He can get into your head

Neurosurgeon Henry Marsh’s superb second memoir is more self-critical than ‘Do No Harm’, says Jessamy Calkin

the “frightening void”. Admissions then weaves elegantly in and out of operations – “26-year-old. Collapsed last night while in the shower. Looks like a spontaneous ICH…” – and evocative memories of Marsh’s childhood, of his parents, of the countryside he grew up in.

Visceral recollections of brain surgery pour out of him, but much more unsettling are the depressingly byzantine workings of the NHS, details of which come to light at regular morning meetings in which Marsh and his colleagues are made to discuss cases while idly tossing around a sky-blue brain-shaped cushion. Marsh here vents his contempt for targets, bureaucratic regulations and punitive budget cuts; lays out his worries about the growing problem of over-treatment and his strong feelings in favour of legalising euthanasia in terminal cases.

There are some shocking moments. Driven to distraction by hospital protocol, he loses his temper with a young male nurse: “I pushed my face in front of his, took his nose between my thumb and forefinger and tweaked it angrily…” But it is offset by humour – Marsh then goes off to wash his hands. “We are supposed to clean our hands after touching patients, so I suppose the same applies to assaulting members of staff.”

He is articulate about balancing the risks of operating with doing nothing: it takes three years, he says, to learn how to do an operation, but 30 years to learn when not to do one. Telling a patient or his family that it is better to go off and wait for death is not easy, but operating often brings the risk of severely impaired quality of life. Marsh has an overwhelming dread of consigning his patients to Persistent Vegetative State – there are around 7,000 people in the UK in PVS – which he describes as “a great underworld of suffering away from which most of us turn our faces”.

And there is another balance to be attained in neurosurgery. In cases where a tumour has deviously infiltrated the brain and looks exactly the same as healthy tissue, the challenge is to remove enough of the cancer but not so much that it destroys crucial neurological functions.

Marsh has helped to pioneer – and performed several hundred – “awake craniotomies”, where the patient is given only a local anaesthetic (for the scalp, as the brain itself does not feel pain) and can therefore react and help the surgeon gauge how far he can cut. It all sounds very crude, and Marsh himself is often struck by the contrast between the heavyhandedness of sawing open a skull and sucking out a tumour, and the delicate mysteries of the human brain.

At NHS meetings Marsh had to toss around a brainshaped cushion

If Do No Harm was an act of atonement, there is an element of that in Admissions, too. In both books, he constantly revisits what the French surgeon Rene