Marsh reflects that doctors learn to view illness as something that happens only to patients, a psychological defense against their exposure to disease and death. When he experienced flashing lights in his left eye, he therefore dismissed the symptom as anxiety. One evening while driving, a shower of lights appeared, and his eye filled with what looked like black ink. Internet research suggested vitreous detachment, and an ophthalmic colleague confirmed he had the beginnings of retinal detachment.

Using private insurance, Marsh saw a specialist who scheduled surgery for the next morning. Despite anxiety about potentially losing his career, he walked six miles home and arrived strangely reconciled to whatever might happen. The gas-bubble vitrectomy was performed under general anesthesia. He found becoming a patient surprisingly easy because his condition seemed minor compared to brain tumors and because private care afforded him the dignity denied to NHS patients.

Effectively blind in one eye for weeks, Marsh was unable to operate for a month. Three months later, he underwent lens replacement surgery and was on call that weekend. On Sunday afternoon, after operating overnight and visiting a garden center, his registrar called for advice on a patient who had jumped off a bridge, intending to die by suicide. His injuries were catastrophic, and, in the unlikely case that he survived, he would be severely disabled. Marsh told the registrar it would be kinder to let the patient die.

That evening, Marsh discussed adding a handrail to his handmade oak staircase with his new wife, Kate, who was recovering from Crohn’s disease. As he went downstairs, his newly soled shoes slipped on the polished steps, and he fell, breaking his leg and dislocating his foot. Neighbors drove him to his hospital’s accidents and emergency department, where, after a bureaucratic check-in, his colleagues ensured he was treated quickly. His orthopedic colleague drove him in a red Mercedes to a private hospital for surgery. After five days there, he had a second vitreous hemorrhage in his other eye, which was easier to fix. He felt profound gratitude for his colleagues’ care.

Following a successful trigeminal neuralgia operation, his Ukrainian colleague, Igor, wanted Marsh to tackle challenging brain tumors during his Ukraine visits, despite Marsh’s reluctance. In summer 1998, he found a long queue of patients with dreadful tumors waiting outside Igor’s chaotic office, where clinics involved multiple patients, families, journalists, and constantly ringing telephones.

The Ukrainian neurosurgeon and hospital director, Andrii Romodanov, banned Marsh from the operating theatres under pressure from Igor’s medical establishment enemies, which became headline news. One patient he agreed to help was Ludmilla. Marsh also saw 11-year-old Tanya from the remote village of Horodok, who arrived with her mother, Katya. Tanya had an enormous, benign tumor at the base of her brain, the largest of its kind he had ever seen. Marsh agreed to bring both patients to London.

Ludmilla’s eight-hour operation succeeded. Tanya’s surgery involved two operations with terrible blood loss. The second operation caused a severe stroke. After six difficult months in hospital, Marsh; his secretary, Gail; and her husband drove Tanya and Katya to Gatwick for their departure home. Tanya died 18 months later, probably from a blocked shunt. For years, Katya sent late-arriving Christmas cards that he kept on his desk as reminders of his failure.

Several years later, filming a documentary about his Ukraine work, Marsh visited Katya in impoverished Horodok. They went to the local cemetery where Tanya’s grave bore a beautiful six-foot headstone with her carved face. Wandering the cemetery, he reflected on the terrible 20th-century history the buried had endured. Next to Tanya’s grave was her father’s. He had been murdered in Poland for the $1,000 he had earned to bring home for Christmas.

Marsh attended a National Institute for Health and Care Excellence (NICE) Technology Appraisal Committee meeting in Manchester to help decide whether the NHS should fund a new cancer drug. Three patient representatives spoke first: one whose support group had dwindled from 36 members to 19 pleaded that life was precious; another described his wife’s death from cancer; a third stated he was only alive because of the drug, which had cost him £300,000 of his own money.

As clinical lead, Marsh presented evidence that the drug effectively reduced spleen size, but the trials lacked clear data on whether patients lived longer or had a better quality of life as a result. A health statistician delivered a complex presentation on cost-effectiveness using Quality Adjusted Life Years and various economic models. An expert oncologist explained that quality-of-life data was difficult to collect from dying patients and that clinicians would like the option to use the drug. When the chairman asked if they wanted it at any cost, the expert could not answer.

After the experts left, the committee discussed the drug using specialized economic terminology. Marsh silently reflected on the immeasurable value of hope that such drugs provided to dying patients, but did not voice this thought. He also believed that inflated drug company pricing had to be resisted by the medical profession and that healthcare costs had to be controlled. The committee agreed on a preliminary rejection because the lowest possible cost-effectiveness ratio was £150,000, far exceeding NICE’s typical £30,000 threshold. The recommendation would go out for consultation.

After taking the train back to London, Marsh walked home across the Thames that January evening among hundreds of commuters, enjoying a brief escape from the world of disease and death.

On a Sunday evening, Marsh cycled to the hospital to see three patients scheduled for surgery the next morning. He encountered a senior sister who was nearly in tears over staff shortages and unhelpful agency nurses. After searching multiple wards, hindered by recent reorganizations and bed shortages, he could not locate his first patient, Mrs. Cowdrey.

Marsh found his second patient on the balcony roof garden that he had campaigned to create. The young ophthalmic surgeon had a recurring oligodendroglioma that both knew would ultimately prove fatal. They exchanged a few words, and the patient signed the consent form.

The third patient was Mr. Mayhew, who had an alcohol addiction and a hemorrhagic glioblastoma. Sitting on the bed, Marsh told him the tumor was probably cancerous. Mr. Mayhew panicked, asking how long he had. When Marsh said perhaps 12 months, the man cried uncontrollably. He revealed he was completely alone—his family would not visit. He desperately asked for a cigarette. Marsh asked a sympathetic nurse to help. As he left the ward, he heard Mr. Mayhew shouting that he did not want to die as nurses wheeled him away.

Marsh returned home to his attic balcony and sat with a gin and tonic, thinking of his patients as the sun set and a blackbird sang.

The next day, all three operations proceeded straightforwardly. Mrs. Cowdrey had been on another ward all along. Days later, he saw Mr. Mayhew being pushed in a wheelchair; they waved at each other. He never saw him again.

After a month off with a broken leg, Marsh returned to work wearing a large plastic boot. At the morning meeting, he chided a new junior doctor for dismissive language and managerial jargon. The cases discussed included a 72-year-old woman with a massive, inoperable brain hemorrhage and a woman with a multiple melanoma brain metastases.

Before Marsh started his outpatient clinic, Gail reminded him to remove his tie and watch to comply with the new chief executive’s strict dress code. The receptionist kept the clinic list covered for confidentiality—a rule he circumvented by calling out the first patient’s name.

The first patient was a young policeman with a small brain tumor. Marsh spent nearly an hour struggling with password problems trying to access the scans on the hospital computer network. After two trips to the X-ray department, a secretary helped him log in using a profane password. The scan showed a benign tumor requiring surgery with serious but acceptable risks. The relieved family thanked him.

Subsequent patients included a single mother with failed back syndrome in constant pain whom he could not help, and a woman with painful numbness from an old operation who angrily demanded he cut the nerve—not understanding that the nerve having been cut had caused her problem. He saw Philip, a man with oligodendroglioma, whom he had treated for 12 years, whose business had gone bankrupt after losing his driving license due to seizures.

The last patient had trigeminal neuralgia. Unable to find her operation notes, he instead found her hospital stool chart with its graphic guide to different types of feces. They shared a long laugh over the absurdity. As she left, she came back and kissed him, saying she hoped never to see him again.

Two years before his retirement, Marsh first met Will, a plumber in his forties with two small children who had previously undergone surgery for a petro-clival meningioma at another hospital. He had nearly bled to death during that operation, and much of the tumor remained. Marsh explained the extreme dangers of re-operating on tumors in the cerebellopontine angle. Damage to the basilar artery or its branches could cause death or a catastrophic stroke, as had happened to the schoolteacher years earlier.

Marsh monitored the tumor with scans every six months for 18 months. Each time, Will remained calm while his wife looked terrified. As the tumor grew incrementally, they agreed that Marsh should operate shortly before his retirement.

On the operation day, radiology colleagues unsuccessfully attempted to embolize the tumor. The operation began badly when Marsh got lost in scar tissue and nearly severed the vertebral artery. Over four hours, he removed the tumor piece by piece, experiencing intense focus despite the bruised brainstem and destroyed cranial nerves buried in scar tissue.

While checking for bleeding, a fine spray of arterial blood appeared from a hole in the basilar artery—a catastrophe. Marsh calmly stopped the bleeding with muslin packing and completed the operation, fearing Will would die or suffer a major stroke. He told Will’s terrified wife that things had gone very badly.

An hour later, Will woke up without major stroke symptoms. At 10 o’clock that night, he was awake and talking. The next morning, he sat eating cornflakes, his face numb and with double vision, but his facial movement unexpectedly intact. Marsh had somehow saved the nerve without ever seeing it. Will thanked him for saving his life.