The burr came out with a wet suck, and the sound of it traveled up through the bone of his jaw and into the hollow behind his eyes, and Tyler felt the hole left behind the way you feel a missing step in the dark — a sudden wrongness where there had been pressure, a cold air moving through a place that was never meant to know air. Dr. Mack held the instrument up to the lamp, examined the flutes the way a jeweler examines a setting, and set it down on the tray with a click that was too small for what it had just done.

The hole was still open. He could feel it with his tongue, and he tried not to, and his tongue went there anyway — a socket, a well, the taste of copper and something colder underneath, like the smell of a basement. The bite block held his jaw cranked wide and there was nothing he could do about any of it, so he lay there with his wrists in the cuffs and his ankles in the cuffs and his chest still tacky where Renata had dabbed at him and left the rest.

Renata had stepped back from the chair. She stood at the tray cart with her arms folded, and she was looking at Dr. Mack, and Dr. Mack was looking at her, and neither of them said anything for a length of time that Tyler felt in his molars.

It was not the look of two people deciding. It was the look of two people who had already decided, some time ago, in a room he hadn't been in, and were now only confirming the order of things. Renata's thumb moved once against her own elbow. Dr. Mack's chin came down a quarter inch. That was the whole conversation.

"He's ready for it to be permanent," Renata said.

She said it the way she'd said he's got more in him — flat, certain, a fact she was reporting rather than a thing she was asking for. Then she turned and walked out of the room, and she did not look back at him, and the door did not quite close behind her, and Tyler lay in the chair with the hole in his jaw and listened to her footsteps go down the corridor and turn.

He had heard that word before. Permanent. He had heard it in Dr. Mack's mouth the first night, in the exam room, when she'd told him he didn't want to be fixed, he wanted to be kept. He had heard it in the receipt that said Paid in full. See you Friday. He had heard it every time he'd told himself he was going to stop coming back, and then come back anyway, and now the word was in the room with him and Renata had said it like a diagnosis and left.

Dr. Mack turned to the tray.

There were instruments on it he had not seen her lay out. A probe. A file. The long thin thing she'd used inside the tooth. And at the back of the tray, behind the steel, a syringe — larger than the first one, the one she'd taken out of her coat pocket in this same room, and this one was filled with something that was not colorless. It was pale and it was amber and it caught the lamp the way honey catches a window, and she picked it up and held it against the light and rolled it between her fingers, once, slowly, watching the fluid move inside the barrel.

"You remember the first one," she said.

Tyler made a sound around the bite block. It was not a word.

"That one was to quiet you," she said. "This one is different." She brought the syringe down and tapped the barrel with one manicured nail, twice, and the amber fluid settled. "This one is to keep you."

She turned to him and her face did something he had not seen it do. The corners of her mouth came up and the skin around her eyes creased and her eyes themselves — pale blue, flat as a coin in every light he'd ever seen her in — went warm, briefly, the way a window goes warm when a lamp is lit behind it. It was a real smile. It reached all the way in. It was the first time he had seen her mean it, and it was worse than anything her face had done before, because a woman who had never smiled at him had nothing to lose by smiling now.

"I told you," she said, "that you would not leave through the front or the side anymore."

She lifted his left arm. The cuff had held his wrist at the chair arm for so long that the skin above it was pale and creased, and she turned the arm over and found the vein in the crook of his elbow with two fingers, the way she'd found it before, and she did not need to look twice. She swabbed it with an alcohol pad that was cold and evaporated fast and left the skin tight.

"This is the part where the last one asked me a question," she said. "He wanted to know what happened to the one before him. I told him I'd tell him when he was in the room." She slid the needle in. It was a small sting, a pinprick, nothing, and then it was in and she had it steady. "He never got to the room."

She pushed the plunger home.

The cold went up his arm first. It was not the cold of the first injection — that one had been a soft dimming, a slow lowering of the lights, a warm hand on his jaw telling him to let go. This one had a direction. It went up the vein like water finding a downhill, past the elbow, into the shoulder, and then it turned and spread across his chest, and it was cold and it was heavy and it was the wrong shape for his body, and his heart, which had been racing since the burr came out, began to slow against it as if something had laid a hand flat on it.

The room tilted. Not much. A few degrees. The lamp above him swung a little to the left and did not swing back, and the tea-colored light on the wall stretched and softened, and the stain under the chair — he could see it now, the old dark shape on the concrete — came into focus the way a face comes into focus when you stop trying to see it.

Dr. Mack was watching his face. She had not stepped back. She was still holding the syringe in his arm, and her thumb was still on the plunger, and she was reading him the way she read a chart.

"There it is," she said.

And Tyler understood — not in words, because the words were getting far away, but in his body, in the way his body had started to feel like a room he was standing in the doorway of — that something bad was going to happen to him. Not the drill. Not the tooth. Not the cuffs. Something after all of that. Something that had been waiting in the room the whole time, under the stain, under the chair, in the drawer with his keys and his shirt, and he had walked past it and knocked on the glass and come back through the side door and laid himself down in the chair and said yes ma'am and thank you and now the door was closing and it was closing from the outside.

His breath came short. The bite block made it worse — he could not get enough air through the plastic and his nose was not enough, and the room tilted further, and the cold in his chest had reached his stomach and was spreading down into his legs, and he tried to say something and the sound he made was not a word and Dr. Mack did not answer it.

She drew the needle out. She capped it and set it on the tray and she looked at the small bead of blood at the crook of his elbow and she wiped it away with her thumb, and she stood there for a moment with her hand on his arm, and her face was still doing the smile, and her eyes were still warm, and she said, "There's no reason to be afraid, sweetheart. You were always going to end up here. You just got to pick the door."

The corridor door opened.

Renata came back in. She had something over her arm — a heavy thing, canvas-colored, with long leather straps hanging off it, and the buckles on the straps were the click he heard a half second before he saw them, because sound was arriving before sight now, the way it does when the room is going soft at the edges. She set it down on the cot and reached for the second thing she was carrying, which was a length of chain, and the chain was attached to two cuffs, and the cuffs were attached to each other, and she laid the whole of it across the cot with a sound like teeth.

She did not look at him. She looked at Dr. Mack, and Dr. Mack nodded once, and Renata began to unbuckle the leather cuffs at his ankles.

"You'll want to be still for this part," Renata said, and her voice was the voice she used on patients, the warm one, the one that remembered your dog's name. "It goes faster if you're still."

Tyler pulled against the cuffs at his wrists. It was not a decision. His body did it without asking him, the way a body flinches from a needle it has already agreed to, and the cuffs held, and the chair did not move, and the pull cost him something — the room went darker at the edges and came back and his arms were shaking and Dr. Mack watched him do it with her head tilted, the way she'd watched him come the first time, with the flat clinical attention of a woman taking a measurement.

"There he is," she said. "I was wondering when that would show up."

Renata had his left ankle free. She moved to the right, and the second cuff came off, and then she stood and leaned over him and unbuckled the strap behind his head, and the bite block came out of his mouth with a wet sound and a string of spit that she wiped away with the edge of her thumb. His jaw stayed open for a moment, stiff and unremembering, and then it came down and his teeth met and the hole in the tooth was there, waiting, a cold socket he could not stop noticing.

"Don't," he said.

It came out thin. It came out like a boy's voice, and he heard it, and he hated it, and he said it again anyway because it was the only word he had. "Don't."

Renata looked at Dr. Mack.

Dr. Mack looked at Tyler, and the smile was gone now, put away, and what was left was the face she wore the rest of the time — the porcelain, the flat blue eyes, the mouth that had said we're not close to done with no more feeling than a clock. She reached down and took his chin in her hand. Her fingers were cool and dry and her grip was the grip of someone who had held a lot of chins.

"You already said yes," she said. "You said it in the exam room. You said it at the side door. You said it when you laid down in this chair and let me open your tooth. You don't get to say it again."

She let go of his chin and stepped back, and the room tilted again, more this time, and the tea-colored light on the wall began to run like something wet, and the cold in his chest had reached his hands and his feet and his tongue, and the taste of copper was gone and the taste of nothing was there instead, a flat mineral nothing, like the inside of a stone.

Renata picked the canvas thing up off the cot. She shook it out once and the straps swung and the buckles clicked, and Tyler saw it for what it was in the last clear second he had — the long sleeves, the straps at the back, the collar that went up around the throat — and he understood that they had not brought it in for the first time, that it had a place on the cot and a place in the room and a place in whatever this was, and that the last one had worn it, and the one before that.

"Renata," he said.

She paused. She looked at him, and for a half second her face did something — a flicker, a tightening at the corner of her mouth, the way a person looks at a thing they used to like — and then it was gone and she was warm again, and she said, "It's all right, honey. Close your eyes."

He did not close his eyes. He watched her come, and he watched the canvas come, and he watched Dr. Mack standing at the tray with her arms folded and her face flat and her eyes on him, and the cold reached his spine and began to climb it, and the room went down and to the left like a table with a short leg, and the last thing he heard was the buckle at the collar of the jacket as Renata drew it closed, and the click of it finding its hole, and then the chain, and then nothing, and then the dark came in and took the rest.