This was a prominent theme in Marsh’s last book, and readers may have a sense of déjà vu while reading this one. Like “Do No Harm,” “Admissions” is wandering and ruminative, an overland trek through the doctor’s anxieties and private shames. Once again, he recounts his miscalculations and surgical catastrophes, citing the French doctor René Leriche’s observation that all surgeons carry cemeteries within themselves of the patients whose lives they’ve lost. Once again, he rails against the constraints of an increasingly depersonalized British health care system, which mummifies its doctors in spools of red tape. Once again, he describes his operating theater in all of its Grand Guignol splendor, with brains swelling beyond their skulls and suction devices “slurping obscenely” as tumors evade his reach.
Some of the procedures are surprisingly crude. They’re basically carpentry with blood. (Carpentry, the old-fashioned kind, is actually one of Marsh’s most passionate hobbies.)
But in this book, Marsh has retired, which means he’s taking a thorough inventory of his life. His reflections and recollections make “Admissions” an even more introspective memoir than his first, if such a thing is possible. And because he’s getting older, his own mortality has become a central preoccupation — if his brain were a pie chart, death would be a fairly substantial slice.
And much of “Admissions” takes place abroad, because Marsh spends the first phase of his retirement in Nepal, working alongside his friend Dev, who has set up a private hospital for neurosurgery in Kathmandu. Marsh has thus been turned into a foreign correspondent, reporting on how medicine is practiced in this poor, polyethnic country, recently ravaged by civil war. Among his most sobering observations: “Only in America have I seen so much treatment devoted to so many people with such little chance of making a useful recovery.”
Yet the reasons are different. The patients Dev treats don’t feel entitled to these operations so much as dazzled by them, with an “exaggerated faith” in their success. “They have no conception of brain damage,” Dev tells Marsh. “They think that if the patient is alive they might recover.” Many patients (or their families) refuse to accept it when Dev tells them that an operation is not worth it or too dangerous.
It’s a tragedy. The results of a superfluous brain surgery — or a botched one — are grim, and if Dev’s procedures go awry, the angriest families don’t just complain or sue, as they do in England. They threaten violence. Dev’s daughter was once kidnapped at gunpoint for a ransom.
“Admissions” contains other cross-cultural musings. Marsh riffs on the excesses of American medicine, which continue to amaze him. Shortly before retiring, he visited the Texas Medical Center in Houston, where he was shown an electric screwdriver for securing titanium plates into the skull. It was state-of-the-art, likely expensive; he estimated it would save five seconds over a manual one. He was similarly shocked (and spooked) when he saw trainees practicing surgery on a severed head — where did they get it? No one had a clue. When Marsh returned to England two weeks later, he told a colleague about it.
“Only one?” the colleague replied. “I had 15 heads, freeze-dried, flown in from the U.S. for my skull base workshop last year.”
The most startling aspect of “Admissions,” however, has nothing to do with medicine. It’s how Marsh portrays himself. As a young man, he writes, he was close to suicidal and spent time in a psychiatric hospital. At the same time, he adds, he “always was a tremendous show-off.”
He also struggled with aggression and he continues to do so — he’s competitive and impatient and has a bad temper. He had an adulterous affair at some point, and at another went through a bitter divorce. He ended his career in an almost vaudevillian gesture of ignominy, tweaking the nose of a male nurse who refused to remove a patient’s nasogastric tube.
He also ended a long, meaningful friendship with a Ukrainian surgeon he had annually visited and assisted. Though he probably did so for the right reasons. The particulars are best left to be read.
Marsh’s retirement is busy but anxious. For the first time, he feels a real kinship with his patients. The older he gets, the more likely it becomes that he’ll have to face the same irresolvable dilemmas they did about prolonging life. “We have to choose between probabilities, not certainties, and that is difficult,” he writes. “How probable is it that we will gain how many extra years of life, and what might the quality of those years be?”
He’s terrified of dying in a hospital, cared for by fleets of indifferent strangers. He opens “Admissions” by telling us he’s acquired a suicide kit, in case his death is painful and slow, and he closes with a civilized discussion of euthanasia. But he confesses he doesn’t know if he’d ever have the courage to hasten his own death. Which may be his most profound admission of all.