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

by Henry Marsh

Modern binocular operating microscopes are wonderful things and I am deeply in love with the one I use, just as any good craftsman is with his tools. It cost over one hundred thousand pounds and although it weighs a quarter of a ton it is perfectly counter-balanced. Once in place, it leans over the patient’s head like an inquisitive, thoughtful crane. The binocular head, through which I look down into the patient’s brain, floats as light as a feather on its counter-balanced arm in front of me, and the merest flick of my finger on the controls will move it. Not only does it magnify, but it illuminates as well, with a brilliant xenon light source, as bright as sunlight.

And the view down the microscope into the patient’s brain is indeed a little magical – clearer, sharper and more brilliant than the world outside, the world of dull hospital corridors and committees and management and paperwork and protocols. There is an extraordinary sense of depth and clarity produced by the microscope’s hugely expensive optics, made all the more intense and mysterious by my anxiety.

I choose one of the retractors – a thin strip of flexible steel with a rounded end like an ice-cream stick – and place it under the frontal lobe of the woman’s brain. I start to pull the brain upwards away from the floor of the skull – elevation is the proper surgical word – cautious millimetre by cautious millimetre, creating a narrow space beneath the brain along which I now crawl towards the aneurysm.

After so many years of operating with the microscope it has become an extension of my own body. When I use it it feels as though I am actually climbing down the microscope into the patient’s head, and the tips of my microscopic instruments feel like the tips of my own fingers.

I carefully cut the gossamer veil of the arachnoid around the great artery that keeps half the brain alive. The arachnoid, a fine layer of the meninges, is named after the Greek word for a spider, as it looks as though it was made from the strands of the finest spider’s web.

‘What a fantastic view!’ says Jeff. And it is, because we are operating on an aneurysm before a catastrophic rupture and the cerebral anatomy is clean and perfect.

Cerebro-spinal fluid, known to doctors as CSF, as clear as liquid crystal, circulating through the strands of the arachnoid, flashes and glistens like silver in the microscope’s light. Through this I can see the smooth yellow surface of the brain itself, etched with minute red blood vessels – arterioles – which form beautiful branches like a river’s tributaries seen from space. Glistening, dark purple veins run between the two lobes leading down towards the middle cerebral artery and, ultimately, to where I will find the aneurysm.

‘CSF used to be called “gin-clear” when there was no blood or infection it,’ I say to Jeff. ‘But probably we’re now supposed to use alcohol-free terminology.’

In reality only a few millimetres in diameter, it is made huge and menacing by the microscope – a great pink-red trunk of an artery which ominously pulses in time with the heart-beat. I need to follow it deep into the cleft – known as the Sylvian fissure – between the two lobes of the brain – to find the aneurysm in its lair, where it grows off the arterial trunk.

With ruptured aneurysms this dissection of the middle cerebral artery can be a slow and tortuous business, since recent haemorrhage often causes the ...

I separate the two lobes of the brain by gently stretching them apart, cutting the minute strands of arachnoid that bind them together with a pair of microscope scissors in one hand while I keep the view clear of spinal fluid and blood with a small sucker. The brain is a mass of blood vessels and I must try to avoid tearing the many veins and minute arteries both to prevent bleeding from obscuring the view and also for fear of damaging the blood supply to the brain.

Sometimes, if the dissection is particularly difficult and intense, or dangerous, I will pause for a while, rest my hands on the arm-rests, and look at the brain I am operating on. Are the thoughts that I am thinking as I look at this solid lump of fatty protein covered in blood vessels really made out of the same stuff? And the answer always comes back – they are – and the thought itself is too crazy, too incomprehensible, and I get on with the operation.

Today, the dissection is easy. It is as though the brain unzips itself, and only the most minimal manipulation is required on my part for the frontal and temporal lobes to part rapidly, so that within a matter of minutes we are looking at the aneurysm, entirely free from the surrounding brain a...

With this kind of surgery, if the aneurysm ruptures before you reach it, it can be very difficult to control the bleeding. The brain suddenly swells and arterial blood shoots upwards, turning the operative site into a rapidly rising whirlpool of angry, swirling red blood, through which you struggle desperately to get down to the aneurysm. Seeing this hugely magnified down the microscope you feel as though you are drowning in blood. One quarter of the blood from the heart goes to the brain – a patient will lose several litres of blood within a matter of minutes if you cannot control the bleeding quickly. Few patients survive the disaster of premature rupture.

The applicator consists of a simple instrument with a handle formed by two curved leaf springs, joined at either end.

My assistants are all as susceptible to the siren call of aneurysms as I am. They long to operate on them, but the fact that most aneurysms are now coiled rather than clipped means that it is no longer possible to train them properly and I can only give them the simplest and easiest parts of the occasional operation to do, under very close supervision.

Jeff says nothing and climbs out of the chair – it would be a rash surgical trainee who ever complained to his boss, especially at a moment like this – and we change places again.

I open my hand and the blades close, neatly clipping the aneurysm. The aneurysm, defeated, shrivels since it is now no longer filling with high pressure arterial blood. I sigh deeply – I always do when the aneurysm is finally dealt with. But to my horror I find that this second applicator has an even more deadly fault than the first: having closed the clip over the aneurysm the applicator refuses to release the clip.

The aneurysm suddenly swells and springs back into life, filling instantly with arterial blood. I feel it is laughing at me and about to burst but it doesn’t. I throw myself back in my chair, cursing even more violently, and then hurl the offending instrument across the room.

‘That’s never happened before!’ I shout but then, quickly calming down, laugh to Irwin, ‘And that’s only the third time in my career I’ve thrown an instrument onto the floor.’

Only later did I remember that the surgeon I had watched thirty years ago, and whose trainee I became, had told me that he had once encountered the same problem, although his patient had been less fortunate than mine. He was the only surgeon I knew who always checked the applicator before using it.

A famous English surgeon once remarked that a surgeon has to have nerves of steel, the heart of a lion and the hands of a woman. I have none of these and instead, at this point of an aneurysm operation, I have to struggle against an overwhelming wish to get the operation over and done with, and to leave the clip in place, even if it is not quite perfectly placed.

‘The best is the enemy of the good,’ I will growl at my assistants, for whom the operation is a wonderful spectator sport. They take a certain pleasure in pointing out that I have not clipped the aneurysm as well as I might have done, since they will not have to cope with the consequences of the aneurysm tearing.

Psychological research has shown that the most reliable route to personal happiness is to make others happy. I have made many patients very happy with successful operations but there have been many terrible failures and most neurosurgeons’ lives are punctuated by periods of deep despair.

We have achieved most as surgeons when our patients recover completely and forget us completely. All patients are immensely grateful at first after a successful operation but if the gratitude persists it usually means that they have not been cured of the underlying problem and that they fear that they may need us in the future. They feel that they must placate us, as though we were angry gods or at least the agents of an unpredictable fate.

Whereas the surgeon, for a while, has known heaven, having come very close to hell.

There was a solid cerebellar haemangioblastoma on the list. These are rare tumours which are formed of a mass of blood vessels. They are benign – meaning that they can be cured by surgery – but they will prove fatal if untreated. There is a small risk of disaster with surgery, since the mass of blood vessels can cause catastrophic haemorrhage if you do not handle the tumour correctly, but there is a much greater chance of success. This is the kind of operation that neurosurgeons love – a technical challenge with a profoundly grateful patient at the end of it if all goes well.

Only later did I realize that he had a red face because he was polycythaemic – he had more red blood cells in his blood than normal, since his particular tumour can stimulate the bone marrow to over-produce red blood cells.

The scan made the tumour look as though it was full of black snakes – ‘flow voids’ – produced by the blood rushing through the potentially disastrous blood vessels. I viewed these on the scan with enthusiasm, as they meant that a challenging operation was in prospect.

‘Informed consent’ sounds so easy in principle – the surgeon explains the balance of risks and benefits, and the calm and rational patient decides what he or she wants – just like going to the supermarket and choosing from the vast array of toothbrushes on offer. The reality is very different. Patients are both terrified and ignorant. How are they to know whether the surgeon is competent or not? They will try to overcome their fear by investing the surgeon with superhuman abilities.

I told him that there was a one or two per cent risk of his dying or having a stroke if the operation went badly. In truth, I did not know the exact figure as I have only operated on a few tumours like his – ones as large as his are very rare – but I dislike terrorizing patients when I know that they have to have an operation. What was certain was that the risk of the operation was many times smaller than the risk of not operating.

If patients were thinking rationally they would ask their surgeon how many operations he or she has performed of the sort for which their consent is being sought, but in my experience this scarcely ever happens. It is frightening to think that your surgeon might not be up to scratch and it is much easier just to trust him. As patients we are deeply reluctant to offend a surgeon who is about to operate on us.

When I underwent surgery myself, I found that I was in awe of the colleagues who had to treat me though I knew that they, in turn, were frightened of me as all the usual defences of professional detachment collapse when treating a colleague. It is not surprising that all surgeons hate operating on surgeons.

Taking the pen I offered him he signed the long and complicated form, printed on yellow paper and several pages in length, with a special section on the legal disposal of body parts. He did not read it – I have yet to find anybody who does.

‘When can I start?’ I asked, unhappy at being kept waiting when I had a dangerous and difficult case to do. Starting on time, with everything just right, and the surgical drapes placed in exactly the right way, the instruments tidily laid out, is an important way of calming surgical stage fright.

The anaesthetist laughed in reply. I left the room. Years ago, I would have stormed off in a rage, demanding that something be done, but my anger has come to be replaced by fatalistic despair as I have been forced to recognize my complete impotence as just another doctor faced by yet another new computer program in a huge, modern hospital.

I dislike talking to patients on the morning of their operation. I prefer not to be reminded of their humanity and their fear, and I do not want them to suspect that I, too, am anxious.

I left the junior doctors and returned to my office, where my secretary Gail had now been joined by Julia the bed manager, one of our senior nurses, who is responsible for the thankless task of trying to find beds for our patients. There are never enough beds, and she spends her working day on the telephone, frantically trying to cajole other bed managers elsewhere to swap one patient for another or to take patients back from the neurosurgical wards so that we can admit a new one.

His face was now hidden by broad swathes of sticking plaster, protecting his eyes and keeping the anaesthetic gas tubing and facial muscle monitoring wires in position. This metamorphosis from person to object is matched by a similar change in my state of mind. The dread has gone, and has been replaced by fierce and happy concentration.

I had decided to carry out the operation in what is called, simply enough, the sitting position. The unconscious patient’s head is attached to the pin headrest which in turn is connected to a shiny metal scaffold, attached to the operating table. The table is then split and the top half hinged upwards, so that the patient is sitting bolt upright. This helps reduce blood loss during surgery and also improves access to the tumour, but involves a small risk of anaesthetic disaster as the venous blood pressure in the patient’s head in the sitting position is below atmospheric room pressure.

As with all operating, it is a question of balancing risks, sophisticated technology, experience and skill, and of luck.

U-Nok, Fiona and I positioned the patient. It took half an hour to make sure his unconscious form was upright with his head bent forward, that there were no ‘pressure points’ on his arms or legs where pressure sores might develop, and that all the cables and wires and tubes connected to his body were free and not under tension.

This type of tumour is the only time in brain tumour surgery that you have to remove the tumour ‘en bloc’ – in a single piece – since if you enter the tumour you will be instantly faced by torrential bleeding. With all other tumours in brain surgery you gradually ‘debulk’ it, sucking or cutting out the inside of it, collapsing it in on itself, away from the brain, and thus minimizing damage to the brain.

With solid haemangioblastomas, however, you ‘develop the plane’ between the tumour and the brain, creating a narrow crevice a few millimetres wide by gently holding the brain away from the surface of the tumour. You coagulate and divide the many blood vessels that cross from the brain to the tumour’s surface, trying not to damage the brain in the process. All this is done with a microscope under relatively high magnification – although the blood vessels are tiny, they can bleed prodigiously.

One quarter of the blood pumped every minute by the heart, after all, goes to the brain. Thought is...

‘All out!’ I shout triumphantly to the anaesthetist at the other end of the table, and wave the scruffy and bloody little tumour, no bigger than the end of my thumb, in the air at the end of a pair of dissecting forceps. It hardly looked worth all the effort and anxiety.

‘Well, we were lucky,’ I said to them, though they probably thought this was false modesty on my part, which I suppose to an extent it was.

An AVM is an arterio-venous malformation, a congenital abnormality which consists of a mass of blood vessels that can, and often do, cause catastrophic haemorrhages. The GCS is the Glasgow Coma Scale and a way of assessing a patient’s conscious level. A score of five meant that the man was in coma, and close to death.

‘Carry on,’ I said. ‘He’s potentially salvageable so make sure they send him up the motorway pronto. You might point out to the local doctors that there’s no point sending him if they don’t do it quickly. Apparently they need to use the magic phrase “Time Critical Transfer” with the ambulance service and then they won’t mess about.’

‘And what did you do today?’ I felt like asking them, annoyed that an important neurosurgeon like myself should be kept waiting after such a triumphant day’s work. But I then thought of how the value of my work as a doctor is measured solely in the value of other people’s lives, and that included the people in front of me in the check-out queue. So I told myself off and resigned myself to waiting.