Marsh recalls his first encounter with neurosurgery 30 years earlier. Watching an aneurysm clipping operation as a junior doctor, he experienced an immediate epiphany, telling his wife that night he would become a brain surgeon. This obsession would eventually end their marriage.

Later in his life, as he approached retirement, Marsh and the other medical staff discussed the case of a 32-year-old woman with a small, incidentally discovered aneurysm. They established that statistics showed that the risk of operating roughly equaled the risk that the aneurysm would rupture at some point in her life. The patient, terrified after internet research, insisted on surgery despite Marsh admitting that at his age, he would decline treatment.

During the operation, the first clip applicator malfunctioned. A second applicator successfully clipped the aneurysm but failed to release. After moments of terror, fearing a catastrophic rupture, Marsh carefully removed the clip. The aneurysm refilled but did not burst. A third applicator worked, though the placement was imperfect. Haunted by past disasters, he repositioned the clip twice more until satisfied. The surgery was a success. That evening, Marsh felt profound pleasure rather than the intense exhilaration of his younger years, reflecting that a surgeon’s greatest success occurs when patients recover completely and forget the surgeon.

One day, Marsh arrived at work anticipating surgery on a 40-year-old accountant with a cerebellar hemangioblastoma, a challenging but curable tumor. The hospital’s new computer system, iCLIP, created chaos. Required blood test results could not be located despite an iCLIP floorwalker attempting to help, delaying surgery for hours. Secretary Gail demonstrated the system’s confusing interface while bed manager Julia struggled to find available beds. Operating assistant U-Nok waited patiently. Eventually, the operation proceeded perfectly with the patient in the sitting position. Marsh removed the tumor intact to avoid catastrophic hemorrhage. The grateful patient recovered well.

Marsh left work for the day, but while grocery shopping, received a call from the hospital. An accident and emergency doctor claimed that an elderly patient had a subdural hemorrhage, and the on-call registrar, James, was unreachable. Marsh dismissed the call, suspecting that the doctor was responding to pressure to reduce patient waiting times. However, he worried that the case could have been a real emergency. Calling the registrar, Fiona, he learned that the on-call registrar had already responded to the “emergency,” and the patient’s brain scan turned out to be normal.

Returning home, Marsh went for a run and received another work call. James reported an uncontrolled postoperative bleed following an emergency operation to remove a blood clot caused by an arteriovenous malformation. Marsh advised James to pack the wound and have a cup of tea, and promised he would be there in 30 minutes. Returning to the hospital, he found James had successfully finished the surgery. In the parking lot, Marsh discovered a parking notice on his car stating he had been clamped and must pay a fine. He reacted furiously before realizing that the parking attendant had added the words “Next time” as a warning rather than an actual penalty.

Marsh describes a recent experience of speaking to the scriptwriters of the medical TV drama Holby City, who requested positive anecdotes. Marsh recalled Melanie, a 28-year-old woman, who was 37 weeks pregnant and rapidly losing her vision from a meningioma accelerated by pregnancy hormones. Though threatening Melanie’s sight, the tumor posed no risk to the baby. Her optic nerves remained relatively healthy, suggesting surgery might restore her vision. Marsh performed the delicate operation while obstetricians and pediatricians waited outside. The tumor proved soft and was removed quickly. Immediately afterward, under the same anesthetic, the baby was delivered successfully by Cesarean section. Hours later, Melanie’s slow pupil reaction suggested possible blindness, but that evening she awoke able to see the baby, her vision nearly restored.

The second case that day—a woman with malignant glioma whose father had died from a brain tumor—ended tragically. Despite a minimal chance of improving her life expectancy, which was two or three months, she chose to have surgery. Postoperatively, a massive hemorrhage left her comatose. Meeting with her devastated husband and daughter, Marsh reflected that he had inadvertently granted her wish not to suffer a prolonged death.

After helping Patrik control bleeding in the third case of the day, a disc prolapse, Marsh returned to find Melanie awake with her ecstatic husband beside her, exemplifying the extreme highs and lows of surgical practice.

In 1992, Marsh’s secretary, Gail, persuaded him to join a medical equipment salesman’s trip to newly independent Ukraine. At Kyiv’s Neurosurgical Research Institute, a staged tour revealed no patients or functioning operating theaters. Visiting the derelict Emergency Hospital, Marsh watched a surgeon performing an ineffective procedure on a paralyzed man. A junior doctor, Igor Kurilets, approached him and bluntly stated that neurosurgery in Ukraine was in a terrible state. His unusual honesty impressed Marsh, who offered to host Igor in London.

After three months’ training in London, Igor returned to Ukraine and publicly campaigned for medical reform, facing years of threats. Ukraine’s medical establishment denounced him as “schizophrenic.” Marsh supported him with articles, equipment shipments, and unprecedented operations.

In 1995, Marsh traveled to Ukraine to operate on a woman with trigeminal neuralgia using second-hand equipment he brought from London. Working under terrible conditions with a television crew filming, he panicked on discovering unexpected bleeding. Despite the difficult start, the filmed operation succeeded. Before leaving, Igor bought Marsh an endangered smoked eel. Unable to eat it and rejected by a fox, Marsh buried it in his garden.

Marsh was from a privileged, non-scientific background. He studied politics, philosophy, and economics at Oxford until he was heartbroken by unrequited love. He then quit university and worked as a hospital porter in a northern mining town, prompting his decision to train as a doctor.

Returning to Oxford to complete his degree, Marsh was then admitted to the Royal Free Medical School after a brief interview with a retiring registrar who mainly talked about fly fishing. He completed the first MB science course (consisting of foundational subjects for students who lack the necessary science background), dissected cadavers, and qualified in 1979 as a junior house officer working 120-hour weeks.

One night, when he was called to examine a breathless patient, Marsh dismissed the man’s symptoms as anxiety. As he walked away, the man’s breathing abruptly stopped—a fatal cardiac arrest. The registrar noted that Marsh had missed crucial ECG signs. The patient’s despairing expression, an example of angor animi (the overwhelming feeling of dread often experienced during a heart attack), still haunts Marsh decades later. The author notes that his frequent contact with dying patients during this time forced an emotional detachment that has only recently faded. 

While working in intensive care, Marsh witnessed an aneurysm operation that became his surgical epiphany. He immediately sought out the neurosurgeon and applied for training. He met separately with two senior neurosurgeons to plan his career, and both asked about his wife’s opinion. The second neurosurgeon warned that decision-making, not operating, constituted the job’s real difficulty.

One Monday morning, the registrar, Anthony, talked Marsh through the overnight hospital admissions. They discussed a 96-year-old woman with a subdural hemorrhage who stated a preference to die over a nursing home placement. This presented an ethical issue, as if they operated, she would need post-surgery nursing home care. They discussed whether they could allow her to die by non-intervention as she wished. Anthony struggled to retrieve the patient’s scans due to the hospital’s poor computer system.

Marsh and Anthony discussed another case: Mrs. Seagrave, an 85-year-old widow with a massive meningioma causing dementia. Three weeks earlier in Marsh’s clinic, she had complained about losing her driving privileges while her three children described her deteriorating memory. Marsh explained the significant surgical risks—approximately a one-in-five chance of making her condition worse—and the profound uncertainty of the outcome. The family chose to proceed, but her operation was canceled when an unnecessary cardiac test was completed too late. 

Mrs. Seagrave was first on the list for surgery that day. However, her swabs showed MRSA, requiring extended postoperative cleaning. Marsh, therefore, had to move her to the end of the day’s schedule. The locum anesthetist then insisted that she could not stay late for the surgery due to childcare commitments. Marsh was relieved when the bed manager, Julia, reported there were no post-operative beds available for the two spinal surgeries scheduled for that day. He canceled them, thereby solving the problem.

The first operation, a microvascular decompression for facial pain, proved difficult when a vein tore, causing a torrential hemorrhage that took 20 minutes to control. After this case was finished, new hospital rules and government regulations about mixed-sex areas caused further delays in starting Mrs. Seagrave’s surgery. Her operation began at 3:30 pm, with Marsh leading and Mike assisting to save time. The tumor proved cooperative and was removed in just 10 minutes. Marsh finished by 5:00 pm, and both surgeries were successful.