Admissions: A Life in Brain Surgery

1

THE LOCK-KEEPER’S COTTAGE

The cottage stands on its own by the canal, derelict and empty, the window frames rotten and hanging off their hinges and the garden a wilderness. The weeds were as high as my chest and hid, I was to discover, fifty years of accumulated rubbish. It faces the canal and the lock, and behind it is a lake, and beyond that a railway line. The property company that owned it must have paid somebody to clear out the inside of the cottage, and whoever had done the work had simply thrown everything over the old fence between the garden and the lake, so the lake side was littered with rubbish – a mattress, a disembowelled vacuum cleaner, a cooker, legless chairs and rusty tins and broken bottles. Beyond the junk, however, lay the lake, lined by reeds, with two white swans in the distance.

I first saw the cottage on a Saturday morning. A friend had told me about it. She had seen that it was for sale and knew that I was looking for a place where I could establish a woodworking workshop in Oxford to help me cope with retirement. I parked my car beside the bypass and walked along the flyover, deafening cars and trucks rushing past me, to find a small opening in the hedge, almost invisible, at the side of the road. There was a long line of steps covered in leaves and beechmast, under a dark archway formed by the low, bending branches of beech trees, leading down to the canal. It was as though I was suddenly dropping out of the present and returning to the past. The roar of the traffic became abruptly muted as I descended to the quiet and still canal. The cottage was a few hundred yards away along the towpath, over an old, brick-built humpback canal bridge.

There were several plum trees in the garden, one of them growing up through an obsolete and rusty old machine with reciprocating blades like a hedge-trimmer, for cutting heavy undergrowth. It had two big wheels with Allensand Oxford stamped on the rims in large letters. My father had had exactly the same model of machine, which he used in the two-acre garden and orchard where I had grown up less than one mile away in the 1950s. He once accidentally ran over a little shrew in the grass of the orchard as I stood watching him, and I remember my distress at seeing its bleeding body and hearing its piercing screams as it died.

The cottage looks out over the still and silent canal and the heavy black gates of the narrow lock. There is no road access – it can only be reached along the towpath on foot or by barge. There is a brick wall with drinking troughs for horses along one side of the garden, facing the canal – I found later the metal rings to which the horses which towed the barges along the canal would have been tethered. A long time ago the lock-keeper would have been responsible for the gates, but the lock-keepers’ cottages along the canal have all been sold off and the gates are now left to be operated by whoever is on the passing barges. I am told that a kingfisher lives here and can be seen flashing across the water, and that there are otters as well, even though only a few hundred yards away there is the roar of the bypass traffic crossing the canal on the high flyover on its concrete stilts. But if I turn away from the road, all I can see are fields and trees, and the reed-lined lake behind the house. I can imagine that I am in ancient, deep countryside, as it was when I was growing up nearby, before the bypass was built sixty years ago.

The young woman from the estate agents was sitting on the grass bank in the sunshine beside the entrance to the cottage, waiting for me. She opened the bolted and padlocked front door. I stepped over a few letters on the floor inside, covered in muddy footprints. The estate agent saw me looking down at them and told me that an old man had lived here by himself for almost fifty years – the deeds for the property described him as a canal labourer. When he died the property developers, who had bought the house some years ago, put it up for sale. She did not know whether he had died here or in hospital or in a nursing home.

The place smelt damp and neglected. The cracked and broken windows were covered by torn, dirty lace curtains and the window sills were black with dead flies. The rooms had been stripped out and had the sad and despondent air of all abandoned homes. Although there was water and electricity, the facilities were primitive, and there was only an outside toilet, smashed into pieces, with the door off its hinges. The dustbin by the front door contained plastic bags full of faeces.

The ancient farmouse nearby where I had spent my childhood was said to have been haunted – at least, according to the Whites, the elderly couple who lived across the road and whom I liked to visit. An improbable tale of a sinister coach and horses in the yard at night and also of a ‘grey lady’ in the house itself. It was easy to imagine the old man’s ghost haunting the cottage.

‘I’ll take it,’ I said.

The girl from the estate agents looked at me sceptically.

‘But don’t you want to get a survey?’

‘No, I do all my own building work and it looks OK to me,’ I replied confidently, but wondering whether I was still capable of the physical work that would be required and how I would manage without any road access. Perhaps I should stop being so ambitious and abandon my obsessive conviction that I must do everything myself. Perhaps it no longer mattered. I ought to employ a builder. Besides, although I wanted a workshop, I wasn’t sure that I wanted to live in this small and lonely cottage, with a possible ghost.

‘Well, you’d better make an offer to Peter, the manager in our local office,’ she replied.

I drove back to London the next day – with the uneasy thought that perhaps this little cottage would be where I myself would eventually end my days and die, and where my story would end. Now that I am retiring, I am starting all over again, I thought, but now I am running out of time.

I was back in the operating theatre on Monday – I was in my blue theatre scrubs, but expected to be only an observer. In three weeks’ time I was to retire – after almost forty years of medicine and neurosurgery. My successor, Tim, who had started off as a trainee in our department, had already been appointed. He is an exceptionally able and nice man, but not without that slightly fanatical determination and attention to detail that neurosurgery requires. I was more than happy to be replaced by him and it seemed appropriate to leave most of the operating to him, in preparation for the time when – and it would probably be something of a shock for him – he suddenly carried sole responsibility for what happened to the patients under his care.

The first case was an eighteen-year-old woman who had been admitted for surgery the previous evening. She was five months pregnant but had started to suffer from severe headaches, and a scan showed a very large tumour – almost certainly benign – at the base of her brain. I had seen her as an emergency in my outpatient clinic a few days earlier; she came from Romania and her English was limited, but she smiled bravely as I tried to explain things to her via her husband, who spoke a little English. He told me that they came from Maramures, the area of northern Romania on the border with Ukraine. I had been there myself two years ago on a journey from Kiev to Bucharest with my Ukrainian colleague Igor. The landscape was exceptionally beautiful, with ancient wooden farms and monasteries – it seemed that the modern world had scarcely caught up with the place at all. There were haystacks in the fields and hay wagons drawn by horses on the roads, with the drivers wearing traditional peasant costumes. Igor was outraged that Romania had been allowed to join the European Union whereas Ukraine had been kept out. My Romanian colleague, who had come to collect us from the border with Ukraine, wore a tweed cloth cap and leather driving gloves, and drove us at high speed on the terrible roads in his son’s souped-up BMW all the way to Bucharest, almost without stopping. We did, however, spend a night on the way at Sighisoara, where the house still stood where Vlad the Impaler – the prototype for Dracula – had been born. It was now a fast-food joint.

The operation on the woman was not an emergency in the sense that it did not need to be done at once, but it certainly had to be done within a matter of days. Such cases do not fit easily into the culture of targets which now defines how the National Health Service in England is supposed to function. She was not a routine case but nor was she an emergency.

My own wife Kate, a few years ago, had fallen into the same trap when awaiting major surgery after many weeks of intensive care at a famous hospital. She had been admitted as an emergency and underwent emergency surgery without any difficulty, but then needed further surgery after several weeks of intravenous feeding. I became accustomed to the sight of a large foil-wrapped bag of glutinous fluid hanging above her bed, dripping into her central line – a catheter inserted into the great veins leading to her heart. Kate was now no longer an emergency but nor was she a routine admission, so there was no provision for her to undergo surgery. For five days in a row she was prepared for surgery – very major surgery, with all manner of frightening potential complications – and each day by midday the operation was cancelled. Eventually, in despair, I rang her surgeon’s secretary. ‘Well, it’s not really up to Prof as to who goes on the routine operating lists,’ she explained apologetically. ‘It’s a manager – the List Broker. Here’s the number to ring…’

So I rang the number only to receive a message that the voice mailbox was full and I could not leave a message. At the end of the week the decision was made to make Kate into a routine case by sending her home with a large bottle of morphine. She was readmitted a week later, presumably now with the List Broker’s permission. The operation was a great success, but I mentioned the problem we had encountered to one of my neurosurgical colleagues at the same hospital when we met at a meeting shortly afterwards.

‘I find it very difficult being a medical relative,’ I said. ‘I don’t want people to think my wife should get better treatment just because I’m a surgeon myself, but it really was getting pretty unbearable. Having your operation cancelled is bad enough – but five days in a row!’

My colleague nodded. ‘And if we can’t look after our own, what about Joe Bloggs?’

So I had gone to work on Monday morning worried that there would be the usual shambles of trying to find a bed for the young girl into which she could go after surgery. If her condition was life-threatening I would be able to start the operation without having to seek the permission of the many hospital staff involved in trying to allocate an insufficient number of beds to too many patients, but her condition was not life-threatening – at least not yet – and I knew that I was going to have a difficult start to the day.

At the theatre reception area there was an animated group of doctors and nurses and managers looking at the day’s operating lists sellotaped to the top of the desk, discussing the impossibility of getting all the work done. I saw that several of the cases were routine spinal operations.

‘There are no ITU beds,’ the anaesthetist said with a grimace.

‘Well why not just send for the patient anyway?’ I asked. ‘A bed always turns up later.’ I always say this, and always get the same reply.

‘No,’ she said. ‘If there’s no ITU bed I will end up having to recover the patient in theatre after the op and it could take hours.’

‘I’ll try to go and sort it out after the morning meeting,’ I replied.

There was the usual collection of disasters and tragedies at the morning meeting.

‘We admitted this eighty-two-year-old man with known prostate cancer yesterday. He had gone first to his local hospital because he was going off his legs and was in retention of urine. They wouldn’t admit him and sent him home,’ Fay, the on-call registrar, told us as she put up a scan. This was met with sardonic laughter in the darkened room.

‘No, no, it’s true,’ Fay said. ‘They catheterized him and wrote in the notes that he was now much better. I have seen the notes.’

‘But he couldn’t fucking walk!’ somebody shouted.

‘Well, that didn’t seem to trouble them. At least they must have achieved their four-hour target by sending him home. He spent forty-eight hours at home and the family got the GP in, who sent him here.’

‘Must have been a very uncomplaining and long-suffering patient,’ I observed to my colleague sitting next to me.

‘Samih,’ I said to one of the other registrars, ‘what do you see on the scan?’ I had first met Samih some years earlier on one of my medical visits to Khartoum. I had been very impressed by him and did what I could to help him to come to England to continue his training. In the past it had been relatively easy to bring trainees over to my department from other countries, but the combination of European Union restrictions on doctors from outside Europe and increasing bureaucratic regulations in recent years has made it very difficult, even though the UK has fewer doctors per capita than any country in Europe other than Poland and Romania. Samih passed all the required examinations and hurdles with flying colours. He was a joy to work with, a large and very gentle man, utterly dedicated to our craft, who was loved by the patients and nurses. He was now to be my last registrar.

‘The scan shows metastatic posterior compression of the cord at T3. The rest of the scan looks OK.’

‘What’s to be done?’ I asked.

‘Well, it depends on how he is.’

‘Fay?’

‘He was sawn off when I saw him at ten o’clock last night.’

This is the brutal but accurate phrase to describe a patient who has a spinal cord so badly damaged that they have no feeling or movement of any kind below the level of the damage and when there is no possibility of recovery. T3 means the third thoracic vertebra, so the poor old man would have no movement of his legs or trunk muscles. He would even have difficulties just trying to sit upright.

‘If he’s sawn off he’s unlikely to get better,’ Samih said. ‘It’s too late to operate now. It would have been a simple operation,’ he added.

‘What’s this man’s future?’ I asked the room at large. Nobody replied so I answered the question myself.

‘It’s very unlikely he’ll be able to get home as he’ll need full twenty-four-hour nursing, with being turned every few hours to prevent bed sores. It takes several nurses to turn a patient, doesn’t it? So he will be stuck in some geriatric ward somewhere until he dies. If he’s lucky the cancer elsewhere in his body will carry him off soon, and he may make it into a hospice first, nicer than a geriatric ward, but the hospices won’t take people if their prognosis is that they might live for more than a few weeks. If he’s unlucky, he may hang on for months.’

I wondered if that was how the old man in the cottage had died, alone in some impersonal hospital ward. Would he have missed his home, the little cottage by the canal, even though it was in such a sorry state? My trainees are all much younger than I am; they still have the health and self-confidence of youth, which I too had at their age. As a junior doctor you are pretty detached from the reality that faces so many of the older patients. But now I am losing my detachment from patients as I prepare to retire. I will become a member of the underclass of patients – as I was before I became a doctor, no longer one of the elect.

The room remained silent for a while.

‘So what happened?’ I asked Fay.

‘He came in at ten in the evening and Mr C. planned to operate but the anaesthetists refused – they said there was no prospect of his getting better and they weren’t willing to do it at night.’

‘Well, there’s not much to be lost by operating – we can’t make him any worse,’ somebody said from the back of the room.

‘But is there any realistic prospect of making him better?’ I asked, but I went on to say: ‘Although, to be honest, if it was me I’d probably say go and operate… just in case… The thought of ending my days paraplegic on a geriatric ward is so awful… indeed, if the operation killed me, I wouldn’t complain.’

‘We decided to do nothing,’ Fay said. ‘We’re sending him back to his local hospital today – if there’s a bed there, that is.’

‘Well, I hope they take him back – we don’t want another Rosie Dent.’ Rosie had been an eighty-year-old woman earlier in the year with a cerebral haemorrhage whom I had been forced to admit by a physician at my own hospital – at least, so many complaints and threats were made if I didn’t admit her to an acute neurosurgical bed that I gave in – even though she did not need neurosurgical treatment. It proved impossible to get her home and she sat on the ward for seven months, before we eventually managed to persuade a nursing home to accept her. She was a charming, uncomplaining old lady and we all became quite fond of her, even though she was ‘blocking’ one of our precious acute neurosurgical beds.

‘I think it will be OK,’ Fay said. ‘It’s only our own hospital which refuses to take patients back from the neurosurgical wards.’

‘Any other admissions?’ I asked.

‘There’s Mr Williams,’ Tim said. ‘I was hoping to do him at the end of your list after the girl with a meningioma.’

‘What’s the story?’ I asked.

‘He’s had some epileptic fits. Been behaving a bit oddly of late. Used to be pretty high-functioning – engineer or something like that. Fay, could you put the scan up please?’

The scan flashed up on the wall in front of us. ‘What’s it show, Tiernan?’ I asked one of the most junior doctors, known as SHOs, short for senior house officer.

‘Something in the left frontal lobe.’

‘Can you be a bit more precise? Fay, put up the Flair sequence.’

Fay showed us some different scan images, sequences that are good for indicating tumours which are invading the brain rather than just displacing it.

‘It looks as though it’s infiltrating all of the left frontal lobe and most of the left hemisphere,’ Tiernan said.

‘Yes,’ I replied. ‘We can’t remove the tumour, it’s too extensive. Tiernan, what are the functions of the frontal lobes?’

Tiernan hesitated, finding it hard to reply.

‘Well, what happens if the frontal lobes are damaged?’ I asked.

‘You get personality change,’ he replied immediately.

‘What does that mean?’

‘They become disinhibited – get a bit knocked off…’, but he found it difficult to describe the effects in any more detail.

‘Well,’ I said, ‘the example of disinhibition loved by doctors is the man who pisses in the middle of the golfing green. But the frontal lobes are where all our social and moral behaviour is organized. You get a whole variety of altered social behaviours if the frontal lobes are damaged – almost invariably for the worse. Sudden outbursts of violence and irrational behaviour are among the commonest. People who were previously kind and considerate become coarse and selfish, even though their intellect can be perfectly well preserved. The person with frontal-lobe damage rarely has any insight into it – how can the “I” know that it is changed? It has nothing to compare itself with. How can I know if I am the same person today as I was yesterday? I can only assume that I am. Our selves are unique and can only know ourselves as we are now, in the immediate present. But it’s terrible for the families. They are the real victims. Tim, what do you hope to achieve?’

‘If we take some of it out, create some space, we’ll buy him a bit more time,’ Tim replied.

‘But will surgery get his personality change any better?’

‘Well, it might,’ Tim said. I was silent for a while.

‘I rather doubt it,’ I eventually commented. ‘But it’s your case. And I haven’t seen him. Did you discuss all this with him and his family?’

‘Yes.’

‘It’s nine o’clock,’ I said. ‘Let’s see what’s happening about beds and find out if we are allowed to start operating.’

An hour later, Tim and Samih started the operation on the Romanian woman. I spent most of the time sitting on a stool, my back propped up against the wall behind me, while Tim and Samih slowly removed the tumour. The lights in the theatre were dimmed as they were using the microscope, and I dozed, listening to the familiar sounds and muted drama of the theatre – the bleeping of the anaesthetic monitors, the sighing of the ventilator, Tim’s instructions to Samih and the scrub nurse Agnes and the hiss of the sucker which Tim was using to suck the tumour out of the woman’s head. ‘Toothed forceps… Adson’s… diathermy… Agnes, pattie please… Samih, can you suck here?… there’s a bit of a bleeder… ah! got it…’

I could also hear the quiet conversation between the two anaesthetists at the far end of the table, where they sat on stools next to the anaesthetic machine with its computer screen showing the girl’s vital functions, as they are called – the functioning of her heart and lungs. These appear as a series of pretty, bright-coloured lines and numerals in red and green and yellow. In the distance, from the prep area between the theatres, there would be occasional bursts of laughter and chatter from the nurses – all good friends of mine, with whom I had been working for many years – as they prepared the instruments for the next cases.

Will I miss this? I asked myself. This strange, unnatural place that has been my home for so many years, a place dedicated to cutting into living bodies and, in my case, the human brain – windowless, painfully clean, air-conditioned and brilliantly lit, with the operating table in the centre, beneath the two great discs of the operating lights, surrounded by machines? Or when the time comes in a few weeks, will I just walk away without any regrets at all?

A long time ago, I thought brain surgery was exquisite – that it represented the highest possible way of using both hand and brain, of combining art and science. I thought that brain surgeons – because they handle the brain, the miraculous basis of everything we think and feel – must be tremendously wise and understand the meaning of life. When I was younger I had simply accepted the fact that the physical matter of brains produces conscious thought and feeling. I thought the brain was something that could be explained and understood. As I have got older, I have instead come to realize that we have no idea whatsoever as to how physical matter gives rise to consciousness, thought and feeling. This simple fact has filled me with an increasing sense of wonder, but I have also become troubled by the knowledge that my brain is an ageing organ, just like the organs of the rest of my body. That my ‘I’ is ageing and that I have no way of knowing how it might have changed. I look at the liver spots on the wrinkled skin of my hands, the hands whose use has been the dominant theme of my life, and wonder what my brain would look like on a brain scan. I worry about developing the dementia from which my father died. On the brain scan that was done some years before his eventual death, his brain had looked like a Swiss cheese – with huge holes and empty spaces. I know that my excellent memory is no longer what it was. I often struggle to remember names.

My understanding of neuroscience means that I am deprived of the consolation of belief in any kind of life after death and of the restoration of what I have lost as my brain shrinks with age. I know that some neurosurgeons believe in a soul and afterlife, but this seems to me to be the same cognitive dissonance as the hope the dying have that they will yet live. Nevertheless, I have come to find a certain solace in the thought that my own nature, my I – this fragile, conscious self writing these words that seems to sail so uncertainly on the surface of an unfathomable, electrochemical sea into which it sinks every night when I sleep, the product of countless millions of years of evolution – is as great a mystery as the universe itself.

I have learnt that handling the brain tells you nothing about life – other than to be dismayed by its fragility. I will finish my career not exactly disillusioned but, in a way, disappointed. I have learnt much more about my own fallibility and the crudity of surgery (even though it is so often necessary), than about how the brain really works. But as I sat there, the back of my head resting against the cold, clean wall of the operating theatre, I wondered if these were just the tired thoughts of an old surgeon about to retire.

The woman’s tumour was growing off the meninges – the thin, leathery membrane that encases the brain and spinal cord – in the lower part of the skull known as the posterior cranial fossa. It was immediately next to one of the major venous sinuses. These are drainpipe-like structures that continuously drain huge volumes of deep-purple, deoxygenated blood – blood which would have been brilliant red when it first reached the brain, pumped up from the heart. Blood flashes through the brain in a matter of seconds, one quarter of all the blood from the heart, darkening as the brain takes the oxygen out of it. Thinking, perceiving and feeling, and the control of our bodies, most of it unconscious, are energy-intensive processes fuelled by oxygen. There was some risk that removing the tumour might tear the transverse venous sinus and cause catastrophic haemorrhage, so I scrubbed up and helped Tim with the last twenty minutes of the operation, carefully burning and peeling the tumour off the side of the sinus without puncturing it.

‘I think we can call that a complete removal,’ I said.

‘I don’t think I’m going to have time to do Mr Williams – the man with the frontal tumour,’ Tim said. ‘I’ve got a clinic starting at one. I’m terribly sorry. Could you possibly do him? And take out as much tumour as you can? Get him some extra time?’

‘I suppose I’ll have to,’ I replied, disliking having to operate on patients I had not spoken to in detail myself, and not at all sure as to whether surgery was really in the patient’s best interests.

So Tim went off to do his outpatient clinic and Samih finished the operation, filling the hole in the girl’s skull with quick-setting plastic cement and stitching together the layers of her scalp. An hour later, Mr Williams was wheeled into the anaesthetic room next to the operating theatre. He was in his forties, I think, with a thin moustache and a pale, rather vague expression. He must have been quite tall as his feet, clad in regulation white anti-embolism stockings with the bare toes coming out at the ends, stuck out over the edge of the trolley.

‘I’m Henry Marsh, the senior surgeon,’ I said, looking down at him.

‘Ah,’ he said.

‘I think Tim Jones has explained everything to you?’ I asked.

It was a long time before he replied. It looked as though he had to think very deeply before replying.

‘Yes.’

‘Is there anything you would like to ask me?’ I said.

He giggled and there was another long delay.

‘No,’ he eventually replied.

‘Well, let’s get on with it,’ I said to the anaesthetist and left the room.

Samih was waiting for me in the operating theatre, beside the wall-mounted computer screens where we can look at our patients’ brain scans. He already had Mr Williams’s scan on the screens.

‘What should we do?’ I asked him.

‘Well, Mr Marsh, it’s too extensive to remove. All we can do is a biopsy, just take a small part of the tumour for diagnosis.’

‘I agree, but what’s the risk with a biopsy?’

‘It can cause a haemorrhage, or infection.’

‘Anything else?’

Samih hesitated, but I did not wait for him to reply.

I told him how if the brain is swollen and you only take a little bit of tumour out, you can make the swelling worse. The patient can die after the operation from ‘coning’: the swollen brain squeezes itself out of the confined space of the skull, part of it becoming cone-shaped where it is forced out of the skull through the hole at its base called the foramen magnum (‘the big hole’ in Latin), where the brain is joined to the spinal cord. This process is invariably fatal if it is not caught in time.

‘We have to take enough tumour out to allow for any post-op swelling,’ I said to Samih. ‘Otherwise it’s like kicking a hornet’s nest. Anyway, Tim said he was going to remove as much of the tumour as possible as this might prolong his life a bit. What sort of incision do you want to make?’

We discussed the technicalities of how to open Mr Williams’s head while waiting for the anaesthetists to finish anaesthetizing him, and to attach the necessary lines and tubes and monitors to his unconscious body.

‘Get his head open,’ I told Samih, ‘and give me a shout when you’ve reached the brain. I’ll be in the red leather sofa room.’

The scan had shown that the left frontal lobe of Mr Williams’s brain was largely infiltrated by tumour, which appeared on the scan as a spreading white cloud in the grey of his brain. Tumours like this grow into the brain instead of displacing it, the tumour cells pushing into the brain’s soft substance, weaving their way between the nerve fibres of the white matter and the brain cells of the grey matter. The brain can often go on working for a while even though the tumour cells are boring into it like deathwatch beetles in a timber building, but eventually, just as the building must collapse, so must the brain.

I lay on the red leather sofa in the neurosurgeons’ sitting room, slightly anxious, as I always am when waiting to operate, longing to retire, to escape all the human misery that I have had to witness for so many years, and yet dreading my departure as well. I am starting all over again, I said to myself once more, but am running out of time. The phone rang and I was summoned back to the theatre.

Samih had made a neat left frontal craniotomy. Mr Williams’s forehead had been scalped off his skull and was reflected forward with clips and sterile rubber bands. His brain, looking normal but a little ‘full’, as neurosurgeons describe a swollen brain, bulged gently out of the opening Samih had sawn in his skull.

‘We can’t miss it, can we?’ I said to Samih. ‘The tumour’s so extensive. But the brain’s a bit full – we’ll have to take quite a lot out to tide him over the post-operative period. Where do you want to start?’

Samih pointed with his sucker to the centre of the exposed surface of brain.

‘Middle frontal gyrus?’ I asked. ‘Well, maybe, but let’s go and look at the scan.’ We walked the ten feet across the room to the computer screens.

‘Look, there’s the sphenoid wing,’ I said to Samih. ‘We should go in just a little above it, but you’ll have to go deeper into the brain than you think from the scan as his brain is bulging out a bit.’

We returned to the table and Samih burned a little line across Mr Williams’s brain with the diathermy forceps – a pair of forceps with electrical tips that we use for cauterizing bleeding tissue.

‘Let’s bring in the scope,’ I said, and once the nurses had positioned the microscope, Samih gently pushed downwards with sucker and diathermy.

‘It looks normal, Mr Marsh,’ Samih said, a little anxiously. Even though there are all manner of checks and cross-checks to make sure we have opened the correct side of the patient’s head, I always experience a moment of complete panic at times like this, and have to quickly reassure myself that we are indeed operating on the correct side – in this case the left side – of Mr Williams’s brain.

‘Well, the trouble with low-grade tumours is that they can look and feel like normal brain. Let me take over.’

So I started to cautiously prod and poke the poor man’s brain.

‘Yes, it looks and feels entirely normal,’ I said, feeling a little sick as I looked through the microscope at the smooth, unblemished white matter. ‘But we’ve got to be in tumour – there’s so much of it on the scan.’

‘Of course we are, Mr Marsh,’ Samih said respectfully. ‘Would Stealth or a frozen section have helped?’

These are techniques that would have reassured me that I was in the right place. Rationally I knew that I had to be in tumour – at least in brain infiltrated by tumour – but the man’s brain looked and felt so normal that I could not suppress the fear that some bizarre mistake had occurred. Perhaps the wrong name was on the brain scan, or it hadn’t been a tumour in the first place and the problem had got better on its own since the brain scan had been done. The thought of removing normal brain – however unlikely – was terrifying.

‘Well, you’re probably right, but it’s too late now and, having started, I can’t stop,’ I said to Samih. ‘I’ll have to remove a lot of normal-looking brain to stop him swelling and dying post-op.’

The brain becomes swollen with the least provocation, and Mr Williams’s brain was already ominously enlarging and starting to bulge out of his opened skull. At the end of a craniotomy – the medical name for opening a person’s head – the skull is closed with little metal screws and plates and the scalp stitched back together over it. The skull becomes once again a sealed box. If there is very severe post-operative swelling as a reaction to the surgery, the pressure inside the skull will become critically raised and the brain will, in effect, suffocate and the patient can die. Surgery, especially for tumours within the actual substance of the brain like Mr Williams’s, where you cannot remove all of the tumour, will inevitably cause swelling, and it is always important to remove enough tumour – to create space within the skull to allow for the swelling. The pressure in the patient’s head after the operation will then not become dangerously high. But you always worry that you might have removed too much tumour and that the patient will wake up damaged and worse than before the operation.

I can remember two cases – both young women – from the early years of my career where my inexperience made me too timid and I failed to remove enough tumour. They both died from post-operative brain swelling within twenty-four hours after surgery. I learnt to be braver with similar cases in future – in effect, to take greater risks when operating on such tumours, because the deaths of the two women had taught me that the risks of not removing sufficient tumour were even greater. And yet both the tumours were malignant and the patients had a grim future ahead of them, even if the operations were to have been successful. Looking back now after thirty years, having seen so many people die from malignant brain tumours since then, these two tragic cases do not seem quite as disastrous as they did at the time.

This is about as bad as it gets, I thought with disgust as I started to remove several cubic centimetres of Mr Williams’s brain, the sucker slurping obscenely. What’s the glory in this? This coarse and crude surgery. This evil tumour, changing this man’s very nature, destroying both himself and his family. It’s time to go.

As I watched my sucker down the microscope, controlled by my invisible hands, working on the poor man’s brain, teasing and pulling out the tumour, I told myself that I wouldn’t have panicked in the past. I would just have shrugged and got on with it. But now that my surgical career was coming to an end, I could feel the defensive psychological armour that I had worn for so many years starting to fall away, leaving me as naked as my patients. Bitter experience of similar cases to Mr Williams’s told me that the best outcome for this man would be if the operation killed him – but I felt unable to let that happen. I knew of surgeons in the distant past who would have done just that, but we live in a different world now. At moments like this I hate my work. The physical nature of our thought, the incomprehensible unity of mind and brain, is no longer an awe-inspiring miracle but instead a cruel and obscene joke. I think of my father slowly dying from dementia and his brain scan, and I look at the age-wrinkled skin of my hands, which I can see even through the rubber of my surgical gloves.

As I worked the sucker, Mr Williams’s brain started slowly to sink back into his skull.

‘That’s enough space now, Samih,’ I said. ‘Close please. I’ll go and find his wife.’

Later in the day I went up to the ITU to see the postoperative patients. The young Romanian woman was well, though she looked pale and a little shaken. The nurse at the end of her bed glanced up from the mobile computer where she was inputting data and told me that everything was as it should be. Mr Williams was three beds further down the row of ITU patients. He was sitting upright, awake, looking straight ahead.

I sat by his bedside and asked him how he felt. He turned to look at me and said nothing for a while. It was hard to know if his mind was blank or whether he was struggling to organize the thoughts in his disrupted, infiltrated brain. It was hard even to know what ‘he’ had now become. Once I would have waited only a short time for an answer. Many of my patients have lost – sometimes permanently, sometimes transiently – language or the ability to think and there is a limit to how long you can put up with waiting. But on this occasion, perhaps because I knew that this would probably never happen again and perhaps also as a silent apology to all the patients I must have hurried by in the past, I sat quietly for what felt like a long time.

‘Am I going to die?’ he suddenly asked.

‘No,’ I said, alarmed at the way he seemed to know what was going on after all. ‘And if you were I promise I would tell you. I always tell my patients the truth.’

He must have understood that because he laughed – an odd, inappropriate sort of laugh. No, you are not going to die just yet, I said to myself, it is going to be much worse than that. I sat beside him for a while longer but it seemed he had nothing further to say.

Samih was waiting for me as usual at 7.30 the next morning at the nurses’ desk. He was a junior doctor in the traditional mould and could not bear to think that he might not be in the hospital when I was there. When I was a junior it was inconceivable that I might leave the building before my consultant, but in the new world of shift-working doctors the master-and-apprentice form of medical training has largely disappeared.

‘She’s in the interview room,’ he said. We walked down the corridor and I sat down opposite Mrs Williams. I introduced myself.

‘I’m sorry we haven’t met before. Tim was going to do the operation but I ended up doing it. I’m afraid this is not going to be good news. What did Tim tell you?’

As a doctor you get used to patients and their families looking so very intently at you as you talk that sometimes it feels as though nails are being driven into you, but Mrs Williams smiled sadly.

‘That it was a tumour. That it couldn’t all be removed. My husband was pretty bright, you know,’ she added. ‘You’re not seeing him at his best.’

‘In retrospect, looking back, when do you think things started to go wrong?’ I asked gently.

‘Two years ago,’ she said immediately. ‘It’s a second marriage for both of us – we married seven years go. He was a lovely man, but two years ago he changed. He was no longer the man that I had married. He started playing strange, cruel tricks on me…’

I did not ask what these might have been.

‘It became so bad,’ she went on, ‘that we had more or less decided to go our separate ways. And then the fits started…’

‘Do you have children?’ I asked.

‘He has a daughter from his first marriage but we have no children from our marriage.’

‘I’m afraid I have to tell you that treatment won’t get him better,’ I said, very slowly. ‘We can’t undo the personality change. All we can do is possibly prolong his life and he may yet live for years anyway, but he will slowly get worse.’

She looked at me with an expression of utter despair – she could not have helped but hope that the operation would undo the horrors of the past, that her nightmare would come to an end.

‘I thought it was the marriage that had gone wrong,’ she said. ‘His family all blamed me.’

‘It was the tumour,’ I said.

‘I realize that now,’ she replied. ‘I don’t know what to think…’

We talked for a while longer. I explained that we would have to wait for the pathology report on what I had removed. I said it was just possible I might have to operate again if the analysis showed that I had missed the tumour. The only potential further treatment would be radiation and, as far as I could tell, this had no prospect of making him any better.

I left her in the little interview room with one of the nurses – most of my patients’ families prefer, I think, to cry after I have left the room, but perhaps that is wishful thinking on my part – perhaps they would prefer me to stay.

Samih and I walked back down the corridor.

‘Well,’ I said, ‘at least the marriage was coming to an end, so I suppose it’s a bit easier for her, but how can anybody know how to deal with something like this?’

I thought of the end of my first marriage fifteen years earlier and how cruel and stupid my wife and I had been to each other. Neither of us had had frontal brain tumours, though I wonder what deep and unconscious processes might have been driving our behaviour. I look back with horror at how little attention I paid to my three children during that time. The psychiatrist I was seeing at the time told me to become more of an observer, but I simply could not detach myself from the raging intensity of my feelings at being forced to leave my own home, so much of which I had built with my own hands. I feel that I have learnt a certain amount of wisdom and self-control as a result of that terrible time, but also wonder whether it might in part be simply because the emotional circuits in my brain are slowing down with age.

I went to see Mr Williams. The nurses had told me, when I had come onto the ward, that he had tried to abscond during the night, and they had had to keep the ward door locked. It was a fine morning and low sunlight streamed into the ward through the east-facing windows, over the slate roofs of south London. I found him standing in front of the windows in his pyjamas. I noticed that they were decorated with teddy bears. His arms were stretched out on either side as though to welcome the morning sun.

‘How are you?’ I said, looking at his slightly swollen forehead and the neatly curved incision behind it across his shaven head.

He said nothing in reply and gave me a vague, cryptic smile, slowly lowered his arms and shook my hand politely without saying a word.

The pathology report came back two days later and confirmed that all the specimen I had sent was infiltrated by a slow-growing tumour. It was going to take a long time to find any kind of long-term placement for Mr Williams and it seemed unlikely he could be managed at home, so I told my juniors to send him back to the local hospital to which he had first gone after the epileptic fits had started. The doctors and nurses there would have to find a solution to the problem. The tumour was certainly going to prove fatal, but it was impossible to know whether this would be a matter of months or longer. When I went round the ward early next morning I saw that there was a different patient in his bed and Mr Williams had gone.




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