Admissions: A Life in Brain Surgery

10

BROKEN WINDOWS

Back in Oxford, I went to inspect the lock-keeper’s cottage. I walked with mixed feelings along the towpath, rain falling from a dull grey sky, past the line of silent narrowboats moored beside the still, green canal. The air smelt of fallen wet leaves. Several friends had told me that I was mad to try to renovate the place: after fifty years of neglect, with fifty years of rubbish piled up in the garden, without any road access, the work and expense involved would be enormous. The plumbing had all been ripped out by thieves for a few pounds’ worth of copper, the plaster was falling off the walls, the window frames were all rotten. The ancient Bakelite electrical sockets and light switches were all broken. The roof was intact, but the staircase and many of the floorboards in the three small bedrooms were crumbling with woodworm. The old man who had lived there was dead, and the cottage itself was dead. The only life was the green wilderness of the garden, where the rampant weeds flourished after fifty years of freedom.

I had spent months making new windows in my workshop in London, with fanciful ogee arches. Glazing them with glass panes cut into ogee curves had been, therefore, difficult and time-consuming. With the help of a Ukrainian colleague and friend, I had ripped out the old windows and carefully installed the new ones before leaving for Nepal. While I was away in Kathmandu they had all been smashed by vandals. This was presumably out of spite for the metal bars I had fitted on the inside. As it was, the thieves had managed to prise apart the metal bars on the window at the back of the cottage and get in. At least I had put the more valuable power tools in two enormous steel chests with heavy locks that I had had the foresight to install. Wheeling them along the narrow towpath on a sack trolley had not been easy and at one point one of them, weighing almost 100 kilograms, had come close to toppling into the canal.

Apparently the thieves had mounted one of the chests on the sack trolley and then abandoned the effort as they couldn’t open the front door – I had spent many hours fitting a heavy-duty deadlock to it. On the other hand, my elder sister, an eminent architectural historian, had remarked that the ogee arches were not very authentic for a lock-keeper’s cottage; perhaps the vandals had shared my sister’s rather stern views about architectural heritage.

I had therefore arranged for rolling metal shutters to be fitted on the outside walls over the windows, which completely defeated the original purpose of decorating the cottage with pretty arched windows. So the vandals then turned their attention, once I was away again, to the expensive roof windows – triple-glazed with laminated glass – that I had installed last year. They had climbed onto the roof, breaking many roof slates in the process, and then heaved a heavy land drain through one of the windows. As far as I could tell, this was done simply for the joy of destruction rather than for burglary – for the love of the sound of breaking glass. I consoled myself with the thought that the frontal lobes in the adolescent brain are not fully myelinated – myelin being the insulating material around nerve fibres. This is thought to be the explanation for why young men enjoy dangerous behaviour: their frontal lobes – the seat of human social behaviour and the calculation of future risks and benefits – have not yet matured, while the rising testosterone levels of puberty impel them to aggression (if only against handmade windows), in preparation for the fighting and competition that evolution has deemed necessary to find a mate.

Each time I walk towards the cottage I feel a sinking feeling at what further damage I will find. Will they have broken the little walnut tree or snapped off the branches of the apple trees? Will they have managed to break open the metal shutters? In the past I always felt anxious when my mobile phone went off for fear that one of my patients had come to harm. Now I fear that it will be one of my friendly neighbours from the longboats nearby on the canal or the police, informing me of another assault on the cottage. I tell myself that it is absurd to worry about mere property, especially as the cottage only contains building tools, all locked up in steel site chests. I remind myself of what I have learnt from my work as a doctor, and from working in poor countries like Nepal and Sudan, but despite this the project of renovating the cottage has started to feel like a millstone. It fills me with a sense of despair and helplessness, when I had hoped it would give me a sense of purpose.

In the weeks before I left for Nepal I had started to clear the mountains of rubbish from the garden. At one end of the garden there is a brick wall, and on the side facing the canal there was a mass of weeds and brambles. I had cleared these to reveal a series of picturesque arched horse troughs made of red brick. The bricks had been handmade – you could see the saw marks on them. They would have been for the horses that pulled the barges along the towpath in the distant past, and there were rusty iron rings set into the bricks for tethering the horses. In front of the troughs, and still on my property, was a fine cobbled floor, which slowly appeared as I scratched away years of muck and weeds. Emma, one of the friendly boat people, stopped by to chat as I worked.

‘There is a rare plant here,’ she said. ‘The local foragers were very excited, though I’m not sure what it’s called. Fred and John [two other local boat dwellers] got into trouble with them a few years back when they tried to clear the area.’

‘I’m worried that I might have dug it up,’ I replied, anxious not to fall out with the local foraging community.

‘Oh it will probably grow back,’ she said. ‘It has deep roots.’

We talked about the old man. He had been frightened of thieves, Emma told me, although as far as I could tell from the rubbish, he had owned little and lived off tinned sardines, cheap lager and cigarettes. He had also told her that the cottage was haunted. According to the locals he had been ‘a bit of a wild one’ when he was younger, but all I got to hear were stories of how he would sometimes come back to the cottage drunk on his bicycle and fall into the canal. He had a son who had once lived in the cottage with him for a while, but it seems that they had become estranged. There had been a few pathetic and broken children’s toys in the rubbish in the garden. I had found shiny foil blister packs of antidepressants – selective serotonin reuptake inhibitors – in the piles of rubbish in the garden. Emma told me that he had died in the cottage itself.

‘We didn’t see him for several days and eventually got the police to break the door down. He was very dead – in an armchair.’

I slowly built up a huge mound of several hundred black plastic builders’ bags, filled with fifty years of my predecessor’s rubbish and discarded possessions. It included a matted pile of copies of the Daily Mail that was almost three foot thick and had acquired the consistency of wood, having been exposed to the elements for a long time. Rusted motorcycle parts, mouldy old carpets, plastic bags, tin cans, bottles galore (some still containing dubious-looking fluid), useless and broken tools, the pathetic children’s toys – the list was endless. None of the rubbish was remotely interesting; even an archaeologist excavating it five hundred years from now, I thought as I laboured away, would find it dull and depressing. The more I dug down, the more rubbish I found.

The community of boat dwellers along the Oxford Canal is supplied with coal and gas cylinders by a cargo barge called Dusty. When I took possession of the cottage I found a cheerful note put through the letterbox from Jock and Kati, the couple who own Dusty, welcoming me to the cottage and offering me their services. This proved invaluable because with their help I was able to load two bargeloads of rubbish onto Dusty and take it up the canal a short distance to where a local farmer had agreed I could put a couple of big skips beside a farm track. It was heavy work, and when it was done I took Jock and Kati out to lunch in a nearby pub. Jock told me that he had backpacked round the world and then become an HGV driver, but he had always wanted to live in a boat from an early age. Kati was a primary school teacher who had taken a year off work and was now reluctant to return. They spent the day travelling slowly up and down the canal, delivering sacks of coal and cylinders of gas to the boat dwellers, all of whom they knew. It was like living in a village. They were very happy, they told me, with their slow and peaceful life, uncluttered by possessions, living in a second barge moored further along the canal.

I had to fell several trees – mainly thorn trees, over thirty feet tall – which had taken over one corner of the garden. Much as I love trees, to the point of worship, I must confess that I also love felling them and I own several splendid chainsaws. After some years I have finally mastered the art of sharpening the chains myself. I suppose tree surgery has a certain amount in common with brain surgery – in particular, the risk and precision. If you don’t make the two cuts on either side of the trunk in precisely the right place the tree might fall on you, or fall to become jammed in the surrounding trees, which makes further work extremely difficult; or the bar of the chainsaw can get completely stuck in the tree trunk. And the chainsaw must be handled with some care – I once saw a patient whose chainsaw had kicked back into his face. But there is also the smell of the cut wood – oak is especially fine – mixed with the chainsaw’s petrol fumes and, depending on where you are working, the silence and mystery of being in a forest. One of the first books I read as a child – perhaps because my mother was German – was Grimms’ Fairy Tales, with its many stories of devils, bloody death and punishment, set in dark woods. Felling trees is also a little cruel – like surgery. There is your joy in mastery over a living creature. To see a tall tree fall to its death, especially if you have felled it yourself, is a profoundly moving sight. But what makes brain surgery so exciting is your intense anxiety that the patient should wake up well, and you fell trees to provide wood for making things or for firewood, or to help the growth of other trees. And, of course, you should always plant new ones.

Twenty-five years ago I acquired twenty acres of land around the farmhouse in Devon where my parents-in-law from my first marriage lived. I planted a wood of 4,000 trees in eight acres – native species, oak and ash, Scots pine, willow and holly. For a few short years I could happily tend the trees when I visited Devon, carefully pruning the lower branches of the young oaks, so that after a hundred years they would provide long lengths of knot-free, good-quality timber. I made an owl box and put it up in the branches of an old oak tree growing in one of the hedges that lined my land. I once saw an owl sitting thoughtfully in the box’s large opening, which was a very happy moment, but to my disappointment the owl did not take up residence in it. I hoped that I would be buried in the wood after my death, and that eventually the molecules and elements of which I am made would be rearranged as leaves and wood. I had no idea at all of the disaster that awaited my marriage. I lost the land and the trees with divorce, and they were soon sold off. You can still see the wood, now overgrown and neglected, on Google Earth. A third of the trees should have been felled to allow the remaining ones to grow stronger, but this has not been done.

I miss the place greatly – not only the fields and the wood, but the workshop I set up in one of the ancient cob-built barns opposite the farmhouse. The windows, which I had made myself, in front of the workbench, which I had also made, looked out over the low hills of north Devon towards Exmoor. Swallows nested in the rafters above my head, and the young ones would learn to fly by fluttering from beam to beam. Their parents would dart in through the open doors and, if they saw me, would at first turn a somersault directly in front of me – I could feel the air under their wings in my face – and then shoot out again, but after a while they became used to my presence. By late summer the young birds would be flying outside in the farmyard and gather on the cables that stretched from the farmhouse to the barns, little crotchets and minims, making a sheet of sky music. Before autumn came, they would leave for Africa. I returned to have a look at the farm twenty years later, explaining to the new owner my connection with the place. He proudly showed me all the improvements that he had made. I probably should not have gone: the barns and my workshop had been converted into hideous holiday chalets and the swallows evicted, never to return.

Once I had cleared the tons of rubbish from the garden of the lock-keeper’s cottage, I planted five apple trees and one walnut tree. The apple trees were traditional varieties such as Cox’s Orange Pippin and Blenheims – the same kind of trees as those in the orchard of my childhood home nearby, where I had grown up sixty years earlier.

It had been a working farm until only a few years before my father bought it in 1953, when I was three years old. It was a very fine Elizabethan stone building with a stone roof. There was a farmyard with thatched stables, a large pantiled barn and the orchard and garden, with sixty apple and other fruit trees and a small copse – a paradise, and an entire world for a child such as myself. It was on the outskirts of Oxford, where open fields met the city. There is now a bypass running over the fields. The neighbouring farm has been replaced by a petrol station and hotel. Most of the orchard has been felled, and a dull housing estate has replaced it. The barn and stables have been demolished. There is still a pine tree there, stranded among the maisonettes and parked cars, which had stood guard at the entrance to the copse. I was frightened of the copse, and thought it was full of the witches and devils I loved reading about in fairy stories. I remember how I would stand by the pine tree, sixty years ago – the tree must have been much smaller then, but looked enormous to me. I was too scared to enter the deep and dark forest it guarded, despite longing to be a brave knight errant. Sometimes, as I stood there, I could hear the sound of the wind in its dark branches above me, and it filled me with a sense of deep and abiding mystery, of many things felt, but unseen.

We had many pets, one a highly intelligent Labrador called Brandy. He belonged to my brother but I wanted to train him to sit and beg. I’m not sure why – I now hate to see animals trained to do tricks. But I did it with great cruelty, using a whip made from electric cable, combined with biscuits. He learnt quickly, and I enjoyed the feeling of power over him until my mother found me once with the poor creature. The dog would never stay alone with me in a room for the rest of his life, a constant reminder of what I had done, however much I now tried to persuade him of my love for him. I was filled with a deep feeling of shame that has never left me, and a painful understanding of how easy it is to be cruel. This was also an early lesson in the corrupting effect of power and I wonder, sometimes, if this has perhaps made me a kinder surgeon than might otherwise have been the case.

I had a slightly similar experience when I started work as an operating-theatre porter in the northern mining town. There was an elderly anaesthetist who I now realize was appallingly incompetent. On the first day that I was on duty to assist him, he seemed to be having difficulties intubating the patient, who started to turn a deep-blue colour (known as cyanosis, the consequence of oxygen starvation). In all innocence, I asked him if patients normally went blue when he anaesthetized them. I do not remember his response – but the other theatre porters fell about laughing when they heard the story. A few weeks later he was having difficulties intubating another patient, who started to struggle – the poor man clearly had not been anaesthetized properly. He told me to hold the patient down, which I did with enthusiasm. I had always liked a good fight when I was at school (although there are more shameful episodes there as well, when my strength and aggression got the better of me and my schoolmates started crying). At that point Sister Donnelly, the theatre matron, entered the anaesthetic room and saw how I was restraining the patient. ‘Henry!’ was all she said, looking genuinely shocked. I cannot forget it. Perhaps it was these experiences that make me cringe when I sometimes see how other doctors can handle patients.

When I worked as a psychogeriatric nursing assistant many years later, it was obvious that the atmosphere on each of the wards was largely determined by the example set by the senior nurses in charge, most of whom understood the duty of care, and how difficult it can sometimes be, as it was a real and daily obligation. As authority in hospitals has gradually passed from the clinical staff to non-clinical managers, whose main duty is to meet their political masters’ need for targets and low taxes, and who have no contact with patients whatsoever, we should not be surprised if care suffers.

At my home in Oxford, with its ancient house and garden – my little paradise – I ran a bit wild, the spoilt youngest child of a family of four. When we moved to London when I was ten years old, it was as though I had been evicted from the Garden of Eden.

As I walked along the towpath towards the cottage I also thought about why I had bought it in the first place and why I felt the need to do it up myself. Most of my life was behind me and I found the physical work involved increasingly difficult and much of it positively depressing. Work seemed to be going backwards, not forwards, let alone the damage caused by the vandals. When I cut into the plaster to install a new power socket, huge pieces of it fell off the wall. The lath-and-plaster ceiling of the room downstairs collapsed in a cloud of dust when I tried to strip the polystyrene tiles that had been glued to it. The new windows that I had made myself had all been smashed and I would have to reglaze all of them, and now one of the roof windows as well. Besides, if I ever finished the work, what would I do then? I had to conclude that what I was doing was not just to prove that I was capable of such work despite growing old, but also an attempt to ward off the future. A form of magic, whereby if I suffered now, I would somehow escape future suffering. It was as though the work involved was a form of penance, a secular version of the self-mortification found in many religions, like the Tibetans who crawl on all fours around Mount Kailash in the Himalayas. But I felt embarrassed by the way in which I was doing all this in the cause of home improvements – it seemed a little fatuous when there was so much trouble and suffering in the world. Perhaps I am just a masochist who likes drawing attention to himself. I always was a tremendous show-off.

Thinking these depressive thoughts, I arrived at the cottage but, just as on my previous visits, as soon as I saw it I had no doubts. There was the wild garden and the old brick horse troughs with the quiet canal in front and the lake behind, lined on one side with tall willows. The two swans were there, perfectly white on the dark water and, beyond them, reeds faded brown with the winter, and then the railway line, along which I had once watched steam trains roaring past as a child. When I went inside – in darkness, now that the broken windows were all boarded up – the light from the open door fell on broken glass, shining and scattered all over the floor, which crunched underfoot as I entered. But it no longer troubled me.

I would restore this pretty and humble building, I would exorcize the old man’s death and all the sad rubbish he had left behind. The six apple trees and one walnut tree would flourish. I would put up nesting boxes in the trees, and an owl box, like the one I had installed in the old oak tree in the hedge beside the wood in Devon.

I would leave the cottage behind, for somebody else to enjoy.

I decided to put motion-detecting floodlights high up on the cottage walls, and also CCTV cameras – a reluctant concession to the thieves and vandals. This involved working up a ladder, high under the eaves of the roof. I have lost count of the number of elderly men I have seen at work with broken necks or severe head injuries sustained by falling off ladders: a fall of only a few feet can be fatal. And there is a clear connection between head injuries and the later onset of dementia. I therefore drilled a series of ringbolts into the cottage wall, like a climber hammering pitons into a rock face, and tied the ladder to the ringbolts and, wearing a safety arrest harness, attached myself to the ladder with carabiners as I fixed the lights and wretched CCTV cameras, wielding a heavy-duty drill to bore through the cottage walls for the cables.

While I was doing this work I received a visitor. I climbed down the ladder. He was a man my age, walking with a golden retriever, which happily explored the wild garden while we talked.

‘I lived here as a child sixty years ago,’ he said, ‘in the 1950s, before Dennis the canal labourer took it over. My brother and I lived here with our parents. It was the happiest time of their lives.’

We worked out that we were of the same age and had lived at the same time in our respective homes less than one mile apart. He produced an old black and white photograph showing the cottage looking tidy and well cared for, with a large flowering plum tree in the front garden. You could just see that the garden had many vegetables growing in neat rows. His mother was standing at the garden gate, wearing an apron.

‘I scattered my parents’ ashes over there,’ he told me, pointing to the grassy canal bank on the other side of the little bridge across from the cottage. ‘I come here to talk to them every so often. I told them today that their grandson had just got a university degree. They would have been so proud.’

I showed him around the inside of the cottage. He gazed at it in silent amazement – so many memories must have come back.

‘My dad used to sit in the corner over there in the kitchen,’ he said, pointing to the place where there had once been a stove. ‘He had a handful of lead balls. He’d throw them at the rats when they came in through the front door, but I don’t know if he ever got one.’