Book Review: Admissions

Admissions, by Henry Marsh, is a searingly honest memoir by the retired brain surgeon who brought us Do No Harm (I have yet to read this earlier book). It is a somewhat regretful looking back on cases the author has worked on, mistakes made, and the balance neurosurgeons must acquire between confidence in their abilities and concern for the patients whose lives can be so drastically altered by their interventions.

Marsh resigned from his position as a senior consultant at a large London hospital when he felt the respect that doctors once enjoyed had been undermined by the target culture and petty rules imposed by bureaucrats granted the power to allocate funds and decide who gets treated in the modern NHS. Marsh continued to travel to Nepal and the Ukraine, where he assisted colleagues who ran private teaching hospitals, although he was questioning the usefulness of his roles here as well. This is a tale of facing up to a life approaching its end, for the author as well as his patients.

Although enjoying many successes, brain surgery carries the risk of patients surviving but with a questionable quality of life. Decisions on whether to operate must take into account the probability of such outcomes. Saving a life may leave relatives burdened with round the clock care of a loved one who has little awareness or, perhaps even worse, aware but catastrophically damaged. Modern sensibilities have made honest discussions about the benefits of death difficult. There is a reluctance to accept that medical intervention merely postpones the inevitable.

Having watched his parents die, from cancer and dementia related illness, Marsh has a pragmatic view of his own mortality. He also struggles with what certain colleagues may regard as professional arrogance and ponders what he will become when he is no longer a renowned surgeon. He recognises that he has, at times, made poor decisions and behaved badly. Even the satisfaction found in his work has been lessened by what he has learned of the reality of patient outcomes over his long career.

Marsh’s musings on the way the brain works and the effect on the body are fascinating. His views on psychosomatic illnesses, whilst in line with well researched medical opinion, are likely controversial amongst patients who demand a physical explanation for their very real suffering. In the chapter, Lawyers, he discusses whiplash injuries.

“An English woman had been involved in a minor car accident in the USA while on holiday, and had subsequently seen me as a patient about her ‘whiplash’ symptoms. I had confirmed with an MRI scan that there were no significant injuries to her neck […] Patients develop an array of aches and pains and altered sensations in their necks and arms which do not correspond to any known pathological processes […] It is well known that these syndromes do not occur in countries which do not have any legal recognition of whiplash injury as a consequence of minor car crashes.

I used to see many of these patients every year in my outpatient clinic and it was clear to me that most of them were not consciously malingering […] With ‘whiplash injury’, the possibility of financial compensation for the victims, combined with the powerful suggestion that they have suffered a significant injury, can result in real and severe disability, even though it is, in a sense, purely imaginary. […] It is the modern equivalent of the well-attested phenomenon of a witch doctor in tribal socity casting a spell on somebody, causing the victim to fall ill, merely through the power of suggestion and belief.”

In his work in Nepal the author encounters many women suffering debilitating headaches which, when scans show no physical problems in the brain, he suggests may be down to some unhappiness they harbour in their personal lives. He explains that pain occurs in the brain but can manifest anywhere in the body, and can have a psychological rather than physical cause. Patients are unhappy if they are not offered a cure involving surgical intervention or costly medication. The suggestion that psychiatric treatment may be more effective does not go down well.

Most of the cases discussed, though, involve the removal of brain tumours. Marsh intersperses the detail of these with anecdotes from his personal life, at the time and throughout his past. What emerges is a picture of a flawed but determined individual who wishes to honestly portray how he got to where he is now.

An interesting medical memoir from an author who is not afraid to state his views, however terse or contentious. It offers a window into the world of brain surgery, and the difficulty of ageing after a brilliant career.