Admissions. A life in brain surgery
Author : Henry Marsh
Edition : First
Publisher : Weidenfeld and Nicolson
Year : 2017
Number of pages : 271
As you might expect, Marsh is a local surname given to families in England, living near a marsh, swamp or a bog. It is derived from the Latin word mariscus and the Middle English word mersche. Families with this name are found in Buckinghamshire, Kent, Lincolnshire, Sussex and Shropshire since the 14th century.
The first and second quotations at the start of the book indicate a current preoccupation of the author.
'Neither the sun nor death can be looked at steadily.’ - La Rochefoucauld
'We should always, as near as we can, be booted and spurred, and ready to go…’ – Michel de Montaigne.
The first paragraph in the preface emphasizes this concern. ‘I like to joke that my most precious possession, which I prize above all my tools and books and the pictures and antiques that I inherited from my family, is my suicide kit, which I keep hidden at home.’ Retirement from an active professional life may have contributed to thoughts turning to death.
As in his earlier book Do no harm, Dr. Marsh voices his thoughts, apprehensions and feelings openly and without beating around the bush. His candour is disarming. As with so many of us, he has pondered upon his future where he has contemplated being afflicted with an incurable illness or dementia. A degrading end would be greatly distressing to him. He discusses a good death and all that the term ‘euthanasia’ encompasses. He wishes to choose the time and mode of his own death under such circumstances. He allows that ‘life, by its very nature, is reluctant to end.’ Believing, as he does, that there is no afterlife and that when the ‘electrochemical dance’ in his brain cells ceases, he will die, he would prefer doing so in his own bed, with his family besides him. He does not want the attentions of ‘terminal-care professionals, who derive their own sense of meaning and purpose from my suffering. The only meaning of death is how I live my life now and what I will have to look back upon as I lie dying.'
Much of the book is a welcome prelude to these thoughts. He takes us back and forth through memorable events – pleasant and otherwise.
Among the latter is the event which led to his resignation from the National Health Service (NHS) that he served faithfully from the time he became a doctor and a neurosurgeon. The NHS now puts greater emphasis on its dress policy and the completion of poorly designed paperwork than on the welfare of patients. His descriptions of the manner in which the National Health Service is being run and the fact that bureaucrats dictate when and where patients should be admitted, operated upon and sent home, regardless of the opinions of their medical consultants, would have greatly saddened Mr. Aneurin Bevan (a Welsh Labour Party politician and the Minister for Health in the post-world war II (from 1945-51) United Kingdom's (UK's) ministry of the Prime minister Attlee, who was responsible for the establishment of the National Health Service (NHS) in the UK).
On page 6, we learn about the exasperation faced by his wife, Kate, a social anthropologist, as she awaited surgery in a NHS hospital. She was being provided her nutrition through a catheter placed in a large vein in her neck. For five days in a row, she was prepared for major surgery and each day, at midday, the operation was cancelled. When Dr. Marsh, a senior consultant at the NHS, talked to the surgeon's secretary, he was told that the decision was made not by the surgeon but by the hospital manager, termed the List Broker. Eventually, she was sent home on morphine and readmitted a week later for surgery! Other similar examples follow.
The instance where he was overcome with rage and tweaked the nose of the male nurse who refused to obey his order for the removal of an unnecessary and distressing nasogastric tube in a patient will evoke nothing but sympathy from all experienced surgeons.
Dr. Marsh was also dismayed at the eventual fate of Atkinson Morley's hospital, surrounded by trees and gardens in Wimbledon, where he had trained and worked in the early part of his career. The gracious, old-worldly building has been demolished and replaced by a block of ‘rich-trash apartments’. The neurosurgery centre housed in it has been attached to St. George's Hospital.
'Both decisions, separated by forty-three years – to abandon my first degree and to resign from my hospital – had been provoked by women.’ He describes these two occasions in the chapter entitled London.
At the start of this chapter, we learn of his decision to abandon his studies in politics, philosophy and economics at Oxford University. He was frustrated by an ‘absurd love’ for a much older woman who seduced him. Leaving Oxford, to the dismay of his father, he worked as a hospital porter in Newcastle. ‘It was my experience as a theatre porter, watching surgeons operate, that led me to become a surgeon.’ The experience with the self-important woman with the pink handbag, who was medical director of his hospital, which prompted him to send in his resignation from the NHS, makes interesting reading.
As he emptied his office after sending in his resignation, he found some books and an ophthalmoscope that had belonged to Sir Wylie McKissock, who had founded the neurosurgery department in Wimbledon, seventy years earlier. They had been handed down to him by his teacher, himself a student of Dr. McKissock.
Always good at working with his hands, he excelled in neurosurgery and many incidents regarding the recovery of patients are the testimonials of his skills. In this book, we also learn of his expertise in repairing and building a home, making furniture, creating a garden with beehives, and homes for owls.
His initial training was in pediatric neurosurgery, and for many years, he treated all the pediatric patients in Wimbledon. This choice may have followed the operation at Great Ormond Street Hospital on his own son by Dr. Norman Grant for a brain tumour.
His thoughts on that wondrous organ – the brain – and its diseases are well expressed. Describing a patient with a large, infiltrating tumour in the dominant left frontal lobe with relatively well preserved function, he writes: ‘…the tumour cells pushing into the brain's soft substance, weaving their way between the nerve fibres of the white matter… (allowing) the brain to go on working for a while even though the tumour cells are boring into it like deathwatch beetles in a timber building, but eventually, just as the building must collapse, so must the brain.'
Chapter 5 describes his contributions to the procedure of awake craniotomy. He describes how he could say to patients treated thus, ‘You are now one of the few people in the history of the human race who have seen their own brain (on the operation theatre monitor).’ ‘I have even had the left visual cortex … looking at itself.'
In this chapter, you will also learn a little on neurosurgery on pets. Cavalier King Charles spaniels often suffer from Chiari malformation More Details. Labradors can develop malignant meningiomas. His veterinary surgical colleague, Clare Rusbridge, and he also operated on a badger with hydrocephalus.
Senior surgeons will recognize his description of the waning of the confidence of youth and middle age and the anxiety that accompanies each operation as we age. Cumulative experiences with patients where the later stages of an apparently straightforward operation resulted in disaster, or when patients took a sudden turn for the worse after an apparently uneventful immediate postoperative period, play a contributory role.
Another factor could be the danger of being sued. Dr. Marsh describes how he had to cut short his visit to Nepal and return to London to appear in a court. ‘A neurosurgeon – justly famous for the very high opinion he had of himself, although less famous for his medico-legal pronouncements – was of the opinion that I had acted negligently.’ His experience with this legal hearing is of considerable interest and is found in the chapter entitled Lawyers. Dr. Marsh has been sued four times.
He has almost succeeded in keeping most of his family out of this narrative. We get glimpses of some striking developments. ‘I thought of the end of my first marriage fifteen years ago and how cruel and stupid my wife and I had been to each other…’ He was forced to leave his own home, much of which he had built with his own hands. Elsewhere, we learn that ‘a passionate – but one-sided adulterous love affair’ three years earlier may have sparked off the crisis. He does not shy away from telling us about ‘… the women with whom I had fallen in love – seven in total – over the course of my life.’ The trauma of some of these experiences necessitated psychiatric therapy. We also learn that his father, Norman, had been an Oxford don and that his mother, Christel, was a German refugee. Her brother had flown for the Luftwaffe. His elder sister is an eminent architectural historian.
The chapter entitled Memory starts off with his father's death at the age of 96, profoundly demented. ‘He was an empty shell… His obituary in the London Times filled an entire page and I was filled in turn with both filial pride and guilt…’ The reticence regarding other members of the family disappears here and we learn about his parents and about himself. His parents were closely involved in the formation of Amnesty International. His mother's last days are also briefly described.
His earlier volume dealt with neurosurgery with Igor Igor Kurilets, working in the State Emergency Hospital, in Ukraine, in considerable detail. Here, he describes his work in Nepal with his friend Dr. Upendra Devkota (called Dev), though there is a chapter entitled Ukraine. Dev and Dr. Marsh had worked together in England over thirty years earlier. Dr. Marsh's descriptions of life and work in Nepal start in chapter 3 and then continue off and on throughout the rest of the book. The difficulties encountered in practicing neurosurgery in Nepal are well described. Dr. Marsh describes Dev as ‘charismatic, a man of great integrity and very determined.’ The difficulties in practicing neurosurgery by Dev are well brought out in the book. Here is one example: ‘If I tell the family now that no treatment is possible, they'll go and see someone else who'll tell them the opposite and then they'll kick up a big fuss. So I am forced to operate…’ In Nepal, as in India, doctors work under the threat of assault by dissatisfied families of patients. Before talking to the angry husband of a patient, Dev ensured that his security guards were in place. Dr. Marsh provides us comparisons between the conditions under which Dev in Nepal and Igor in Ukraine live and work.
As with his experiences in Nepal, his account of the lock-keeper's cottage, a short distance from his old family home in Oxford, are narrated at intervals and make fascinating reading.
Dr. Marsh used a foldable bicycle to get to-and-fro his hospital in London. This fact led to an amusing misconception whilst I researched his life and work for writing this review.
Looking out for details on his work for which he became world famous, I chanced upon an essay in The Economist entitled Cranium cracker in its issue dated 3 February 2005. Turning to this essay in eager anticipation, I learned that it featured not Dr. Marsh but the history of the bicycle he used. Frenchman Jacques Ozanam proposed it as a ‘self-moving vehicle’ in 1696. Half a century was to pass before pedals were added to this machine. Till then ‘You sat astride it, you pushed yourself off, and you wore out the shoe leather.’ The term that misled me arose from the fact that whilst rolling along on the early machines at great speed, you were liable to land head first.'
Some of Dr. Marsh's statements are aphoristic:
'The first rule of microscopic surgery, I tell my trainees, is to be comfortable.'
'We were lucky,’ I said. ‘No, no,’ said Samih (his registrar), obeying the first rule for all surgical trainees, flattering me, ‘That was fantastic.'
Talking to the brother of a patient with catastrophic bleeding into the brain: ‘We sat in silence for several minutes. It is important not to try to fill these sad silences with talking too much.'
On the medico-legal cases that follow treatment of whiplash injuries to the neck: ‘It is well known that these syndromes (that lead to the suing of the surgeon) do not occur in countries which do not have any legal recognition of whiplash injury as a consequence of minor car crashes.'
His comments on spinal implants – ‘all manner of very expensive titanium nuts and bolts, and bars… is a six-billion-dollar-a-year business in the US. It is a prime example of the over-treatment that is a growing problem in modern health care…'
On errors in surgery: ‘As I say to my juniors, when you make a stupid mistake, pick your patient carefully.’ (In the chapter entitled Sorry, he provides the example of the patient to whom he confessed that the operation had been done on the wrong side. ‘I quite understand,’ said the patient. ‘I put in fitted kitchens for a trade. I once put one in back to front.')
'We always learn more from failure than from success. Success teaches us nothing and easily makes us complacent.'
Finally, on possessions: ‘There are no pockets in the shroud.'
I also learnt a new word here: wegotist. Dr. Marsh assures us that it exists in the Oxford English Dictionary and so it is. I will leave you to look up the meaning.
It is of interest that this book, published in London, was printed and bound in India by Manipal Technologies Ltd., Manipal.
I warmly recommend this book, not only to neurosurgeons but to anyone interested in the workings of an exceptional mind.