IN NATHANIEL HAWTHORNE’s story “Ethan Brand,” the eponymous protagonist travels the world in pursuit of “the Unpardonable Sin” before eventually coming to realize that he need never have left home. Brand’s transgression, which he carried within all along, was to have violated the sanctity of another person’s heart without the gravest reverence. He’d “lost his hold of the magnetic chain of humanity,” and as such, he “was no longer a brother-man, opening the chambers or the dungeons of our common nature by the key of holy sympathy, which gave him a right to share in all its secrets …”

There is no mention of Hawthorne’s wayfarer in Henry Marsh’s extraordinary memoir detailing his 27 years as a top-flight British neurosurgeon, but Marsh’s anxieties are not dissimilar to Ethan Brand’s, haunted as he is by the irony at the heart of his chosen profession; namely the inability to make real medical progress without incurring human casualties.

Neurosurgeons must reckon with the melancholy fact that “you only get good at doing the really difficult cases if you get lots of practice, but that means making lots of mistakes at first and leaving a trail of injured patients behind you.” Over the course of 25 lithe and affecting chapters that are structured around Marsh’s experience with specific neurological ailments like “Meningioma,” “Pineocytoma,” or “Infarct,” we learn that he is not really preoccupied by what we might call technical errors, or gross medical negligence, though he has seen both up close. (Marsh once told a grieving family “to sue me. I told them that I had made a terrible mistake.”) No, his misgivings are more subtle, involving errors of judgment that he believes are the products of temperament more than anything else. Even technically flawless surgery can lead to disaster, Marsh explains, chance’s strange arithmetic having determined long ago that “much of what happens in hospitals is a matter of luck, both good and bad.”

But if a measure of grief is every surgeon’s portion, Marsh is at pains to emphasize the unique emotional toll of botched brain surgery. Sometimes the most difficult decision he has to make is whether to operate at all. Not all aneurysms will burst, for example; on occasion it may well be safer to leave the berry-like sacks of arterial blood unmolested in a patient’s head. Likewise, the indignities he could unintentionally inflict on a gravely sick child during surgery might prove ultimately more degrading than a natural death. (Marsh observes in this regard that “death is not always a bad outcome.”) And it is hard to know when to resist a family’s white-lipped insistence that he operate on “a sad tangle of tumor, dying brain and blood vessels,” if only to facilitate a dying sister’s hope for a few extra months. Marsh is keen to celebrate the wonderful technology at his disposal, including “a form of GPS for brain surgery.” But nothing in this arsenal is of much assistance as he faces a series of challenges that are beyond mere technical skill. The author dismisses the antique suggestion that surgeons require “nerves of steel, the heart of a lion and the hands of a woman” on the grounds that “I have none of these.” The real requirements, as he experiences them, are more elusive. A brain surgeon must be able to comfort without giving false hope or surrendering to the “simple altruism of youth.” He must honor the pastoral component of their work, even as he is simultaneously vigilant against what Marsh calls “the vulgarity of my distress,” and he must never go beyond that “wary sympathy all doctors develop, anxious to help but worried that patients will make difficult emotional demands of us.”

Marsh chides himself on several occasions for failing to show the requisite emotional decorum in his dealings with various patients. But it is clear that he found the appropriate synthesis of analytical clarity and human solidarity on at least one occasion. Marsh details the circumstances of the day it fell to him to tell one long-term patient, David, that his aggressive brain tumor had finally surpassed the narrow economy of his surgeon’s art. The doctor watched in silent awe as David’s dignity grew in lock step with the high-grade glioblastoma, “a tumor within the brain itself,” that was killing him. Having concluded that further surgery would only result in “prolonging death,” Marsh went to speak to David, who lay twisted, paralyzed, and half-blind in his bed. The doctor knelt beside his patient to explain “that if he was a member of my own family I would not want him to have any more treatment.” David, he tells us, “had been a competitive cyclist and runner and he had large, muscular arms. I felt awkward as I shyly reached out to hold his big, masculine hand. ‘It’s been an honour to look after you,’ I said and stood up to leave.”

Viewed through the prism of David’s ordeal, Marsh’s book is best understood as commingled testimony and admonition. He is testifying not just to the intricacy of the brain and the “electrochemical chatter of one hundred billion nerve cells” that somehow sustains consciousness, but also to his perpetual wonder “at the way we cling so tightly to life,” even after calamitous physical damage. His admonition is less abstract. We feel we make the big decisions, Marsh suggests, but ultimately we find that these decisions have really made us. The stresses of this work seem to have produced a curious fissure in his own personality. On the one hand, he has been obviously brutalized. A life spent amidst helplessness, terror and the “deep sense of shame” that follows surgical failure has given him a “visceral hatred of hospitals.” He refers repeatedly and wincingly to patients that he left “wrecked,” and to the fact that “I prefer not to be reminded of their humanity and their fear.”

On the other hand, though, Marsh berates his juniors for using jargon because he feels this only serves to frighten already demoralized patients. (When an assistant tells him that he is about to give a patient a highly technical diagnosis, Marsh asks irately: “What the fuck will that mean to her ?”) He, himself, takes the time to personally wash and blow-dry the hair of his female patients before they come round from anaesthesia. And even at moments of abject failure, something in his personality seems to appeal to grieving relatives. When he has to tell the mother of a “very beautiful girl with long red hair” that the child has died on the operating table, he braces himself for a tirade, but instead the mother “reached out to me and held me in her arms and consoled me for my failure …”

“You learn,” Marsh writes jauntily early on, “to accept intense anxiety as a normal part of the day’s work and to carry on despite it.” This kind of anxiety takes two forms, the actual and the spiritual. Several of the more bravura passages in the book describe the intense, practical drama of the surgical craft. At a crucial moment during the “clipping” of an aneurysm as Marsh attempts to block off the deadly supply of arterial blood, his instrument fires the titanium staple, but then jams. As a result, Marsh finds himself holding the staple gun which remains attached to the throbbing aneurysm. “What the fuck do I do now?” he roars. (The patient survived). Another operation involves coaxing a tumor off a woman’s optic nerve. This is especially challenging because Marsh had “once left one person completely blind with a similar operation,” and also because of the fact that this woman is 37 weeks pregnant.

But these jolting moments feed into a more elusive worry. Marsh’s general melancholy grows out of his dawning comprehension that neurosurgery penalizes good and bad intentions alike. In retrospect, he sees his hubristic younger self as having been doomed in certain respects. An older colleague once airily encouraged Marsh to operate on a massive brain tumor. (“Ah, Henry! This chap with the petroclival. Needs to come out.”) The eager young surgeon set about the tumor for over 15 hours, and began to dream of imminent glory in the medical journals if he could extract it in its entirety. However, he confesses, “as I started to remove the last part of the tumor I tore a small perforating branch off the basilar artery.” His patient was rendered permanently comatose. Sentiment overwhelmed him, and ended in similar calamity in the case of Tanya, an 11-year-old Ukrainian girl “with the awkward long-legged grace of a foal” who had the biggest tumor at the base of her brain Marsh had ever seen. He flew her to London, and tried heroically to save her during two operations, which together lasted 22 hours. Tanya suffered a massive stroke after the second procedure, and lingered on in great pain and disfigurement for another 18 months before dying back at home. A distraught Marsh concludes that he did her more harm than good, his sympathy having overwhelmed his judgment. “I should have left Tanya in the Ukraine,” he writes.

At the end of Hawthorne’s story, Ethan Brand’s bleached skeleton is found at the bottom of a kiln, but “within the ribs — strange to say — was the shape of a human heart,” the very thing which in life had “ceased to partake of the universal throb.” What of Henry Marsh’s heart? It too looms as large and as impressively as his gifted hands. And his readers know it to be the home of a fierce moral sensibility that functions much like his indispensable surgical microscope: “Not only does it magnify, but it illuminates as well, with a brilliant xenon light source, as bright as sunlight.”

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John-Paul McCarthy has a doctorate in Victorian history from the University of Oxford. He is currently a freelance writer and book critic.