Surgeon Henry Marsh's passionate and often moving reflections on a life in medicine are not for the faint-hearted.
Brain surgery was an arcane and secretive specialism when Henry Marsh was a medical student in the Seventies. He caught his first glimpse of a brain surgeon in action through the porthole door of an operating theatre. A naked woman was strapped to a vertical table while a figure he describes as “immensely tall” stood behind her, painting her shaven head with iodine. Marsh remembers the horror-film-like air. Three years later, as a junior doctor, he chose to become a brain surgeon himself.
Do No Harm is an elegant series of meditations at the closing of a long career. Many of the stories are moving enough to raise tears: a good few would make a Dalek squeamish. There are the operations that work and, often, those that fail. In one episode, Marsh visits a Roman Catholic nursing home dedicated to caring for patients with catastrophic brain damage. “The doors were all open and through the doorways I could see the motionless forms of the patients in their beds,” he writes. “To my dismay I recognised at least five of the names.” These are patients that, in Marsh’s own word, he “wrecked” in operations that went wrong.
Brain surgery has advanced in many ways over Marsh’s career. It is rare that he treats aneurysms, because radiologists can feed tubes through veins and treat them from the inside without fear of their bursting. Most of his work is taken up with tumours, and new methods of mapping the brain help to distinguish living brain from the almost identical grey jelly of the tumours. Operations are carried out on conscious patients who perform simple tasks so the surgeon can see what is working and, hopefully, leave it alone. The brain cannot feel pain, Marsh explains, because it is the place where pain sensations are created.
Yet for all these advances, a surgeon requires many hours of practice in order to become competent, and the greatest advances are often the result of cavalier risk-taking. Marsh wonders whether some of the great brain surgeons might have been psychopaths, they appeared so untroubled by the operations that went wrong. One great surgeon removed tumours with an implement designed to open the skull, reducing operating times from several hours to 30 minutes: “Inevitably this would sometimes lead to disaster,” Marsh remarks.
At heart, this is a book about wisdom and experience. As a young man, Marsh took risks that he would not dare contemplate as an older man. Wisdom has taught him to under-treat tumours and even to contemplate the idea of a good death, albeit it with sorrow and equanimity. Yet he misses the risk-taker he once was. At times he may have been reckless, but taking risks in a mindful, considered way also brought him close to his patients. He was once a passionate, wilful and selfish surgeon. The fiery passions of youth have given way to the cares and regrets of old age, but Marsh has remained devoted to those he treats.
A part of his professional life was spent in Ukraine on work funded by a charity he established. His partner, a local surgeon named Igor, ran a chaotic hospital with no waiting lists. Igor was in a never-ending war with authority and refused the traditional “roof”, as the Russians say: the mentor/benefactor who offers a protégé political protection. Marsh admires and fears Igor, a risk-taker to his core.
Back in London, Marsh’s hospital is run by an army of indifferent managers, and the Government has cut working hours to the extent that junior surgeons have little experience in the operating theatre. Meanwhile, the financial wizards behind the PPI schemes that built the new hospitals suck money out of the health service. Marsh looks at the present with enough disillusion to half-welcome his retirement. Yet brain surgery remains his first love. He may be unable to pursue it with youthful zest but he hopes the NHS will allow him the freedom to be a “roof” to junior surgeons, taking some responsibility from their shoulders so that they will continue to dream and dare as he once did.