by Henry Marsh
‘The gyrus rectus serves olfaction,’ I told my small audience. ‘The patients are better off with perhaps some impairment of smell than dying from another haemorrhage if they don’t have the aneurysm treated.’
I handed over the operation to the two residents and walked round to look at the dead face: head shaved, eyes closed, stubble on his cheeks, blackened stumps of a few remaining teeth. He clearly had never seen a dentist. As far as I could tell he was not – or rather had not been – that old before he died. It was impossible not to wonder for a moment who he had been and what sort of life he had led, and to think that once he had been a child, with all his future in front of him.
Workshops like this are not unusual, but I had never been at one before and I found it rather distressing. I would consider this to be a weakness on my part – it is clearly much better that trainee surgeons should practise in workshops like this than on living patients. When I was back in England two weeks later I mentioned this to a colleague who had recently organized a similar workshop in the UK.
‘Ah!’ he said with a laugh. ‘Only one? I had fifteen heads, freeze-dried, flown in from the US for my skull base workshop last year. I needed to put them all through the MRI scanner before the meeting and drove to the hospital with the heads in the boot of my car. I wasn’t quite sure what I would say if I was stopped by the police. The other problem was that they were starting to thaw. I don’t know where they get them from,’ he added.
I left the room with its severed head and anaesthetized pigs and found another huge breakfast laid out next to the lecture theatre where we had started. After breakfast I was taken on a whirlwind tour of the hospital.
The hospital consisted of a series of multi-storey towers, and we went through what seemed to be an almost endless series of huge lobbies and halls. The hospital had its own twelve-floor hotel; patients came from all over the world for treatment, not just from America. There were twenty – twenty! – other hospitals next to my colleague’s, as well as many other medical and clinical research institutions. The Medical Center occupies more than a square mile, and when I looked out of my twelfth-floor hotel window all I could see was hospital after hospital, all built of glittering glass, receding into the distance like a mountain range. Medicine in the USA is notoriously extravagant. I saw one hospital in Chicago which had a luxurious restaurant, bar and garden on its roof. The hospitals are locked in fierce competition for business and many are designed to look as little like hospitals as possible. They resemble instead luxury hotels or shopping malls or first-class airport lounges. They are the peacocks’ tails of health care.
That evening my colleague took me to his country club. We drove there through the city’s suburbs, past large mansions with pillared porticoes and extensive lawns. The club too was built on a grand scale and the clubhouse – icy-cold with air-conditioning – had a massive baronial fireplace in the Scottish style decked out with mounted stags’ heads on either side, and a large reproduction of the famous Victorian painting by Landseer of a stag, known as The Monarch of the Glen, hung above the grand staircase. We had an excellent dinner there. The waiters were elderly Mexican men with solemn and expressionless Aztec faces. They were dressed in black suits with white aprons and they moved with slow dignity as they served the clientele, nearly all of whom were dressed in baggy shorts and long T-shirts. Over dinner there was the usual surgical gossip – mainly about a colleague who had been sacked for having an affair with a rep, and whether the rep was enhanced with silicone or not. Opinions differed as to this latter question. After his dismissal she had apparently sued him successfully for sexual harassment but now, my colleague told me, they were back together again. I also learnt that the operation on the pig to create an aneurysm had not been a success: one of the technicians had forgotten to give the animal an anti-coagulant injection and the pig had suffered a major stroke as a result of the surgery to its carotid artery. It would, however, have presumably been sacrificed – as it is called – in any case, even if the mistake had not occurred.
After dinner we went out into the sweltering, humid heat to inspect a car show outside the clubhouse. Thirty or so classic cars were drawn up in the car park, shiny and polished, many with their bonnets up so that you could see the spotless, chromed engines inside. A red Ferrari inched its way past us to find a parking place.
My colleague nudged me and said with awe: ‘That’s a seven-million-dollar car. And the guy driving it is a billionaire.’
It transpired later that the car was only a reproduction, but was still worth a million dollars. The billionaire apparently was a real billionaire but looked a fairly ordinary sort of guy. A group of people gathered admiringly around the car once the billionaire had parked it, and they took photographs of each other in front of it.
I went out for a run next morning as the sun was rising. I was streaming with sweat within a matter of minutes as I ran along the street beneath the tall hospital towers, past neatly tended flowerbeds. At the edge of the great block of hospitals there was a large park, with a miniature railway line running round it. Several dozen homeless people were dossing out on the benches and sidewalks in one corner of the park. I was told later that there was a church nearby which gave out free meals. As I ran back to the hotel the sun rose behind me, over the dozens of buildings of the Medical Center, and I was almost blinded by its dazzling reflection in the thousands of hospital windows facing me.
5
AWAKE CRANIOTOMY
For a surgeon to help operate on patients he did not know, whom he would scarcely ever see again, for whom he carried no practical responsibility – if there were problems Dev would have to deal with them – had always been anathema to me. And yet I had already discovered, to my surprise, that my lack of human contact with the Nepali patients both before and after surgery had not reduced my anxiety when I was operating. It did not seem to matter after all. Operating in Kathmandu I was in the same state of tense concentration as I was in London and it seemed that I cared just as much for the patients, even though my concern for them had now become entirely abstract and impersonal. I used to feel critical of surgeons if they were remote and detached from their patients but now, very late in my career, I was forced to recognize that some of this had perhaps been vanity on my part, and simply yet another attempt to feel superior to other surgeons.
Surgeons describe operating on patients with whom they have no personal or emotional contact as being veterinary. There was a veterinary surgery near the old hospital in Wimbledon and one of the vets there – Clare Rusbridge – specialized in veterinary neurological disorders. Devoted pet owners can take out insurance for their pets which includes the cost of MRI brain and spinal scans. Clare would bring to our weekly X-ray meetings fascinating scans of cats and dogs with neurological disorders. We would look at the scans at the end of the meeting and called it Pets’ Corner. They provided a bizarre contrast in anatomy to the images of human brains and spines with which we were so familiar. Cavalier King Charles spaniels, we learnt, often suffer from the brain abnormality known as a Chiari malformation, which humans also get. Labradors can develop malignant meningiomas. The spaniels’ problem is the result of selective breeding aimed to produce the small round head which wins points at dog shows. The malformation leads to spinal cord damage, and the poor creatures suffer from intractable pain and scratch themselves incessantly.
I operated with Clare on a couple of occasions, though she was unable to find an owner of a King Charles spaniel who was willing to let us operate on their pet. We did, however, once operate on a badger, which had been found confused and wandering on Epsom Downs and had been rescued and brain-scanned by an animal charity. The brain scan suggested that she might have hydrocephalus, although, to be honest, not much is known about badger brains. She was a beautiful creature and once she had been anaesthetized, I held her on my lap for a few minutes, stroking her grey and white fur, before Clare removed most of it with a pair of clippers in preparation for the surgery
. I tried to carry out an operation for the possible hydrocephalus. I already had an article published entitled ‘Brain Surgery in Ukraine’ and I hoped I would be able to add to my CV ‘Brain Surgery in Badgers’, but the operation was not a success and the poor creature died. Or rather, she was ‘euthanased’.
‘At least our patients don’t have to suffer,’ one of Clare’s colleagues, who had watched the operation, commented afterwards. ‘Unlike yours.’
The first case I had done with Dev – two days before the operation on the child – had been an awake craniotomy for a tumour. This was the first time that such surgery had been carried out in Nepal. I had brought the equipment for cortical brain stimulation from London in my suitcase. Many years ago I had been the first surgeon in Britain to use the technique of awake craniotomy for treating a particular type of brain tumour known as a low-grade glioma. It was unorthodox at the time, but is now standard practice in most neurosurgical departments. It is, in fact, a very simple way of operating which allows you to remove safely more of a tumour in the brain than with the patient asleep under a general anaesthetic. The problem is that the ‘tumour’ is in fact part of the brain which has tumour growing in it – brain and tumour are muddled up together. The abnormal area, especially at its edges, looks almost identical to normal brain and only by having the patient awake, so that you can see what is happening to them as you remove the tumour, can you tell if you are straying into normal brain and running the risk of causing serious damage. Patients tolerate the procedure much better than you might expect, once they understand why it has been recommended.
The brain cannot feel pain: pain is a sensation created within the brain in response to electrochemical signals sent to it from the nerve endings in the body. When I see patients with chronic pain, I try to explain to them that all pain ‘is in the mind’ – that if I pinch my little finger, it is an illusion that the pain is in my finger. It is not ‘in’ my finger but really in my brain – an electrochemical pattern in my brain, in a map that my brain has made of my body. I try to explain this in the hope that the patient will understand that a psychological approach to pain might be just as effective as a ‘physical’ treatment. Thought and feeling, and pain, are all physical processes going on within our brains. There is no reason why pain caused by injury to the body to which the brain is connected should be any more painful, or any more ‘real’, than pain generated by the brain itself without an external stimulus from the body. The phantom limb pain of an amputated arm or leg can be excruciating. But most patients with chronic pain problems or conditions like chronic fatigue syndrome find this hard to accept. They feel that their symptoms are being dismissed – as they often are – if it is suggested that there is a psychological component to their problem and that a psychological approach might help. The dualism of seeing mind and matter as separate entities is deeply ingrained in us, as is the belief in an immaterial soul which will somehow outlive our bodies and brains. My ‘I’, my conscious self, writing these words, does not feel like electrochemistry, but that is what it is.
So, for an awake craniotomy, only the scalp needs to be anaesthetized and the rest of the operation is painless, although patients find having their skull drilled into very noisy – the skull acts like a sounding board. I therefore usually do this part of the operation under a brief general anaesthetic. The patient is then woken up, but unlike normal operations, where you wake up in a bed back on a hospital ward, with an awake craniotomy you wake up in the operating theatre, in the middle of the operation. There are various ways of conducting the ‘awake’ part of the operation. All involve using an electrode to stimulate the patient’s brain, which tells you where, in functional terms, you are on its surface. You will be able to produce limb movement or interfere with the ability to talk as the electrode momentarily stimulates or stuns the relevant part of the brain. It is a little like pulling the strings of a puppet. You also need to ask the patient to perform simple tasks or name and identify pictures if the tumour is near the speech centres of the brain. Some surgeons rely on speech therapists or physiotherapists to talk to the patient and assess them as the operation proceeds. I always relied on my anaesthetists, in particular Judith Dinsmore, whose highly skilled and reassuring manner never failed to keep the patients calm and cooperative.
I operate with a transparent screen between myself and the patient. Judith would sit facing the patient, talking to them and assessing the relevant functions – their ability to talk fluently, or to read, or to move the limbs on the opposite side of their body to the tumour (for obscure evolutionary reasons, each half of the brain controls the opposite side of the body). I would be standing behind and above the patient’s opened head and exposed brain, and watch and listen to Judith through the transparent screen as she put the patient through their paces. When she started to look anxious, I knew it was time to stop. If the patient had been under a general anaesthetic for all of the operation, I would have had to stop much earlier and would have removed less of the tumour. There would have been no way of knowing whether I was still removing tumour or normal, functioning brain. Obviously, more subtle social or intellectual functions cannot be tested, but this is not usually a problem. It would seem that low-grade gliomas have to be very extensive indeed – and effectively inoperable – before the patient’s personality is at risk.
I operate with a microscope which has a camera connected to a video monitor. The operation is mainly done with a simple sucker or an ultrasonic aspirator (which is a sucker with an ultrasonic tip that emulsifies what you are operating on). All you can see, as you look into the patient’s brain with the microscope, is the brain’s white matter, which is like a smooth, thick jelly. It is usually – but not always – slightly darker than normal because of the presence of tumour within it. It took me some time to learn to operate like this, with the patient awake. I am always a little anxious when operating and, at first, having the patient awake made this worse, especially as I had to affect a complete calm and confidence for their sake that I did not inwardly feel.
‘Do you want to see your brain?’ I will usually ask the patient. Some say yes and some say no. If they say yes, I go on to say: ‘You are now one of the few people in the history of the human race who have seen their own brain!’ And the patients gaze in awe at their brains on the monitor. I have even had the left visual cortex – the part of the brain responsible for seeing things on the right-hand side – looking at itself. You feel there should be some philosophical equivalent of acoustic feedback when this happens, a metaphysical explosion, but there is nothing, although one patient, having looked at his speech cortex, as I brushed it with a sucker and told him that was what was talking to me, commented: ‘It’s crazy.’
Towards the end of the first ever awake craniotomy in Nepal, the patient’s leg had suddenly become paralysed.
‘It’s probably temporary,’ I assured Dev. ‘It can happen when operating in the supplementary motor area, which was where the tumour was.’
I nevertheless awoke next morning feeling miserable. But Dev came to find me as I sat with a cup of coffee in the garden of his home – I had only stayed two nights in the hotel to which I had first been taken, and was now living in the guest house at the end of Dev’s garden. He told me that the juniors had rung to say that the patient had started to move his leg.
‘I knew you were upset, though you said nothing,’ he said.
The morning was instantly transformed.
‘Were there any admissions overnight?’ I asked.
‘Couple of head injuries,’ Dev replied.
I would often be rung at night when I was on call in London, although unlike Dev I was not on call every night. The telephone would ring and I would be dragged out of sleep, often with the strange illusion that I had chosen to wake up before the phone started ringing. These emergency cases were usually cerebral haemorrhages – bleeding into the brain caused by head injuries or a weakened blood vessel. I had to decide whether the patient should be oper
ated on or not. Sometimes it was obvious that they would die if they did not undergo surgery and that they would make a good recovery after surgery. Sometimes it was obvious that they did not need surgery and would survive without it, and sometimes it was obvious that they would die whatever we did. But often it was not clear whether to operate and, if you did, whether they would make a good recovery. If the haemorrhage had been a big one, the patient was going to be left disabled, however well the operation went, as the brain – being so intricate and delicate – has much less capacity for repair and recovery than other parts of the body. The question then was whether the disability might be so severe – the patient left a ‘vegetable’, as the saying goes – that it might be kinder to let them die.
You can rarely predict with absolute certainty from a brain scan what sort of recovery the patient might make, but if we operate on everybody (as some surgeons do), without any regard to the probable outcome, we will create terrible suffering for some of the patients, and even more for their families. It is estimated that there are 7,000 people in the UK in a ‘persistent vegetative or minimally conscious state’. They are hidden from view in long-term institutions or cared for at home, twenty-four hours a day, by their families. There is a great underworld of suffering away from which most of us turn our faces. It is so much easier to operate on every patient and not think about the possible consequences. Does one good result justify all the suffering caused by many bad results? And who am I to decide the difference between a good result and a bad result? We are told that we must not act like gods, but sometimes we must, if we believe that the doctor’s role is to reduce suffering and not just to save life at any cost.