Do No Harm by Henry Marsh

In the searingly honest, acerbic and compelling Do No Harm (2014), the eminent British neurosurgeon Henry Marsh takes us through his career using by drawing on a wealth of stories, from surgical anecdotes to conversations with patients to exasperating meetings with managers.  We follow him through his career as he climbs the medical hierarchy from a student job as a hospital porter to consultant neurosurgeon, from a gung-ho young scalpel wielder to a wiser, more reflective senior practitioner.  Marsh’s goal is to tell us of his ‘attempts, and occasional failures, to find a balance between the necessary detachment and compassion that a successful surgical career requires’.

That search for balance is key, and this is very much the story of a surgical life.  It is not a series of Oliver Sacks style vignettes or an in depth exploration of the philosophy of mind and brain.  We aren’t given those one in a million stories about men who mistake their wives for hats or lose their ability to see in colour.  The patients here are those that come through the neurology wards of the NHS on a regular basis: an elderly woman with a brain tumour whose family are desperate for an operation, an alcoholic with no family who will not get home again, a cyclist with a fractured skull.

The stories Marsh tells, both professional and those of his own life, of serve as a memoir, and a rather candid one at that.  This is a chronicle of Marsh’s thirty years in medicine in which we see the impact on his life, the changes in his outlook and the results of NHS reform.  He confesses to having no vocation, but admits that he drifted into medicine via a very privileged upbringing and an early life crisis.  His motives are several and they include the attraction of ‘controlled and altruistic violence’, ‘a combination of manual and mental skills’ and ‘power and social status’.  He is aware of his pride, a pride he openly attributes in part to the failure of his first marriage.

Marsh writes competently; the simple prose, sarcasm and confessional style endearing him to this reader, although his attention to the non-surgical world can be flat or clichéd.  Hospital conditions are ‘out of a nightmare’, drug company representatives are ‘anonymous looking’, and he lives in a mining town with ‘high chimneys pouring white smoke and steam into the wind’.  I sense that desire for mystification that all doctors have, to hide behind a veil of specialist knowledge.  Although each chapter is titled with a term like ‘Leucotomy’ or’ Glioblastoma’ along with a dictionary definition, there is sometimes a little too much medical jargon left dangling without explanation.

The better prose comes when he is writing about the brain, and the blood and gore, literally, of the operating theatre.  We have the optic nerves as a ‘pair of miniature white trousers although thin and stretched’.  It is likened to ‘bomb disposal work’ and one operation is characterised as ‘more like a blood sport than a calm dispassionate technical exercise’.  We are as in awe as the doctor at blood vessels forming ‘beautiful branches like a river’s tributaries seen from space’ and the ‘fine surgical poetry’ of names like ‘the Great Vein of Galen’.

This is what excites Marsh: the thrill of the chase, the hunt for a tumour and a desire to excise completely malignant material from the brain.  He has a great feel for surgery as a craft, describing his operating microscope and other tools as extension of himself.  He still retains a deep desire to carry out operations, watching junior colleagues at work with ‘a little jealousy’.

Marsh is funny, in the way that only someone who has reached a certain age and professional seniority can be.  He regularly fulminates against the modern NHS, and he has written well elsewhere about hospital design.  He is particularly proud of his successful lobbying for a rooftop garden for patients.  It is a shame that this more incisive criticism can be overshadowed by standard old man grumbling about health and safety.  Here he is at a training session on ‘Principles of Customer Service and Care’

How strange…after thirty years of struggling with death, disaster and countless crises…that I should be listening to a young man with a background in catering telling me that I should develop empathy, keep focused and stay calm.

What this book is best at is conveying the range of difficulties – ‘so often of a human rather than technical nature’ – that come with being a surgeon.  Marsh is very honest about how big a part failure, hubris, error and – something that is uncomfortable for those of us who put our lives in doctors’ hands – luck has in medical practice.  He quotes the French surgeon Leriche who spoke of every surgeon carrying within himself a ‘small cemetery…a place of bitterness and regret, where he must look for an explanation for his failures’.  Marsh, with great honesty and asking for no pity, takes us into his mental cemetery on many occasions and he is more than alive to his failures.  He even encourages one patient’s family to sue, a lawsuit that will eventually be settled for six million pounds.

It is the failures which haunt him, and one senses, drive him the most.  The misreading of a scan and the subsequent grief of a bereaved parent, the desire to excise every last bit of tumour that leaves a patient in a permanent coma, giving an operation to a junior colleague who severs a nerve and causes paralysis.  Marsh does not shy away from the human details in these stories; the anger, grief and recrimination they cause making for painful and upsetting reading.

At one point, struggling with an uncooperative aneurysm, Marsh has a vision of ‘my past disasters…parade before me like ghosts.  Faces, names, wretched relatives…’  It is against the judgement of these ghosts that Marsh weights his decisions while wielding the knife, increasingly aware of the cataclysm that a poor decision, or a terrible slice of luck, could cause.

One such ghost is Darren, a boy he operates on at twelve years old but whose ‘shunt’ (a drainage tube) periodically block over the years.  Marsh’s son had exactly the same operation at a young age (a story recounted earlier in the book) and he recalls his anger at the perceived carelessness of a doctor almost leading to his son’s death.  Years later as a student, Darren in brought in for surgery but haemorrhages beforehand and dies.  It is Marsh who is confronted with the mother’s grief, a woman he has got to know well

‘My son cried out “Help me, help me, Mummy!” ‘, she said, in a torment…how utterly unbearable it must be if it were one’s own child crying for help, and if one could not help them.

This book gets across very well the great rewards but also the deathly lows that a surgical career can bring and Marsh can said to have been successful in his declared attempt to ‘highlight the human difficulties that one faces when working as a doctor.’  It ends with a patient who has escaped the cemetery (the overwhelming majority) telling Marsh what we all hope to be able to say to our doctors: ‘I hope I never see you again’.  Marsh, ever the understanding doctor and someone I can imagining enjoying a well placed sardonic quip replies that he understands completely

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