Our New Voices series highlights the most exciting emerging talents on granta.com. The latest in the series is Henry Marsh, a brain surgeon turned memoirist, whose piece here describes an operation on the deeply buried pineal gland. You can also read an interview with the author here.
I often have to cut into the brain and it is something I hate doing. With a pair of short-wave diathermy forceps I coagulate a few millimetres of the brain’s surface, turning the living, glittering pia arachnoid – the transparent membrane that covers the brain – along with its minute and elegant blood vessels, into an ugly scab. With a pair of microscopic scissors I then cut the blood vessels and dig downwards with a fine sucker. I look down the operating microscope, feeling my way through the soft white substance of the brain, trying to find the tumour. The idea that I am cutting and pushing through thought itself, that memories, dreams and reflections should have the consistency of soft white jelly, is simply too strange to understand and all I can see in front of me is matter. Nevertheless, I know that if I stray into the wrong area, into what neurosurgeons call eloquent brain, I will be faced with a damaged and disabled patient afterwards. The brain does not come with helpful labels saying ‘Cut here’ or ‘Don’t cut there’. Eloquent brain looks no different from any other area of the brain, so when I go round to the Recovery Ward after the operation to see what I have achieved, I am always anxious.
There are various ways in which the risk of doing damage can be reduced. There is a form of GPS for brain surgery called Computer Navigation where, instead of satellites orbiting the Earth, there are infrared cameras around the patient’s head which show the surgeon on a computer screen where his instruments are on the patient’s brain scan. You can operate with the patient awake under local anaesthetic: the eloquent areas of the brain can then be identified by stimulating the brain with an electrode and by giving the patient simple tasks to perform so that one can see if one is causing any damage as the operation proceeds. And then there is skill and experience and knowing when to stop. Quite often one must decide that it is better not to start in the first place and declare the tumour inoperable. Despite these methods, however, much still depends on luck, both good and bad. As I become more and more experienced, it seems that luck becomes ever more important.
I had a patient who had a tumour of the pineal gland. The dualist philosopher Descartes, who argued that mind and brain are entirely separate entities, placed the human soul in the pineal gland. It was here, he said, that the material brain in some magical and mysterious way communicated with the mind and with the immaterial soul. I wonder what he would have said if he could have seen my patients looking at their own brains on a video monitor, as some of them do when I operate under local anaesthetic.
Pineal tumours are very rare. They can be benign and they can be malignant. The benign ones do not necessarily need treatment. The malignant ones are treated with radiotherapy and chemotherapy but can prove fatal nevertheless. In the past they were considered to be inoperable but with modern microscopic neurosurgery this is no longer the case: it is usually now considered necessary to operate at least to obtain a biopsy – to remove a small part of the tumour for a precise diagnosis of the type so that you can then decide how best to treat it. The biopsy result will tell you whether to remove all of the tumour or whether to leave most of it in place, and whether the patient needs radiotherapy and chemotherapy. Since the pineal is buried deep in the middle of the brain the operation is, as surgeons say, a technical challenge; neurosurgeons look with awe and excitement at brain scans showing pineal tumours, like mountaineers looking up at a great peak that they hope to climb. To make matters worse, this particular patient – a very fit and athletic man in his thirties who had developed severe headaches as the tumour obstructed the normal circulation of cerebro-spinal fluid around his brain – had found it very hard to accept that he had a life-threatening illness and that his life was now out of his control. I had had many anxious conversations and phone calls with him over the days before the operation. I explained that the risks of the surgery, which included death or a major stroke, were ultimately less than the risks of not operating. He laboriously typed everything I said into his smartphone, as if taking down the long words – obstructive hydrocephalus, endoscopic ventriculostomy, pineocytoma, pineoblastoma – would somehow put him back in charge and save him. Anxiety is contagious – it is one of the reasons surgeons must distance themselves from their patients – and his anxiety, combined with my feeling of profound failure about an operation I had carried out a week earlier meant that I faced the prospect of operating upon him with dread. I had seen him the night before the operation. When I see my patients the night before surgery I try not to dwell on the risks of the operation ahead, which I will already have discussed in detail at an earlier meeting. His wife was sitting beside him, looking quite sick with fear.
‘This is a straightforward operation,’ I said, with false optimism.
‘But the tumour could be cancerous, couldn’t it?’ she asked.
‘Well, it’s possible,’ I replied. ‘That’s why we’ll get a biopsy – it’s called a frozen section – during the op. If the pathologist says it’s not cancerous I don’t have to try to get every last little bit of tumour out. And if it’s a tumour called a germinoma I don’t have to remove the tumour at all and he can be treated with radiotherapy.’
‘So if it’s not cancer, and not a germinoma, then the operation is safe,’ she said, her voice tailing off uncertainly.
I hesitated, not wanting to frighten her but reluctant to make false promises. ‘Yes – it makes it a lot less dangerous if I don’t try to take it all out,’ I said, choosing my words carefully.
We talked for a little longer and then I wished them goodnight and went home.
I woke early on the morning of the operation and lay in bed thinking about the young mother I had operated on the previous week. I had operated on a tumour deep in the right side of her brain and somehow – I do not know how since the operation had seemed to proceed uneventfully – I had caused a major stroke, so that she awoke from the operation paralysed down the left side of her body. I had probably tried to take too much of the tumour out. I had probably strayed too deeply into her brain. I must have been too self-confident. I had been insufficiently fearful. I longed for this next operation, the operation on the pineal tumour, to go well – that there should be a happy ending, that everybody would live happily ever after, and that I could feel at peace with myself once again. But I knew that however bitter my regret, and however well the pineal operation went, there was nothing that I could do to undo the damage I had done to the young woman. I also knew that any unhappiness on my part was nothing compared to what she and her family were going through. I knew too that there was no reason why the next operation should go well just because I hoped so desperately that it would, or because the previous operation had gone so badly. The outcome of the pineal operation – whether the tumour was malignant or not, whether I could remove the tumour or whether it was hopelessly stuck to the brain and everything went horribly wrong – was largely outside my control. I also knew, however, that as time went by the grief I felt at what I had done to the young woman would fade. The memory of her lying in her hospital bed, her mother sitting beside her with her daughter’s newborn baby on her lap, would become a scar rather than a painful wound. She would be added to the list of my disasters – another headstone in that cemetery which the French surgeon Leriche once said all surgeons carry within themselves.
As soon as an operation begins, however, the surgeon usually finds that any morbid fear disappears. You take up the scalpel – no longer from the scrub nurse’s hand but, in accordance with some Health and Safety protocol, from a metal dish – and full of surgical self-confidence, press it precisely into the patient’s flesh. As the blood rises from the wound the thrill and excitement of the chase take over and you feel, more or less, in control of what’s happening. At least that is how it seems as the operation starts, and you operate in the blind faith that that is how the operation will continue, although you know that it may not.
My assistant and I stood behind the patient, who was propped upright in the sitting position, as we opened the back of his head, splitting the neck muscles apart and then drilling through the bone of his skull.
‘Really cool. Exciting,’ my registrar said.
‘Well,’ I replied, unable to deny my own excitement. ‘It’s like mountaineering – although it’s mountaineering for cowards since it’s not our lives that are at risk.’
The man’s head opened, the muscles retracted, the meninges incised and reflected – surgery has it own ancient descriptive language – I had the operating microscope brought in and I settled down in the operating chair. With this particular operation you are looking along a narrow crevice that separates the upper part of the brain – the cerebral hemispheres – from the lower part of the brainstem and cerebellum. You feel as though you are crawling through a long tunnel. At about three inches’ depth – although it feels a hundred times longer because of the microscope’s magnification – you will find the tumour. You are looking directly into the centre of the brain, a secret and mysterious place where all the most vital functions that keep us alive and conscious are to be found. Above you, like the great vault of a cathedral roof, are the deep veins of the brain – the Internal Cerebral Veins, and beyond them the basal veins of Rosenthal and then in the midline the Great Vein of Galen, dark blue and glittering in the light of the microscope, names that inspire awe in neurosurgeons, veins that carry huge volumes of venous blood away from the brain, and vessels which, if damaged, will result in the patient’s death.
In front of you is the granular red tumour and beneath it the tectal plate of the brainstem, where damage can produce permanent coma.
On either side are the posterior cerebral arteries that supply the parts of the brain responsible for vision. In the distance ahead, beyond the tumour, a door opened into a distant white-walled corridor once the tumour has been removed, is the third ventricle.
There is a fine, surgical poetry to these names which, combined with the beautiful optics of a modern, counter-balanced microscope, makes this one of the most wonderful neurosurgical operations – if all goes well, that is. The disastrous operation of the preceding week, however, had destroyed much of my surgical self-confidence and I was as nervous as I had been when I had first become a surgeon. As I approached the tumour there were several blood vessels in the way that had to be cut – one needs to know which can be sacrificed and which cannot. It was as though I had lost all my knowledge and experience, and every time I divided a blood vessel I shook with fright. And yet as a neurosurgeon you learn at an early stage of your career to accept intense anxiety as a normal part of the day’s work and to carry on despite it – so eventually I reached the tumour. I removed a minute fragment of it which was then sent off to the pathology laboratory and I sat back in my operating chair.
‘We’ll now have to wait,’ I said to my assistant with a sigh. It is not easy to break off in the middle of an operation and I sat slumped in my chair, full of nervous excitement: longing to get on with the operation, hoping that my pathology colleague would report the tumour to be both benign and operable, hoping that the patient would live, hoping that I would be able to tell his wife after the operation that all would be well.
After forty-five minutes of waiting I couldn’t stand the delay any longer and, pushing my chair away from the operating table, leapt out of it and went to the nearest phone – still in my sterile gown and gloves. I rang the path lab and demanded to speak to the pathologist. There was a brief delay and then he came to the phone.
‘The frozen,’ I shouted. ‘What’s happening?’
‘Ah,’ he said imperturbably. ‘So sorry about the delay. I was in another part of the building.’
‘What the hell is it?’ I asked.
‘Yes. Well, I’m looking at it now. Ah! Yes, it looks like a straightforward benign pineocytoma . . . ’
‘Wonderful!’ I cried, forgiving him instantly. I went back to the operating table where everyone was patiently waiting.
‘Let’s get on with it!’ I said.
I scrubbed up again and climbed back into my operating chair, rested my elbows on the armrests and got back to work on the tumour. Each brain tumour is different – some are as hard as rock, some as soft as jelly. Some are completely dry, some pour with blood – sometimes to such an extent that the patient can bleed to death during the operation. Some shell out like peas from a pod, some are hopelessly stuck to the brain and its blood vessels. You can never know for certain from a brain scan exactly how a tumour will behave until you start to remove it. This man’s tumour was, as surgeons say, co-operative, and with a good surgical plane – in other words, it was not stuck to the brain. I slowly cored it out, collapsing the tumour in on itself away from the surrounding brain. After three hours it looked as though I had got most of it out.
Since pineal tumours are rare and exciting cases, one of my colleagues came into my theatre from his own operating theatre, to see how the operation was going. He was probably a little jealous. He peered over my shoulder.
The operation continued uneventfully and by the end it seemed that I had removed all, or almost all of the tumour without injuring any of the surrounding vital architecture of the brain. Since the tumour was a benign pineocytoma it probably would not matter even if post-operative scans showed I had left a small fragment of it behind. I left my assistant to close the wound and, leaving the operating theatres, walked the short distance to the wards.
I had only a few inpatients, one of them the young mother I had left paralysed one week earlier. I found her on her own in a side-room. Approaching a patient you have damaged makes the handle of the door behind which the patient is lying feel as though it is made of lead. There is a force-field pushing you away from the patient’s bed, resisting your attempts to raise a hesitant smile on your face. You are a villain and perpetrator, or at best incompetent, no longer heroic and all-powerful. It is difficult to know what role you now should play. It is much easier to hurry past the patient, looking busy and important, without saying anything at all.
I went into the room and sat down in the chair beside her.
‘How are you?’ I asked lamely.
‘Not too good,’ she replied, pointing with her good right arm to her paralysed left arm and then lifting it up to let it fall lifeless onto the bed.
‘I’ve seen this happen before,’ I said. ‘And the patients got better, although it took months. I really do believe you will get largely better.’
‘I trusted you before the operation,’ she said. ‘Why should I trust you now?’
I had no immediate reply to this and could only look uncomfortably at my feet.
‘But I believe you,’ she said after a while, although I think she spoke out of pity.
I went back to the theatres. The pineal patient had been transferred from the table to a bed and was already awake. He lay with his head on a pillow, looking blearily around himself while one of the nurses washed blood and bone dust left from the operation out of his hair. The anaesthetists and theatre staff were laughing and chatting as they busied themselves around him, rearranging the many tubes and cables attached to him, in preparation for wheeling him round to the ITU. If he had not woken up so well they would have been working in silence.
‘He’s fine,’ my assistant happily shouted to me across the room.
I went to find his wife. She was waiting in the corridor outside the ITU, her face rigid with fear and hope as she watched me approach her.
‘It went as well we could hope,’ I said, in a formal and matter-of-fact voice, playing the role of a detached and brilliant brain surgeon – but then I could not help but reach out to her, to put my hands on her shoulders, and as she put her hands on mine and we looked into each others’ eyes, and I saw her tears, and had to struggle for a moment to control my own, I allowed myself a brief moment of celebration.
‘I think everything’s going to be all right,’ I said.
Photograph © Alex E. Proimos