Capítulo 4
Perfect Tumors and Bureaucratic Nightmares
I arrived at work feeling cheerful, anticipating a solid cerebellar haemangioblastoma operation. These rare tumors, formed of blood vessels, are benign and curable through surgery, though fatal if untreated. They present the perfect neurosurgical challenge-technically demanding with potential for catastrophic hemorrhage if mishandled, but offering excellent chances of success.
My forty-year-old accountant patient had been suffering severe headaches for months. His noticeably red face (polycythaemia caused by the tumor stimulating overproduction of red blood cells) was a telltale sign. When I showed him his brain scan, he saw what looked like black snakes-"flow voids" from blood rushing through potentially dangerous vessels-a sight that excited me professionally while clearly disturbing him.
"I've never been seriously ill before," he said unhappily. "And now this."
I reassured him the tumor was almost certainly benign, explaining that without surgery he would die within months. Unlike with many brain tumors where I must guard against giving false hope, here I could offer genuine reassurance.
The reality of "informed consent" is far from its theoretical ideal. Patients are terrified and ignorant, often investing surgeons with superhuman abilities rather than questioning competence. My patient signed the complicated consent form without reading it, as virtually all patients do.
On operation day, we faced hours of waiting due to a new hospital computer system called iCLIP. Despite posters claiming minimal delays, the "iCLIP Floorwalker" support staff proved unhelpful, and my secretary Gail showed me the bizarre interface with nonsensical options like "Mortuary Discharge" and "Reverse Decease."
When we finally began, I positioned the patient in the "sitting position"-upright with head bent forward. Unlike most brain tumors where you gradually "debulk" the mass, with haemangioblastomas you must remove them whole to avoid catastrophic bleeding. Working under high magnification, I carefully separated the tumor from the brain by coagulating tiny blood vessels. Eventually, I freed the small tumor-no bigger than my thumb-and triumphantly lifted it out.
Post-operation, I visited my patient in Recovery. He was remarkably alert with his grateful wife beside him. "Well, we were lucky," I told them, though they likely interpreted this as false modesty. Later, I checked on him in the intensive care unit-the only conscious patient among ten connected to flashing machinery. Despite the chaotic environment, he was sitting upright, still red-faced but awake. I congratulated him on his survival, warning him about the noisy "war zone" where he wouldn't get much sleep.
Capítulo 5
When Miracles and Tragedies Collide
I was recently asked to speak to the script-writing team for TV medical drama Holby City. After discussing mostly grim aspects of neurosurgery, they asked for more positive stories. This reminded me of Melanie's case-a twenty-eight-year-old woman in her thirty-seventh week of pregnancy who was rapidly losing her vision due to a suprasellar meningioma pressing on her optic nerves.
When I first met her, her husband was guiding her down the corridor, one hand on her shoulder while carrying a suitcase, as she stretched her right arm forward to avoid obstacles and pressed her left hand protectively against her unborn child. Without surgery, she would go completely blind within days. I arranged for obstetricians to perform a Caesarean section immediately after removing the tumor, all under the same anesthetic.
The next morning, we performed the operation with an almost carnival-like atmosphere-excited obstetricians, pediatricians and nurses gathered outside the theater. After making an incision behind Melanie's hairline and creating a small opening in her skull, we gently lifted her right frontal lobe to access the tumor beneath. The optic nerve appeared horribly stretched over the granular red mass.
To my relief, the tumor was soft and removed easily without being stuck to the optic nerves. After an hour, we had a clear view of both optic nerves, the carotid arteries, and the pituitary stalk. We closed quickly so the obstetricians could perform the Caesarean section.
That same day, my second patient was a woman in her fifties with a malignant left temporal glioma. The operation went well enough, though we found the tumor spreading more widely than the scan had shown. After surgery, her left pupil suddenly dilated-a dire sign. A scan revealed a massive, fatal hemorrhage deep in her brain. I had to tell her husband and daughter the devastating news that she would die within 24 hours.
"I trusted you," her husband said through tears, "and I still do."
Meanwhile, Melanie had awakened with her vision restored, her husband deliriously happy: "You're a miracle worker, Mr. Marsh!" What a day of contrasts-one family's tragedy, another's joy. This is the reality of neurosurgery-moments of triumph and despair often separated by mere hours, sometimes even happening simultaneously in adjacent operating rooms.
Capítulo 6
Beyond Borders: Neurosurgery in the Post-Soviet World
I found myself operating on a woman with trigeminal neuralgia in Ukraine in 1995, horrified to discover blood obscuring her brain under dim lighting. The stakes were impossibly high-operating illegally, 2,000 miles from home, using second-hand equipment I'd brought myself, with a television crew filming and doctors watching from above through a cracked glass dome.
I first went to Kiev in winter 1992, shortly after the Soviet Union's collapse. The Emergency Hospital I visited was depressing-a ten-story building only a decade old yet already looking derelict, surrounded by broken buildings and gray wasteland. The electricity had failed, leaving much of the hospital in darkness. Everything reeked of ammonia-the only cleaning agent available.
In one dark theater, a surgeon was "operating" on a long-paralyzed man by injecting cold saline into his spine, bizarrely claiming the resulting reflex movements showed improvement. I met Igor Kurilets, who refreshingly admitted "Everything terrible here!" Unlike other doctors driven by shame or patriotism to deny reality, Igor acknowledged Ukrainian neurosurgery's dire state.
After working with me in London, Igor returned to Kiev and boldly declared Ukrainian neurosurgery backward, creating years of professional difficulties for himself. Despite the challenges, my work with Igor continued-bringing equipment, training doctors, and performing groundbreaking surgeries.
Working in impoverished healthcare systems like Ukraine and Sudan showed me that despite vast technological differences, many things remain universal: patients' vulnerability, their fear of death, and the need for honesty and kindness from doctors. The contrast with American hospitals, where they seem to take "death is optional" too literally, was striking.
What began as curiosity rather than altruism became a significant part of my career. The experience taught me about both the universality of human suffering and the privilege of working in a well-resourced healthcare system, despite its frustrations. It also revealed how easily medical practice can become corrupted when divorced from evidence and exposed to political pressure-a lesson relevant even in more developed healthcare systems.
Capítulo 7
The Making of a Neurosurgeon: Crisis and Calling
Until age twenty-one, I followed the privileged path laid out by my family and education-private schooling focused on classics, followed by Oxford to study Politics, Philosophy and Economics. With virtually no scientific background and no medical family history except a great-grandfather who'd been a Prussian village doctor, I seemed destined for academia or administration.
But unrequited love drove me to abandon Oxford and work as a hospital porter in a northern mining town. For six months I lived in a derelict fever hospital, watching surgeons operate while writing self-pitying poetry. This melodramatic exile was both self-punishment and rebellion against my father.
After six months, I returned to Oxford, completed my degree, and applied to medical schools. Despite lacking science qualifications, I was accepted at the Royal Free after a five-minute interview with a retiring administrator who advised me to see medicine as craft rather than art or science.
My medical education began with pre-clinical studies followed by three years in hospital. Anatomy involved dissecting embalmed cadavers in the formaldehyde-scented Long Room-an important initiation rite marking our transition from the lay world to the realm of disease and death. After qualifying in 1979, I proudly donned a long white coat with stethoscope and pager, working 120-hour weeks as a junior house officer.
Working in a dilapidated former workhouse hospital in south London, I learned medicine quickly but painfully. One night, I was called to see a breathless middle-aged man admitted for a possible heart attack. Finding his ECG seemingly normal, I dismissed his fears despite his insistence something was wrong. Walking away between rows of beds, I heard his breathing suddenly stop. We failed to resuscitate him. My registrar later pointed out the ventricular tachycardia I'd missed on the ECG.
This encounter with angor animi-the soul's anguish felt by dying patients-haunts me still, thirty years later. With responsibility came fear of failure, and patients became sources of anxiety rather than objects of simple altruism. I became hardened, seeing patients as separate from invulnerable doctors like myself. Only now, nearing career's end, has this detachment faded as I recognize my own mortality and vulnerability.
After deciding on neurosurgery, my path became clearer. I approached the neurosurgeon whose aneurysm operation had inspired me and sought advice from senior figures in the field. One senior neurosurgeon asked, "What does your wife think about it?" followed by a warning about the difficult lifestyle that had cost him his first marriage. Another, looking more like a jovial farmer than a brain surgeon, offered wisdom: "The operating is the easy part. By my age you realize that the difficulties are all to do with the decision-making."
Capítulo 8
Age, Ethics, and Impossible Choices
On a rainy February Monday, I cycled to work anticipating a frustrating day. The hospital was overflowing with a shortage of beds, meaning I'd likely have to postpone scheduled operations. After reviewing a 96-year-old patient with a subdural hematoma and discussing the ethical dilemma of operating on someone who feared nursing home placement more than death, we examined my next case: an 85-year-old woman with a massive meningioma pressing on her left brain.
I explained to my junior colleagues how surgical age limits had changed dramatically during my career-when I started, anyone over 70 was considered too old for neurosurgery, but now there seemed to be no upper age limit.
I first met Mrs. Seagrave, the articulate 85-year-old widow of an eminent doctor, in my outpatient clinic. She arrived with her three professional adult children, marching authoritatively into my office despite her condition. She lacked insight into her difficulties, insisting she was "perfectly all right" and primarily concerned that her children wouldn't let her drive-an injustice she attributed to sexism rather than her brain tumor.
The scan showed a grapefruit-sized mass compressing her brain. Her children explained she had become increasingly confused and forgetful, initially attributed to age until a geriatrician ordered the scan. I warned them that while the tumor might be causing her dementia-like symptoms, removing it carried significant risks-particularly a 20% chance the tumor might be stuck to the brain, potentially leaving her paralyzed on her right side and unable to communicate.
The evening before Mrs. Seagrave's scheduled operation, complications arose with unnecessary tests and MRSA concerns. On surgery day, I found myself in the cramped Day Room apologizing to patients whose operations were canceled while my registrar bluntly explained surgical risks to others within earshot.
My first case was a microvascular decompression for trigeminal neuralgia-a rare condition causing excruciating facial pain spasms like electric shocks or hot knives, driving some sufferers to suicide. Though usually straightforward, this case became complicated when an abnormally large vein tore, causing torrential bleeding. "It's not cool to lose your cool over venous hemorrhage," I told Mike as I struggled to control it. After twenty minutes, the patient had lost a quarter of his blood volume before I finally stopped the bleeding.
More frustrations followed with bureaucratic obstacles. The anesthetist refused my request to start preparing the next patient, citing a new rule from the ODA manager that cases couldn't overlap. When I finally returned to the Day Room for Mrs. Seagrave, I discovered she hadn't changed into her gown because "the government" apparently forbids patients of different sexes sitting together in theater gowns.
Despite my worries, Mrs. Seagrave's operation went remarkably well. After forty minutes exposing her brain, the tumor took just ten minutes to remove, "peeling gently off the brain as it shrank" without complications. By 5 p.m., she was in Intensive Care, alert and grateful. The man with trigeminal neuralgia was equally pleased, touching his previously painful cheek in awe: "It's gone... That's wonderful."
Capítulo 9
When the Doctor Becomes the Patient
Illness is something that happens only to patients-an important lesson medical students learn early. When first exposed to the terrifying world of illness and death, students often imagine they have various diseases until they develop necessary detachment. This detachment grows as junior doctors perform increasingly invasive procedures. Patients become objects of both sympathy and fear, as the responsibility brings anxiety about making mistakes.
When doctors fall ill themselves, they often dismiss initial symptoms and struggle to become mere patients. I ignored the flashing light in my left eye that appeared after a summer holiday. When it progressed to a shower of flashing lights and my eye filled with a swirling black cloud while driving, I finally investigated. The internet revealed I had a vitreous detachment, which could progress to retinal detachment.
Being a doctor, I called an ophthalmic colleague who saw me on a Sunday and confirmed the beginnings of a detached retina. I arranged to see a specialist vitreo-retinal surgeon at a private London hospital. Despite my concerns, I performed surgery the next morning, ironically on the visual area of a patient's brain under local anesthetic. Only after finishing did my own anxiety return.
After my eye surgery, I spent the evening watching fascinating morphine-enhanced light shows in my bandaged eye, like flying over a pitch-black desert with distant fires burning. The next morning, the surgeon removed my bandage. I could only see a dark blur until he had me bend forward and look at my watch, which appeared hugely magnified. For weeks afterward, I was effectively blind in that eye, with the gas bubble inside gradually shrinking like a planet's horizon.
The weekend after a subsequent lens replacement procedure, I broke my leg falling down a staircase I had built myself. At A&E in my own hospital, I was treated just like any other patient despite being "the senior consultant neurosurgeon." Throughout these ordeals, I felt profound gratitude to my colleagues and recognized how fortunate I was compared to my patients.
My personal experience with illness taught me valuable lessons about the suffering of patients' families. Years earlier, when my infant son William was diagnosed with acute hydrocephalus, I entered "that strange world one enters when you fear for your child's life." After a brain scan revealed a tumor, we endured agonizing delays in treatment. William's operation was successful, the tumor proving to be a benign choroid plexus papilloma. Years later, when training as a pediatric brain surgeon, I witnessed a child bleed to death in the same operating theater where my son had been saved. These experiences led me to tell my trainees, with a laugh that masks the seriousness: "Doctors can't suffer enough."
Capítulo 10
The Privilege and Pain of Neurosurgery
This book isn't meant as a confession but an honest account of neurosurgery-as much about failure as success. My readiness to admit fallibility may be characteristically English, but these challenges are familiar to doctors and patients everywhere.
In neurosurgery, mistakes can have catastrophic consequences, yet surgeons often find it difficult to admit errors. As I approach the end of my career, I feel obligated to share my worst mistakes so trainees might learn from them. Despite regular "Morbidity and Mortality" meetings where mistakes should be discussed, these are typically tame affairs with doctors reluctant to criticize each other publicly.
The transition from trainee to consultant brings a sudden weight of responsibility that makes training seem carefree in retrospect. I learned this painfully when treating a kind Italian man with acromegaly-a condition causing facial changes from excess growth hormone due to a pituitary tumor. The operation through his nostril went well, and he initially recovered perfectly. But days later, he suffered a major stroke in his left hemisphere, leaving him aphasic-utterly without language. He unexpectedly deteriorated further and died. His family showed extraordinary kindness, saying they didn't blame me. As I left, his wife asked me to remember her husband in my prayers.
By 1987 when I became a consultant, I was already experienced, having performed most operations for the senior surgeon I was replacing. Yet experience doesn't prevent all disasters. I once prepared for a challenging operation, bringing fruit and chocolates for the theater staff and enough CDs to last through what would be a long procedure. The first few hours went perfectly as we removed more and more of the tumor. By midnight, after fifteen hours of operating, most of it was out with cranial nerves intact. I felt I was joining the ranks of the really big neurosurgeons.
I should have stopped then and left the last piece of tumor, but I wanted to remove it all completely. As I tried to remove the final part, I tore a small perforating branch off the basilar artery. A jet of bright red arterial blood pumped upwards-a catastrophe. Though the blood loss was trivial, the damage to the brainstem was terrible. The patient never woke up.
For years afterward, I deemed similar tumors inoperable. The experience taught me crucial lessons: never do an operation that more experienced surgeons avoid, be skeptical of keynote lectures at conferences where post-operative scans never show residual tumor, and sometimes knowing when to stop is more important than technical skill.
Despite these painful lessons, neurosurgery remains a profound privilege. Working with the brain-that mysterious organ that houses consciousness itself-offers moments of wonder alongside the anxiety and responsibility. As I tell my patients when they thank me for successful operations: "We were lucky." And increasingly, as I near retirement, I understand that luck, skill, judgment, and humility are inseparable companions in this most demanding of surgical specialties.
