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

by Henry Marsh

  So she told me about them, and also the fact that they were already better. They certainly sounded harmless in retrospect. If headaches have a serious cause it is usually obvious from the nature of the headaches. 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.

  I showed her the angiogram on the computer on the desk in front of us. I explained that the aneurysm was very small and might very well never burst. It was the large ones which were dangerous and definitely needed treating, I said. I told her that the risks of the operation were probably very much the same as the risk of her having a stroke from the aneurysm bursting.

  ‘Does it have to be an operation?’ she asked.

  I told her that if she was to be treated it would indeed have to be surgery. The problem was knowing whether to do it or not.

  ‘What are the risks of the operation?’ She started to cry as I told her that there was a four to five per cent chance she would die or be left disabled by the operation.

  ‘And if I don’t have the operation?’ she asked through her tears.

  ‘Well, you might manage to die from old age without the aneurysm having ever burst.’

  ‘They say you’re one of the best neurosurgeons in the country,’ she said with the naive faith that anxious patients use to try to lessen their fears.

  ‘Well, I’m not. But I’m certainly very experienced. All I can do is promise to do my best. I’m not denying that I’m completely responsible for what happens to you but I’m afraid it’s your decision as to whether to have the op or not. If I knew what to do I promise I would tell you.’

  ‘What would you do if it was you?’

  I hesitated, but the fact of the matter was that by the age of sixty-one I was well past my best-by date and I knew that I had already lived most of my life. Besides, the difference in our ages meant that I had fewer years of life ahead of me so the life-time risk of the aneurysm rupturing, if it was not operated on, would be much lower for me and the relative risk of the operation correspondingly higher.

  ‘I would not have the aneurysm treated,’ I said, ‘although I would find it quite hard to forget about it.’

  ‘I want the op,’ she said. ‘I don’t want to live with this thing in my head,’ emphatically pointing at her head.

  ‘You don’t have to decide now. Go home and talk things over with your family.’

  ‘No, I’ve decided.’

  I said nothing for a while. I was not at all sure she had really listened to what I had told her about the risks of surgery. I doubted if going over it all over again would achieve much so we set off on the long trek along the hospital corridors to find my secretary’s office and arrange a date for the operation.

  On a Sunday evening three weeks later I trudged in to the hospital, as usual, to see her and the other patients due to have surgery the next day. I went to the hospital reluctantly, irritable and anxious, much of the day having been overhung with the thought of having to see the woman and face her anxiety.

  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. Once I have seen the patients, however, and spoken to them, and discussed with them what will happen to them next day, the fear leaves me and I return home happily enough, ready for the next day’s operating.

  I found her in one of the crowded bays on the women’s ward. I had hoped her husband might be with her so that I could talk to them together but she told me that he had already left as their children were at home. We talked about the operation for a few minutes. The decision was now made, so I did not feel the need to stress the risks as I had done in the outpatient clinic, although I still had to refer to them when I got her to sign the complicated consent form.

  ‘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.

  I saw the other two patients who were also on the list for surgery and went over the details of their operations with them. 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. Playing with these happy nautical metaphors as I left the hospital, I went home.

  After the morning meeting I went to the anaesthetic room where the patient was lying on a trolley, waiting to be anaesthetized.

  ‘Good morning,’ I said, attempting to sound cheerful. ‘Did you sleep well?’

  ‘Yes,’ she replied calmly. ‘I had a good night’s sleep.’

  ‘Everything’s going to be fine,’ I said.

  I could only wonder once again whether she really appreciated the risks to which she was about to be exposed. Perhaps she was very brave, perhaps naive, perhaps she had not really taken in what I had told her.

  In the changing room I stripped off and climbed into theatre pyjamas. One of my consultant colleagues was getting changed as well and I asked him what was on his list for the day.

  ‘Oh, just a few backs,’ he said ‘You’ve got the aneurysm?’

  ‘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.’

  I went in to the theatre where Jeff, my registrar, was positioning the woman on the operating table. My department is unusual in having American surgeons from the neurosurgical training programme in Seattle who train with us for a year at a time. Jeff was one of these and, as with most of the American trainees, he was outstanding. He was clamping her head to the table – three pins attached to a hinged frame are driven through the scalp into the skull to hold the patient’s head immobile.

  I had promised her a minimal head shave and Jeff started to shave the hair from her forehead. 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.

  With the minimal head shave completed we go to the scrub-up sink and wash our hands and then, gloved and masked and gowned, return to the table and start the operation. The first ten minutes or so are spent painting the patient’s head with antiseptic, covering her with sterile towels so that I can only see the area to be operated upon, and setting up the surgical equipment and instruments with the scrub nurse.

  ‘Knife,’ I say to Irwin, the scrub nurse. ‘I’m starting,’ I shout to the anaesthetist at the other end of the table, and off we go.

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

  ‘Lights away, microscope in and the operating chair!’ 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.

  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.

  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 me 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. 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. It is a very private view, and although the surgical team is around me, watching me operate on a video monitor connected to the microscope, and although my assistant is beside me, looking down a side-arm, and despite all the posters in the hospital corridors about something called clinical governance proclaiming the importance of team-working and communication, for me this is still single combat.

  ‘Well, Jeff, let’s get on with it. And let’s have a brain retractor,’ I add to Irwin.

  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 point out the carotid artery to Jeff and ask Irwin for the microscopic scissors. I carefully cut the gossamer veil of the arachnoid around the great artery that keeps half the brain alive.

  ‘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.

  ‘Let’s have another retractor,’ I say.

  Armed now with two retractors I start to prise apart the frontal and temporal lobes. They are held together by a fine layer of the meninges which is called the arachnoid, after the Greek word for a spider as it looks as though it was made from the strands of the finest spider’s web. 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.

  ‘Awesome!’ Jeff says again.

  ‘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.’

  I soon find the right middle cerebral artery. 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 sides of the two lobes to stick together. Dissecting them is difficult and messy, and there is always the fear that the aneurysm will rupture again while I am doing this.

  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 and the dark purple veins, glittering in the brilliant light of the microscope.

  ‘Well. It’s just asking to be clipped, isn’t it?’ I say to Jeff, suddenly happy and relaxed. The greatest risk is now past. 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.

  ‘Let’s have a look at the clips,’ I say.

  Irwin hands me the metal tray containing the gleaming titanium aneurysm clips. They come in all shapes and sizes, corresponding to the many shapes and sizes of aneurysms. I look at the aneurysm down the microscope and at the clips and then back at the aneurysm.

  ‘Six millimetre, short right-angled’ I tell him.

  He picks out the clip and loads it onto the applicator. The applicator consists of a simple instrument with a handle formed by two curved leaf springs, joined at either end. Once the clip is loaded at the instrument’s tip, all you have to do is press the springs of the handle together to open the blades of the clip, position the opened blades carefully across the neck of the aneurysm and then allow the springs to separate gently apart within your hand so that the clip blades close across the aneurysm, sealing it off from the artery from which it has grown, so that blood can no longer get into it. By finally letting the springs of the handle separate even more fully the clip is released from the applicator which you can then withdraw, leaving the clip clamped across the aneurysm for the rest of the patient’s life.

  That, at least, is what is supposed t
o happen and had always happened with the hundreds of similar operations I had carried out in the past.

  Since this looks a straightforward aneurysm to clip I let Jeff take over, and I clamber out of the operating chair so that he can replace me. 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.

  Once Jeff is settled in, the nurse hands him the loaded clip applicator, and he cautiously moves it towards the aneurysm. Nothing much seems to happen, and down the assistant’s arm of the microscope I nervously watch the clip wobble uncertainly around the aneurysm. It is a hundred times more difficult and nerve-wracking to train a junior surgeon than it is to operate oneself.

  After a while – probably only a few seconds though it feels much longer – I can stand it no longer.

  ‘You’re fumbling. I’m sorry but I’ll have to take over.’

  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 take the applicator and place it against the aneurysm, pressing the springs of the handle together. Nothing happens.

  ‘Bloody hell, the clip won’t open!’

  ‘That was the problem I was having,’ Jeff says, sounding a little aggrieved.

  ‘Bloody hell! Well, give me another applicator.’

  This time I easily open the clip and slip the blades over the aneurysm. 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. I cannot move my hand for fear of tearing the minute, fragile aneurysm off the middle cerebral artery and causing a catastrophic haemorrhage. I sit there motionless, with my hand frozen in space. If an aneurysm is torn off its parent artery you can usually only stop the bleeding by sacrificing the artery, which will result in a major stroke.