July 07

Inside the German Brain: An English Neurosurgeon Abroad

Simon Shaw

Once you get used to the smell of formaldehyde, operating on the heads of cadavers is one of the pleasures of being a surgeon. Cutting open any human head to appreciate and learn its anatomy is a unique opportunity for reflection on our humanity and, in sheer practical terms, altruistically-donated bodies are far more forgiving than living patients. However, this opportunity, especially for a Jewish surgeon, takes on a different cast when surrounded by the murmur of German voices and accompanied by the smell of burning flesh – which was exactly the situation I found myself in this spring.

The sequence of events leading me there started one damp autumn day in central London. I was practising a new technique in a “wet-lab” at the Royal College of Surgeons as a participant in a course on “endoscope-assisted keyhole micro-neurosurgery.” Medical theatre does stage its occasional drama, but in the surrounding profession surgical proselytising is not particularly dramatic, at least not east of the Atlantic. This prosaically-named course, though, made me stop and think. Little was new or unique, but a strongly-held philosophy, enthusiastically delivered by a German faculty, was surprisingly persuasive as they dictated a particular and consistent surgical approach to each pathology.

The aim of the technique is to keep surgical access – both the incision and the extent of the craniotomy (the fenestration made in the skull) – as small as possible, to help further minimise tissue disturbance. This is often easier said then done although practising on skulls of the deceased did make it appear pretty straightforward. Enough was different to my weekly practice that I was prompted to delve further. I was keen to see the theory in action and see how well it translated to live surgery. A spring visit to Mainz to see Professor Perneczky’s philosophy in action was sprung – a chance to see the technique up close and to delve into the German brain.

Mainz is an old German city that sits on the confluence of the Rhein and Main rivers not far from Frankfurt in the state of Rhineland-Palatinate. At the start of the last millennium it was, like many major European cities of the time, the site of crusader massacres of the Jewish community. Later it played its part in the Reformation as the home of Gutenberg and the birthplace of modern printing. Of more immediate note for the beer lover is its son Adolphus Busch who emigrated to America and co-founded both Budweiser and Michelob. These brews are, however, a world away from the plentiful local German lagers, which offer a more individual and characterful flavour than the uniformity of their mainstream American cousins.

Das Bier is one third of the German Holy Trinity of comestibles, the other two being Das Brot (bread) and Die Wurst (wurst). Related to the latter is the ubiquitous consumption of pig. More than just a practical acknowledgement of its versatility, the fatherland seems to harbour a true love of the pig. A loving adherence to the principles of “nose-to-tail” eating was sharply demonstrated during an evening visit to a Greco-German grill-house, a form of fusion-cooking of which neither I nor any of my non-German friends had been previously aware. Reading neither Greek nor German, I took a random stab at the menu which prompted the kitchen to send out a plate upon which a foundation of thinly cut sautéed potatoes strained to support an enormous mound of varied, grilled porcine delights. How the Greek had influenced the proceedings beyond some strategically placed Hellenic postcards was not clear – no pita or retsina here, just some fine, heavy German rye bread and local wheat beer to wash down a “light” supper.

Allied bombing destroyed most of the town centre but spared a portion of the old town. This remains a picturesque amble, a small enclave of the mediaeval within the clean lines of 20th century Deutsch rebuilding. In the architectural stakes, Arne Jacobsen and Otto Weitling’s Rathaus (town hall) – completed following Jacobsen’s death in the early seventies – stands out from a domineering position overlooking the river. Persuaded by local priest Klaus Mayer in 1973, Marc Chagall included Mainz as a sign of Judeo-Christian reconciliation in Germany with his stained glass contribution to the rebuilding of the Collegiate Church of Saint Stephan. Despite an appreciation of the artistic beauty, my increasing intolerance of religious iconography meant a rather fleeting visit here and a simplistic conclusion that the church is typically gothic, the windows very blue and that, for most, its contribution to the reconciliation process was probably negligible.

Priests deal with the divine soul, but for a rationalist the seat of the essential humanity is the central nervous system and brain. Neurosurgery – the art of healing that humanity – is a rationalist’s religion and my pilgrimage to Mainz was not to a church, but to a hospital.

The University Hospital of Mainz, my host institution, is a pleasant place to be – insofar as this is possible of any hospital – with an air of cleanliness and an abundance of natural light. An immensely hospitable, splendidly hierarchical neurosurgical team of multinational origin all spoke impeccable English and made welcome their linguistically-challenged visitor. My arrival at the daily team meeting wearing one of my favourite suits was greeted with gentle amusement by my grinning contact Gerrit. A very casual work clothes policy for the doctors sat unusually, to my English mind, with a rigid adherence to the wearing of a white coat. In London one has to look the part of a professional doctor and occasionally don a white coat. Apparently in Mainz, however, even jeans and a T-shirt of dubious taste are acceptable because the uniform white coat is worn over it at all times – no exceptions.

This mixture of formality and informality, their different approach to appearance and substance, and the unfailing hospitality and politeness juxtaposed with their infamous behaviour to perceived outsiders (Jews, Turks, blacks) are continual reminders that Germany is never quite how or what you expect. For example Germany – a progressive, health-aware country – continues to have a rather relaxed attitude to smoking, with an ongoing social acceptance of the habit that seems at least a generation out of date to an Englishman or American. Unlike the quiet, odourless mess of English common rooms, the common room beside the operating theatre in Mainz was a pungent combination of table-football, the smell of coffee, the dictation of operation notes, and the rich hang of cigarette smoke.

The high standard of German healthcare is internationally renowned. Compared to the UK there is a noticeably higher number of specialists: 2.3 for every 1000 people in contrast to 1.5 in the UK. However, it is a costly service – Germany’s healthcare system ranks as the third most expensive per capita in the world, behind those of the United States and Switzerland. As a consequence the country suffers a health budget shortfall of $10 billion a year. This has previously been funded by compulsory public and private insurance schemes, although this is due to be replaced in 2009 by a new centralized fund. Like Britain the national health budget situation in Germany is parlous, but unlike the National Health Service of the UK this had not prevented the unit in Mainz from investing in some readily visible high tech equipment. An embrace of new technologies – such as state-of-the-art image-guidance systems, microscopes or endoscopes - is central to the philosophy of minimal access surgery. All are used to help plan the surgical approach as precisely as possible with the “minimal” mindset applied. The end result is surgery through as small a hole as possible, which may not sound revolutionary, but this can mean minimal disturbance of the healthy brain and craniotomies measuring only a few centimetres in width: keyhole brain surgery.

If all goes well the retraction of the brain can be kept to a minimum, and hence brain injury restricted whilst the pathology is tackled. It does, however, also mean that the corridor of access into the head is extremely limited with little scope for error – one has to be very certain of one’s anatomical location and direction of travel and there is an obviously increased technical demand upon the surgeon. Marc Chagall might have welcomed the challenge, but painting his stained glass windows through a hole the size of his finger would fatally threaten the artistry. Unsurprisingly, the neurosurgical world is anxiously debating the costs and benefits of the whole approach. Yet this larger context does not detract from the pleasure of watching a skilled surgical hand at work – indeed it is vital to be able to weigh the benefits accurately. Complex and delicate (“fine”) dissections of normal tissue performed under the microscope which led to the exposure of either a tumour or aneurysm were made to look beautifully simple. I enjoyed firm demonstrations of the classical surgical qualities of economy of movement, delicacy of touch, and operative confidence. And yes, the theory does indeed translate from the dead head to the living brain.

Despite being a Jewish doctor in Germany I viewed this trip as a clinical attachment to a European country. The modern environment and unfailing welcome of my hosts made it easy not to hark back to the events of the Shoah. This having been said, there were a number of jolting sensations that involuntarily prompted my mind to run. The first was the Barbarossa Bakery conveniently placed in the wing’s entrance hall: a popular chain purveying fine bread, rolls, and splendid pastries. Unfortunately, whilst taking my daily bread, my first thought was not of the quality of the middle European delicacies, but of the horrendous consequences of Operation Barbarossa, the codename given to the attempted Nazi invasion of the Soviet Union in 1941. Given that the Holy Roman Emperor Frederick Barbarossa was a 12th century crusading zealot, it’s not the most community-friendly of company names to put in the foyer of a modern cosmopolitan hospital.

More heartening though was a reflection on our medical similarities. All was not the clichéd smooth running German machine, with issues akin to the spluttering British National Health Service dogging the daily business – an operation cancelled due to lack of an intensive care bed, a chronic lack of theatre nurses, and even stairwell graffiti in defiance of the unfailingly scrubbed floors. Long hours for both the surgical and paramedical staff are endured and the residents have the same concerns about training, jobs, and money as many of my colleagues at home.

The smell of burning brains, however disturbing, is not peculiar to Germany. Diathermy has been a “work-horse” instrument of surgery for many years (and incidentally has its origins in neurosurgery). It involves the passage of high frequency alternating current (AC) through body tissue resulting in an extreme localized heat that provides the ability to cut or coagulate body tissue. It does this very effectively. A consequence of the heat and cutting and coagulation is the production of smoke and a particular smell of burning body tissue. Although this is a weekly experience at work I have always found it somewhat disconcerting, but it seemed to bother my hosts no more and no less than my colleagues at home. There’s always a small price to pay for an effective technique and diathermy comes with a smell.

All places have their similarities and differences from what we are used to and what we expect. Despite its history modern Germany is no aberration. The most reassuring similarity came when a called-away resident meant the lack of an assistant for an ongoing case. I eagerly “scrubbed in” to assist. Soon I had a genuine German brain in front of me open and exposed, allowing close-up, direct examination. Pink and squishy just like the rest of us.

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