ANATOMY OF ERROR
A surgeon remembers his mistakes.
BY JOSHUA ROTHMAN
For the schoolteacher, the changes had come slowly. First, his walking had grown unsteady; then his hearing had worsened. He had become stooped, and had begun walking with a cane, even though he was only in his late fifties. Now he sat with his wife and son in the consulting room of Henry Marsh, a London neurosurgeon, looking at a scan of his brain, which showed a tumor growing near the base of his skull. The question was whether it could, or should, be removed. Marsh, who had been practicing neurosurgery for only a few years, was unsure. The tumor was massive—he was startled by its size—and it was situated in the brain stem, a vital area. Left to itself, it would destroy the schoolteacher’s hearing, rob him of his ability to walk, and, eventually, kill him. But, Marsh explained, surgery could leave him paralyzed, or worse. The family faced a difficult choice, between the certainty of a slow, predictable decline and the possibility of an immediate cure—or catastrophe.
They decided to seek a second opinion from an older, eminent neurosurgeon. A few days later, the surgeon phoned Marsh. “It’s a young man’s operation,” he said. “I’ve told them you should do it.” Flattered, Marsh agreed to go ahead. The surgery began at nine in the morning and continued late into the night. Brain surgery is slow and dangerous, and removing a tumor can be like defusing a bomb. Often, surgeons look through a microscope and use long-handled, fine-tipped instruments to pull the tumor away from the brain before removing it with a sucker. A quarter of the body’s blood courses through the veins and arteries of the brain; if one of them is torn, bleeding and stroke can result. It’s also possible to remove important parts of the brain by accident, because brain tissue and tumor tissue look pretty much the same. Unlike the rest of the body, the brain and the spinal cord rarely heal. If a neurosurgeon makes a mistake, the damage is often permanent.
By midnight, Marsh and his team had removed almost all of the tumor. The atmosphere in the operating theatre was relaxed and celebratory; the surgical team paused for cigarette breaks and listened to Abba and Bach. “I should have stopped at that point, and left the last piece of tumor behind,” Marsh writes in his memoir, “Do No Harm” (Thomas Dunne). Instead, he ventured further—he wanted to be able to say that he had taken it all out. “As I started to remove the last part of the tumor,” Marsh writes, “I tore a small perforating branch off the basilar artery, a vessel the width of a thick pin. A narrow jet of bright red arterial blood started to pump upwards.” The basilar artery carries blood to the brain stem, which regulates the rest of the brain. Marsh quickly stopped the bleeding, but the oxygen deprivation was enough to irreparably damage the man’s brain stem, and he never regained consciousness.
Marsh, who is now sixty-five, is one of Britain’s foremost neurosurgeons. He is a senior consultant at St. George’s Hospital, in London, and he helped to pioneer a kind of surgery in which patients are kept awake, under local anesthesia, so that they can converse with their surgeons while they operate, allowing them to avoid damaging what neurosurgeons call “eloquent,” or useful, parts of the brain. Marsh has been the subject of two documentary films. Still, he writes, “As I approach the end of my career I feel an increasing obligation to bear witness to past mistakes I have made.” A few years ago, he prepared a lecture called “All My Worst Mistakes.” For months, he lay awake in the mornings, remembering the patients he had failed. “The more I thought about the past,” he recalls in his book, “the more mistakes rose to the surface, like poisonous methane stirred up from a stagnant pond.”
There’s a tradition of physicians writing about their errors. “When the Air Hits Your Brain,” a neurosurgical memoir by Frank Vertosick, Jr., begins with a scene in which a resident, while drilling a hole in a man’s skull, accidentally goes too far, plunging the drill bit into the brain. “Oh, shit!” he exclaims. (An older doctor reassures him: “It’s just the lateral hemisphere.”) Physician writers usually view such errors with a generous spirit. They point out that medicine is built on mistakes, because doctors, like the rest of us, learn by screwing up.
Marsh isn’t interested in the usefulness of error. He is the Knausgaard of neurosurgery: he writes about his errors because he wants to confess them, and because he’s interested in his inner life and how it’s been changed, over time, by the making of mistakes. As an epigraph to “Do No Harm,” he quotes the French doctor René Leriche: “Every surgeon carries within himself a small cemetery, where from time to time he goes to pray.” Marsh knows there’s something unprofessional about this inwardness—a surgeon’s emotions are supposed to be beside the point compared with his patients’ suffering—but he is drawn to “reckless honesty.” (When he delivered “All My Worst Mistakes” to an audience of neurosurgical colleagues, he writes, “it was met by a stunned silence and no questions were asked.”) “Do No Harm” is an act of atonement, an anatomy of error, and an attempt to answer, from the inside, a startling question: How can someone spend decades cutting into people’s brains and emerge whole?
Marsh became a neurosurgeon almost by accident. Midway through his undergraduate years, at Oxford, he fell in unrequited love and, inspired by the Jack Nicholson movie “Five Easy Pieces,” fled to Newcastle, in the rugged northeast of England, to nurse his broken heart. There, he wrote bad poetry, worked as a hospital porter, and saw his first surgery. “I found its controlled and altruistic violence deeply appealing,” he writes. After he finished his degree, in 1973, he entered the Royal Free Hospital School of Medicine. Students weren’t allowed into the neurosurgical theatres, but one day Marsh caught a glimpse through a round porthole in a closed door—“a naked woman, anaesthetized, her head completely shaven, sitting bolt upright on a special operating table.” The image stayed in his mind, and struck him as “a scene from a horror film.”
Marsh married, and qualified as a doctor. Not long afterward, his three-month-old son, William, developed a tumor in the center of his brain and successfully underwent surgery to remove it. Marsh feels now that he didn’t fully appreciate the risks: he writes that, much later, “I watched a child bleed to death in the very same operating theatre where my son had been treated, as my boss—the very surgeon who had saved my son’s life—now failed with a similar tumor.” Soon after his son’s surgery, while working in intensive care, Marsh observed an aneurysm operation. The surgeon had to make his way deep into the brain, exposing the small, deadly balloon of arterial blood so that, without rupturing it, he could seal it off using a miniature metal clip. It “was more like a blood sport than a calm and dispassionate technical exercise,” Marsh writes. It also “involved the brain, the mysterious substrate of all thought and feeling… . The operation was elegant, delicate, dangerous, and full of profound meaning. What could be finer, I thought, than to be a neurosurgeon?” Neurosurgery—strange, brutal, and miraculous—had seduced him, and he started the training as soon as he could.
Marsh is fascinated by the brain. He loves looking at it through his counterbalanced surgical microscope, which “leans out over the patient’s head like an inquisitive, thoughtful crane.” To Marsh, the view is beautiful. At the center of the brain, he writes, the internal cerebral veins are like “the great arches of a cathedral roof”; the Great Vein of Galen can be seen “dark blue and glittering in the light of the microscope.” It is “a very private view,” “clearer, sharper and more brilliant than the world outside,” and “made all the more intense and mysterious by my anxiety.”
That anxiety begins long before surgery, with the decision to operate in the first place, which could easily be wrong. (A brain scan is mute on the all-important question of how tightly a tumor will cling to the brain.) It continues through a series of meetings in which Marsh must try to explain that uncertainty without alarming his patients. (It’s tempting to be reassuring, he writes, but after failed operations he has “bitterly regretted having been too optimistic.”) Bicycling to the hospital, Marsh is oppressed by dread—“almost a feeling of doom”—and, before surgery, he is often seized by panic, which is swept away, at the last moment, by “fierce and happy concentration.”
Brain surgery itself, Marsh writes, is “something I hate doing.” Beforehand, patients are depersonalized—their heads are shaved, and they are covered in sterile drapes—although you can’t entirely depersonalize the brain. Often, there’s a question about how far to go: if an aneurysm clip is not quite perfectly positioned, should Marsh take the risk of repositioning it? To do so, he must struggle against the “urge to finish the operation and escape the fear of causing a catastrophic haemorrhage.” Eventually, he writes, “I decide at some unconscious place within myself, where all the ghosts have assembled to watch me.”
Neurosurgical disasters can be cruel. A patient can wake up and appear healthy only to die, a few days later, of a stroke or a hemorrhage that’s related, in “some unknowable way,” to the operation. And patients can live on despite severe brain damage—an outcome that’s a particular source of fear for Marsh. He tells a colleague, “Nobody, nobody other than a neurosurgeon, understands what it is like to have to drag yourself up to the ward and see, every day—sometimes for months on end—somebody one has destroyed and face the anxious and angry family at the bedside.” The schoolteacher lived on in just this way. Seven years after that failed surgery, Marsh was visiting a home for vegetative patients when he looked into a room and “saw his grey curled-up body in its bed.” Of the feelings such experiences produce in him, Marsh writes, “I will not describe the pain.”
In his decades of medical practice, Marsh has been a witness or a party to almost every kind of mistake. There are errors of commission (the hubristic removal of too much tumor) and of omission (the missed diagnosis). There are errors that go unreported (after a successful surgery, Marsh might decide not to tell a patient about a close call) and errors for which Marsh is held accountable. (He writes that, after one operation, “I told them to sue me. I told them I had made a terrible mistake.”) There are errors of delegation—as when Marsh allows a resident to perform a simple spinal surgery, and the patient is left with a paralyzed foot—and historical errors: at a mental hospital, Marsh encounters victims of lobotomy. One morning, Marsh operates after having a petty argument with another surgeon, and the operation paralyzes half the patient’s face. He writes, “Perhaps this was going to happen anyway—it is called a ‘recognized complication’ of that particular operation—but I know that I was not in the right state of mind to carry out such dangerous and delicate surgery, and when I saw the patient on the ward round in the days afterwards, and saw his paralyzed face, paralyzed and disfigured, I felt a deep sense of shame.”
In a 1976 essay, the philosopher Bernard Williams explored a concept that he called “moral luck.” Often, he observed, we are morally responsible for actions that contain an element of chance. Imagine two people who drink too much at the same party, and who both drive home drunk; suppose that one of them hits a pedestrian. The driver in the accident is morally responsible for this outcome, and yet only chance distinguishes him from the other driver. Much of moral life, Williams thought, contains a similar element of luck. We happen to find ourselves in situations that bring judgment upon us. Yet this doesn’t absolve us of responsibility for what we do. It underscores an unsettling fact about moral life—that the distribution of moral fault in the world depends, in many ways, on good and bad luck.
A soldier’s life is deeply shaped by such moral luck. So, it turns out, is a neurosurgeon’s. “As I become more and more experienced it seems that luck becomes ever more important,” Marsh writes. Even so, he will be blamed for what goes wrong and praised for what goes right—treated as a murderer in the morning, by one family, and as a savior in the afternoon, by another. People who are regularly exposed to moral luck often find it helpful to have some standard other than morality by which to judge themselves—a code, more or less. Marsh’s code has to do with his own emotions. If he can’t control how a surgery turns out, he will control how he feels. He tries not to let his feelings add to his patients’ fear and unhappiness; at the same time, he tries never to lie. He yearns, therefore, for feelings that are strong but realistic, fully voiced yet even-keeled. In one of the book’s most moving passages, he is called to the bedside of a favorite patient, David, a warm, accomplished, and intelligent man, whom he has known for twelve years. Marsh has fought David’s tumor in three surgeries, but now it has reached a deeper, fatal stratum of the brain. Marsh explains, with great sadness, that a fourth operation won’t do any good; David says that he’s suspected as much. Marsh holds David’s hand, is embraced by his wife, and says, “It’s been an honor to look after you.”
Given the circumstances, it’s an ideal meeting. And yet, afterward, Marsh’s emotions rebel. Leaving the hospital, he writes,
“I quickly became stuck in the rush-hour traffic, and furiously cursed the cars and their drivers as though it was their fault that this good and noble man should die and leave his wife a widow and his young children fatherless. I shouted and cried and stupidly hit the steering wheel with my fists. And I felt shame, not at my failure to save his life—his treatment had been as good as it could be—but at my loss of professional detachment and what felt like the vulgarity of my distress compared to his composure and his family’s suffering, to which I could only bear impotent witness.”
In writing “Do No Harm,” Marsh has seemingly violated his code: he expresses many of the feelings that he’s worked very hard to keep hidden. But codes, by their nature, exclude the complexities of inner and moral life, and Marsh wants to understand himself—and wants us to know him—in the light of those complexities.
Marsh writes like a novelist—he thinks in terms of scenes, patterns, and contrasts—and, reading “Do No Harm,” I thought of another Henry: Henry Perowne, the neurosurgeon protagonist of Ian McEwan’s novel “Saturday.” (In writing his book, McEwan shadowed a younger English neurosurgeon, Neil Kitchen.) The two Henrys could not be more different. Perowne, who is in his late forties, is confident and optimistic. In his surgeries, he says, he can “control outcomes”; he experiences “the pleasure of knowing precisely what he’s doing.” He admires the impersonality of scientific knowledge. He enjoys “the relief of the relatives when he comes down from the operating room like a god, an angel with the glad tidings—life, not death.” Most of his patients survive, and even, McEwan writes, “thrive.” Presumably, the same is true of Marsh’s patients. The difference is one of temperament. “It’s not the successes I remember,” Marsh writes, “but the failures.”
Years ago, when I read “Saturday,” I was in awe of Perowne. Now that I’ve read Marsh’s memoir, the character comes across as curiously unburdened by his work. (The novel imagines Perowne humbled, but by forces—time, evil, history—that lie outside the surgical theatre.) Perowne has, apparently, never done what Marsh did to the schoolteacher, whose story Marsh tells in a chapter called “Hubris.” That experience changed Marsh, professionally and spiritually. He no longer operates for so long at a stretch. He has become wary of his own optimism and talent, and suspicious of the exhilarations of surgery. (“I can no longer bear to listen to music while operating,” Marsh writes; Perowne listens to the Goldberg Variations.)
The Henry Marsh of “Do No Harm” is a character, too. In 2007, the documentarian Geoffrey Smith made a film about Marsh, titled “The English Surgeon.” It seems to star a slightly different man. In the film, Marsh is goofy; he’s very tall, and wears bold, perfectly round glasses. When he talks about medical equipment, he becomes boyish. At a frozen lake—the documentary takes place in Ukraine, where Marsh has been doing pro-bono brain surgery for decades—he slides across the ice with ease. If he’s nervous before an operation, his voice rises and he grabs his head. He smiles regularly. When he delivers bad news, his eyes fill with tears: “Life can be very cruel,” he says, “I’m sorry.” It’s obvious that he’s an emotional man—the sort who might leave school to nurse a broken heart. At one point, Marsh visits Katya, the mother of a young girl whose life he tried to save. Marsh describes the scene in “Do No Harm”: sitting at her dinner table, surrounded by her family, “I was so intensely moved to see Katya again that I could scarcely talk,” he writes. It’s remarkable that such a sensitive man has become a brain surgeon. There, too, age may play a role: “I became hardened in the way that doctors have to become hardened,” Marsh writes, but “now that I am reaching the end of my career this detachment has started to fade.”
In Kiev, Marsh works with a neurosurgeon named Igor Kurilets to perform state-of-the-art procedures with second-hand surgical equipment. In “Do No Harm,” Marsh writes about the terror of operating in a strange place, with substandard equipment, but he can’t quite bring himself to describe his work there accurately. (It’s heroic.) His self-portrait, in short, leaves something out. Marsh writes that, when speaking with patients, he struggles to find the balance between “hope and reality,” “optimism and realism,” “detachment and compassion.” He also struggles to find that balance in writing about himself.
Why should that be? The darkness of Marsh’s book isn’t a kind of false modesty; his self-abnegation isn’t disguised self-regard. Instead, his desire for atonement seems to darken his recollections—faced with the irrevocability of his patients’ suffering, he is unable to escape from its shadow. And the memoir’s final chapter suggests a further possibility. Marsh writes about a woman who comes to see him in his clinic. Twenty years earlier, she had a benign brain tumor removed; even as the operation saved her life, it severed one of her facial nerves. Surgeons call this kind of trade a “sacrifice.” In most people, the result of this sacrifice would be a numbness of the face, with which they come to terms. Only a few, Marsh writes, are, like the woman, “driven mad by the numbness.” The Latin name for this, he says, is “anaesthesia dolorosa—painful loss of feeling”; the final chapter is named for that condition. Marsh, I think, is afraid of anaesthesia dolorosa. He can’t bear the thought of going numb. He is determined to feel as much as he can.
PHOTOGRAPH BY TOM PILSTON / PANO
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