Patients see neurosurgeons as gods, but what is the reality? Henry Marsh has written a memoir of startling candour.
We go to doctors for help and healing; we don't expect them to make us worse. Most people know the aphorism taught to medical students, attributed to the ancient Greek Hippocrates but timeless in its quiet sanity: "First, do no harm." But many medical treatments do cause harm: learning how to navigate the risks of drug therapies, as well as the catastrophic consequences of botched or inadvised surgical operations, is a big part of why training doctors takes so long. Even the simplest of therapies carries the risk of making things worse. Drugs such as statins that lower cholesterol might reduce your risk of stroke or heart attack, but they also stiffen your muscles and inflame your liver. Drugs to thin your blood against clots run the risk of devastating haemorrhage. Operations to remove prostate cancer might leave you impotent and incontinent; removing a gall bladder can ruin your digestion. The most dangerous speciality is widely considered to be neurosurgery. When a surgeon meddles with your brain it's not just incontinence or bad digestion you risk but coma, paralysis and death.
Brain surgeons such as Henry Marsh, the author of this startling and moving memoir, have to live, breathe, operate and make urgent decisions in full awareness of a terrible dilemma: if they open the skull they might save the patient's life, but a slip of the scalpel can cause appalling disability, which, as Marsh puts it, can be much worse than death. I worked as a junior neurosurgical trainee once, at the bottom of what he calls "the strict medical hierarchy", and realised then that living with such responsibility is not just onerous, it utterly transforms the lives of those who bear it. It's understandable that it should be demanding: most of us, if we were to have our brains cut open, would prefer it be done by someone who prioritises their work over their personal life. As a trainee I realised that I had too many other interests to be a good neurosurgeon, and quit for emergency medicine – a tranquil backwater by comparison. Readers of this book, as well as the thousands of patients Marsh has treated over his career can be thankful that he did not.
He describes visiting a nursing home in the countryside outside London, run by Catholic nuns and dedicated to the long-term care of patients with catastrophic brain damage. Walking along the quiet, orderly corridors he recognised "at least five" of the names on the door plaques as those of former patients of his – the home is like a museum of his operative failures. Cut by cut, chapter by chapter, he takes the reader through many of these "failures", and the well appreciated risks he and his patients knew they were taking, as well as behind the closed doors of a successful malpractice suit made against him. Passing a young colleague in the intensive care unit, just after visiting a patient rendered comatose through surgery, he remarks: "Terrible job, neurosurgery. Don't do it." It's this disarming candour that makes the book such an enthralling read. Marsh is not interested in giving us a glossed image of the brain surgeon as superman; he wants to shows us the dreadful pressures under which he has lived throughout his professional life.
A friendly orthopaedic surgeon, called in to set Marsh's broken leg, pities him for his choice of career. "Neurosurgery," he says, "is all doom and gloom." But this is not a gloomy book, it is a testimony of wonder – the wonder Marsh has felt through being able to operate on the brain. Many of the chapters describe his triumphs, and, in intricate and fascinating detail, his daily work. As a junior surgeon the first procedure he witnessed was to clip an aneurysm – a pathological weakening of a brain artery that, if it ruptures, can cause paralysis or death. The operation seemed to him charged with meaning and set him off on his career. "What could be finer, I thought, than to be a neurosurgeon?" he writes. "The operation involved the brain, the mysterious substrate of all thought and feeling, of all that was important in human life – a mystery, it seemed to me, as great as the stars at night and the universe around us." The wonder doesn't leave him: decades later, separating two lobes at the back of the brain, he reveals the pineal gland, which Descartes believed to be the seat of the soul. It is "a secret and mysterious area where all the most vital functions that keep us conscious and alive are to be found. Above me, like the great arches of a cathedral roof, are the deep veins of the brain … this is anatomy that inspires awe in neurosurgeons."
But if this book is about wonder, it is also about entitlement. Exhilarated after performing a successful and protracted life-saving operation one day, he confesses how irritating it was to have to stand in the queue at the supermarket: "'What did you do today?' I felt like asking them, annoyed that an important neurosurgeon like myself should be kept waiting." This plea for special treatment would come across as insufferably self-important were it not balanced by Marsh's awareness of how pompous he can sound. We're also given to understand that by living so long under the seismic pressure of such responsibility, Marsh has earned himself some privileges.
It's the incremental stripping of those privileges that take up the final quarter of the book; his sense as he approaches retirement that he is expected to bow before the management newspeak, health and safety directives and "clinical governance protocols" that are overwhelming the modern NHS – initiatives that no one understands and that do nothing for patient care. He describes wards full of agency staff who don't know where his patients are, or hours spent trying to find brain scans lost by the latest computer system. Government meddling has made his clinical career into a game of musical chairs, he says. The coalition has taken this one step further: not content just to pull away resources, it keeps on changing the orchestra.
Marsh's style is admirably clear, concise and precise, as you'd expect from someone accustomed to writing operation and clinic notes in a hurry. It is unexpectedly honest on a range of controversial issues facing the modern health service, even as Marsh expresses his relief that he's about to retire from it. It touches on the way greed leads some surgeons to perform ill-advised operations in private practice, as well as the corrupting influence of Big Pharma (Marsh's charitable work in Ukraine has shown him how drug trials are often fixed by corrupt and desperate physicians). There is no forcing of a narrative arc or a happy ending, just the quotidian frustrations, sorrows, regrets and successes of neurosurgical life. "They call us heroes, and sometimes gods," Marsh writes of his patients. "Perhaps they never quite realised just how dangerous the operation had been and how lucky they were to have recovered so well. Whereas the surgeon, for a while, has known heaven, having come very close to hell."