Medic's eulogy to surgery operates as study of living
Memoir: Admissions, Henry Marsh, W&N, hdbk, 288 pages, €21.48
Henry Marsh knows a thing or two about getting inside people's heads. It was a skill he employed in a four-decade career as a neurosurgeon. Then, in his last years of practice, he found a different way of going about it, by writing Do No Harm: Stories of Life, Death and Brain Surgery, which became an international bestseller in 2014.
It must have been an exacting task to follow such a book, but Marsh has pulled it off with Admissions, his second memoir, which weaves reflections on his own impending mortality with further tales of surgical life. The ground it covers is, admittedly, similar to that of Do No Harm, but it's markedly more personal.
The book opens in 2015, as he is about to retire from St George's Hospital in London, torn between his longing to "escape all the human misery that I have had to witness for so many years" and his simultaneous dread of the "frightening void". Admissions then weaves elegantly in and out of operations - "26-year-old. Collapsed last night while in the shower. Looks like a spontaneous ICH…" - and evocative memories of Marsh's childhood.
Visceral recollections of brain surgery pour out of him, but much more unsettling are the depressingly byzantine workings of the UK's health service, details of which come to light at regular morning meetings in which Marsh and his colleagues are made to discuss cases while idly tossing around a sky-blue brain-shaped cushion.
Marsh here vents his contempt for targets, bureaucratic regulations and punitive budget cuts; lays out his worries about the growing problem of overtreatment and his strong feelings in favour of legalising euthanasia in terminal cases.
There are some shocking moments. Driven to distraction by hospital protocol, he loses his temper with a young male nurse: "I pushed my face in front of his, took his nose between my thumb and forefinger and tweaked it angrily..." But it is offset by humour - Marsh then goes off to wash his hands. "We are supposed to clean our hands after touching patients, so I suppose the same applies to assaulting members of staff."
He is articulate about balancing the risks of operating with doing nothing: it takes three years, he says, to learn how to do an operation, but 30 years to learn when not to do one. Telling a patient or his family that it is better to go off and wait for death is not easy, but operating often brings the risk of severely impaired quality of life. Marsh has an overwhelming dread of consigning his patients to Persistent Vegetative State, which he describes as "a great underworld of suffering away from which most of us turn our faces".
And there is another balance to be attained in neurosurgery. In cases where a tumour has deviously infiltrated the brain and looks exactly the same as healthy tissue, the challenge is to remove enough of the cancer but not so much that it destroys crucial neurological functions.
Marsh has helped to pioneer "awake craniotomies", where the patient is given only a local anaesthetic (for the scalp, as the brain itself does not feel pain) and can therefore react and help the surgeon gauge how far he can cut. It all sounds very crude, and Marsh himself is often struck by the contrast between the heavy-handedness of sawing open a skull and sucking out a tumour, and the delicate mysteries of the human brain.
If Do No Harm was an act of atonement, there is an element of that in Admissions, too. In both books, he constantly revisits what the French surgeon René Leriche called his "inner cemetery" - "filled with the headstones of all the patients who have come to harm at our hands". Despite his many successful operations, it is the ones that went wrong that Marsh returns to, and his shame is on display for all to see.
Now that his career is coming to an end, Marsh writes, "the psychological armour that I had worn for so many years is starting to fall away, leaving me as naked as my patients".
It is this nakedness that he explores so beautifully in the book. In Admissions, his list of regrets has become longer: not leaving his failed marriage earlier, not giving enough time to his children; the cruel way he trained his family's Labrador as a child.
But this is not a catalogue of confessions - it is also a eulogy to surgery, and a study of living. Marsh's anguish is inextricably intertwined with his energy and love of life, in the same way that a tumour can pervade a healthy brain.
I didn't want this book to end. Henry Marsh is part of a growing canon of superb modern medical writers whose storytelling and prose are transportative. Marsh writes about the "fierce joy" of operating and the "controlled and altruistic violence of surgery"; how attempted suicides are "often viewed by hospital staff with scorn and condescension - as failures in both living and dying".
Marsh is particularly lyrical in his description of his time in Kathmandu, his daily walk to work and the little garden surrounding the guesthouse he stayed in. He also describes his passion for carpentry. His sentences, too, feel like works of the finest craftsmanship, made with the same love that goes into both his woodwork and his surgery.
"A long time ago, I thought brain surgery was exquisite," he writes, "that it represented the highest possible way of using both hand and brain, of combining art and science."
Now it seems he has found another calling, and I very much hope this book won't be his last.