by Henry Marsh
My first few months in the role passed without incident. I was then referred a man with acromegaly. The disease is caused by a small tumour in the pituitary gland producing excess growth hormone. The person’s face slowly changes – it becomes heavy and block-like, not unlike the cartoon figure Desperate Dan in the Dandy magazine, with a massive jaw and forehead. The feet enlarge and the hands become large and spade-like. The changes in this patient’s case were not especially severe, and often the changes are so gradual over so many years that most patients and their families do not notice them. If one knew he had the condition one might notice that his jaw was a little heavy. The high levels of growth hormone ultimately damage the heart and it is for that reason, not the cosmetic changes, that we operate. The operation is done through the nostril, since the pituitary gland lies beneath the brain at the top of the nasal cavities, and is usually simple and straightforward. There are, however, two major arteries next to the pituitary gland that can, if the surgeon is exceptionally unlucky, be damaged during the operation.
His wife and three daughters had all come with him to my office when I first saw him. They were Italian and had become extremely emotional when I said that surgery would be required. They were obviously a close and loving family. Despite their anxieties about the operation, they expressed great confidence in me. He was a particularly nice person – I had been in to see him on the Sunday evening before the operation and we talked happily together for a while. It is a pleasant feeling when your patient obviously trusts you so completely. I operated the next day and the operation went well. He awoke perfectly. I went round to see him late that evening, and his wife and daughters were full of praise and thanks, which I happily acknowledged. The next day some of the symptoms of acromegaly – the feeling that his fingers were swollen – were already a little better and on Thursday morning I went to see him before he went home.
When I went to his bed and spoke to him he looked blankly back at me and said nothing. I then noticed that his right arm was lying useless beside him. One of the nurses hurried up to the bedside.
‘We were trying to find you,’ she said. ‘We think he must have had a stroke just a few minutes ago.’ My patient and I looked uncomprehendingly at each other. I could scarcely believe, and he could not understand, what was happening. I felt a bitter wave of dread and disappointment break over me. Struggling against this I did my best to reassure him (though he would not have understood the words) that all would be well. But a brain scan later that morning confirmed a major stroke in his left cerebral hemisphere. This must have been caused in some unknowable way by the operation. He was by now aphasic – utterly without language. He did not seem too distressed by this, so presumably had little awareness of the problem and was living in some strange language-less world like a speechless animal.
Forgotten memories of other patients I had reduced to this grotesque state in the past suddenly came back to me. A man with an aneurysm in his brain, one of the first such operations I had carried out on my own as a senior registrar; another was an operation I had done on a man with a blood-vessel malformation in his brain. Unlike with this man, where the stroke occurred three days after the operation, with both these patients the operations had gone badly and they had suffered major strokes during the procedures. They had both looked at me afterwards with the same terrible dumb anger and fear, a look of utter horror – unable to talk, unable to understand speech – the look of the damned in some medieval depiction of hell. With the second patient, I remember the intense relief when I came to work next morning to find that he had suffered a cardiac arrest – as though the sheer trauma of what had happened to him had proved too much for his heart. The resuscitation team were working away at him – they were clearly not achieving anything, so I told them to stop and leave him in peace. I do not know what happened to the other man other than that he survived.
At least the Italian man seemed merely puzzled, and looked at me with a vague and empty expression. I had many long and emotional conversations with the family later that day. This involved floods of tears and much embracing. It is difficult to explain, let alone to understand, what it must be like to have no language – to be unable either to understand what is said to one, or put one’s thoughts into words. After major strokes people can die from brain swelling, but this patient remained unchanged for forty-eight hours, and the next evening I assured the family that he would not die, although I did not know if he would regain his speech, and rather doubted it. Nevertheless, two days later, at one o’clock in the morning he deteriorated.
My young and inexperienced registrar rang me.
‘He’s gone off and blown both his pupils!’ he excitedly told me.
‘Well, if both pupils have blown that means he’s coned. He’s going to die. There’s nothing to be done,’ I told him. Coning refers to the way in which the brain is squeezed like toothpaste out of the hole in the base of the skull when the pressure in the skull becomes very high. The extruded part of the brain is cone-shaped. It is a fatal process.
I went to bed, having growled to my registrar that I was not going to come in. But I couldn’t get to sleep and instead drove in to the hospital, the streets deserted apart from a single fox confidently trotting across the road in front of the hospital, summer rain falling. The empty hospital corridors were ringing with the family’s cries, including the three-year-old grand-daughter’s. So I gathered them all together and sat in a chair facing them and explained things and told them how sorry I was. The patient’s wife was on her knees in front of me, clasping her hands, begging me to save her husband. This went on for half an hour or so – it felt longer. They came to accept the inevitability of his death, and perhaps even that it was better for him than to live without language.
I remember another time I had had a patient die from a stroke after an operation. The family had sat staring at me, glaring at me and saying nothing as I tried to explain and to apologize. It was quite clear they hated me and felt that I had killed their father.
But this family was extraordinarily kind and considerate. His daughters said that they did not blame me, and that their father had had great confidence in me. Eventually we parted – one of the daughters brought the three-year-old grand-daughter to me, who had now stopped crying. She looked up at me with two large and dark eyes above her tear-stained cheeks.
‘Kiss the doctor good night, Maria, and say thank you.’
Maria laughed happily as we rubbed each other’s cheeks.
‘Goodnight, sweet dreams, Maria,’ I dutifully said.
My registrar had been watching all this. He thanked me for sparing him the painful task of talking to the family.
‘Terrible job, neurosurgery. Don’t do it,’ I said as I went past him on my way to the door.
I passed the patient’s wife, standing beside the public phone in the corridor, as I walked to the front door.
‘Remember my husband, please think of him sometimes,’ she said, reaching a despairing hand out to me. ‘Remember him in your prayers.’
‘I remember all my patients who die after operations,’ I said, adding to myself as I left, ‘I wish I didn’t.’
I was relieved that he had died – if he had survived he would have been left terribly disabled. He had died because of the operation but not as a result of any obvious mistake on my part. I do not know why the stroke had happened or what I could have done to avoid it. So, just for once, I felt, at least in theory, innocent. But when I arrived home I sat in my car outside my house, the rain falling in the dark, for a long time, before I could drag myself off to bed.
17
EMPYEMA
n. a condition characterized by an accumulation of pus in a body cavity.
It was a simple list: a craniotomy for a tumour, with a couple of routine spinal operations to follow. The first patient was a young man with a glioma on the right side of his brain that could not be removed comp
letely. I had operated for the first time five years ago. He had remained perfectly well but his follow-up brain scans showed that the tumour was starting to grow back again and further surgery was now required, which would hopefully keep him alive for a few more years. He was unmarried and running his own business in IT. We got on well together whenever we met in the outpatient clinic and he had taken the news that he now needed further surgery with remarkable composure.
‘We can hope that another op will buy you some extra years,’ I told him. ‘But I can’t promise it . . . It might be much less. And the operation is not without some risks.’
‘Of course you can’t promise, Mr Marsh,’ he replied.
I carried out his operation under local anaesthetic, so that I could check directly – simply by asking him – that I was not producing any paralysis down the left side of his body. When I tell a patient that I think I should do their operation under local anaesthetic they usually look a little shocked. In fact the brain cannot itself feel pain since pain is a phenomenon produced within the brain. If my patients’ brains could feel me touching them they would need a second brain somewhere to register the sensation. Since the only parts of the head that feel pain are the skin and muscles and tissues outside the brain it is possible carry out brain surgery under local anaesthetic with the patient wide awake. Besides, the brain does not come with dotted lines saying ‘Cut here’ or ‘Don’t cut there’ and tumours of the brain usually look, more or less, like the brain itself, so it is easy to cause damage. If – as was the case here – the tumour was growing near the movement area in the right side of his brain that controlled the left side of his body, the only certain way I had of knowing if I was doing any damage while I operated was by having him awake. It is much easier to carry out brain surgery under local anaesthetic than you might think, provided that the patient knows what to expect, and trusts the surgical team – especially the anaesthetist who will look after the patient while the operation proceeds.
This man coped especially well and while I worked away he talked happily with my anaesthetist Judith – they remembered each other from the first operation and it was like listening to two old friends as they talked about holidays and families and recipes (he was a keen cook), while every few minutes Judith would ask him to move his left arm and leg and make sure that he could still move them as I worked on his brain with my sucker and diathermy.
So it was indeed a straightforward operation and after supervising my registrar with the two spinal cases I walked round to the ITU to see that he was fine, chatting to the nurse looking after him. I left the hospital to travel in to central London where I had a conference to attend.
I took my folding bicycle on the train to Waterloo. It was a singularly cold day with freezing rain and the city looked bleak and grey. I cycled to the legal chambers off Fleet Street where the conference was to be held. The case was over an operation I had carried out three years earlier. The patient had developed a catastrophic streptococcal infection afterwards, called a subdural empyema, which I had initially missed. I had never encountered a post-operative infection like this before and did not know any other neurosurgeons who had either. The operation had gone so well that I had found it impossible to believe it might all go wrong and I dismissed the early signs of the infection, signs which in retrospect were so painfully obvious. The patient had survived but because of my delay in diagnosing the infection she had been left almost completely paralysed and will remain so for the rest of her life. The thought of the conference had been preying on my mind for many weeks.
I presented myself to the receptionist in the grand and imposing marble lobby and was ushered into a waiting room. I was soon joined by a fellow neurosurgeon I know well who was advising my Defence Union over the case.
I told him about how I had come to make such a disastrous mistake.
Her husband had rung me up on my mobile phone on a Sunday morning when I was in the hospital dealing with an emergency. I didn’t really take in what he said and misdiagnosed the infection as harmless inflammation. I should never have diagnosed that on the basis of a phone call but I was busy and distracted and I’d never had a serious complication with that particular operation before in twenty years.
‘There but for the grace of God it could have been me,’ my colleague said, trying to cheer me up. We were then joined by two solicitors from the Defence Union. They were very polite but quite without smiles. I thought that they looked tense and drawn but perhaps this was simply my imagination, produced by my awful feeling of guilt. I felt as though I was attending my own funeral.
We were taken downstairs to a basement room where a courteous QC – many years younger than me – was waiting for us. A large wall display extolled the virtues of his chambers in fine Roman capital lettering. I cannot remember what was claimed – I was too miserable to take much in.
Coffee was served and one of the solicitors unpacked box after box of documents onto the table.
‘It’s terrible how much trouble one phone call can cause,’ I said sadly as I watched her, and she now smiled briefly at me.
‘I need to start’, the QC said very gently, ‘to explain where we are coming from. I think this will be difficult to defend . . .’
‘I entirely agree,’ I interrupted.
The meeting only lasted a couple of hours. It was painfully clear – as I had always known – that the case could not be defended.
At the end of the meeting the barrister asked my colleague to leave.
‘Mr Marsh, perhaps you could stay behind,’ he said.
I remembered once having to wait outside the office of my school headmaster fifty years ago, sick with anxiety, to be punished by the kind old man for some misdemeanour. I knew that the barrister was going to be professional and matter-of-fact but I nevertheless felt overcome with dread and shame.
After my colleague had left he turned to me. ‘I’m afraid I don’t really think we have a case here,’ he said with an apologetic smile.
‘I know,’ I said. ‘I’ve felt it was an indefensible mistake all along.’
‘I’m afraid this might all drag on for a while,’ one of the solicitors added, sounding as I suspect I must sound when I break bad news to my patients.
‘Oh that’s all right,’ I said, trying to sound brave and philosophical. ‘I’m reconciled to this. It’s neurosurgery. I’m just sorry to have wrecked the poor woman and to have cost you millions of pounds.’
‘That’s what we’re here for,’ she said. The three of them looked at me with kind, slightly questioning expressions. Perhaps they expected me to burst into tears. It felt strange to be an object of pity myself.
‘Well, I’ll leave you to discuss the awful financial consequences.’ I said and picked up my satchel and folding bike.
‘I’ll see you to the door,’ said the barrister and insisted on showing me the professional courtesy of accompanying me to the lift in the corridor outside. I did not feel that I deserved it.
We shook hands and he returned to discuss quantum, as lawyers call it – the cost of the settlement – with the two solicitors.
I found my colleague waiting for me in the lobby.
‘It’s the professional shame that hurts the most,’ I said to him. I wheeled my bike as we walked along Fleet Street. ‘Vanity really. As a neurosurgeon you have to come to terms with ruining people’s lives and with making mistakes. But one still feels terrible about it and how much it will cost.’
The weather forecast had promised a dry morning and neither of us were dressed appropriately. Our professionals’ pinstripe suits were getting soaked as we crossed Waterloo Bridge. As the rain streamed off my face my cheeks turned to ice.
‘I know one has to accept these things,’ I went on lamely, ‘But nobody, nobody other than a neurosurgeon understands what it is like to have to drag yourself up to the ward and see, every day – sometimes for months on end
– somebody one has destroyed and face the anxious and angry family at the bedside who have lost all confidence in you.’
‘Some surgeons can’t even face going on those ward rounds.’
‘I told them to sue me. I told them that I had made a terrible mistake. Not exactly the done thing, is it? So I remained – crazily enough – quite good friends with them. At least I think so but I can’t expect them to have a very high opinion of me, can I?’
‘You can’t stay pleased with yourself for long in neurosurgery,’ my colleague said. ‘There’s always another disaster waiting round the corner.’
We walked into Waterloo Station, where the crowds were gathering to head south for the weekend, and shook hands and went our respective ways.
I had not dared to ask for how many millions of pounds the case would probably be settled. The final bill, I learned two years later, was for six million.
Back at the hospital that evening I went up to the ITU to see the young man with a recurrent tumour whom I had operated upon in the morning – it already felt like a lifetime ago. The operation had gone well enough but we both knew that I had not cured him and that the tumour would grow back again, sooner or later. He was sitting up in his bed, with a lopsided bandage around his head.
‘He’s fine,’ said the nurse looking after him as she looked up from the lectern at the end of his bed where she was writing down the observations.
‘Once again, Mr Marsh,’ my patient said, looking at me intensely, ‘My life in your hands. Really I can’t thank you enough.’ He wanted to say more but I put my finger to my lips.
