June, he noticed his middle finger was going numb. Then his thumb and second finger got harder to close.

Is this beginning to sound like a bad dream you have? By the end of September, Mr. Townshend was at the doctor's again. He had begun to notice something — "a bit of a thing there, a bit of a buildup."

The lump got the doctor's attention. It took a few weeks to get in to see an orthopedic surgeon, a few more weeks to get an MRI, a few more still to get a better one. By now it was nearly Christmas. Some Christmas. In the spring, an oncologist finally performed a biopsy.

You'll never guess: It was cancer. An epithelioid hemangioendothelioma, a rare soft-tissue sarcoma. "The worst of it is," the cancer doctor told him, "it can spread to your lungs and your bones."

No one would say Mr. Townshend is an angry man. Still, it upset him a little, the way the medical system missed his tumour for 10 years until it was so bad his whole arm was endangered.

His wife, Dianne, a former nurse, always said that "everybody should take responsibility for their own health, and pressure the system if it doesn't feel right."

But to act that way, you have to feel entitled to attention — and that was not the way Mr. Townshend felt, not when he was otherwise as healthy as a trout, especially not when he read and heard every day how expensive Canadian health care was, how it was abused and overused, how we can't afford it.

So when he arrived at Mount Sinai three days ago, it seemed like another planet. "I'm the kind of guy who, if he had to get up on that roof, he'd think, 'How can I do that without a ladder? Because it's so much trouble to get a ladder.' And that was the worst of the cancer. I couldn't figure any way out of it. I was trapped. I couldn't get out of it."

Now, suddenly, he can get anything he needs, when he needs it. "I see a huge hospital, and people everywhere, and waiting rooms full of people, and I'm here to see the world-famous doctor. And he says, 'I want another MRI, I'll fit you in this afternoon.' And I'm thinking, how in blazes can you do this? I'm not the only person in Toronto. How can they do it?"

They can do it because once you reach Mr. Townshend's stage of cancer, they can do anything. The question is, do you need to get to that stage?

Criticizing big-city medicine is almost a national sport in Canada. But at the high end of the medical ladder, an acute-care hospital such as Mount Sinai is without peer. It was at the other, everyday end of the Canadian medical system, down where most of us live, where Mr. Townshend found it hard to attract any attention.

***

Seven thousand, two hundred and seventy-two children were born at Mount Sinai last year. An additional 542 patients died.

A few more dead arrive at the hospital through the back door — as research cadavers, delivered from the University of Toronto to the hospital's surgical-skills centre early in the morning, via black Econoline truck, in black plastic bags inside funeral bags. The funeral bags are navy blue with Swiss dots.

Perhaps you assumed the well-tended body you plan to donate to science would go intact, looking good, to all the noblest causes. You would be wrong. Today's delivery is five female torsos, bottom halves only so Mount Sinai's surgeons can practise a new bladder-lining technique designed to help women control incontinence. There's also a bag of temporal bones for an ear, nose and throat doctor. The half-stiffs cost $200 each.

By 10 a.m., though, the surgical-skills centre is hopping with live bodies. It's Day 1 of classes for first-year surgical residents associated with the University of Toronto's teaching hospitals, of which Mount Sinai is one — brand-new doctors who graduated from medical school in June with brand-new degrees and not much else. A third are women, a radical development in what has always been a male enclave. Zane Cohen, surgeon in chief, is happy to see them. "They take more time with the patient," he says, "and they have more empathy."

Residents practise in the skills lab — gall bladder surgery on a pig's liver, microsurgery on the blood vessels in a turkey thigh. And of course there's that brown, plastic...backside, curved over the edge of that table. It's the Accutouch Endoscopy Simulator, which can convey the actual feel of steering a camera into someone's posterior, with heads-up display: You have perforated the patient's colon. This is a potentially fatal complication.

Today, the newbies are being led through gowning and gloving and draping and wrapping. Some are already wearing scrubs, the specially non-linting cotton tops and pants that doctors and nurses wear.

This is the beginning of professional life for these young men and women. They work 85 to 110 hours a week, with every fourth night on call. For this, they make $45,000 a year — thanks to the Professional Association of Interns and Residents in Ontario, their union. Thirty years ago, a cardiology resident made $400 a year and was on call every other night. Even so, on an hourly basis, these new doctors make half of what the cleaners do. By the time the most highly trained ones finish— the cardiologists, the plastic surgeons, the neurosurgeons — they'll be just shy of 35 years old.

(Of course, life then gets instantly better. According to Dr. Cohen, top surgeons at Mount Sinai with a full complement of research, teaching and OR time can slice themselves off about $600,000 a year.)

One thing that gives the newbies trouble is naming and recognizing surgical instruments: Balfour retractors, rib strippers and mosquitoes. Instruction begins with the knife, the famous scalpel — the "slender fish," Richard Selzer called it — though these days most surgeons use an electric cauterizing pen to do their cutting. ("The pen is less emotional than the knife," a resident says. "It's not what it used to be.")

The new residents don't seem to savour the beautiful names: They're surgeons, they prefer action. "Surgeons know nothing and do everything," James Downar, Mount Sinai's chief medical resident, told me one morning, repeating the standard hospital joke. "Whereas we, the internists, know everything and do nothing." Surgeons are cavemen, internists are medheads.

But what all doctors want, even the surgeons, what they have competed to claim all their lives in school, is knowledge. Knowledge to a doc is what money is to a broker — the universal commodity.

Cagla Eskicioglu — she's watching the chest draping — became a doctor only last spring, but she's already convinced she wants to be a colorectal surgeon. She's in the middle of her colorectal surgery rotation, studying with the much-admired Dr. Cohen. She feels she could cut bowel for the rest of her days.

"There's just such a range of things to do," she explains enthusiastically. "There's really complicated stuff, like colon cancer, on the one hand. And for the days you don't feel up to it, there're always hemorrhoids."

***

By 2:31 on Wednesday afternoon, four hours and 57 minutes after his surgery began, Don Townshend's arm is open as wide as a gutted salmon. Dr. Wunder has sawed the tumour away from the humerus, just above the elbow. He has taken the afflicted artery and nerve with it. He has opened a flap in Mr. Townshend's hip, cut a slice of hip, replaced the flap, stapled it down; and then screwed the hip bone graft in to replace the tumorous humerus.

Tom Lindsay, a vascular surgeon from the Toronto Hospital, across the street, has now harvested a 30-centimetre length of vein from Mr. Townshend's left thigh. He has already begun the delicate process of stitching into his arm.

Then it happens. "Wait a minute," Dr. Lindsay says. He can feel something on the artery. Something lumpy.

There's more cancer higher up in the arm.

An instant biopsy confirms the bad news. The cancer seems to be tracking his lymphatic system into his shoulder. Even amputation won't help now.

Dr. Wunder leans his back against the OR wall, slides to a sitting position on the floor. He's devastated.

Why? Because Dr. Wunder is a surgeon, a cutter, one of the last of the body invaders in an age when medicine is becoming more internal, more chemical and genomic. This isn't to say he isn't interested in why his patient's genes cause cancer while his own do not: It's one of his major fascinations. But the surgeon in him likes results.

Over the course of his career, Jay Wunder has been offered jobs all over the United States — Harvard, the Mayo Clinic, you name it. He has turned them all down.

"I hated the medical system," he says one morning, describing his year-long fellowship at New York's famous Memorial Sloan-Kettering Cancer Centre. "A place like Sloan-Kettering, it's like this pinnacle of cancer care. But we would get these people in acute care, from Africa, with tumours the size of basketballs, who had no money, no insurance — so they got sent to county hospital.

"What's the point of having a place like that where you've got all these resources, and you can't even provide basic humanity?"

At a Canadian teaching hospital such as Mount Sinai, on the other hand, he gets everything he needs — research money, the team he wants, OR time, focus, patients from all over the world. The result is that though he looks after seriously sick orthopedic-cancer patients, he manages to cure as many as 70 per cent of them.

For most of us, death occurs randomly: No one knows if this is the last cup of coffee before that vein explodes, the last few steps before the heart clutches or the safe falls. Next to that, 70 per cent saved is practically a sure thing. Predictability is part of why Dr. Wunder loves surgery: "It's fantastic to have a plan, and do what you planned to do."

But Mr. Townshend is unplannable, what doctors call "a bad outcome." So while Dr. Lindsay stitches, Dr. Wunder heads to his office to regroup and make some calls.

A modern hospital sometimes feels like a genius in a wheelchair. The genius can figure out just about anything. He just can't always get where he wants to go.

***

The emergency department runs under the hospital like a geyser, threatening to throw bodies to the upper floors, to fill beds the hospital can't spare. Mount Sinai isn't a trauma hospital, yet Howard Ovens's emergency department absorbed more than 38,000 visits last year — a 40-per-cent increase in the past eight years. No wonder the hospital pays so much attention to shortening patients' stays. Thirty years ago, removing a patient's gall bladder put him in hospital for a week. Now, he stays overnight.

The ER is a city of its own. Tonight, there's "something spooky" in Room 305, as the resuscitation nurse describes the case — a 50-year-old high-school principal with a numb face and slurring speech, a potential stroke. She will eventually be discharged as suffering from a migraine. The emergency roomette next to her contains an American who had chest pains while attending a medical convention in town: another discharge.

A Mrs. Sykes has a swollen tongue, possible anaphylactic shock, but recovering. A Korean-Canadian 20-year-old has a heartbeat of 120, but doesn't even feel it. The cardiac resident wants him admitted — "You could literally drop dead 10 minutes after leaving here" — but his aunt wants him home. He goes home.

A miscarriage; a hernia; an obese smoker, racked with asthma; a women listed as "unresponsive," due to an overdose (she leaves on her own after three hours' sleep and some energetically public Bible reading); a ruptured ovarian cyst that might be an appendicitis; a woman, drunk, desperate to detox. ("And that gentleman," Dr. Ovens asks, referring to her surly companion, "is he a boyfriend?" "Well, I guess so," she replies. " I can't get rid of him.")

Then there is Mrs. Sakis, 71, who has been falling over for four days. It turns out her husband, Andrew, gives her all her medications — six different drugs designed to be taken three times day — all at once. He didn't want to forget. No wonder she's falling over. She's admitted.

The Chinese man at the end of the hall is 92, lives with his wife across the street from his dutiful daughters, walks with a cane. This afternoon at half-past-four, he fell off the toilet and snapped his thigh. They're admitting him too.

An average night, in other words, of mild drama. The emergency nurses wear navy blue T-shirts bearing the slogan "What's Your Emergency?" over cartoon stick men depicting the many possibilities: "Choking" shows the stick figure holding his throat. "Foreign Object" shows the stick man holding his bum. "Because," one nurse explains, "that's usually where they are."

***

An operating room is an interesting vantage point from which to look at the state of Canadian health care. Everybody at the hospital talks about waiting lists for surgery: According to the Ontario Ministry of Health and Long-term Care, the average wait for a new hip in downtown Toronto is 169 days. And that's just the average. Ninety per cent of the hip replacements on order will require 314 days — about ten-and-a-half months.

This is the sort of thing Zane Cohen thinks about all the time. Short, trim, quiet, organized, Dr. Cohen, a colorectal surgeon, has been Mount Sinai's chief of surgery for 15 years. He's 63 and looks 15 years younger.

Dr. Cohen and his 16 fellow surgeons use 10 of Mount Sinai's 12 operating theatres from 7:30 in the morning until 3:30 in the afternoon. They would operate more, but each OR costs upward of $750,000 a year to run. At $70-million, Dr. Cohen's surgical-services budget already consumes almost a third of the hospital's budget — roughly the same as non-surgical services, the same as the women's-and-obstetrical-care arm.

But the cause of waiting lists isn't underused ORs. The problem is a shortage of beds and surgeons.

In the late 1990s, when then-premier Mike Harris's Ontario government reorganized medical care, Mount Sinai's budget — the money received from the government — sank to just over $100-million. That sum has only just rebounded to $238-million — one of the biggest hospital increases in the province — in part because the government gives hospitals extra money if they perform what the government deems essential surgeries, i.e., cataracts and hips and knees and cancer, the ones on the waiting lists.

Since April, 2004, Mount Sinai has performed 110 more gastrointestinal-cancer operations than it would have without the extra payments. The result? Even longer waits for non-designated surgeries. "What are we supposed to tell our other patients?" asks Dr. Cohen. "That they're second-class citizens?"

But the single greatest cause of waiting lists, he insists, is the Harris government's stirring decision, 10 years ago, to reduce provincial health-care costs by restricting the number of students who became doctors. It was a wacky theory, with endless consequences. When Dr. Cohen graduated from U of T medical school in 1969, there were 250 surgeons in his class. By 1995, that number had dropped to 165. It has since climbed to 180, but it takes at least nine years to produce a surgeon.

So it comes as no surprise that Dr. Cohen is not optimistic about the future of universal health care. "I'm a firm believer in universal health care, I have to say," he tells me one morning. "But I also have to say the system we promote is not sustainable as it is now. The population is aging, and we don't have enough beds. We have more complex older patients coming into the OR, with complicated co-morbidities — that is, more than one illness, because they're living longer. That, in turn, lengthens hospital stays."

The prices of new cancer drugs and new medical technologies are spiking costs even higher. Roughly 48 per cent of the provincial budget now goes to health care; Dr. Cohen can see it reaching 68 or 70 per cent within two decades. "If the government feels that isn't sustainable — and in a way, they are admitting that already — then I think some private-sector form of health-care system has to come into play."

Think about this: At the moment, there aren't enough colorectal specialists to screen men over 50 for colon cancer, as recommended — and bowel cancers are on the rise, at an average cost of $40,000 a case. Right now, Mount Sinai can perform 10 preventative endoscopies in a morning: The waiting list in downtown Toronto is 10 months long. (In fact, Dr. Cohen spent an hour this morning pitching a hospital donor on a new endoscopy suite.)

But a dedicated private clinic operating two machines could perform 200 a week — provided the machines and doctors were available, or drawn by the potential profits.

Of course, as Dr. Cohen points out, the amount the government pays a doctor for a colonoscopy depends "how far you get up the colon." The first stretch, to the sigmoid bend of the descending colon, is one payment. Around the next corner and across the transverse colon is another hit. If the investigator gets as far as the liver, he scores a third time. All the way around the next bend, down to the beginning of the large intestine and into the ileum of the small, bingo: That's $250.

If anything speaks to how keenly we want to believe we can afford government-funded universal health care, in the face of equally keen evidence that says we can't, it's that strange, surreal fee schedule. But whichever way we go, public or private, it's bound to be a pain in the rear.

***

By 5:30, Dr. Wunder is back in OR 11. He looks chipper again. He has had something to eat. He certainly seems to have recovered from his disappointment. "So, Dr. Lindsay," he says, noticing the music is off. "Very quiet in here. No way to operate.

"What you told me was his vein turned out to be his artery." They're like two old pals bantering as they fix a lawn mower.

Gradually, the great try is coming to an end. Dr. Lindsay is releasing blood to the newly transplanted vessel, to test the refit. He asks for the Doppler machine, to listen to the flushing of the blood. It sounds like a broken toilet. This is good.

"So we'll give him a functional hand, close him up, give him some radiation, and hope for the best," Dr. Lindsay says.

"Low-grade, slow-growing tumour," Dr. Wunder ventures. He takes a deep breath.

"With a little bit of rads, he might..."

"Might be okay for a while."

Might be okay for a while. It is not the sort of answer a cancer surgeon likes.

At a quarter to 7, Peter Nelligan and his plastics team arrive from the Toronto Hospital across the street to transfer tendons from the back of Mr. Townshend's hand to his wrist. Five hours left to go, with no cure in sight.

***

Two weeks later, Don Townshend is ready to go home. Dr. Wunder has broken the bad news: He still has cancer, he'll need radiation. But he is happy to have his arm. He can wiggle his figures. He has even changed his mind.

"I used to think, before this happened, that I shouldn't be a burden," he says. "When people asked if they could do anything, I'd say, 'Oh, no, it's fine.' But I've realized now that people like to help; it gives them something to do, makes them feel needed. I never realized I was being so selfish before."

The irony is that 10 years ago, when Mr. Townshend first felt a twinge in his elbow, governments across the country began to warn Canadians about rising costs of health care — that we ought not to abuse it or unnecessarily indulge our worries. Don Townshend is the ultimate good citizen, and he took it to heart.

If he hadn't, he might never have needed to visit Mount Sinai at all.