Every Third Thought Read online

  Despite these caveats, he remains impressively optimistic about the prospects for neurology. ‘Am I hopeful?’ he asks, turning rhetorical. ‘Yes – I believe we will know much more in the future. Is the brain complicated? Of course it is. But I believe in happy accidents. We always say we are “five years” from some important breakthrough. But it could happen now, tomorrow.’ Lees wears the serene expression of a wizard who trusts his magic. ‘We need blind luck – and prepared minds,’ he concludes.

  Lees himself seems to derive some of his impressive equanimity from the practice of mental and physical exercise, a vital element in keeping mind and body equally fit. There is, otherwise, no reliable treatment for neuro-degeneration. ‘Age remains the major risk factor,’ he says. ‘Sixty-five,’ he concludes, almost merrily, as a man in his sixties, ‘is still the watershed in the diagnosis and treatment of Alzheimer’s and Parkinson’s.’

  This fear of neuro-degeneration haunts the profession. The renowned neurosurgeon Henry Marsh is a former colleague of Lees’, and equally well versed in the complexity of the cortex. The bestselling author of Do No Harm turned out to be impressively sanguine about brain surgery but – perhaps because he has spent a lifetime operating on diseased brains – profoundly apprehensive about his own neurological future prospects.

  8

  DO NO HARM

  The brain is wider than the sky,

  For, put them side by side,

  The one the other will include

  With ease, and you beside.

  Emily Dickinson, Complete Poems, CXXVI

  I first met Henry Marsh in the grounds of the Bishop’s Palace at the Wells Festival of Literature in October 2014. He had just published Do No Harm: Stories of Life, Death and Brain Surgery, and I was due to interview him about it in front of an audience. I was looking forward to this encounter, but I did not know quite what to expect. By reputation, Marsh is a bit of a maverick, an ‘eminent brain surgeon’, and Alpha male, who used to bicycle to work without a safety helmet, a free-thinker who is not afraid to speak his mind about his disaffection with NHS bureaucracy, and also the engaging subject of Your Life in their Hands, an award-winning TV documentary about his work as a charismatic surgeon which I had once watched on a transatlantic flight.

  Do No Harm, a title inspired by the Hippocratic oath, spoke directly to my fascination with the brain, but it was, on first reading, distinctly shocking. In twenty-five unsparing chapters, replete with gripping detail, Marsh takes the reader through the often bloody crises of brain surgery from Aneurysm to Oligodendroglioma (‘a tumour of the central nervous system’). In the course of this journey, he exempts no one, least of all himself. ‘How does it feel’, he asks at the outset, ‘to hold someone’s life in your hands, to cut into the stuff that creates thought, feeling and reason?’

  I had always known that brain surgeons are the sort of characters who relish the drama of the operating theatre. Their risk-taking, rock-star instincts are essential if they are to perform their often dangerous procedures. Here, on paper, was a senior member of his profession who not only celebrated, in blunt terms, the art of playing God, but who was also tormented by the cost of his life’s work. ‘How does it feel’, he challenges himself, ‘to perform a live-saving operation that goes badly wrong?’ From the first page of Do No Harm (I soon got over my squeamishness), I was hooked, not least because Marsh exhibits a fearsome and exhilarating candour. ‘Much of what happens in hospitals’, he writes, ‘is a matter of luck, both good and bad; success and failure are often out of the doctor’s control.’

  None of this prepared me for our first meeting, in a tent next to the main stage of the Wells Festival. Marsh was waiting there in his pin-stripe suit, but he was far from the ice-cool master of the scalpel. A newcomer to literary self-promotion, he was chatty, animated, and obviously nervous. My first job that afternoon was to reassure him that his book was compulsive reading (it was, indeed, about to become a bestseller), and also that every member of the sold-out audience was going to be on the edge of their seat.

  The next hour flashed by. From the moment Marsh began to describe, in stomach-turning detail, what it’s like to saw open a patient’s skull before brain surgery, his audience of open-mouthed seniors was rapt. As blood and bone-matter spattered our conversation, my ‘interview’ became a formality. I threw away my well-rehearsed questions about ‘consciousness’, ‘mind/body’, and ‘neuro-plasticity’, and surrendered to the tales he was telling about the emergencies of his ‘operating theatre’. Rarely had that arena seemed so dramatic or life-changing.

  As we talked, during that weekend in Wells, I found Henry – as I now knew him – to be a passionate man who freely confided the romance of his younger days, the ‘exquisite pleasures’ of his early career in neurosurgery, and ‘the wonderful mystery’ of the brain. Unlike some surgeons, he openly admitted deriving ‘spiritual consolation’ from Crick’s ‘hard problem’, the infinite conundrum of human consciousness. ‘The problem for neuroscience,’ said Henry, ‘is that we’ve never met a brain, apart from our own, and so we have to describe it by analogy.’ Thus it was that the brain would be described by Descartes as a hydrostatic fountain.

  The wonder of the brain is only equalled by its astounding role in the narrative of our humanity, and our life on earth. Considering the dazzling complexity of the organ, the idea that a brain surgeon must cut into thought itself, and through emotion and reason, is still mind-boggling. The idea that memories, dreams, and reflections should consist of jelly is beyond our ordinary comprehension.

  ‘The truth,’ said Henry, ‘is that even now we don’t begin to understand how “matter” (the brain) becomes “mind” (consciousness).’ He looked at me across the table where we had been enjoying a late breakfast as festival guests. ‘When we talk together now, it’s all to do with the electro-chemical activity of our nerve cells, and yet our scientific world cannot begin to elucidate that.’ It’s an intriguing point: as individuals, we have a very limited experience of our mind’s actual working. What, I wondered, about the twentieth century’s advances in neuroscience? Will we ever break the old cerebral constraint that we can never really know what we know?

  ‘I’m not going to predict the future of neuroscience,’ he replied, ‘but there are very many sound reasons to doubt whether we can ever make much progress. We cannot experiment on our own consciousness, and we certainly can’t experiment on other people’s. So the investigation must remain acutely subjective, and that’s its fundamental limitation. Besides, medical science is probably at odds with our ethical concerns. What interests us most about ourselves is what makes us human, not what makes us neurologically complex. You can do some often rather nasty experiments on chimpanzees, but what that tells us about the human brain is actually quite limited.’

  Who better to address the frailty of the ageing brain than a man who has spent his professional life examining it under surgical lights? A year after our first meeting in Wells, having just begun to write Every Third Thought, I went to visit Henry at home in Wimbledon. I was coming to terms with the three principal ways a brain can fail – cancerous tumour; stroke or stroke-related illness such as aneurysm; and diseases such as Alzheimer’s – and I wanted to explore the meaning of these failures with Henry, the eminent brain surgeon, one-to-one.

  *

  South Park Road, London SW19, is a typical suburban street, with speed bumps to deter boy racers. Towards Wimbledon Hill, there’s a comfortable world of bankers, architects, and surgeons. In the other direction, approaching Collier’s Wood, it’s appropriate that Marsh, who cherishes his lone-wolf identity, should live towards the more marginal end.

  Henry’s house, shaded by trees, presents a dark, cluttered exterior with boxes of discarded papers outside the front door. Inside, it’s like stepping aboard a late-Victorian yawl, skippered by a veteran sea dog, a character from Treasure Island, perhaps. Captain Marsh is a passionate amateur woodworker who has designed every detail of the interio
r himself from the overflowing library to the study-cum-screening room upstairs to his own loft conversion, an attic eyrie reached by a treacherous wooden stairway that would not seem out of place on an old tea-clipper or in a scene from Chitty-Chitty Bang-Bang.

  Up there, facing into the wind on Henry’s crow’s nest, and looking across Haydons Road Recreation Ground, the suburbs seem remote. You can smell the distant fields of merrie England, and see transatlantic jets circling to land at Heathrow. Glance down, and you discover a wild back garden, two sheds (one for woodworking; the other for guests), some sinister undergrowth, and three beehives, another of his private passions. Henry’s domain perfectly mirrors his personality: highly idiosyncratic, full of delightful surprises, and offering unexpected vistas of opinion and imagination.

  In the distance, on ragged green playing fields, I can see schoolboys in the mist kicking a muddy ball. I turn away, as I always do: I often find free movement – jogging, skipping, walking, or running – almost unbearable to watch, and still cannot bear to be reminded of my ‘deficits’. At least these kids are far away.

  Henry, who loves to exercise, is still fully active. As we discuss the mystery of the brain, he describes a daily regime which kicks off, first thing, with an energetic run, a cup of black coffee, freshly ground, and a cold shower. ‘Cold water is good for “vagal tone”,’ he remarks, cheerfully instructing me in the mysterious activity of the vagus nerve, the extraordinarily long nerve that runs from the brain to the heart.

  Henry has the air of a man driven by a need to challenge himself, who combines restless self-starting with infusions of high anxiety. His inner demons, however, seem to be fundamentally benign. Do No Harm reports his frequent explosive irritation, rage, and frustration, but, on our various meetings, I’m always surprised to find him projecting such an air of bonhomous serenity that ill temper and frustration seem strangers to his personality. Perhaps that’s to do with the larger satisfaction of doing the thing he loves: brain surgery.

  Marsh, now sixty-seven, has worked as a surgeon for about forty years. Both his parents are dead, his father at ninety-six from Alzheimer’s, his mother from cancer. In Do No Harm he writes, in moving terms, of his mother drifting in and out of consciousness, sometimes lapsing into German, her first language. ‘It’s been a wonderful life,’ she told her son on her deathbed. ‘We have said everything there is to say.’ Henry has a profound investment in ‘a good death’. The better I came to know him, though, the more this robust veteran from the battlefields of neurosurgery admitted to being ‘haunted by fears of senile dementia’.

  When I ask exactly what that meant to him, Marsh recalls ‘the grotesque caricatures of human beings I nursed when I worked as a psycho-geriatric nursing assistant in 1976, and also the hollow, though benign and decent shell, my admirable father became. It means being only interested in eating, and otherwise being lost, dribbling prostatically with trousers smelling of urine.’

  As well as being thoughtful, humane, and articulate, Mr Marsh (as he’s known to colleagues at St George’s Hospital) is an ideal person with whom to explore the darker dimensions of cerebral failure. He has not only operated on hundreds of human brains, and studied thousands of brain scans, he has also reflected deeply on the meaning of his remarkable experience as a neurosurgeon, on the limits of human reason, and on his own errors of judgement.

  ‘We often don’t cure people with our interventions,’ he admits, addressing a crux of modern medicine, ‘we simply prolong their lives at a cost.’ Marsh’s firmly held belief is that, in neurosurgery, death is often a good outcome, compared to being left horribly disabled or in a persistent vegetative state. He recalls the times he has been woken in the night to adjudicate the appropriate response to a cerebral emergency. ‘It’s always easier to treat a patient than not to treat,’ he tells me. ‘But you’re almost certainly going to create a disabled person at the cost of saving a life.’ Marsh seems to despair at the impossibility of the task, and begins to speak about the disjunction between the act of surgery and the workings of the brain. ‘Surgery,’ he says, ‘is still relatively crude compared to the delicacy of the cortex. At what point do you stop? At what age? For instance, if the patient is going to be left without language, is it worth it?

  ‘And then,’ Henry goes on, getting agitated, ‘the question becomes: how bad is the disability? How many “good” results justify how many “bad” ones? That is very, very difficult to assess. If you decide you must treat everyone, you will generate a lot of human suffering, especially among families.’

  Marsh digresses into anecdote, in the chatty way he prefers. ‘The mother of a very good friend of mine had surgery for narrowing of the carotid arteries in her neck in her late seventies, to prevent a stroke. The operation was successful but she went on to develop Alzheimer’s and became foul-mouthed and paranoid – completely out of keeping with her previous personality – and eventually died twelve years later in institutional care, doubly incontinent, etc.’ The tone of his recollection darkens as he continues: ‘It became difficult for her family to remember her as she was when well, as opposed to what she was when her brain was rotting and rotten.’ Marsh seems troubled by the memory. ‘Really, it would have been better if she had not had her carotid arteries operated upon, and had died from a stroke – or so it seems in retrospect.’

  *

  Henry begins to explain his motives in writing Do No Harm. He is troubled by the casual tyranny exercised by his profession. ‘As I approach the end of my career,’ he says, ‘I feel an increasing obligation to bear witness to past mistakes I have made, in the hope that my trainees will learn how not to make the same mistakes themselves.’ He has a lecture, entitled ‘All My Worst Mistakes’, that’s often heard in stunned silence by his audiences, where he likes to quote René Leriche in La philosophie de la chirurgie (1951): ‘Every surgeon carries within himself a small cemetery, where from time to time he goes to pray – a place of bitterness and regret, where he must look for an explanation for his failures.’

  Failure haunts brain surgery more than any other profession, and there’s something quite compulsive about Marsh’s confession. ‘It’s the professional shame that hurts the most,’ he concedes with a rueful grin, his trademark. ‘It’s vanity really. As a neurosurgeon you have to come to terms with ruining people’s lives and with making mistakes. But one still feels terrible about it. As a surgeon you float on the thermals of your patients’ trust. However,’ he continues, with cheerful pragmatism, ‘you must learn to be objective about what you see, and yet not lose your humanity in the process.’ Marsh admits that as a young doctor, he became ‘hardened in the way that doctors have to become hardened’, and also confesses that now he’s reaching the end of his career, ‘I am less frightened by failure, and can dare to be a little less detached.’ Here, he begins to address his anxieties. ‘Besides, with advancing age I can no longer deny that I am made of the same flesh and blood as my patients, and that I am equally vulnerable.’

  Today, in the comfort of his home, I direct our conversation towards that most obvious vulnerability, his own fears about old age. ‘I hope for a quick end,’ he says, ‘with a heart attack or stroke, preferably while asleep. But I realize that I may not be so fortunate.’ What might that mean, from his experience? ‘I may very well have to go through a time when I am still alive but have no future to hope for and only a past to look back on.’ In that diminished condition, old age might seem like a new kind of mental torture, inexorably conditioned by cerebral atrophy. Marsh knows what dying can mean, and will pray for ‘a good death’. How often does he think about this? ‘About every third minute.’ Another sheepish grimace. ‘More often than sex.’

  Like Andrew Lees, Henry believes that an exercise regime is the way to keep the brain healthy. ‘The brain is a living organism,’ he instructs. ‘It’s good to keep it busy and active, and stimulated by physical activity.’ ‘Mind and body,’ he concludes, alluding to the classical wisdom of mens sana in corpor
e sano, ‘are inseparable.’

  Beyond these relatively simple areas of concern, there is the larger question of human consciousness, the terra incognita of neuroscience. Occasionally, for effect, he will say that we know less about the brain than we do about the infinite spaces of the universe. ‘Nobody,’ adds Henry, reverting to his favourite theme, ‘can begin to explain consciousness. It seems to me highly unlikely that we’ll ever work out how it operates.’ This does not trouble him. ‘As I get older,’ he confides, ‘I derive a certain spiritual consolation from this profound mystery, the origin of consciousness. You know’ – his smile is almost mischievous – ‘I find that quite appealing.’

  It’s here, inexorably, that the reflections of the brain surgeon begin to coincide with the inner life of the patient. This is a subject, with almost as much complexity as medicine itself, that precisely mirrors the fears and worries expressed by Henry Marsh. One classic statement of the patient’s predicament can be found in Devotions upon Emergent Occasions, Meditation 5, where John Donne writes:

  As Sickness is the greatest misery, so the greatest misery of sicknes, is solitude . . . Solitude is a torment which is not threatened in hell itselfe.

  In the course of growing old, there’s one thing as certain as death (or taxes): at some point in the future we shall join an invisible grey army of reluctant conscripts. In doctors’ waiting rooms, in hospitals, and in ambulances, we shall become ‘the patient’.

  9

  ASTRIDE OF A GRAVE

  ‘I feel monotony and death to be almost the same’

  Charlotte Brontë, Shirley

  As a long-term convalescent, with a history of steady neurological recovery, I have intimate experience of being a patient. During 2015/16, my own tally of tedious waiting, always with a book, but just as often with frustration, included three appointments for MRI scans at Queen Square; two waiting-room sessions to see my stroke consultant, Richard Greenwood; another in the National Hospital to see one of his colleagues, a professor of neurology; four appointments to see a hand-surgeon for an operation on Dupuytren’s contracture; and another appointment for a DAT scan and more blood tests. Adding up this year’s dead time, I calculate I spent the best part of two days in the waiting rooms of the medical profession. Such delays seem interminable; and you acquire new strategies. I have now mastered the art of appropriating other people’s appointments. I am, no doubt, a bad patient.