Brain surgeon Henry Marsh: ‘You have to have a big ego’

Henry Marsh is signing a copy of his book for me. Later, I'll discover that his handwriting is a sequence of beautiful black ink flourishes, closer to calligraphy than the usual scrawl of people in 2017 when given a pen and asked ad-hoc to write something.

But while he’s signing the book, I don’t notice the script, because that’s not what I’m focused on.

It’s Henry Marsh’s hands I can’t stop staring at. These are the dextrous, confident hands of a brilliant neurosurgeon; hands that pioneered the first awake craniotomy (of which more anon), a procedure that is now standard practice in brain surgery. These hands have literally been inside hundreds of people’s heads. Does he take particular care of his hands, I wonder aloud?

Not only does Marsh laugh at the suggestion, he points out that his ongoing creative pastime is woodwork.

“I’m always thinking when I use a bandsaw, that one day I am going to saw a finger off, but it hasn’t happened yet,” he says briskly. “The more dangerous the equipment, the more careful you are, on the whole.”

Henry Marsh’s rather grand accent suggests a privileged background.

“I had the benefit of an excellent education.” He rattles off his places of education. “The Dragon School in Oxford [very grand], Westminster School [beside the famous London abbey], Oxford University [self-explanatory]. It was only later I strayed into brain surgery, in the way one does,” he deadpans. “I was a bit of a prune back then.”

Prune?

“Twit,” he explains cheerfully. “I was rather a twit as a boy.”

‘Decisive and confident’

Only the most confident of men will admit they were prunes or twits in their younger days. “To be a neurosurgeon, you have to have a big ego, and be decisive and confident,” he says. “A lot of operating is still a one-man act.”

Marsh is dressed in dark blue needle cords, with a pale blue shirt and dark blazer. He has just turned 67 and looks admirably fit (he runs and exercises as often as he can). Yesterday he was in Finland. Tomorrow he’ll be in Huston. By the end of the week, he’ll be in Sydney. Home is London and Oxford.

Although now retired from the position of senior consultant neurosurgeon at St George’s Hospital in London, he continues to practise, mostly in a volunteer capacity, working in clinics in Nepal and the Ukraine. In addition to continuing to practise part-time, he has since applied himself to words, showing the same precise and devastating ability with pen as with scalpel.

His first memoir, Do No Harm: Stories of Life, Death and Brain Surgery, was published in 2014 and received wide critical and public acclaim. We're here to talk about his just-published second book; a companion memoir to the first, entitled Admissions: A Life in Brain Surgery.

'I'm very good at talking people into letting me open their head up when they're awake'

It’s an astonishing, gripping read, beautifully written, with its first-hand experience of life and death situations and decisions that almost none of us will ever be faced with; such as whether to risk operating on someone’s brain who may or may not survive the operation.

However, Admissions – a clever, subtle title, suggested by his social anthropologist wife, Kate Fox – is not just about his work. It's also a self-portrait of Marsh the man, and that buoyant, irrepressible ego. There is his frank admission of his past failures as a husband (Fox is his second wife, and, with a surgeon's precision, he informs us that the number of women he has fallen in love with during his life is seven), his meditations on ageing and death, and the drive that continues to propel him forwards, as he advances to his eighth decade.

Still conscious

But back to awake craniotomy. It was Marsh who pioneered this practice, which, in the simplest of language, involves operating on a patient’s brain while they are still conscious.

He sits up like a meerkat when I mention craniotomy, and gives a great big smile. “All that’s different about it is that fact that the patient is awake, and what you are doing is safer than what you do when the patient is asleep.”

How does one pioneer such surgery, I ask. How, for instance, did he get the first patient to volunteer for it?

“Patients tend to accept what doctors tell them on the whole, and if they are terribly plausible and articulate like me, all the better!” Marsh howls with self-deprecating laughter at his description of himself. He knows he’s right, though, and on the evidence of his book alone, it’s clear he has an exceptional gift for eloquence.

“I’m very good at talking people into letting me open their head up when they’re awake. Surgeons tend to be very persuasive. What I explain to people is that ultimately, this is a much safer way of operating, which it is, and there is a much better chance of getting more, and, in a few small number of cases, all of the tumour out without causing damage.”

Marsh waves his hands expressively in the air a lot when talking, as if he’s conducting the symphony of his own voice. “I always was a tremendous show-off,” he writes in the book. That confident voice is loud, and his beautiful enunciation is clear as an actor’s, carrying across the room. There is a table of elegantly-dressed women finishing their lunch at a nearby table, and I catch sight of one, fork suspended in mid-air as she stares across at us in something like frozen horror.

“It’s the thought of it, though,” I say weakly, reaching for my water and hoping I won’t disgrace myself by fainting in the Merrion Hotel. That would be the thought of being conscious when someone has actually cut open your skull and is operating on your brain.

"Well, the thought is grotty," he agrees cheerfully. "But I've done this now hundreds of times. It was only in the early years, when we still hadn't quite worked out the combination between local anaesthetic and sedation, that I had two patients who couldn't cope. Everyone else sailed through it. The brain itself doesn't feel pain. The first patient I did that operation on is still alive, 30 years later, and I still keep in touch with her."

Paying in wine

In Admissions, he writes that doctors traditionally pay their colleagues in wine. I'm curious to know what the going wine rate is for an operation on a colleague, or a colleague's family member.

“It depends on how big the operation is,” he explains. “When they operated on my wife, who had Crohn’s Disease, it cost me three cases. It’s a tradition in England. It’s not payment, it’s a sort of gift; an old professional courtesy.

"It also reflects the fact that when you operate on your colleagues, its much more frightening, because they’re members of your tribe. They’re part of the in-group. And one of the first things you learn as a young doctor is patients are an out-group. You don’t identify with them. You can’t.

“It is this huge central moral problem to medicine: how to find a balance between compassion and detachment. I don’t like the word empathy. I think it’s a word that has become very misused. I like the word compassion. As a doctor, you have to exercise rational compassion, rather than feeling. I’m always telling my students, ‘Your patients are frightened of you. It’s fear, not respect, they have for you.’”

'You are important. You hold the power of life and death over your patients'

Students need to practise, and the book’s most startling chapter, which Marsh describes to me as “rather fun”, is entitled “America”. There is a near-dystopian narrative of a cerebro-vascular workshop in Houston, Texas, in which trainee surgeons learn how to operate on the brain’s blood vessels.

The students are operating on pigs, “about the size of a 10-year-old child,” as he writes. “It was strange to feel the hoofed trotters under the drapes at the end of the operating table.” There are pages about the practice of operations on pigs, and, just as the reader (me) is recovering, thinking, well that’s very grim but pigs are still only pigs, there is this:

“Two trainees were operating on a severed human head . . . head shaved, eyes closed, stubble on his cheeks, blackened stumps of a few remaining teeth. He had clearly never seen a dentist . . . It was impossible not to wonder for a moment who he had been.”

“What happened the rest of that man’s body?” I ask, after I’ve read out this section to an attentive Marsh. I daren’t look across at the lunching ladies. “Where did that severed head come from?”

“I think in America, the law is, if you die on the street, your body goes straight to medical research,” he says. “I’m pretty sure that the default position is that if you die unclaimed on the street your body can go for research. In England, if you’re running anatomical dissection courses, you get all these freeze-dried corpses over from the States.”

Grimms’ Fairy Tales

It's no surprise to discover in Admissions that one of the first books Marsh read as a child was Grimms' Fairy Tales. The stories he has to tell, of life and death, are both universal and also fantastical.

When he retired from full-time surgery, he bought a derelict lock-keepers cottage in Oxford, and converted it into a workshop for the carpentry he loves to do, with his big saws with their hungry blades.

There's a Grimms' Fairy Tale-like element to the story of the renovation. One day, as Marsh is working in the garden, a man his own age comes by, walking a dog. It turns out he had lived in the cottage, some 60 years before. The two men chat, former occupant and current owner, about the cottage. The visiting man with his dog shares his memories of the cottage, but in the manner of a dark fairy tale, these memories are far from pastoral.

“My dad used to sit in the corner over there in the kitchen,” he said, pointing to the place where there had once been a stove. “He had a handful of lead balls. He’d throw them at the rats when they came in through the front door.”

These are some of the qualities that Marsh describes about himself in his book. He’s refreshingly open about his opinion of himself:

“My deeply competitive nature . . .”

“My obsessive conviction that I must do everything myself . . .”

“Perhaps I am just a masochist who likes drawing attention to himself . . .”

“I loved the fact that I was – at least in my own little hospital pond – quite important . . .”

Did he consider himself to be an important person?

"Oh yes!" He says immediately. "But you are an important person. You hold the power of life and death over your patients. Ultimately, the decision about the risks of surgery and the benefits of surgery are still taken by the individual surgeon. When faced with a life-and-death situation, we inevitably invest our surgeon with supernatural abilities as a way of coping with our anxieties. You do have an ego, but you change over time.

"In my mid 40s and early 50s, I was pretty pleased with myself. I did have a huge practice. I can probably claim to have been about the busiest neurosurgeon in England at the time. My opinion of myself changed in my case, partly by a very traumatic divorce which taught me a lot about how stupid I was.”

Marsh is fully aware of the ethical and moral responsibilities that come with making such life-and-death decisions for patients. “What always interests me is this problem with communication and how well you deal with patients. So much of neurosurgery is palliative, not curative, so that decisions to be made about whether to treat people are about quality of life, rather than about life and death, often.

"If most surgery was about life or death, most of us would accept quite a lot of risk, but with neurosurgery, all you are doing quite often is postponing dying, at a risk of damaging the quality of life and these are incredibly difficult equations to solve, and I don’t personally think neurosurgeons discuss it enough.”

Death’s frontiers

Is he afraid of death, having been vicariously at its frontiers for so long?

“I’m not frightened by death at all, because death is nothing. I’m a total physicalist. What does bother me a lot is dying. I’m a deeply independent, rather anxious, hypochondriacal, and I hate being out of control and I feel very anxious when I’m not in control of my situation. The idea of dying and being stuck in hospital with some nasty illness is awful.

“It’s the loss of autonomy that gets me. Pain is not normally a problem, but it’s the loss of physical dignity and independence, particularly if you are in hospital, which I think most of us find so awful.

"You’ll put up with almost anything if you think you’re going to come out alive and well at the other end, but to put up with the loss of freedom, the loss of autonomy and the loss of dignity when you’re dying, knowing you’re not going to get out of it is, I think, very, very difficult.”

'The enemy of the brain surgeon is complacency and being pleased with yourself'

Marsh is in support of the availability of euthanasia, although he says he prefers the expression “assisted dying”.

“I’m very impressed with countries like Holland, Belgium, Switzerland and some of the States and Canada, where assisted dying is legally permitted. Has the moral fabric of Switzerland collapsed because of Dignitas? No, is the answer. But we all find if very difficult to think about death. We all avoid it.

"There is the argument that every time I operate there is a risk that I will actually do more harm than good, and we accept that. We accept that some patients will suffer and hence the title of my first book, Do No Harm. But the fact is, we have to do harm to some people for the sake of a larger number of people."

I think of the “two patients who couldn’t cope” during his early years of practising awake craniotomy. I didn’t ask what happened to them: I found myself unable to ask.

What does a neurosurgeon who volunteers abroad, makes complicated bespoke furniture, and has written two books in four years do for down time?

“I don’t do down time,” he says. “I’m a bit like a gyroscope; I keep spinning. I’m not depressive, but I’m very intense in my feelings. I’m either terribly enthusiastic, or I’m terribly downcast. I like talking about myself, so I’m quite happy now. In the same way I liked writing my books; there was a strong element of exhibitionism involved.”

Enemy of the brain surgeon

I ask what the enemy of the brain surgeon is. Arthritis, perhaps?

“The enemy of the brain surgeon is complacency and being pleased with yourself,” he replies.

When will he stop doing surgery?

“I’ll have to stop at some point. I’m not ready to yet, but I know it’s important to stop too soon rather than too late, but the problem is knowing when. I’m still sort of hopelessly in love with the work.”

How does the man of science define happiness? There is a very long pause; the longest by far of an interview in which Marsh gives consideration to all the questions.

“I can’t define it,” he says eventually. “When have I been happiest? Having gone for a long run around Oxford, had a cold shower, and then sitting in the medieval library in the Bodleian for two hours and writing. Then I feel completely at peace; happy and at peace. It’s a combination of physical exercise and total intellectual relaxation.”

Not many writers would consider the act of writing as “total intellectual relaxation”. I point out that Marsh’s particular construction of happiness is a solitary one. “Very solitary,” he agrees. “But it only lasts about two hours.”

Pig corpses. A human severed head. Seven loves. Two wives. A carpentry workshop in a cottage once overrun by rats. Hundreds of awake craniotomy operations. Two memoirs. What’s next for the self-confessed over-achieving Henry Marsh?

"Philip Pullman's publisher, David Fickling, has asked me to write a book about the brain for children," he says. "It would be about the nuts and bolts of the brain. Heads being opened, that kind of thing. Thought is a physical process. Thought is not free. It's like optical illusions. We trick ourselves. We need to step back a bit from our feelings.

"It’s the question of when do children become self-aware? When do you become aware of your awareness? Children’s philosophical views are fascinating, so I may well do that.”

Admissions: A Life in Brain Surgery, by Henry Marsh, is published by Weidenfeld & Nicolson