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Title: Do No Harm: Stories of Life, Death, and Brain Surgery
Author: Henry Marsh, CBE, FRCS
Publisher: Thomas Dunne Books
Publication date: May 26, 2015
Price: $25.99, hardcover; 288 pages
“I often have to cut into the brain and it is something I hate doing. With a pair of diathermy forceps I coagulate the beauty and intricate red blood vessels that lie on the brain’s shining surface.” So begins Do No Harm, a bracing and fascinating book by neurosurgeon Henry Marsh, CBE, FRCS.
The human brain possesses about 100 billion neurons with roughly 1 quadrillion synapses. If each neuron of a single human brain were laid end to end, they could be wrapped around the Earth twice over. Deciphering the biologic conundrum of this most complex of organs makes unraveling the genome, for example, look like child’s play. Within this mind-boggling complexity lurk our memories, hopes, fears, and aspirations. No wonder the author hates cutting into it.
As he makes clear on page 1, “Brain surgery is dangerous, and modern technology has only reduced the risk to a certain extent…. [I]f I stray into the wrong area, into what neurosurgeons call eloquent brain, I will be faced by a damaged and disabled patient when I go round to the Recovery Ward after the operation to see what I have achieved.”
Dr. Marsh studied medicine at the Royal Free Hospital in London and became a fellow of the Royal College of Surgeons. He has been the subject of two major documentary films on brain surgery. He is also a very capable writer who uses delicate personal and clinical brushstrokes to illustrate the drama of brain surgery. And for readers of The ASCO Post, several of his most compelling chapters are devoted to brain cancers.
Valuable Introspection
When he was younger, Dr. Marsh recalls, he used to feel an “intense exhilaration” after a successful operation—he felt, he writes, “like a conquering general,” having averted disaster and safely delivered his patient: “It was a deep and profound feeling which I suspect few people other than surgeons ever get to experience.” But while he’s made many patients very happy with successful operations, he says that there have also been “many terrible failures and most neurosurgeons’ lives are punctuated by periods of deep despair.”
This bit of introspection, which, in various ways, punctuates each chapter, is one aspect that makes this book a valuable read for doctors and those aspiring to the profession. No doubt, Dr. Marsh’s despair will ring true to those in the oncology community who experience a sense of failure when running out of treatment options for their patients. The oncology community will also relate to the fact that many of the most difficult moments the author recounts take place not in the operating room but in conversations before or after surgery—conversations in which Dr. Marsh tries to balance realism with patients’ need for hope and his own knowledge that “they are being stalked by death and I am trying to hide, or at least disguise, the dark figure that is slowly approaching them.”
Dr. Marsh gives a compelling account of a surgery gone wrong and how it affected his confidence as he moved to his next patient, a high-powered executive in denial who had a pineal tumor. The night before the operation, he met with the patient and his wife, “who was sitting beside him looking quite sick with fear.” In carefully chosen words, Dr. Marsh explained the operation’s risks of stroke and death, as well as the tumor’s chances of being benign or malignant, and what those two possible scenarios meant for the outcomes.
This well-written section, and others like it, bring the reader into the patient’s realm of apprehension and hope. They also describe the complicated calculus of risk involved in making decisions—weighing the possibility of saving patients from slow deterioration or constant pain against the danger of making them worse.
He writes, “Early the next morning I lay in bed thinking about the young woman I had operated on the previous week. She had had a tumour in her spinal cord … and although the procedure seemed to proceed uneventfully, she awoke from the operation paralysed down the right side of her body.” He realizes that he was probably too aggressive in his approach to get it “all out.” This is tough stuff, but he has another patient counting on him, so he needs to push past this patient and put on his scrubs.
Spellbinding Account
Dr. Marsh’s account of the pineocytoma operation is spellbinding, even for the most seasoned readers of medical literature. And for readers who are not surgeons, the “action” is blunt and dramatic.
He writes, “‘Knife,’ I said to Agnes, the scrub nurse.… I quickly cut down through the back of the man’s head. Mike [his assistant surgeon] used a sucker to clear the blood away and I then split the neck muscles apart so that we could start drilling through the bone of his skull.” He describes the tumor, noting, “Each brain tumour is different. Some are hard as a rock, some soft as jelly. Some completely dry, some pour with blood.”
In this particular operation, the tumor turns out to be benign, and the operation is a success. After giving the good news to the patient’s wife, Dr. Marsh returns to the theater, where “the nurses were tidying the instruments on the trolleys and stuffing the discarded drapes and cables and tubes into plastic rubbish bags. One of the porters was already mopping the blood off the floor in preparation for the next case.”
However much Dr. Marsh may talk about the detachment that doctors must learn, it’s clear from this book how much he cares for his patients. When he sees the tears in a patient’s eyes, he has to struggle for a moment to control his own.
In a subsequent chapter, Dr. Marsh describes a patient with glioblastoma. After he breaks the bad news to his patient, telling him it will be no use to operate again, he said, “It’s a bit inappropriate, but all I can say is good luck…. It’s been an honor to look after you.” He was unable to say goodbye, since he knew it was the last time he’d see a patient he’d grown fond of.
Added Value
This book is not all operating room drama, which adds to its value. Dr. Marsh gets into some excellent gripe sessions about health-care disparities in the United Kingdom, taking a few swipes across the pond at the U.S. system. And in a chapter called “Hubris,” the author engages in some riveting psychoanalysis of himself and the profession of neurosurgery. “Sometimes we go too far into the brain. We should know when to stop, but we’re a prideful bunch,” he writes.
Perhaps the strongest chapter is one called “Carcinoma.” Here, his elderly mother is dying of breast cancer, and Dr. Marsh’s description of her last days, replete with discussions of high-value palliative care, is excellent. He ends this fine book with his mother’s final words, “It’s been a wonderful life. We have said everything there is to say.” ■
