Henry Marsh (2017) Admissions: A Life in Brain Surgery.

Henry Marsh is a neurosurgeon. One of the 200 brain surgeons in Britain. I should use the past tense because he’s retired. He wrote a book about that too in 2023, And Finally. His fist book was the 2014 bestseller, Do No Harm. As well as being a master surgeon, he’s a competent DIY craftsman and a master wordsmith. This is the in-between book of his trilogy, I hadn’t read. Or at least thought I hadn’t. But when Marsh relates confessing to a patient that he’d operated on the wrong side of his brain (it happens) the patient took it better than I might, he said he was a kitchen fitter and had once fitted the units around the wrong way. I remembered that anecdote. Perhaps it was from another of his books. Do not resuscitate versus Do No Harm? Morbidity versus morality and mortality. As we get older they become much the same thing. Henry Marsh is a master dissector in whatever field he operates.

‘A good man knows his limits,’ said Dirty Harry (the film has the same name). ‘Now have I used one bullet or two?’ Psychopathic murderers, or politicians like the moron’s moron, Trump, know no such limits and have to be shown the right way.

Admissions is a play on words. A confessional tome in which Marsh writes about his humanity and insecurities about his life and work, two weeks before he retired. Admissions was also signage. Places were patients queued to be admitted to hospitals and still do, although the name has changed.  

Marsh quotes Sir William Ostler, ‘Medicine is the science of uncertainty, and an art of probability’.

The flip side of this Marsh quickly learned as a junior doctor was doctors need to lie to patients, (and to themselves?) They need to project the appearance of certainty and capability, when in fact, they are learning by doing, on the job. Old-fashioned, pre-NHS teaching hospitals, for example, was a great place for would-be specialists to practise on poor—and grateful—patients. Hence, Marsh is critical of any attempts to restrict the number of hours junior doctors work. He believed the quantity of hours immersed him in medical emergencies in the way that textbook learning never could. Science is a box of magical tricks to master by rote learning.  

It’s worth quoting again the dictum in Do No Harm, attributed to Rene Leriche (1951): ‘Every surgeon carries within himself a small cemetery, where from time to time he goes to pray… a place of bitterness and regret, where he must look for an explanation of his failures’.

Marsh names his failures, such as his first marriage and his overreaching himself and patients dying, bleeding out during surgery, for example, which happens very fast with around a quarter of our blood flow entering the brain. Instead of heroic competence he is the villain. These failures written on other’s bodies were not the worst. It was the others that survived but incapacitated to such a degree he wondered if the kindest conceit would have been to let them die. Marsh favours the option of euthanasia (as I do).

When he travels to Nepal and pre-war Ukraine to act as a consultant the weight of age and his own coming mortality asks questions of himself and his former beliefs. The thrill of the chase in opening up a person’s skull and curing gives him the chance to play the hero. In Dirty Harry, the movie separates the good and the bad. Everything in the beautiful architecture of the brain is related and relative. Marsh knows there are no simple answers. He admits there are more competent neurosurgeons than himself.

But in handing on his learning, he can’t let go. Adam Kay, In This is Going to Hurt, burnt-out and had to give up medicine after being unable to save a mother or her baby. He couldn’t bear to watch more junior doctors fumble and therefore learn.

Once a brain has been opened by power tools, Marsh looks into the architecture of the brain through binoculars. Rene Descartes (I think, therefore I am of millions of undergraduate philosophy essays) thought the soul resided in the pineal gland. A flick of Marsh’s finger and he causes a quarter-ton machine to move as if attached to his will. Microscopic scissors magnify and cut through grey tissue. As counter-balances, he illuminates his world, but with little margin for error, Marsh cannot let go. He cannot bear to watch those that need to sit in the chair he sits in make mistakes and learn. Marsh questions himself and knows his limits. Read on.