Wednesday, July 29, 2015

Do No Harm

Quick:  what do Michael Crichton, Saint Luke, Anton Chekhov, Copernicus, Ethan Canin, William Carlos Williams, Sir Arthur Conan Doyle, Carl Jung and Rabelais all have in common?  None of them are women?  Okay, throw in Tess Gerritsen, Alison Sinclair and Alice Weaver Flaherty.  They are doctors and writers.  What is it about the medical profession that along with the fragile art of healing comes the ability to tell a story?  Is it because the illness of the patient is steeped in narrative?  Is it that one cannot begin to heal what ails a patient until he or she understands that unique backstory?

To that list of physician-writers must be added British neurosurgeon Henry Marsh.  His recently published memoir, Do No Harm: Stories of Life, Death, and Brain Surgery (Thomas Dunne Books, 2015) is an insightful and poetic look inside the human mind.  It is, at the same time, technical but accessible, brilliant and beautiful.  We follow the surgeon’s microscope into the patient’s brain in the opening pages:  “I am looking directly into the centre of the brain,” he writes, “a secret and mysterious area where all the most vital functions that keep us conscious and alive are to be found.  Above me, like the great arches 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.  This is the anatomy that inspires awe in neurosurgeons.”  It inspires awe in readers as well.

The human brain, of course, has its own disturbing poetry.  Marsh tells us of the “angor animi—the anguish of the soul—the feeling that some people have, when they are having a heart attack, that they are about to die.”  The same feeling haunts those who face the surgeon’s scalpel as it slices through the brain.  Most of the pathologies that Marsh confronts are cancerous, and he names each chapter after a particular tumor type or affliction.  These are stories about life and the living hidden in the grey gelatinous structures of synapse and dopamine.  It is a brilliant ride, like venturing into space at light speed through the streaking light of the stars.

In many ways, Marsh critically examines his own arrogance.  He admits mistakes and blunders, patients he has ruined, left paralyzed, incapacitated, brain dead.  Still, here in the 21st century, surgery on the brain is an inexact science, which is the reason that Marsh operates on so many patients using only local anesthesia.  The brain itself does not feel pain.  Pain signals must resonate in the brain as they are felt in the body and therefore, all the nerve fibers spread throughout the body are connected back to the brain.  A physician may heal himself, but a brain cannot feel itself.  When the patient’s skull is opened while he or she is awake, Marsh and his surgical team can ask questions and elicit responses from him or her as different areas of the brain are touched and explored.  He will know immediately if something has gone wrong.  However, it is probably something most people would not want:  to be awake during brain surgery.

Throughout, Marsh does a lot of shouting at people.  He shouts in surgery to make himself heard over the controlled roar of the machinery.  He shouts at other people who annoy him, even once saying, as he is shouting, that he feels like a “pompous fool.”  He does not shout when he must deliver bad news, and this book is threaded through with these tragic scenes.  He does not shy away from describing the moments.  For instance:  “I left them in the little room, their knees squeezed together as the four of them sat on the small sofa and wondered, yet again, as I walked away down the dark hospital corridor, at the way we cling so tightly to life and how there would be so much less suffering if we did not.  Life without hope is hopelessly difficult but at the end hope can so easily make fools of us all.”

Perhaps what makes Marsh such a top surgeon in the United Kingdom is not just his skill in the surgical suite.  He has been touched by brain disease in his own family.  He must witness his son’s medical intervention and recovery.  The good doctor, himself, suffers a broken leg and nearly loses his eyesight.  So when he faces the loved ones of others, he must strike a delicate balance.  He has a duty to his patients from which he cannot shrink.  “Surgeons must always tell the truth but rarely, if ever, deprive patients of all hope.  It can be very difficult to find the balance between optimism and realism.”

In dealing with death and the end of consciousness every day, Marsh does not escape thoughts of his own end.  “Will I be so brave and dignified when my time comes?” he asks himself.  He walks out to his car in a lonely parking lot.  “The snow was still falling and I thought yet again of how I hate hospitals.”  He must remain detached and professional with his patients because if he does not, he risks being overwhelmed by the power of emotion and the tragedy of their plights.  His job is to bear witness, even if he is impotent to bring the patient back.  “I must hope that I live my life now in such a way that…I will be able to die without regret.”  He remembers his mother on her death bed saying, “It’s been a wonderful life.  We have said everything there is to say.”  We should all be so lucky.

Marsh believes that it is unlikely we have souls, or that we continue to exist after the brain is dead.  What we know as consciousness ends when the brain depletes its oxygen supply and is destroyed.  “Our sense of self, our feelings and our thoughts, our love for others, our hopes and ambitions, our hates and fears all die when our brains die.”  I do not want to believe this, nor do I want to agree with him, but the passage stopped me in my reading and I found myself staring off into the shadows of a hot summer night immersed in silence and lost in contemplation.  “There are one hundred billion nerve cells in our brains,” he goes on.  “Does each one have a fragment of consciousness within it?”  That is what makes this book so relatable and moving for the non-scientist:  Marsh asks the questions we want to ask.  In his musings and ruminations, he is not the superior surgeon with the highly trained surgical skill set.  He is just a human being questioning the mystery of existence.

This is a beautiful book, a life-affirming, human story of a man whose life intersects with so many others in the frailty of disease and the search for healing.  Henry Marsh is a philosopher at heart, the human embodiment of a deep and feeling intellect composed of those millions of nerve fibers.  In an age where doctors seem more worried about keeping drug companies happy and charging insurance companies for another round of tests rather than healing the patient, Marsh tries to live out the oath to do no harm.  But what we see in this book is that sometimes, despite the heroic efforts of the surgeon, the patient is harmed.  That is the cost of business in medicine, especially in neurosurgery.  Some patients cannot be made better.  In this book, we see the frustrations, the disappointments, the tragedies faced by this doctor, as well as the triumphs, the miracles, the resilience of the human body fighting to stay alive.  It is a rich and riveting story, one I could not stop reading and which left me thinking long after I finished the final chapter.

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