It seemed a bit of a joke at the time – that I should have my brain scanned. I should have known better. I have always advised patients and friends to avoid brain scans unless they have serious problems. You might not like what you see, I told them.
I volunteered to participate in a study of brain scans in healthy people. I was curious to see my own brain, if only in the grayscale pixels of an MRI scan. I had spent much of my life looking at brain scans or live brains during surgery, but the awe I felt as a medical student when I saw brain surgery for the first time faded pretty quickly once I started training as a neurosurgeon. Also, when you operate, you don’t want to be distracted by philosophical thoughts about the deep mystery of how the physical matter of our brains generates thoughts and feelings, and the mystery of how it is conscious and unconscious. Nor do you want to be distracted by thoughts of the family of the patient under your knife, waiting, desperate with anxiety, somewhere in the world outside the theater. You must separate yourself from these thoughts and feelings, even though they are never far away. All that matters is the surgery and the self-belief it requires. You live very intensely when you operate.
Perhaps I thought that seeing my own brain would confirm my fascination with neurology, which had led me to become a neurosurgeon in the first place, and that it would fill me with a sense of the sublime. But it was vanity. I had blithely assumed that the scan would show that I was one of the few elderly people whose brains showed no signs of aging. I see now that even though I had retired, I still thought like a doctor – that diseases only happen to patients, that I was still quite smart and had a good memory, with perfect balance and coordination. I ran lots of miles every week, lifted weights and did pushups. But when I finally looked at my brain scan, all that effort looked like King Canute trying to stem the rising tide.
I watched aging in action. My 70-year-old brain was shrunken and withered
As I looked at the images on my computer monitor, one by one, just as I looked at the scans of my patients, piece by piece, working up from the brainstem to the cerebral hemispheres, I was overcome with a sense of utter helplessness and despair. I thought of folk stories about people who had premonitions about attending their own funeral. I watched aging in action, in black and white MRI pixels, death and decay predicted and already partially achieved. My 70-year-old brain was shrunken and withered, a worn and sad version of what it must have once been. There were also eerie white spots in the white matter, signs of ischemic damage, small vessel disease, known in the trade as white matter hyperintensity – there are different names for these. They looked like some kind of bad pox. Not to elaborate, my brain is starting to rot. I’m starting to rot. That’s the writing on the wall, deadline.
I have always felt awe as well as awe when looking at the stars at night, although poor eyesight that comes with age makes them increasingly difficult to see now. Their cold and perfect light, their incomprehensible number and remoteness, the near eternity of their lives, in such contrast to the brevity of mine. Looking at the brain scan gave me the same feeling. The urge to avert my eyes was very strong. I forced myself to work through the scan images one by one and never looked at them again. It’s just too scary.
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There is extensive medical literature on changes in white matter on brain scans, the white matter being the billions of axons – electrical wires – that connect the gray matter, the actual nerve cells. By the time we reach 80, most of us will have these changes. Their presence is associated with an increased risk of stroke, although it is not clear whether they predict dementia or not. If we reach 80, we have a one in six risk of developing dementia, and the risk increases the longer we live. It is true that a so-called “healthy lifestyle” reduces the risk of dementia to some extent (some researchers suggest 30%), but no matter how carefully we live, we cannot escape the effects of aging. We can only slow them down if we’re lucky. A long life is not necessarily a good thing. Perhaps we should not look too desperately for it.
We accept that wrinkled skin comes with age, but we have a hard time accepting that our inner selves, our brains, are subject to such changes. These changes are called degenerative in radiological reports, although all this alarming adjective means is simply related to age. For most of us, as we age, our brains shrink steadily, and if we live long enough, they eventually resemble shriveled walnuts floating in a sea of cerebrospinal fluid trapped inside our skulls. And yet we usually still feel that we are our true selves, albeit diminished, slow and forgetful. The problem is that our true selves, our brains, have changed, and because we have changed with our brains, we have no way of knowing that we have changed. It’s the old philosophical problem—when I wake up in the morning, how can I be sure that I’m the same person today that I was yesterday? And for 10 years ago?
Hope is one of the most valuable medicines doctors have
I have always played down the extent of these age-related changes seen on brain scans when talking to my patients, just as I have never said that in some surgeries you have to remove part of the brain. We are all so susceptible to suggestion that doctors have to choose their words very carefully. It’s easy for doctors to forget how patients hang on every word, every nuance of what we say. You can unknowingly trigger all sorts of psychosomatic symptoms and anxieties. I usually told cheerful white lies. “Your brain looks very good for your age,” I would happily tell patients, no matter what the scans showed, as long as they only showed age-related changes and nothing more sinister. Patients left the room with a happy smile and feeling much better. The eminent American cardiologist Bernard Lown has written about how important it can be to lie to patients – or at least to be far more optimistic than the facts might warrant. He tells stories of his patients who were on the verge of death from heart failure but rallied and survived when he was too positive.
Hope is one of the most valuable medicines doctors have. Even if there is only a 5% chance of survival, a good doctor will emphasize that 5% hope without denying or hiding the 95% chance of death. It’s Pandora’s box – no matter how many horrors and diseases come out of the box, there is always hope. Only at the very end does hope finally flare up. Hope is not a matter of statistical probability or utility. Hope is a state of mind, and states of mind are physical states in our brains, and our brains are intimately connected to our bodies (and especially our hearts). Indeed, the idea of a disembodied brain promoted by the more extreme proponents of artificial intelligence may be nonsensical. This does not mean that being good and hopeful will cure cancer or allow us to live forever. The human mind always tries to reduce all events to a single cause, but most diseases are the product of many different influences, and the presence or absence of hope is only one of many.
I should have known that I might not like what my brain scan showed, just as I should have known that the prostatism symptoms that were increasingly bothering me were just as likely to be caused by cancer as by a benign enlargement of the prostate , which happens to most men as they age. But I continued to think that diseases happened to the patients, not to the doctors, even though I was already retired. Twenty months after my brain scan, I was diagnosed with advanced prostate cancer. I’ve had the typical symptoms for years that kept getting worse, but it took me a long time to bring myself to ask for help. I thought I was stoic, but in reality I was a coward. At first I just couldn’t believe the diagnosis, so deep was my denial.
I had planned to see a fellow doctor about my increasingly irritating prostate symptoms—poor flow, urgency, and frequency—but the blockage put that off. Also, the pandemic was such a strange and intense experience that I completely forgot about my symptoms and it was another seven months before I made an appointment. To save time, I decided to go private even though I no longer had private medical insurance.
After carefully washing my bottom, in anticipation of a rectal examination, I cycled into Harley Street, sipping a liter of mineral water as I went. I was told to do this so I could measure my urine flow upon arrival. I had to see a friendly nurse who made me drink many more glasses of water. From time to time she poked her head around the door. “Are you farting yet?” she’ll ask.
Henry Marsh, at home in Oxford. Photo: Sebastian Nevols/The Guardian
When I finally got there, I was directed to a urinal who took the necessary measurements and recorded my sad and agonizing attempt to empty my bladder, a problem I had been living with for many months, maybe even years. This being done, I was ushered up a great carpeted staircase to the office.
The room’s double oak doors were so tall and imposing that I hesitated to enter, finding it hard to believe they were just for a doctor’s office. But this was Harley Street, not the NHS. The room was huge and my…
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