by Henry Marsh
I carried out the operation first thing the next morning with Patrik, the senior registrar who was working with me at the time. The operation had inevitably caused great excitement and there was a small army of obstetricians, paediatricians and nurses with paediatric resuscitation kit in the corridor outside the operating theatre. Doctors and nurses enjoy dramatic cases like this and there was a carnival-like atmosphere to the morning. Besides, the idea of a baby being born in our usually rather grim neurosurgical operating theatres was delightful and the theatre staff were all looking forward to the event as well. The only worry – which was largely mine and Melanie’s and her family’s – was whether I could save her eyesight or whether I might even leave her completely blind.
She was brought to the theatre from the women’s ward on a trolley with her husband walking beside her, her pregnant belly rising up like a small mountain under a hospital sheet. Her husband, fighting back his tears, kissed her goodbye outside the doors to the anesthetic room and was then escorted out of the theatre by one of the nurses. 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 talked Patrik through the opening stages of the procedure.
‘She’s young, she’s good-looking,’ I said. ‘We want a good cosmetic result.’ I showed him how to make a single burr hole in the skull just out of sight behind the orbit and then use a wire saw called a Gigli saw after its inventor – a sort of glorified cheese wire which makes a much finer cut through bone than the power tools we usually use – to make a very small opening in the skull just above Melanie’s right eye. Using the Gigli looks brutal since, as you use your hands to pull the saw backwards and forwards, a fine spray of blood and bone flies upwards and the saw makes an unpleasant grating sound. But, as I said to Patrik, it makes a fine and perfect cut.
Once Patrik had removed the small bone flap – measuring only three centimetres or so – 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. I told Patrik to open the meninges with a pair of scissors. 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. Patrik tented up the dura with a fine pair of toothed forceps and started to cut an opening in it with a pair of scissors. Patrik was a short, determined and outspoken Armenian-American.
‘They’re blunt. They don’t cut, they chew,’ he said as the scissors jammed on the leathery meninges. ‘Give me another pair.’ Maria the scrub-up nurse turned back to her trolley and returned with a different pair with which Patrik now exposed the tip of the right frontal lobe of Melanie’s brain by cutting through the dura and folding it forwards.
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’. There was little risk of this happening to Melanie but if we damaged the surface of her brain as we lifted the right frontal lobe up by a few millimetres to reach the tumour it was quite likely that we would leave her with life-long epilepsy. It was good to see that Melanie’s brain, as a result of the lumbar drain and my drilling of her skull, looked ‘slack’ as neurosurgeons say – there was plenty of room for me and Patrik to get underneath it.
‘Conditions look lovely,’ I shouted to Judith at the other end of the table where she sat in front of a battery of monitors and machines and a cat’s cradle of tubes and wires connected to the unconscious Melanie – all the anesthetists can see of the patients are the soles of their feet. Judith, however, had to worry here not just about Melanie’s life but about the unborn baby’s as well who was being subjected to the same general anaesthetic as his mother.
‘Good,’ she said.
‘Bring the ’scope in and give Patrik a retractor,’ I said and, once the heavy microscope had been pushed into position and Patrik was settled in the operating chair, Maria held out a handful of retractors, fanned out like a small pack of cards, from which he took one. I stood at one side, a little nervously looking down the assistant’s arm of the microscope.
I told Patrik to place the retractor gently under Melanie’s frontal lobe while sucking away the cerebrospinal fluid with a sucker in his other hand. He slowly pulled her brain upwards by a few millimetres.
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.
‘Is that the right nerve?’ asked Patrik.
It most certainly was, I told him, and it looked horribly stretched. We could now see the granular red mass of the tumour over which the right optic nerve – a pale white band a few millimetres in width – was tightly splayed.
‘I think I’d better take over now,’ I said. ‘I’m sorry, but what with the baby and her eyesight being so bad it’s not really a training case.’
‘Of course,’ said Patrik, and he climbed out of the operating chair and I took his place.
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. It did not take long to debulk the tumour with the sucker in my right hand and the diathermy forceps in my left. I gradually eased the hollowed out tumour away from the optic nerves. The tumour was not stuck to the optic nerves and after an hour or so we had a spectacular view of both right and left optic nerves and their junction, known as the chiasm. They look like a pair of miniature white trousers although thin and stretched because of the tumour which I had now removed. On either side were the great carotid arteries that supply most of the blood to the brain and further back the pituitary stalk, the fragile structure that connects the all-important pea-sized pituitary gland to the brain, which co-ordinates all the body’s hormonal systems. It sits in a little cavity, known as the sella, just beneath the optic nerves, which is why Melanie’s tumour is called a ‘supra-sellar’ meningioma.
‘All out! Let’s close up quick and the obstetricians can do the C section,’ I announced to the assembled audience. I muttered in an aside to Patrik that I hoped to God that her eyesight would recover.
So Patrik and I closed up Melanie’s head and left our colleagues to get on with delivering the baby. As we walked out of the theatre the paediatricians passed us wheeling a paediatric ventilator and resuscitation equipment into the room.
I went off to get a cup of coffee and get some paperwork done in my office. Patrik stayed behind to watch the Caesarean section.
He rang me an hour later. I was sitting at my desk dictating letters.
‘It all went fine. She’s on the ITU and the baby�
�s next to her.’
‘Can she see?’ I asked.
‘Too early to say,’ Patrik said. ‘Her pupils are a bit slow . . .’
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.
‘We’ll have to wait and see,’ I replied.
‘The next patient’s on the table,’ Patrik said. ‘Shall we start?’
I left my office to go and join him.
The second patient on the list was a woman in her fifties with a malignant left temporal glioma, a cancerous tumour of the brain itself. I had seen her a week earlier in my outpatient clinic. She had come with her husband, and they held each other’s hands as they told me how she had become confused and forgetful over the preceding weeks. I explained to them that her brain scan showed what was undoubtedly a malignant tumour.
‘My father died from a malignant brain tumour,’ she told me. ‘It was terrible to watch him deteriorate and die and I thought that if that happened to me I would not want to be treated.’
‘The trouble is,’ I said reluctantly, ‘it will happen to you anyway. If I treat you, with a bit of luck, you might have some years of reasonable life but if we do nothing you have only a few months left to live.’
In reality this was probably optimistic. The scan showed a foul malignant tumour in her dominant temporal lobe – dominant meaning the half of the brain responsible for speech and language – that was already growing deep into her brain. 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. 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. I did not think we had done her any serious harm though nor had we done her much good.
‘What’s her prognosis, boss?’ Patrik asked me as he stitched the dura and I cut his stitches with a pair of scissors.
‘A few months, probably,’ I replied. I told him about her father and what she had said to me.
‘It’s difficult to do nothing,’ I said. ‘But death is not always a bad outcome, you know, and a quick death can be better than a slow one.’
Patrik said nothing as he continued to close the woman’s meninges with his sutures. Sometimes I discuss with my neurosurgical colleagues what we would do if we – as neurosurgeons and without any illusions about how little treatment achieves – were diagnosed with a malignant brain tumour. I usually say that I hope that I would commit suicide but you never know for certain what you will decide until it happens.
As we stitched her head up I did not expect any problems. Judith took her round on her trolley, pushed by one of the ODAs and nurses, to the ITU while I sat down and wrote an operating note. A few minutes later Judith put her head round the theatre door.
‘Henry, she’s not waking up and her left pupil is bigger than her right. What do you want to do?’
I swore quietly and quickly walked the short distance to the Intensive Care Unit. In the corner of the room I could see Melanie, and a baby’s cot beside her bed, but I hurried past to look at the second patient. With one hand I gently opened her eyelids. The left pupil was large and black, as large as a saucer.
‘We’d better scan her,’ I said to Patrik who had come hurrying up when he had heard the news. Judith was already re-anaesthetizing the woman and putting a tube down into her lungs so as to put her back on a ventilator. I told Patrik to tell the staff in the scanner that we would be bringing her for a scan immediately and never mind what else they were doing. I wasn’t going to wait for a porter. Patrik went to the nurses’ desk and picked up the phone while Judith and the nurses disconnected the woman from all the monitoring equipment behind her and with my help wheeled her quickly out of the ITU to take her to the CT scanner. Together with the radiographer we quickly slid her into the machine. I walked back to the control room with its leaded, X-ray- proof window looking out into the room where the patient lay with her head in the scanner.
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.
I went round to the surgical sitting room and I lay on the sofa, staring at the sky through the high windows, waiting for her husband and daughter to arrive.
I spoke to them an hour later in the little interview room on the ITU. They collapsed into each other’s arms in tears. Dressed in my theatre pyjama suit, I looked on miserably.
As she was going to die the nurses had moved her into a side room where she lay on her own. I took her husband and daughter to see her. They sat down beside her. She was unconscious and mute, her eyes closed, with a lop-sided bandage around her head beneath which her bloodied hair hung down. The ventilator which was keeping her alive gently sighed beside her.
‘Are you really sure she cannot hear anything we say to her?’ her daughter asked me.
I told her that she was in a deep coma but that even if she could hear she would not understand what she heard since the haemorrhage was directly in the speech area of her brain.
‘And will she have to stay in hospital? Can’t she come home?’
I said that I was certain that she would die within the next twenty-four hours. She would become brain dead and then the ventilator would be switched off.
‘She’s been taken from us. So suddenly. We were going to do so many things together in the time we had left, weren’t we?’ her husband said, turning to his daughter as he spoke. ‘We weren’t ready for this . . .’ He held his daughter’s hand as he talked.
‘I trusted you,’ he said to me, ‘and I still do. Are you certain that she might not wake up? What if she wakes up and finds that we aren’t here? It would be so frightening for her although I know she kept on telling us last week that she did not want to be a burden to us.’
‘But love is unconditional,’ I said and he burst into tears again.
We spoke for a while longer. Eventually I turned to the door saying that I had to leave or I would start crying myself. The husband and daughter laughed at this through their tears. 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.
Back in the operating theatre Patrik was having difficulties stopping the bleeding after removing the disc prolapse in the third and last case on the list. I cursed and abused him half-jokingly and scrubbed up and quickly brought the bleeding under control. We closed up the man’s incision together and afterwards I returned to the ITU to see Melanie. She was peacefully asleep and her baby son was asleep in the cot beside her. Her observation chart showed that her pupils were now reacting to light and the nurse looking after her said that all was well. There was a small group of laughing and smiling nurses beside the cot looking at the baby.
Her husband rushed up to me, almost delirious with joy.
‘She can see again! You’re a miracle w
orker Mr Marsh! She woke up from the op and she could see the baby! She said her eyesight’s almost back to normal! And our son is fine! How can we ever thank you enough?’
What a day, I thought as I went home, what a day. When I recounted this story – which I had quite forgotten until then – to the Holby City writers gathered round the hotel table, they broke out in little cries of delight and amazement, though whether they used the story about Melanie or not, I do not know.
5
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.
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.
I was operating on a woman with 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 was filming the operation for the national news. 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 snow falling onto a grey wasteland of broken machinery and derelict buildings. I often have an audience when operating and I dislike it when things are going badly – but this was many times worse. I had to radiate a calm, surgical self-confidence, which was not what I felt.
