Do No Harm: Stories of Life, Death, and Brain Surgery

by Henry Marsh

‘Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.’ René Leriche, La philosophie de la chirurgie, 1951

I have learned much from them and as with many Brits who have worked with Americans I love their optimism, their faith that any problem can be solved if enough hard work and money is thrown at it, and the way in which success is admired and respected and not a cause for jealousy. This is a refreshing contrast to the weary and knowing skepticism of the English.

I wonder whether the doctors and patients there have yet to understand that the famous dictum that in America death is optional, was meant as a joke.

My readiness to admit to my fallibility is perhaps rather English, but I hope that the problems I describe will be familiar to doctors and patients everywhere.

I often have to cut into the brain and it is something I hate doing. With a pair of diathermy forceps I coagulate the beautiful and intricate red blood vessels that lie on the brain’s shining surface. I cut into it with a small scalpel and make a hole through which I push with a fine sucker – as the brain has the consistency of jelly a sucker is the brain surgeon’s principal tool.

The idea that my sucker is moving through thought itself, through emotion and reason, that memories, dreams and reflections should consist of jelly, is simply too strange to understand.

I can use a form of GPS for brain surgery called Computer Navigation where, like satellites orbiting the Earth, infra-red cameras face the patient’s head. The cameras can ‘see’ the instruments in my hands which have little reflecting balls attached to them. A computer connected to the cameras then shows me the position of my instruments in my patient’s brain on a scan done shortly before the operation.

Pineal tumours are very rare. They can be benign and they can be malignant. The benign ones do not necessarily need treatment.

Neurosurgeons look at brain scans showing pineal tumours with both fear and excitement, like mountaineers looking up at a great peak that they hope to climb.

He laboriously typed everything I said into his smartphone, as though typing down the long words – obstructive hydrocephalus, endoscopic ventriculostomy, pineocytoma, pineoblastoma – would somehow put him back in charge and save him.

She would be added to the list of my disasters – another headstone in that cemetery which the French surgeon Leriche once said all surgeons carry within themselves.

As the blood rises from the wound the thrill of the chase takes over and I feel in control of what is happening. At least, that is what usually happens. On this occasion the disastrous operation of the preceding week meant that I came to the theatre suffering from severe stage fright.

‘Can’t wait,’ said Mike – a standard joke the bolder of my registrars will make now that I am reaching the end of my career. There are currently more trainees than there are consultant jobs and my trainees all worry about their future. ‘Anyway, she’ll probably get better,’ he added ‘It’s early days.’

The man’s scalp incised, the muscles retracted, a craniectomy of the skull performed, the meninges opened and reflected – surgery has its own ancient descriptive language – I had the operating microscope brought in and I settled down in the operating chair.

With a pineal operation, unlike other brain tumours, you do not need to cut through the brain to reach the tumour; instead, once you have opened the meninges, the membrane beneath the skull that covers the brain and spinal cord, you are looking along a narrow crevice that separates the upper part of the brain, the cerebral hemispheres, from the lower part – the brainstem and cerebellum. You feel as though you are crawling along a long tunnel. At about three inches’ depth – although it feels a hundred times longer because of the microscope’s magnification – you will find the tumour.

Above me, like the great arches of a cathedral roof, are the deep veins of the brain – the Internal Cerebral Veins and beyond them the basal veins of Rosenthal and then in the midline the Great Vein of Galen, dark blue and glittering in the light of the microscope. This is anatomy that inspires awe in neurosurgeons. These veins carry huge volumes of venous blood away from the brain. Injury to them will result in the patient’s death.

In front of me is the granular red tumour and beneath it the tectal plate of the brainstem, where damage can produce permanent coma. On either side are the posterior cerebral arteries which supply the parts of the brain responsible for vision. Ahead, beyond the tumour, like a door opening into a distant white-walled corridor once the tumour has been removed, is the third ventricle.

On this occasion as I approached the tumour there were several blood vessels in the way that had to be cut – you need to know which can be sacrificed and which cannot.

Each brain tumour is different. Some are as hard as rock, some as soft as jelly. Some are completely dry, some pour with blood – sometimes to such an extent that the patient can bleed to death during the operation. Some shell out like peas from a pod, others are hopelessly stuck to the brain and its blood vessels. You can never know for certain from a brain scan exactly how a tumour will behave until you start to remove it.

‘Looks OK.’ ‘So far,’ I said. ‘Things only go wrong when you’re not expecting them,’ he replied as he turned to go back to his own theatre.

When you approach a patient you have damaged it feels as though there is a force-field pushing against you, resisting your attempts to open the door behind which the patient is lying, the handle of which feels as though it were made of lead, pushing you away from the patient’s bed, resisting your attempts to raise a hesitant smile. It is hard to know what role to play.

The surgeon is now a villain and perpetrator, or at best incompetent, no longer heroic and all-powerful. It is much easier to hurry past the patient without saying anything.

‘It went as well we could hope,’ I said, in a formal and matter-of-fact voice, playing the part of a detached and brilliant brain surgeon. But then I could not help but reach out to her, to put my hands on her shoulders, and as she put her hands on mine and we looked into each other’s eyes, and I saw her tears and had to struggle for a moment to control my own, I allowed myself a brief moment of celebration. ‘I think everything’s going to be all right,’ I said.

I never saw any neurosurgery as a medical student. We were not allowed into the neurosurgical theatre in the hospital where I trained – it was considered too specialized and arcane for mere students.

Once, when walking down the main theatre corridor, I had had a brief view through the small port-hole window of the neurosurgical theatre’s door of a naked woman, anaesthetized, her head completely shaven, sitting bolt upright on a special operating table. An elderly and immensely tall neurosurgeon, his face hidden by a surgical facemask and a complicated headlight fixed to his head, was standing behind her. With enormous hands he was painting her bare scalp with dark brown iodine antiseptic. It looked like a scene from a horror film.

I had been qualified as a doctor for one and a half years by then and was already disappointed and disillusioned with the thought of a career in medicine. I was working at the time as a senior house officer, or SHO for short, in my teaching hospital’s intensive care unit. One of the anaesthetists who worked on the ITU, seeing that I looked a little bored, had suggested that I come down to the operating theatre to help her prepare a patient for a neurosurgical operation.

Aneurysms are small, balloon-like blow-outs on the cerebral arteries that can – and often do – cause catastrophic haemorrhages in the brain. The aim of the operation is to place a minute spring-loaded metal clip across the neck of the aneurysm – just a few millimetres across – to prevent the aneurysm bursting.

Aneurysms have thin, fragile walls, yet they have high pressure, arterial blood within them. Sometimes the wall is so thin that you can see the swirling dark red vortices of blood within the aneurysm, made enormous and sinister by the magnification of the operating microscope.

The staff in the theatre were silent. There was none of the usual chatter and talk. Neurosurgeons sometimes describe aneurysm surgery as akin to bomb disposal work, though the bravery required is of a different kind as it is the patient’s life that is at risk and not the surgeon’s. The operation I was watching was more like a blood sport than a calm and dispassionate technical exercise, with the quarry a dangerous aneurysm. There was the chase – the surgeon cautiously stalking his way beneath the patient’s brain towards the aneurysm, trying not to disturb it, to where it lay deep within the brain.

More than that, the operation involved the brain, the mysterious substrate of all thought and feeling, of all that was important in human life – a mystery, it seemed to me, as great as the stars at night and the universe around us. The operation was elegant, delicate, dangerous and full of profound meaning.

What could be finer, I thought, than to be a neurosurgeon? I had the strange feeling that this was what I had wanted to do all my life, even though it was only now that I had realized it. It was love at first sight.

Neither of us could have known then that my obsession with neurosurgery and the long working hours and the self-importance it produced in me would lead to the end of our marriage twenty-five years later.

A heat wave had just ended and heavy grey rain clouds hung over south London. It had poured with rain during the night. There was little traffic – almost everybody seemed to be away on holiday. The gutters at the entrance to the hospital were flooded so that the passing red buses sent cascades of water over the pavement and the small number of staff walking to work had to jump to one side as the buses swept past.

Although neurosurgery is no longer what it once was, the neurosurgeon’s loss has been the patient’s gain. Most of my work is now concerned with tumours of the brain – tumours with names like glioma or meningioma or neurinoma – the suffix ‘-oma’ coming from the ancient Greek word for tumour and the first part of the word being the name of the type of cell from which the tumour is thought to have grown.

It was at the time when the government was starting to reduce the long working hours of junior hospital doctors. The doctors were tired and overworked, it was said, and patients’ lives were being put at risk. The junior doctors, however, rather than becoming ever more safe and efficient now that they slept longer at night, had instead become increasingly disgruntled and unreliable. It seemed to me that this had happened because they were now working in shifts and had lost the sense of importance and belonging that came with working the long hours of the past. I hoped that by meeting every morning to discuss the latest admissions, to train the juniors with constant teaching as well as to plan the patients’ treatment, we might manage to recreate some of the lost regimental spirit.

The meetings are very popular. They are not like the dull and humourless hospital management meetings where there is talk of keeping in the loop about the latest targets or of feeling comfortable about the new Care Pathways.

Every day at eight o’clock sharp, in the dark and windowless X-ray viewing room, we shout and argue and laugh while looking at the brain scans of our poor patients and crack black jokes at their expense. We sit in a semi-circle, a small group of a dozen or so consultants and junior doctors, looking as though we were on the deck of the Starship Enterprise. Facing us is a battery of computer monitors and a white wall onto which brain scans are projected, many times larger than life-size, in black and white. The scans are of patients admitted as emergencies over the pre...

We sit there, alive and well and happy in our work, and with sardonic amusement and Olympian detachment we examine these abstract images of human suffering and disaster, hoping to find interesting cases on which to operate. The junior doctors present the cases, giving us the ‘history’ as it is called – the stories of sudden catastrophe or of terrible trag...

I explained how the arteries to the brain were like the branches of a tree, narrowing as they spread outwards. I pointed to a little swelling, a deadly berry, coming off one of the cerebral arteries and looked enquiringly at Emily.

‘A right middle cerebral artery aneurysm,’ I replied. I explained how the woman’s headaches had in fact been quite mild and the aneurysm was coincidental and had been discovered by chance. It had nothing to do with her headaches.

‘It’s an unruptured aneurysm, seven millimetres in size,’ Fiona – the most experienced of the registrars – said. ‘So there’s a point zero five per cent risk of rupture per year according to the international study published in 1998.’ ‘And if it ruptures?’ ‘Fifteen per cent of people die immediately and another thirty per cent die within the next few weeks, usually from a further bleed and then there’s a compound interest rate of four per cent per year.’ ‘Very good, you know the figures. But what should we do?’ ‘Ask the radiologists if they can coil it.’ ‘I’ve done that. They say they can’t.’ The interventional radiologists – the specialist X-ray doctors who now usually treat aneurysms – had told me that the aneurysm was the wrong shape and would have to be surgically clipped if it was to be treated. ‘You could operate…’ ‘But should I?’ ‘I don’t know.’

She was perfectly well at the moment, the headaches for which she had had the scan were irrelevant and had got better. The aneurysm had been discovered by chance. If I operated I could cause a stroke and wreck her – the risk of that would probably be about four or five per cent. So the acute risk of operating was roughly similar to the life-time risk of doing nothing. Yet if we did nothing she would have to live with the knowledge that the aneurysm was sitting there in her brain and might kill her any moment.

The investigation organized by her GP – hoping, perhaps, that a normal brain scan would reassure her – had created an entirely new problem and the woman, although no longer suffering with headaches, was now desperate with anxiety. She had been on the Internet, inevitably, and now believed that she had a time bomb in her head which was about to explode any minute. She had been waiting several weeks to see me.

Every Sunday evening I cycle to the hospital full of foreboding. It is a feeling that seems to be generated merely by the transition from being at home to being at work irrespective of the difficulty of the cases awaiting me. This evening visit is a ritual I have performed for many years and yet, try as I might, I cannot get used to it and escape the dread and pre-occupation of Sunday afternoons – almost a feeling of doom – as I cycle along the quiet backstreets.

‘I hope you get some sleep,’ I said. ‘I promise you I will, which is more important in the circumstances.’ She smiled at the joke – a joke I make with all my patients when I see them the night before surgery. She probably knew already that the last thing you get in hospital is peace, rest or quiet, especially if you are to undergo brain surgery next morning.

They signed the consent forms and as they did so both of them had told me how they trusted me. Anxiety might be contagious, but confidence is also contagious, and as I walked to the hospital car park I felt buoyed up by my patients’ trust. I felt like the captain of a ship – everything was in order, everything was ship-shape and the decks were cleared for action, ready for the operating list tomorrow.

‘The trouble with unruptured aneurysms,’ I said, ‘is that if they wake up wrecked you have only yourself to blame. They’re in perfect nick before the op. At least with the ruptured ones they’re often already damaged by the first bleed.’ ‘True. But the unruptured ones are usually much easier to clip.’

There is no evidence that the complete head shaves we did in the past, which made the patients look like convicts, had any effect on infection rates, which had been the ostensible reason for doing them. I suspect the real – albeit unconscious – reason was that dehumanizing the patients made it easier for the surgeons to operate.

After thirty minutes of working with drills and cutters powered by compressed air the woman’s skull is open and the uneven ridges of bone on the inside of her skull have been smoothed down with a cutting burr.

I shout, as much from excitement as from the need to make myself heard above the rattle and hum and hissing of all the equipment and machinery in the theatre.