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Do No Harm - Henry Marsh
Think brain surgery and you think calm competence, clinical precision. Think again. Top neurosurgeon Henry Marsh sheds light on the chaos, confusion and self-doubt of life inside the operating theatre.
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. 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.
All I can see in front of me is matter. Yet I know 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.
Brain surgery is dangerous, and modern technology has only reduced the risk to a certain extent. Much of what happens in hospitals is a matter of luck, both good and bad; success and failure are often out of the doctor’s control.
Now that I am reaching the end of my career as a senior consultant neurosurgeon [at St George’s Hospital in South London] I am less frightened by failure – I have come to accept it. Increasingly, I feel an obligation to bear witness to past mistakes, in the hope that my trainees will learn how not to make the same mistakes themselves.
I hope I am a good surgeon but I am certainly not a great surgeon. I once paid a visit to a nursing home devoted to people with catastrophic brain damage and, to my dismay, recognised at least five of the names as former patients of mine. Some of them were people I had simply been unable to help, but there was at least one man – his grey curled up body in its bed – who, as my juniors put it in their naive and tactless way, I had wrecked.
The patient had been a schoolteacher in his late fifties, tall and bespectacled, who walked with a stick and was a little stooped. A local neurologist had arranged a brain scan and as a result, he had been sent to see me. I had only been a consultant for four years but I already had a very large practice, larger than any other neurosurgeon’s I knew. I sat the patient down by my desk with his wife and son next to him and took the films of his brain scans over to the viewing box on the wall. I already knew what the scans would show but I was still startled by the size of the tumour growing from the base of his skull.
A trailer for The English Surgeon - the documentary film based on Henry Marsh's work.
All of the brainstem and the cranial nerves – the nerves for hearing, movement, sensation for the face, and for swallowing and talking – were stretched over its sinister humpbacked mass. It was an exceptionally large petroclival meningioma. I had only seen tumours this size before in the textbooks. I was not sure whether to feel excited or alarmed.
“What have you been told?” I asked.
“The neurologist said it was benign,” he replied. “And that it was up to you as to whether it should be removed or not.”
He told me how he had noticed that his walking had slowly been becoming a little unsteady and that he was also starting to lose hearing.
“But what will happen if it stays there?” his son asked. I replied that it would go on growing slowly and that he would slowly deteriorate.
I explained that surgery was not without risks. There were so many brain structures involved with the tumour that the dangers of surgery ranged from deafness to death.
The three of them sat in silence for a while.
“We’re told that Professor M is the best neurosurgeon in the country,” he said. “And we’re going to see him for a second opinion.”
I felt humiliated but knew any operation was going to be exceptionally difficult.
“That’s a good idea,” I said. “I’d be very interested to hear what he thinks.”
“I’ve got Professor M on the line for you,” said Gail, my secretary, two weeks later. I picked up my phone to hear the professor’s booming, confident voice. I had known him briefly when I was a trainee and he was certainly a superb surgeon. Self-doubt had never seemed to be one of his weaknesses. I had heard that he would soon be retiring.
“Ah, Henry!” he said. “This chap with the petroclival. Needs to come out. He’s starting to have some difficulties with swallowing so it’s only a matter of time before he gets aspiration pneumonia and that will be the end of him. It’s a young man’s operation. I’ve told them you should do it.”
“Thank you very much, Prof,” I replied, a little surprised but delighted to have been given what felt like a papal dispensation.
I made arrangements for the operation, which I expected to be a long one. This was many years ago, when hospitals were different places, and all I had to do was ask the theatre staff and anaesthetists to stay on longer than usual. There were no managers whose permission had to be sought. The operation started in an almost festive spirit. This was mansized brain surgery – a “real Big Hit” as the American registrar assisting me put it.
It’s one of the painful truths about neurosurgery that you only get good at doing the really difficult cases if you get lots of practice, but that means making lots of mistakes at first and leaving a trail of injured patients behind you. I suspect you’ve got to be a bit of a psychopath to carry on. If you’re a nice doctor you’ll probably give up, let Nature takes its course and stick to the simpler cases. My old boss used to say, “If the patient’s going to be damaged I’d rather let God do the damage than do it myself.”
The first few hours of the operation went perfectly. We slowly removed more and more of the tumour, and by midnight, after 15 hours of operating, it looked as though most of it was out and the cranial nerves were not damaged.
I started to feel I was joining the ranks of the really big neurosurgeons. I would stop every hour or two, and join the nurses in the staff room, have something to eat and smoke a cigarette. It was all very convivial. Music played continuously while we operated – I had brought all sorts of CDs in, ranging from Bach to Abba to African music. In the old hospital I always listened to music when operating and my colleagues seemed to like it, especially what we called “closing music”, which meant playing Chuck Berry or other fast blues music when stitching up a patient’s head.
I should have stopped at that point, and left the last piece of tumour behind, but I wanted to be able to say I had removed all of the tumour. The postoperative scans shown by the big international names when they gave their keynote lectures never showed residual tumour so surely this was the right thing to do, even if it involved some risk.
As I started to remove the last part of the tumour I tore a small perforating branch off the basilar artery, a vessel the width of a thick pin. A jet of bright red arterial blood started to pump upwards. I knew at once that this was a catastrophe. The blood loss was easy enough to stop, but the damage to the brainstem was terrible. The basilar artery is the artery that keeps the brainstem alive and it is the brainstem that keeps the rest of the brain awake. As a result the patient never woke up and that was why, seven years later, I saw him curled into a sad ball, on a bed in the nursing home.
For the next few years, whenever I saw similar cases, I deemed the tumours inoperable and left the unfortunate patients to go elsewhere or to have radiation treatment. These were also the years when my marriage fell apart and the old hospital was closed. I am not sure whether I realised it then, but this was the time when I became a little sadder but much wiser. I gradually regained my courage and used what I had learnt from the tragic consequences of my hubris to achieve much better results. I would, if necessary, operate in stages over several weeks; I would operate with a colleague, taking the operating in turns with an hour on and an hour off, like drivers in a military convoy. I would rarely let an operation take longer than seven or eight hours.
The problem remains, however, that such tumours are very rare. In Britain, with a culture that believes in the virtues of amateurism, and where most neurosurgeons are very reluctant to refer difficult cases on to a more experienced colleague, no individual surgeon will ever gain as much experience as our colleagues in the US. In America there are far more patients, and therefore more patients with such tumours. The patients are less deferential and trusting than they are in Britain. They are more like consumers, so they make sure they are treated by an experienced surgeon.
After 25 years I would like to think that I have become relatively expert – but it has been a very long, slow advance with many problems along the way, although none as awful as that first operation.
There were two other lessons that I learnt that day. One was not to do an operation that a more experienced surgeon than me did not want to do; the other was to treat some of the keynote lectures at conferences with a degree of scepticism. And I can no longer bear to listen to music when operating.
© Henry Marsh 2014. Extracted from Do No Harm: Stories of Life, Death and Brain Surgery