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  ‘But he couldn’t fucking walk!’ somebody shouted.

  ‘Well, that didn’t seem to trouble them. At least they must have achieved their four-hour target by sending him home. He spent forty-eight hours at home and the family got the GP in, who sent him here.’

  ‘Must have been a very uncomplaining and long-suffering patient,’ I observed to my colleague sitting next to me.

  ‘Samih,’ I said to one of the other registrars, ‘what do you see on the scan?’ I had first met Samih some years earlier on one of my medical visits to Khartoum. I had been very impressed by him and did what I could to help him to come to England to continue his training. In the past it had been relatively easy to bring trainees over to my department from other countries, but the combination of European Union restrictions on doctors from outside Europe and increasing bureaucratic regulations in recent years has made it very difficult, even though the UK has fewer doctors per capita than any country in Europe other than Poland and Romania. Samih passed all the required examinations and hurdles with flying colours. He was a joy to work with, a large and very gentle man, utterly dedicated to our craft, who was loved by the patients and nurses. He was now to be my last registrar.

  ‘The scan shows metastatic posterior compression of the cord at T3. The rest of the scan looks OK.’

  ‘What’s to be done?’ I asked.

  ‘Well, it depends on how he is.’

  ‘Fay?’

  ‘He was sawn off when I saw him at ten o’clock last night.’

  This is the brutal but accurate phrase to describe a patient who has a spinal cord so badly damaged that they have no feeling or movement of any kind below the level of the damage and when there is no possibility of recovery. T3 means the third thoracic vertebra, so the poor old man would have no movement of his legs or trunk muscles. He would even have difficulties just trying to sit upright.

  ‘If he’s sawn off he’s unlikely to get better,’ Samih said. ‘It’s too late to operate now. It would have been a simple operation,’ he added.

  ‘What’s this man’s future?’ I asked the room at large. Nobody replied so I answered the question myself.

  ‘It’s very unlikely he’ll be able to get home as he’ll need full twenty-four-hour nursing, with being turned every few hours to prevent bed sores. It takes several nurses to turn a patient, doesn’t it? So he will be stuck in some geriatric ward somewhere until he dies. If he’s lucky the cancer elsewhere in his body will carry him off soon, and he may make it into a hospice first, nicer than a geriatric ward, but the hospices won’t take people if their prognosis is that they might live for more than a few weeks. If he’s unlucky, he may hang on for months.’

  I wondered if that was how the old man in the cottage had died, alone in some impersonal hospital ward. Would he have missed his home, the little cottage by the canal, even though it was in such a sorry state? My trainees are all much younger than I am; they still have the health and self-confidence of youth, which I too had at their age. As a junior doctor you are pretty detached from the reality that faces so many of the older patients. But now I am losing my detachment from patients as I prepare to retire. I will become a member of the underclass of patients – as I was before I became a doctor, no longer one of the elect.

  The room remained silent for a while.

  ‘So what happened?’ I asked Fay.

  ‘He came in at ten in the evening and Mr C. planned to operate but the anaesthetists refused – they said there was no prospect of his getting better and they weren’t willing to do it at night.’

  ‘Well, there’s not much to be lost by operating – we can’t make him any worse,’ somebody said from the back of the room.

  ‘But is there any realistic prospect of making him better?’ I asked, but I went on to say: ‘Although, to be honest, if it was me I’d probably say go and operate… just in case… The thought of ending my days paraplegic on a geriatric ward is so awful… indeed, if the operation killed me, I wouldn’t complain.’

  ‘We decided to do nothing,’ Fay said. ‘We’re sending him back to his local hospital today – if there’s a bed there, that is.’

  ‘Well, I hope they take him back – we don’t want another Rosie Dent.’ Rosie had been an eighty-year-old woman earlier in the year with a cerebral haemorrhage whom I had been forced to admit by a physician at my own hospital – at least, so many complaints and threats were made if I didn’t admit her to an acute neurosurgical bed that I gave in – even though she did not need neurosurgical treatment. It proved impossible to get her home and she sat on the ward for seven months, before we eventually managed to persuade a nursing home to accept her. She was a charming, uncomplaining old lady and we all became quite fond of her, even though she was ‘blocking’ one of our precious acute neurosurgical beds.

  ‘I think it will be OK,’ Fay said. ‘It’s only our own hospital which refuses to take patients back from the neurosurgical wards.’

  ‘Any other admissions?’ I asked.

  ‘There’s Mr Williams,’ Tim said. ‘I was hoping to do him at the end of your list after the girl with a meningioma.’

  ‘What’s the story?’ I asked.

  ‘He’s had some epileptic fits. Been behaving a bit oddly of late. Used to be pretty high-functioning – engineer or something like that. Fay, could you put the scan up please?’

  The scan flashed up on the wall in front of us. ‘What’s it show, Tiernan?’ I asked one of the most junior doctors, known as SHOs, short for senior house officer.

  ‘Something in the left frontal lobe.’

  ‘Can you be a bit more precise? Fay, put up the Flair sequence.’

  Fay showed us some different scan images, sequences that are good for indicating tumours which are invading the brain rather than just displacing it.

  ‘It looks as though it’s infiltrating all of the left frontal lobe and most of the left hemisphere,’ Tiernan said.

  ‘Yes,’ I replied. ‘We can’t remove the tumour, it’s too extensive. Tiernan, what are the functions of the frontal lobes?’

  Tiernan hesitated, finding it hard to reply.

  ‘Well, what happens if the frontal lobes are damaged?’ I asked.

  ‘You get personality change,’ he replied immediately.

  ‘What does that mean?’

  ‘They become disinhibited – get a bit knocked off…’, but he found it difficult to describe the effects in any more detail.

  ‘Well,’ I said, ‘the example of disinhibition loved by doctors is the man who pisses in the middle of the golfing green. But the frontal lobes are where all our social and moral behaviour is organized. You get a whole variety of altered social behaviours if the frontal lobes are damaged – almost invariably for the worse. Sudden outbursts of violence and irrational behaviour are among the commonest. People who were previously kind and considerate become coarse and selfish, even though their intellect can be perfectly well preserved. The person with frontal-lobe damage rarely has any insight into it – how can the “I” know that it is changed? It has nothing to compare itself with. How can I know if I am the same person today as I was yesterday? I can only assume that I am. Our selves are unique and can only know ourselves as we are now, in the immediate present. But it’s terrible for the families. They are the real victims. Tim, what do you hope to achieve?’

  ‘If we take some of it out, create some space, we’ll buy him a bit more time,’ Tim replied.

  ‘But will surgery get his personality change any better?’

  ‘Well, it might,’ Tim said. I was silent for a while.

  ‘I rather doubt it,’ I eventually commented. ‘But it’s your case. And I haven’t seen him. Did you discuss all this with him and his family?’

  ‘Yes.’

  ‘It’s nine o’clock,’ I said. ‘Let’s see what’s happening about beds and find out if we are allowed to start operating.’

  An hour later, Tim and Samih started the operation on the Romanian woman. I spent most of th
e time sitting on a stool, my back propped up against the wall behind me, while Tim and Samih slowly removed the tumour. The lights in the theatre were dimmed as they were using the microscope, and I dozed, listening to the familiar sounds and muted drama of the theatre – the bleeping of the anaesthetic monitors, the sighing of the ventilator, Tim’s instructions to Samih and the scrub nurse Agnes and the hiss of the sucker which Tim was using to suck the tumour out of the woman’s head. ‘Toothed forceps… Adson’s… diathermy… Agnes, pattie please… Samih, can you suck here?… there’s a bit of a bleeder… ah! got it…’

  I could also hear the quiet conversation between the two anaesthetists at the far end of the table, where they sat on stools next to the anaesthetic machine with its computer screen showing the girl’s vital functions, as they are called – the functioning of her heart and lungs. These appear as a series of pretty, bright-coloured lines and numerals in red and green and yellow. In the distance, from the prep area between the theatres, there would be occasional bursts of laughter and chatter from the nurses – all good friends of mine, with whom I had been working for many years – as they prepared the instruments for the next cases.

  Will I miss this? I asked myself. This strange, unnatural place that has been my home for so many years, a place dedicated to cutting into living bodies and, in my case, the human brain – windowless, painfully clean, air-conditioned and brilliantly lit, with the operating table in the centre, beneath the two great discs of the operating lights, surrounded by machines? Or when the time comes in a few weeks, will I just walk away without any regrets at all?

  A long time ago, I thought brain surgery was exquisite – that it represented the highest possible way of using both hand and brain, of combining art and science. I thought that brain surgeons – because they handle the brain, the miraculous basis of everything we think and feel – must be tremendously wise and understand the meaning of life. When I was younger I had simply accepted the fact that the physical matter of brains produces conscious thought and feeling. I thought the brain was something that could be explained and understood. As I have got older, I have instead come to realize that we have no idea whatsoever as to how physical matter gives rise to consciousness, thought and feeling. This simple fact has filled me with an increasing sense of wonder, but I have also become troubled by the knowledge that my brain is an ageing organ, just like the organs of the rest of my body. That my ‘I’ is ageing and that I have no way of knowing how it might have changed. I look at the liver spots on the wrinkled skin of my hands, the hands whose use has been the dominant theme of my life, and wonder what my brain would look like on a brain scan. I worry about developing the dementia from which my father died. On the brain scan that was done some years before his eventual death, his brain had looked like a Swiss cheese – with huge holes and empty spaces. I know that my excellent memory is no longer what it was. I often struggle to remember names.

  My understanding of neuroscience means that I am deprived of the consolation of belief in any kind of life after death and of the restoration of what I have lost as my brain shrinks with age. I know that some neurosurgeons believe in a soul and afterlife, but this seems to me to be the same cognitive dissonance as the hope the dying have that they will yet live. Nevertheless, I have come to find a certain solace in the thought that my own nature, my I – this fragile, conscious self writing these words that seems to sail so uncertainly on the surface of an unfathomable, electrochemical sea into which it sinks every night when I sleep, the product of countless millions of years of evolution – is as great a mystery as the universe itself.

  I have learnt that handling the brain tells you nothing about life – other than to be dismayed by its fragility. I will finish my career not exactly disillusioned but, in a way, disappointed. I have learnt much more about my own fallibility and the crudity of surgery (even though it is so often necessary), than about how the brain really works. But as I sat there, the back of my head resting against the cold, clean wall of the operating theatre, I wondered if these were just the tired thoughts of an old surgeon about to retire.

  The woman’s tumour was growing off the meninges – the thin, leathery membrane that encases the brain and spinal cord – in the lower part of the skull known as the posterior cranial fossa. It was immediately next to one of the major venous sinuses. These are drainpipe-like structures that continuously drain huge volumes of deep-purple, deoxygenated blood – blood which would have been brilliant red when it first reached the brain, pumped up from the heart. Blood flashes through the brain in a matter of seconds, one quarter of all the blood from the heart, darkening as the brain takes the oxygen out of it. Thinking, perceiving and feeling, and the control of our bodies, most of it unconscious, are energy-intensive processes fuelled by oxygen. There was some risk that removing the tumour might tear the transverse venous sinus and cause catastrophic haemorrhage, so I scrubbed up and helped Tim with the last twenty minutes of the operation, carefully burning and peeling the tumour off the side of the sinus without puncturing it.

  ‘I think we can call that a complete removal,’ I said.

  ‘I don’t think I’m going to have time to do Mr Williams – the man with the frontal tumour,’ Tim said. ‘I’ve got a clinic starting at one. I’m terribly sorry. Could you possibly do him? And take out as much tumour as you can? Get him some extra time?’

  ‘I suppose I’ll have to,’ I replied, disliking having to operate on patients I had not spoken to in detail myself, and not at all sure as to whether surgery was really in the patient’s best interests.

  So Tim went off to do his outpatient clinic and Samih finished the operation, filling the hole in the girl’s skull with quick-setting plastic cement and stitching together the layers of her scalp. An hour later, Mr Williams was wheeled into the anaesthetic room next to the operating theatre. He was in his forties, I think, with a thin moustache and a pale, rather vague expression. He must have been quite tall as his feet, clad in regulation white anti-embolism stockings with the bare toes coming out at the ends, stuck out over the edge of the trolley.

  ‘I’m Henry Marsh, the senior surgeon,’ I said, looking down at him.

  ‘Ah,’ he said.

  ‘I think Tim Jones has explained everything to you?’ I asked.

  It was a long time before he replied. It looked as though he had to think very deeply before replying.

  ‘Yes.’

  ‘Is there anything you would like to ask me?’ I said.

  He giggled and there was another long delay.

  ‘No,’ he eventually replied.

  ‘Well, let’s get on with it,’ I said to the anaesthetist and left the room.

  Samih was waiting for me in the operating theatre, beside the wall-mounted computer screens where we can look at our patients’ brain scans. He already had Mr Williams’s scan on the screens.

  ‘What should we do?’ I asked him.

  ‘Well, Mr Marsh, it’s too extensive to remove. All we can do is a biopsy, just take a small part of the tumour for diagnosis.’

  ‘I agree, but what’s the risk with a biopsy?’

  ‘It can cause a haemorrhage, or infection.’

  ‘Anything else?’

  Samih hesitated, but I did not wait for him to reply.

  I told him how if the brain is swollen and you only take a little bit of tumour out, you can make the swelling worse. The patient can die after the operation from ‘coning’: the swollen brain squeezes itself out of the confined space of the skull, part of it becoming cone-shaped where it is forced out of the skull through the hole at its base called the foramen magnum (‘the big hole’ in Latin), where the brain is joined to the spinal cord. This process is invariably fatal if it is not caught in time.

  ‘We have to take enough tumour out to allow for any post-op swelling,’ I said to Samih. ‘Otherwise it’s like kicking a hornet’s nest. Anyway, Tim said he was going to remove as much of the tumour as possible as this might prolong his life a bit. What sort
of incision do you want to make?’

  We discussed the technicalities of how to open Mr Williams’s head while waiting for the anaesthetists to finish anaesthetizing him, and to attach the necessary lines and tubes and monitors to his unconscious body.

  ‘Get his head open,’ I told Samih, ‘and give me a shout when you’ve reached the brain. I’ll be in the red leather sofa room.’

  The scan had shown that the left frontal lobe of Mr Williams’s brain was largely infiltrated by tumour, which appeared on the scan as a spreading white cloud in the grey of his brain. Tumours like this grow into the brain instead of displacing it, the tumour cells pushing into the brain’s soft substance, weaving their way between the nerve fibres of the white matter and the brain cells of the grey matter. The brain can often go on working for a while even though the tumour cells are boring into it like deathwatch beetles in a timber building, but eventually, just as the building must collapse, so must the brain.

  I lay on the red leather sofa in the neurosurgeons’ sitting room, slightly anxious, as I always am when waiting to operate, longing to retire, to escape all the human misery that I have had to witness for so many years, and yet dreading my departure as well. I am starting all over again, I said to myself once more, but am running out of time. The phone rang and I was summoned back to the theatre.

  Samih had made a neat left frontal craniotomy. Mr Williams’s forehead had been scalped off his skull and was reflected forward with clips and sterile rubber bands. His brain, looking normal but a little ‘full’, as neurosurgeons describe a swollen brain, bulged gently out of the opening Samih had sawn in his skull.

  ‘We can’t miss it, can we?’ I said to Samih. ‘The tumour’s so extensive. But the brain’s a bit full – we’ll have to take quite a lot out to tide him over the post-operative period. Where do you want to start?’

  Samih pointed with his sucker to the centre of the exposed surface of brain.

  ‘Middle frontal gyrus?’ I asked. ‘Well, maybe, but let’s go and look at the scan.’ We walked the ten feet across the room to the computer screens.