And Finally: Matters of Life and Death by Henry Marsh
My rating: 4 of 5 stars
Henry Marsh started out as a student of philosophy at Oxford, but “fled to the more practical world of medicine,” partly (perhaps) because he feared he was “not clever enough to understand philosophy.” For the next forty years he was a neurosurgeon, but modestly explains that he is not a scientist – to claim so would be to “like saying that all plumbers are metallurgists.” He became a man of practical action: he cuts open people’s heads and brains; he is a devoted woodworker and builder of things by hand (even though his roofs may leak). He runs. He bicycles. He hikes across mountain ranges. He keeps bees. He also keeps a journal, and – as his previous books (Admissions: A life in brain surgery and Do No Harm: Stories of Life, Death, and Brain Surgery) suggest – ponders questions personal, intellectual, and philosophical about his life and career.
Which is, apparently, coming to a close. After retiring from medicine, he volunteers for a study of brain scans in healthy people. He assumes his scan will be a fine example of a 70-year-old brain kept lively, supple, and unchanged from his long regimen of activity. But when he receives the copy of the scan, he is afraid to look at it. When he finally does, it shows him a shrunken brain speckled with “white-matter hyperintensities,” typical of aging. “…My brain is starting to rot. I am starting to rot. It is the writing on the wall, a deadline,” he says. But he feels fine, lives normally, so learns to shelve the distress.
As he does with some other symptoms, which he ignores or minimizes for years, choosing to think they indicated common older-man benign prostatic hypertrophy. When he at long last seeks medical attention, he initially wants to attribute his sky-high prostate-specific-antigen to pressure on the prostate from his bicycle seat as he rode to his appointment. However, what it really is is advanced prostate cancer. Strangely mixed with his dismay at this dire diagnosis is relief that he has likely been released from a greater fear of dementia, triggered by his father’s decade-long suffering and the ominous “pox” on his brain scan.
George Eliot’s magnificent novel Middlemarch describes a moment when the rigid, lonely, self-absorbed, and bitterly disappointed old scholar Causaubon has been diagnosed with an incurable heart ailment. “Here was a man who now for the first time found himself looking into the eyes of death—who was passing through one of those rare moments of experience when we feel the truth of a commonplace, which is as different from what we call knowing it, as the vision of waters upon the earth is different from the delirious vision of the water which cannot be had to cool the burning tongue. When the commonplace “We must all die” transforms itself suddenly into the acute consciousness “I must die—and soon,” then death grapples us, and his fingers are cruel…” Henry Marsh movingly explores that moment and the months that follow.
At this point, And Finally morphs into a more or less typical health-professional-gets-sick memoir. Theresa Brown’s recent Healing: When a nurse becomes a patient is one such – an expert oncology nurse is diagnosed with breast cancer, and discovers that being at the other end of the radiation beams is a revelation: all the things she never noticed or understood about what her patients actually felt or thought or experienced as she briskly gave treatments and managed complications while tut-tutting “Hey, we saved her life!” if they complained. Similarly, Marsh undergoes uncomfortable, embarrassing, and frightening procedures. Like many other patients, he frantically googles for information on survival rates, treatment options, complications. He, of course, is well equipped to understand the technicalities and statistical probabilities… and he still freaks out at times. Will he die of his disease, or with it? Will he see his granddaughters grow up? (Probably not, he concludes.) He cries. And he looks back on patients he realizes now he did not serve as well as he could have. He recalls a patient (an actor) whose delicate and difficult surgery left her with a permanently damaged face. He meets her again some years later, and she tells him: “I could see that you were so upset when you saw me after the operation, that I forgave you.” He muses on the difference between telling a patient he has a 5% chance of surviving versus a 95% chance – regardless of the actual number used, if there is any chance at all, they will take hope from it. He endures the indignities and depersonalization of the modern healthcare system: his anthropologist wife remarks that hospital patients ask each other the exact same question prisoners do when they meet: “What are you in for?” Information and instructions are provided in the form of generic printed handouts rather than conversation. Hospital balconies with lovely views are locked and off-limits to patients. Radiation departments are often deep in the lower levels, but those who have managed to place a sunlit window or even a mural of a beautiful landscape bolster their patients’ morale. (He got funding for and oversaw the creation of a garden for the use of neurosurgical patients at his hospital, and considers it one of the prime accomplishments of his career.)
This is a smallish book, but Marsh packs a lot into it. His voice is serious, clear, and steers well away from any sort of “inspirational” revelations or triumphant acceptance of his cancer as any sort of “gift.” There are detailed technical explanations of prostate cancer radiation treatments and brachytherapy, which may overwhelm a patient seeking a layperson’s understanding. Marsh’s personal beliefs do not include any sort of afterlife, and his discussion of the life-extension movement is bitterly critical. Even as he so longs to live, he pleads passionately in support of accessible, compassionate assisted-dying services. This is personal and powerful. A reminiscence about the elaborate doll houses he built for his beloved granddaughters is touching; a very long description of fairy tales he has written for them, overstuffed with dragons and unicorns and magical objects of all kinds, is less so. The book rambles and swerves at times, jumping back and forth from memory to contemplation of the future, from former patients to current doctors, from woodworking to brain surgery, from medical journals to children’s stories, from London to Ukraine (where he volunteered for many years, and his heart aches for that country’s woes now), from hope to terror and back again.
In a lovely passage, Marsh muses over his hoard of exotic woods with beautiful names he has collected – burr elm, spalted beechwood, cocobolo, sandalwood – and the places they came from, and what he planned to make with them. What will become of all of it? For “I am constantly having new ideas of things to make with all this wood – but the fact of the matter is, whatever happens, I will not live long enough to use even a fraction of it. I would look at my hoarded wood with deep pleasure, but as old age and decline approach, this pleasure is starting to fade and instead is replaced by a feeling of futility, and even of doom – of the future suggested by my brain scan. Besides, anything I now make will outlive me, and I should only make things that deserve to survive in their own right. I no longer have the excuse of the craftsman – who sees all the faults, often invisible to others, in what he has made – that I will do better next time.”
As it happens, Marsh’s cancer responds well to his therapies. He likely has more time ahead of him than he feared – but perhaps no more books. This rambling, effusive, thoughtful exploration of the mind of a man facing down the “commonplace” that he must die, and soon, is useful and moving.
** Thanks to NetGalley for an advance copy in exchange for an honest review. **