Take the bloody tube out!

Henry Marsh is a neurosurgeon. But he's very much more than that. In two compelling books - Do No Harm, and now Admissions - he reflects, with scrupulous honesty, on his experience of chiselling into skulls and sucking out tumours. Grim work, but - like clearing the drains - someone has to do it. From this unpromising subject-matter, Marsh has produced two magnificently elegaic books, elegantly written, eminently readable, full of wonderful anecdotes. They are also unostentatiously profound.

A sample of Henry Marsh paragraphs give you a good idea about about the man, his topic, his approach. Here’s a few. “It is difficult to talk of death to a dying patient, it takes time, and it is difficult if the room stinks of shit. And I know that I let this man down and was a coward.”… “‘Get his head open,’ I told Samih, ‘and give me a shout when you’ve reached the brain. I’ll be in the red leather sofa room.'”… “But I am a neurosurgeon. I frequently see people whose fundamental moral and social nature has been changed for the worse, often grotesquely so, by physical damage to the frontal lobes of their brains. It is hard to believe in an immortal soul, and any life after death, when you see such things.”

It’s a pity he might be slowing down; after all, he’s only just begun on a byway that shows him to be that rare thing, a writer with an authentically personal voice

Some trying-too-hard clever-clogs has called Henry Marsh ‘the James Boswell of neurosurgery’; but he’s not a Scotsman and nor does he write about a huge literary figure, so that seems pretty bloody useless at telling us anything much. Let’s just say Marsh is a very, very fine writer, hugely compassionate, fiercely intelligent, with continually surprising flashes of anger and gentleness.

Marsh is now 67. He’s spent around 30 years cutting into heads and spinal cords for the UK’s National Health Service, coping with accidental damage and genetic mutation, through tumours of one sort of another. You get the impression that if he hasn’t seen it all, then no-one has. He’s seen the NHS in its glory days; he seen it in the dumps (right now, so far). His latest book – Admissions: A Life in Brain Surgery – is suffused with an awareness of his own, inevitably approaching, mortality.

This book was clearly commissioned after the remarkable commercial success of his 2014 book, Do No Harm: Stories of Life, Death and Brain Surgery, which (justifiably) was garlanded with critical awards and lavish praise, probably much to the surprise of his publisher. Does this latest book advance our understanding of Henry Marsh the person, his work, the experiences that lead him to reflect on human tragedy? Yes, in that it is more outspoken, more personally revealing, and deals in much greater detail with his pro bono work in Nepal and Ukraine than Do No Harm. But although I am sure this will be an equal success as the first, it’s difficult to imagine that there is much left in this seam that could be fruitfully mined for a third book. And Marsh himself admits he’s getting tired. Writing a book – even a crappy one (and Marsh’s are far from that) is hugely demanding. It’s a great pity he might be slowing down; he’s only just begun on a byway that shows him to be that rare thing, a writer with an authentically personal voice. And this is only a hobby. Many full-time writers will be seething with envy that Marsh appears to do so effortlessly what they may well spend a lifetime trying to perfect. He’s a great storyteller, and great speaker, and if you have the chance either to read his books or hear him speak then you should do so.

Neurosurgeon gets stuck in; wins some, loses some; feels like a shit sometimes, at other times much better

So let’s radically boil down the new book – reduce it to case notes, perhaps: ‘Neurosurgeon gets stuck in; wins some, loses some; feels like a shit sometimes, at other times much better; reveals himself to be carrying a huge sack of guilt around; probably had a nervous breakdown around 20; is completely puzzled by patent absurdities; wrecked first marriage and feels troubled by that; gets very angry at the NHS, particularly in the last few years; has very short fuse and does not suffer fools gladly (and most are fools); NHS managers and some co-workers no doubt find him a bit of a bastard; finds contentment while tidying up and restoring a canalside Oxford wreck of a cottage; visits Nepal to do pro bono work helping long-standing colleague and friend struggle to operate under miserable conditions; visits Ukraine, ditto; contemplates his own creeping physical decline; shamefacedly admits to being arrogant but also thinks arrogance is necessary if you are going to have sufficient self-belief to take a chisel to a stranger’s skull; recommends assisted dying for those that want it. Possibly thinks that entropy in the universe has already set in.’

That’s not an inaccurate description, but what it fails to convey is Marsh’s wonderful powers of description, and his superb rendition of dialogue. The book is an elegy, almost, as Marsh seems to be saying farewell to his lifetime’s work. It is wistful in places and reveals different sides of him – one deeply engaged in nature and compassionate for animals; two swans accompany his musings at Oxford, and he hopes to attracts owls to his wilderness retreat. He recalls how he assisted a vet one day in (unsuccessful) surgery on a badger. Another side is that Marsh seems to be a highly skilled and certainly painstaking carpenter.

Marsh is an obsessive; a perfectionist. He spends weeks – months – making an oak table for a daughter from scratch, including cutting and curing the raw planks, sanding it almost to a mirror-finish. One wonders to what extent this literally labour of love, and others on behalf of his children, is done in some hope of expiating what clearly was a difficult childhood, as the young Marsh spent all the hours God sent at the hospital cutting, chipping, sucking and intently looking through a microscope, to see if he’d managed to get all the filth out. It is interesting that he mentions his father frequently and with love and reverence, but of his mother little is said. He reveals himself to have had a sadistic , streak while a child, training a pet labrador to sit-and-beg “with great cruelty, using a whip made from electric cable, combined with biscuits. He learnt quickly…The dog would never stay alone with me in a room for the rest of his life, a constant reminder of what I had done…I was filled with a deep feeling of shame that has never left me, and a painful understanding of how easy it is to be cruel…I wonder, sometimes, if this has perhaps made me a kinder surgeon than might otherwise have been the case.” Or, just maybe, made him a difficult bastard who knew how to torture colleagues? That thought doesn’t occur to him. The ‘admissions’ perhaps only go so far.

Marsh has a love-hate relationship with neurosurgery, though his prose is never as crude as putting it that way. “A long time ago,” he writes, “I though that brain surgeons – because they handle the brain, the miraculous basis of everything we think and feel – must be tremendously wise and understand the meaning of life.” But now, in the final days of his career, he has acquired wisdom – or maybe just weariness: “I have learnt that handling the brain tells you nothing about life – other than to be dismayed by its fragility. I will finish my career not exactly disillusioned but, in a way, disappointed.”

“My concern is simply to achieve a good death. When the time comes, I want to get it over with.”

Part of that disappointment must be how he has seen his beloved NHS become an underfunded political football, in which the managerial-class breeds like rabbits, each new generation coming up with new acronyms, new structures, new layers, all having the effect (if not the intention) of rendering what once was a clear straighforward service into something that now has more rules than Mahjong and, yes, no-one understands why they exist.

The last straw for Marsh and the NHS came in the form of the medical director of his hospital, who “was sent one day by the hospital’s chief executive to talk to the consultant neurosurgeons…she sat down and carefully placed her large pink handbag on the floor.” The eight neurosurgeons are lectured on their dress – not that they are being too sloppy, but too smart, wearing suits and ties. For Marsh, a suit and tie at his workplace was just a matter of courtesy to his patients. “‘If you do not follow Trust policies, disciplinary action will be taken against you’, she concluded. There was no discussion, no attempt to persuade us.” He sends in his letter of resignation the next day, “unwilling to work any longer in an organisation where senior managers could demonstrate such a lack of awareness of how to manage well, although I prudentlypostponed the date of my departure unti my sixty-fifth birthday so that my pension would not suffer.” Actually it’s not just this incident that sets Marsh fuming – there are many. I won’t spoil the uncomfortable one involving taking the bloody tube out…

Towards the close of his book he writes that he does not believe in an afterlife: “my concern is simply to achieve a good death. When the time comes, I want to get it over with. I do not want it to be some prolonged and unpleasant experience, presided over the terminal-care professionals, who derive their own sense of meaning and purposes 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 lay dying.” This is a memoir that pretty much bares everything, I suspect. It’s painful, moving, fascinating.