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

by Henry Marsh

Besides, I had to admit to myself that soon I will be old and retired and then I will no longer count for much in the world. I might as well start getting used to it.

By the time that I had got home it had started to rain. I changed into my running clothes and reluctantly headed for the small suburban park behind my home. Exercise is supposed to postpone Alzheimer’s.

‘I’ve taken the clot out and put a drain in but the cavity is oozing a lot.’ ‘Not to worry. Line it with Surgicel, pack it and take a break. Go and have a cup of tea. Tea is the best haemostatic agent! I’ll look by in thirty minutes or so.’

It was dark by now, with a strong wind, and there had been heavy snowfalls in the north, even though it was already April. I parked my car in the scruffy delivery bay by the hospital basement. Although I am not supposed to park there, it does not seem to matter at night and it means that I can get up to the theatres more quickly than from one of the official car parks which are further away.

‘Yes. It’s fine,’ he replied. ‘But it took quite a while.’ ‘Did you go and have a cup of tea to help stop the bleeding?’ ‘Well, no, not tea,’ he said, pointing to a plastic bottle of Coca-Cola on one of the worktops behind him. ‘Well, no wonder the haemostasis took so long!’ I said with mock disapproval and all the team laughed, happy that the case was over and that they could now go home.

The ITU had had a busy week and there were ten patients in the large and brightly-lit warehouse of a room, all but one of them unconscious, lying on their backs and attached to a forest of machinery with flashing lights and digital read-outs the colour of rubies and emeralds. Each patient has their own nurse, and in the middle of the room there is a large desk with computer monitors and many members of staff talking on the phone or working on the computers or snatching a plastic cup of tea in between carrying out the constant tasks that are needed in intensive care.

‘Well done!’ I replied, as I think patients need to be congratulated for their surviving just as much as the surgeons should be congratulated for doing their job well.

‘It’s a bit of a war zone here, I’m afraid,’ I said to him, gesticulating to the depersonalized forms of the other patients and all the technology and busy staff around us. Few – if any – of these patients would survive or emerge unscathed from whatever it was that had damaged their brains.

The brain scan had shown a meningioma – a ‘suprasellar’ meningioma growing from the meninges, the membrane that encases the brain and spinal cord – at the base of her brain. It was pressing upwards onto the optic nerves where they run back from the eyes to enter the brain. These particular tumours are always benign and usually grow quite slowly, but some of them have oestrogen receptors and, very occasionally, the tumours can expand rapidly during pregnancy when oestrogen levels rise.

The eyes are said by poets to be the windows to the soul but they are also windows to the brain: examining the retina gives a good idea of the state of the brain as it is directly connected to it. The miniature blood vessels in the eye will be in a very similar condition to the blood vessels in the brain. To my relief I could see that the end of the optic nerve in her eye still looked relatively healthy and not severely damaged, as did the retinal blood vessels.

There was also some risk, I told them, that the operation might leave her blind. It was all a question of whether the tumour was badly stuck to the optic nerves or not, which I would not know until I had operated.

Once Judith had anaesthetized her, Melanie was rolled onto her side and Judith carried out a lumbar puncture, using a large needle up which she then threaded a fine white catheter which we would use to drain all the cerebrospinal fluid out of Melanie’s head. This would create more space inside her head – a matter of a few millimetres – in which I could operate.

After a minimal headshave Patrik and I made a long curving incision a centimetre or so behind her hairline following it all the way across her forehead. Pressing firmly with the tips of our fingers on either side of the incision to stop the scalp bleeding we placed plastic clips over the skin edges to close off the skin’s blood vessels. We then pulled her scalp off her forehead and folded it down over her face, already covered in the adhesive tape that secured Judith’s anaesthetic tube in place.

– I took over for a while, and used an air-powered drill to smooth off the inside of Melanie’s skull. There are a series of ridges, like a microscopic mountain range, two to three millimetres in height, that run across the floor of the skull. By drilling them flat I create a little more space beneath the brain so that I can use less retraction when climbing down under the brain to get at the tumour.

The lumbar drain had done its work and the blue-grey dura, the outer layer of the meninges, was shrunken and wrinkled as the brain had collapsed downwards away from the skull as the cerebrospinal fluid had been removed.

‘They’re blunt. They don’t cut, they chew,’ he said as the scissors jammed on the leathery meninges.

The right frontal lobe of the human brain does not have any specific role in human life that is clearly understood. Indeed, people can suffer a degree of damage to it without seeming to be any the worse for it, but extensive damage will result in a whole range of behavioural problems that are grouped under the phrase ‘personality change’.

Look for the lateral third of the sphenoid wing, I told him, and then follow it medially to the anterior clinoid process – these being the important bony landmarks that guide us as we navigate beneath the brain. Patrik cautiously pulled Melanie’s brain upwards.

I quickly cut into the tumour to the left of the optic nerve and to my relief the tumour was soft and sucked easily – admittedly, most suprasellar tumours do.

I felt a familiar drag of fear in my stomach. The fact that the pupils of her eyes were not reacting properly to light might just be a temporary anaesthetic effect but it could also mean that the nerves were irreparably damaged and that she was completely blind, even though the operation had seemed to go so well.

The operation went well enough, though as soon as Patrik drilled open her head and cut through the meninges, we could see that the tumour was already spreading widely, more widely than in the brain scan done only two weeks earlier. We removed as much of the tumour as we safely could, tangled as it was with the distal branches of the left middle cerebral artery.

The scan showed a huge haemorrhage deep in her brain, on the side of the operation although slightly separate from it. It was clearly both inoperable and fatal – a post-operative intracerebral haemorrhage, a ‘rare but recognized’ complication of such surgery.

As I left I thought of how I had granted her wish, albeit inadvertently, that she should not die miserably as her father had done.

Once I had sawn open the woman’s skull and opened the meninges I found to my horror that her brain was obscured by a film of dark, red blood that shouldn’t have been there. It probably meant that something had already gone wrong with the operation. The light from the battered old operating lamp above me was so dim that I could scarcely see what I was doing.

The possible repercussions for my colleague and me did not bear thinking about. I had to fight to control my mounting panic.

an agonizing facial pain called trigeminal neuralgia (which is also known as tic douloureux) – a condition that was considered by her doctors to be inoperable. A television crew...

There were many doctors and nurses, looking down on me like gods through the glass panes of a large dome built into the ceiling above the operating table. Many of the panes in the glass dome were cracked and broken and the view outside through the large windows of the operating theatre was of ...

We had arrived in Kiev early in the morning on the overnight train from Moscow. The line crosses one of the long bridges over the great river Dnieper which flows through Kiev, and as we approached the steep western riverbank we could see the golden domes of the Lavra monastery above us catching the light of the rising sun – a dramatic contrast to the dark railway stations we had passed through during the night and the grim apartment blocks on the outskirts of the city. I had lain in my bunk, under a thin blanket, drifting in and out of sleep, listening to the old-fashioned, rhythmic sound of a train running over bolted rails, travelling southwards across Russia, stopping at dimly lit stations where I could hear incomprehensible announcements echoing over the empty, snow-covered platforms.

Once in Kiev we were taken to the Neurosurgical Research Institute, a huge and ugly building with the endless corridors that are the curse of all large hospitals. The corridors were dark and poorly lit. On the walls one could see serious displays of the triumphs of Soviet neurosurgery, with grainy black and white photographs of heroic men in the tall white chef’s hats that Soviet surgeons used to wear, interspersed with hammers and sickles, red stars, inspirational slogans and photographs of scenes from the Great Patriotic War, as the Russians call the Second World War. But everything, from the building itself to the pictures on the walls, and the stale air which smelt of cheap tobacco and some odd, sickly smelling disinfectant, felt tired and faded.

The hospital was ten storeys high, apparently with eight hundred beds. It was only ten years old but already looked derelict. We approached it through a wasteland of broken buildings and those gigantic, incomprehensible pipes that always seem to surround Soviet buildings, on which pure white snow was starting to fall from a leaden sky. At one side there was a large and ramshackle open-air market, with battered zinc-covered huts displaying rather sad little collections of cheap cosmetics and vodka. Decrepit Lada and Moskvitch and Volga cars were parked in utter disorder. Everything was grey, colourless and drab in the way that only Soviet cities could be.

I was taken to one of the dark operating theatres – a huge cavernous place with a large window looking out onto what appeared to be a bombsite. Flurries of snow could be seen there, caught in the dim light from the window of the theatre. An operation was going on. A surgeon was ‘operating’ on a paralysed man, paralysed from the neck down in an accident some years previously, I was told.

‘Everything terrible here!’ he said. I liked Igor immediately.

The room, panelled in cheap plywood like most Soviet government offices, had tall windows that looked out onto an attractive park. Snow was starting to fall again. A police van was disgorging heavily armed riot police in grey uniforms with German shepherd dogs. Both dogs and men seemed to be jumping out of the back of the vehicle with great enthusiasm.

Rather than find a new source of patronage and support (an essential requirement in Ukrainian society and known as ‘a roof over your head’) Igor proceeded to declare in public that Ukrainian neurosurgery was primitive and backward and that a revolution was required. Matters were not helped by the fact that a somewhat Byzantine struggle for succession to Academician Romadanov’s post was going on. The position came with important perks such as a large apartment and a chauffeur-driven car. Igor’s own boss had been hoping to get the job and his chances were not helped by Igor’s insubordination.

On our way to the airport we made a detour to the Bessarabian Market in central Kiev. The Bessarabian Market is Kiev’s equivalent of Les Halles or Covent Garden – a large circular nineteenth-century building with a ribbed cast-iron glass roof. Below is a market, with fierce but friendly women in brightly coloured headscarves, standing behind pyramids of beautifully displayed fruit and vegetables and pickles. There is a flower section – the Ukrainians give flowers to each other on any social occasion – and a meat section, with whole hog’s heads and mounds of fresh meat, and the rear-quarters of pigs, hanging up from hooks like pairs of trousers. There is a directness and rawness, a rough beauty to the place that is typical of Ukraine but which is starting to disappear now that supermarkets have arrived.

I was rather saddened to find it later a few yards away under a bush – it had been rejected even by the fox. So I dug a hole and buried it, the last Ukrainian eel, in an overgrown flowerbed at the end of the garden.

While at Oxford, I fell in love, love which was unrequited, and driven by self-pitying despair I had, to my father’s deep dismay, abandoned university and run away to work as a hospital porter in a mining town in the north of England, trying to emulate Jack Nicholson heading off for Alaska at the end of the movie Five Easy Pieces.

I lived in a small room in a semi-derelict old fever hospital with a corrugated iron roof on the muddy banks of the polluted River Wansbeck. It was a few miles away from the coast where the beaches were black with sea-coal. There was a huge coal-fired power-station which I could see in the distance from my room, with high chimneys pouring white smoke and steam into the wind off the sea. At night the rising steam was lit by the arc-lamps that stood over the mountains of coal beside the turbine halls, over which I could see bulldozers crawling beneath the stars.

Full of youthful melodrama I saw myself as living in a world as red as blood and as white as snow – although the surgery I saw was not especially bloody and the winter was mild, without any snow.

I was profoundly lonely. In retrospect I was obviously trying to realize my own unhappiness by working in a hospital, in a place of illness and suffering, and perhaps I was curing myself of my adolescent angst and unrequited love in the process. It was also a ritual rebellion against my poor, well-meaning father who up till then had largely determined the course of my life.

I found its controlled and altruistic violence deeply appealing. It seemed to involve excitement and job security, a combination of manual and mental skills, and power and social status as well.

The atmosphere was anxious, verging on hysterical – we were all desperate to become doctors and most of us felt a failure for some reason or other, although as far as I can remember we all passed the final examination.

The bodies were kept in the Long Room – a large and high attic space with skylights, with half a dozen trolleys on either side with sinister shapes covered by green tarpaulins. The place smelled strongly of formaldehyde.

As a surgeon one has to learn real anatomy all over again – the anatomy of a living, bleeding body is quite different from the greasy, grey flesh of cadavers embalmed for dissection. The anatomy we learnt from dissection was perhaps of limited value, but it was an important initiation rite, marking our transition from the lay world to the world of disease and death and perhaps inuring us to it.

I remember being particularly fascinated by the anatomy of the hand. There was a plastic bag of severed hands in the anatomy department in various stages of dissection from which I liked to make elaborate, coloured drawings, in imitation of Vesalius.

I enjoyed the feeling of power and importance the long hours gave me. In reality, I had little responsibility.

Looking back now, thirty years later, my sense of my own importance at that time seems quite laughable.

My next six months as a houseman were in a dilapidated old hospital in south London. The building had housed a workhouse in the nineteenth century and it was said it had not yet escaped its dismal previous reputation with the local population.

Even though I got little sleep at night there was a doctors’ mess and bar run by a friendly Spanish lady who would cook me a meal at any time of night. There was even a lawn outside the main building where I would play croquet with my fellow junior doctors when we had the time.

It used to be called angor animi – the anguish of the soul – the feeling that some people have, when they are having a heart attack, that they are about to die.