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

by Henry Marsh

‘First, do no harm…’ Commonly attributed to Hippokrates of Kos, c. 460 BC

‘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

Throughout my career I have been fortunate to work with colleagues from America—mainly neurosurgical residents who come to work for one year in my department in London as part of their training. 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.

Yet when I visit American hospitals and see the extremes to which treatment can sometimes be pushed, 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. I have also worked in countries such as Ukraine and Sudan that have very impoverished health care systems compared to America. You realize quite quickly, however, that despite the very great differences in equipment and technology many things are the same.

This book is as much about failure as success, but it is not intended as a confession and instead is an attempt to give an honest account of what it is like to be a neurosurgeon.

The book is also the story of an all-encompassing love affair, and an explanation of why it is such a privilege—although a very painful one—to be a neurosurgeon. —Henry Marsh, August 2014

PINEOCYTOMA n. an uncommon, slow-growing tumour of the pineal gland. I often have to cut into the brain and it is something I hate doing.

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 know that if I stray into the wrong area, into what neurosurgeons call eloquent brain, I will be faced by a damaged and disabled patient when I go round to the Recovery Ward after the operation to see what I have achieved. Brain surgery is dangerous, and modern technology has only reduced the risk to a certain extent.

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 han...

I can operate with the patient awake under local anaesthetic so that I can identify the eloquent areas of the brain by stimulating the brain with an electrode. The patient is given simple tasks to perform by my anaesthetist so that we can see if I am causing any damage as the operation proceeds. If I am operating on the spinal cord – which is even more vulnerable than the brain – I can use a method of electrical stimulation known as evoked potentials to warn me if I am about to cause paralysis.

In the seventeenth century the dualist philosopher Descartes, who argued that mind and brain are entirely separate entities, placed the human soul in the pineal gland. It was here, he said, that the material brain in some magical and mysterious way communicates with the mind and with the immaterial soul. I don’t know what he would have said if he could have seen my patients looking at their own brains on a video monitor, as some of them do when I operate under local anaesthetic.

The memory of her lying in her hospital bed, with a paralysed arm and leg, would become a scar rather than a painful wound. 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.

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.

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.

I went home that night and announced to my wife that I was going to be a brain surgeon. She looked a little surprised, given that I had been so undecided about what sort of doctor I should be, but she seemed to think the idea made sense. 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.

The morning always starts with a meeting – a practice I began twenty years ago. I had been inspired by the TV police soap Hill Street Blues, where every morning the charismatic station police sergeant would deliver pithy homilies and instructions to his officers before they set off onto the city streets in their police cars with their sirens wailing. It was at the time when the government was starting to reduce the long working hours of junior hospital doctors.

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.

Two of the theatre nurses, bent over with the effort, slowly push the heavy microscope up to the table and I climb into the operating chair behind it – a specially adjustable chair with armrests. This moment still fills me with awe. I have not yet lost the naive enthusiasm with which I watched that first aneurysm operation thirty years ago. I feel like a medieval knight mounting his horse and setting off in pursuit of a mythical beast.

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.

Doctors like to talk of the ‘art and science’ of medicine. I have always found this rather pretentious, and prefer to see what I do as a practical craft. Clipping aneurysms is a skill, and one that takes years to learn. Even when the aneurysm is exposed and ready to take a clip, after the thrill of the chase, there is still the critical question of how I place the clip across the aneurysm, and the all-important question of whether I have clipped the aneurysm’s neck completely without damaging the vital artery from which the aneurysm has grown.

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.

I left Jeff to close, retired to the surgical sitting room next to the theatre and lay down on the large red leather sofa which I had bought for the room some years ago and thought, once again, of how so much of what happens to us in life is determined by random chance.

There have been too many disasters and unexpected tragedies over the years, and I have made too many mistakes for me to experience such feelings now, but I still felt pleased with the way the operation had gone. I had avoided disaster and the patient was well.

Psychological research has shown that the most reliable route to personal happiness is to make others happy.

We have achieved most as surgeons when our patients recover completely and forget us completely.

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

HAEMANGIOBLASTOMA n. a tumour of the brain or spinal cord arising from the blood vessels.

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.

One quarter of the blood pumped every minute by the heart, after all, goes to the brain. Thought is an energy-intensive process.

I joined a long queue of people at the check-out. ‘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. 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.

It was unlikely that she had more than a few months left to live whatever I did, but there is always hope, and there are always a few patients – sadly only a small minority – who are statistical outliers and defy the averages to live for several years. We had agreed that we should operate. Patrik did most of it, and I assisted him. 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.

Impatient and anxious I watched the transverse slices of the scan appear on the computer monitor, gradually working their way up towards where I had been operating. 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. I picked up the phone in the control room and rang her husband. ‘I’m afraid I have rather bad news for you…’ I said.

TIC DOULOUREUX pl.n. brief paroxysms of searing pain felt in the distribution of one or more branches of the trigeminal nerve in the face.

I expected the long and tedious description to continue. I was quickly becoming familiar with the litany of departments and beds and achievements with which one was greeted when one visited a Ukrainian hospital and expected to be reassured that Ukrainian emergency spinal neurosurgery was the equal of the world, if not better. ‘Everything terrible here!’ he said. I liked Igor immediately.

The Soviet Union had excelled at producing guns and rockets but failed miserably at producing decent health care. Although there were impressive-sounding research institutes and thousands of professors, the reality was of poorly trained doctors and poorly equipped hospitals that were often little better than what one might find in the Third World.

Most of the doctors I met, driven by a mixture of shame, patriotism, envy and embarrassment, felt compelled to deny this, and did not welcome people like Igor who dared to point out the emperor’s lack of clothes. Soviet culture had never encouraged criticism and had gone to great lengths to isolate its citizens from the rest of the world.

ANGOR ANIMI n. the sense of being in the act of dying, differing from the fear of death or the desire for death.

Having been rejected by all the other London Medical Schools since I had neither O-levels nor A-levels in science I had telephoned the Royal Free Medical School. They asked me to come for an interview next day. The interview was with an elderly, pipe-smoking Scot, the Medical School Registrar, in a small and cramped office. He was to retire a few weeks later and perhaps he let me in to the Medical School as a kind of joke, or celebration, or perhaps his mind was elsewhere.

He said that it was best to see medicine as a form of craft, neither art nor science – an opinion with which I came to agree in later years. The interview took five minutes and he offered me a place in the Medical School starting three weeks later.

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. I then spent two years of pre-clinical studies in the medical school – anatomy, physiology, biochemistry and pharmacology – followed by three years as a clinical student in the hospital.

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.

There was a slightly grim, exhilarating intensity to the work and I quickly lost the simple altruism I had had as a medical student. It had been easy then to feel sympathy for patients because I was not responsible for what happened to them. But with responsibility comes fear of failure, and patients become a source of anxiety and stress as well as occasional pride in success. I dealt with death on a daily basis, often in the form of attempted resuscitation and sometimes with patients bleeding to death from internal haemorrhage.

I became hardened in the way that doctors have to become hardened and came to see patients as an entirely separate race from all-important, invulnerable young doctors like myself. Now that I am reaching the end of my career this detachment has started to fade. I am less frightened by failure – I have come to accept it and feel less threatened by it and hopefully have learned from the mistakes I made in the past.

Besides, with advancing age I can no longer deny that I am made of the same flesh and blood as my patients and that I am equally vulnerable. So I now feel a deeper pity for them than in the past – I know that I too, sooner or later, will be stuck like them in a bed in a crowded hospital bay, fearing for my life.

It was while working on the ITU that I had gone down to the operating theatres and seen the aneurysm operation that prompted my surgical epiphany. Now that I knew exactly what I wanted to do my life became much easier. A few days later I went to find the neurosurgeon I had watched clipping the aneurysm and told him I wanted to become a neurosurgeon. He told me to apply for the neurosurgical SHO job in his department which was shortly to be advertised.

‘The operating is the easy part, you know,’ he said. ‘By my age you realize that the difficulties are all to do with the decision-making.’

MENINGIOMA n. a benign tumour arising from the fibrous covering of the brain and spinal cord; usu. slow-growing, produces symptoms by pressure on the underlying nervous tissue.

By 2050 a third of the population of Europe will be over sixty. My first boss in general surgery – a lovely man – ended his days in a nursing home because of dementia. His daughter told me he kept on saying that he wanted to die but he was terribly fit and it took ages.