Admissions: A Life in Brain Surgery

11

MEMORY

By the time that he died at the age of ninety-six my father had become profoundly demented. He was an empty shell, although his gentle and optimistic good nature remained intact. The live-in carers my brother had organized to look after him in his flat often remarked on how easy it was to look after him. Many of us, as we dement, increasingly confused and fearful as our memory fades, become aggressive and suspicious. I had seen this myself when I worked briefly as a geriatric nursing assistant, although in the grim and hopeless environment of a long-term psychiatric hospital – an environment which must have made the poor old men’s problems many times worse than they might otherwise have been. He was famously eccentric – the porters at the Oxford college where he had been a don after the Second World War regaled me – when I went there as an undergraduate myself many years after he had left – with stories of his many eccentricities. He once met one of his former pupils, who told him that he had always been terrified when having a tutorial with him. My father, the mildest of men, was painfully surprised, until his former pupil went on to explain that he had rarely had any matches with him when giving tutorials. He would light the gas fire in his room by turning on an electric fire – one of those old models with a red-hot bar – and pressing it against the gas fire. The tutorial would therefore start with an alarming explosion. There had been an electric fire like that in my bedroom in the old farmhouse. There was no central heating: in winter there would often be frost flowers on the bedroom windows in the mornings and I would lean out of bed, trying to stay under the blankets, heating my clothes in front of the fire before getting up to bicycle to school.

I used to read late at night with a torch under the blankets after my mother had kissed me goodnight and turned off the lights in the room. At the age of seven I borrowed a school friend’s book about King Arthur and his knights. I became slightly obsessed by these stories and read everything I could find about knights and chivalry, including Malory’s Morte d’Arthur. I considered Lancelot and Galahad to be hopeless goody-goodies but greatly admired Sir Bors, who was tough, loyal and reliable. He would have had no time for women or religion, I thought. My edition of Malory had many coloured illustrations by Sir William Russell Flint, the popular late-nineteenth-century artist, who was famous for his erotic paintings of women. His illustrations for Malory had heroic knights and beautiful maidens with long Pre-Raphaelite hair in tresses and wearing long and flowing robes, which I found highly attractive. This night-time reading probably contributed to my severe short-sightedness, which resulted in retinal detachments many years later.

I found my weekly attendances at Sunday School extremely boring, and the illustrations in the little books of Bible stories for children very dull compared to the pictures in the Morte d’Arthur. Both my parents were sincere – although relaxed – Christians. I received a traditional English middle-class Christian education at Westminster School, including morning service six days a week in Westminster Abbey when I was a teenager. Every so often the organist would play the last movement of Widor’s Fifth Symphony – the only piece of French organ music I could abide – at the end of the service. I would stay behind in the now empty building as the music crashed and boomed under the great Gothic roof and round all the marble statues and monuments, until my anxiety about being late for the first class would overcome me and I would run back to the school through the empty cloisters, over the worn gravestones, with the music fading behind me.

I was bitterly unhappy in my first year at the school. I was a boarder for the first time in my life. I think my parents thought it would be good for me, and it was a fairly traditional part of a middle-class boy’s education at the time. I missed having my own room and, being very innocent and prudish, was shocked by the other boys’ endless talk about sex. I once went to the housemaster to complain about this – I squirm at the memory. After a year I finally dared to tell my parents how unhappy I was. I remember the overwhelming sense of relief when I realized that it was going to be possible for me to become a day boy.

In my last year at the school I spent Friday afternoons in the Abbey Muniments Room, filing nineteenth-century inquest reports from the Westminster Coroner’s Court. The Cadet Corps had been abolished. Until then we had spent Friday afternoons in military uniforms marching round the school yard with ancient rifles, .303 Lee Enfields said to date back to the Boer War, but converted to .22 bore. We were offered various alternatives to the Corps and I chose the Muniments Room. The room was part of the south transept of the Abbey, above the aisle, and you looked directly down into the Abbey itself. I was tasked with filing a large number of Coroners’ Inquests from the Westminster Court in the 1860s. The reports, bound in crumbling green tape, were kept in a huge, semicircular medieval chasuble chest made of oak which was black with age. I found an old sword on top of the chest. Henry V’s sword, I was told, which indeed it was. I liked to wave it around my head while quoting the appropriate lines from Shakespeare. The Keeper of the Muniments was a small, round and bird-like man who wore bright yellow socks and rolled rather than walked. He took very long – probably liquid – lunch breaks so I was left largely to my own devices. Although I found the inquests fascinating – stories of death in Dickensian London in perfect copperplate writing – I was more excited to discover a spiral stone staircase leading up from the Muniments Room to the triforium and roof of the Abbey. I therefore spent most of my Friday afternoons exploring all the empty spaces and the roof of Westminster Abbey, with wonderful views of central London.

As far as I can remember, I never believed in God, not even for a moment. At one morning service in the Abbey I remember seeing the school bursar – a retired air commodore – praying. He was kneeling opposite me on the other side of the gilded choir stalls. There was a look of the most terrible pain and pleading on his face. He disappeared from the school shortly afterwards and I heard later that he had died from cancer.

My father’s dementia was probably avoidable. He had suffered two significant head injuries in his seventies – once when falling between the rafters of a friend’s attic and knocking himself unconscious on a marble fireplace in the room below, and once falling off a ladder when trying to read the gas meter in his huge eighteenth-century house in London. He already had form for losing his footing between attic rafters: in the ancient house in Oxford where we lived in the 1950s, his leg, much to the surprise of the family’s au pair, once appeared in a shower of plaster through the ceiling above her bed, but fortunately not the rest of him. At the time of the two head injuries he had seemed to make a reasonable recovery, but they probably contributed to his slow deterioration in old age.

I was not a good son. In his declining years, after our mother’s death, although I lived quite nearby I rarely went to visit him. I was impatient with his forgetfulness and distressed by the fact that he was no longer the man that he had been. My siblings went to see him more often than I did. Both my parents expected very little from me – they took pleasure in any success that I had, and were always anxious to help me in any way that they could – yet rarely, if ever, seemed to ask for anything in return for themselves and rarely, if ever, complained. I exploited their love, although their love was certainly the principal source of my feeling of self-importance, something which has been both a strength and a weakness throughout my life.

My father had been an eminent lawyer, although his career is not easy to categorize. An Oxford don for fourteen years, he left Oxford to run various international legal organizations and finally worked for the British government on reforming and modernizing British law as one of the first Law Commissioners. When I was young I had no interest in the law or in my father’s work – it seemed terribly boring. It was only in the closing years of my own career as a doctor, mainly from my work overseas, and having to witness so much corruption and the abuse of power, that I came to understand the fundamental importance of the rule of law to a free society – the principle that lay at the heart of my father’s work and view of the world. Democratic elections, for instance, mean little without an independent judiciary. His obituary in the London Times filled an entire page and I was filled in turn with both filial pride and guilt. My own career, as a doctor, now seems to me rather slight in comparison to his.

The profoundly serious nature of his work – and his deeply moral and almost austere view of the world – were completely at odds with the way he did not seem to take himself at all seriously. The family followed his lead, and I fear that we treated him more as a figure of fun than of authority. There were only a few rare occasions when he would briefly lose his temper with us over the way that we treated him with such a singular lack of respect. He enjoyed telling stories against himself and of his – not entirely unselfconscious – eccentricities. He often talked of writing his memoirs but he never got beyond the first page, which described how he pulled the lanyard on an artillery piece in Victoria Park in Bath in 1917, at the age of four, as a reward for his parents buying war bonds to help finance the First World War. I often said that I would sit down with a tape recorder and record his many memories and stories – he had led a most unusual and very interesting life and was an excellent raconteur – but I never did, and this is something I deeply regret. His past, and many of the stories that he had heard in turn about his family’s origins in the countryside of Somerset and Dorset, faded as his brain decayed and are now lost for ever. I know only a few fragments.

During the war he had been in Military Intelligence, interrogating high-ranking German prisoners of war, as he spoke German. His preferred technique, he once told us, was to treat the interrogation sessions like an Oxford tutorial, and encourage the prisoners to write essays for him on democracy and the rule of law. ‘The hardened Nazis were a lost cause,’ he said. ‘But it worked for some of the others.’ One U-boat captain, he discovered, was something of ananti-Nazi, so my father dressed him in a British Army greatcoat and smuggled him out of the prison camp to take him on a tourist trip round London, although he said he was a little worried as to what he would say if they were stopped by the police. He was outraged when stories emerged of the British Army hooding – effectively torturing – IRA suspects in Northern Ireland at the start of the Troubles. Like many experienced interrogators, he was of the opinion that kindness and persuasion worked much better than torture. His particular interest, when interrogating prisoners, was in German morale. He wrote a report arguing that the carpet bombing of German cities was strengthening it rather than breaking it. Apparently, when ‘Bomber’ Harris – the head of RAF Bomber Command – saw the report, he was so enraged that he wanted to have my father court-martialled. This did not happen, fortunately, and history, of course, has entirely vindicated my father.

He liked to claim – I suspect with some exaggeration – that there were only three books in his parents’ house in Bath, where his father ran a jewellery business and his mother had a dress-making business until she had children. She was a farmer’s daughter – one of eight children – and used to walk eight miles to work every day as a seamstress, eventually owning her own shop, which, our father assured us, had been highly fashionable. He had a difficult relationship with his father, and once had even come close to blows.

‘Did you feel bad about that?’ I asked him, when he once told me this.

‘No,’ he replied calmly. ‘Because I knew I was right.’

His certainty was not arrogance, but was based on a coherent and stubbornly moral outlook which was usually correct, and which was most frustrating for the rebellious, selfish teenager that I once was. His own father – whom Inever knew, as he died shortly after my birth – could not understand how his son had become a left-leaning liberal intellectual, with a house packed with many thousands of books and a German refugee for a wife.

Before reading law at Oxford he had been educated at a minor public school near Bath which, he once told me, specialized in turning out doctors and evangelical missionaries. In later life he said he still had nightmares about the place – Tom Brown’s Schooldays were nothing, he once told me, compared to what he had to put up with. So he hated the place, yet he became the Sergeant Major for the school’s army cadets, played rugger in the First XV and rowed in the First Eight. He said that he owed everything that he became to one inspirational history teacher. His attitude to success and conventional authority remained deeply ambiguous throughout his life. One of the few times I saw him seriously distressed (other than the various occasions when I caused him great pain) was when the teacher who had so inspired him wrote to him asking for a contribution to a fundraising campaign for his old school. My father was a deeply generous man and involved in much charitable activity, but after a great deal of painful heart-searching, he wrote to his old teacher and mentor saying that he felt unable to send any money.

He had been secretary to the Oxford League of Nations Association – an organization both idealistic and doomed – and had met my mother when he went to Germany to learn German in 1936. He stayed in the town of Halle, where he found himself in the same lodgings as my mother, who was training to be a bookseller. Her strongly anti-Nazi political views had prevented her from going to university and so she chose bookselling as the career closest to her love of philology. My father was the first person she met to whom she could pour out her heart about her deep unhappiness as to what was happening in Germany. Her views eventually got her into trouble with the Gestapo. Her colleagues at work, with whom she had been overheard exchanging anti-Nazi views, were tried and imprisoned but my mother was let off on the grounds that she was – as one of the two Gestapo men who interrogated her put it – a ‘stupid girl’. They told her, however, that she would be cross-examined as a witness in her colleagues’ trial and she felt that she would not be able to cope with this. So, in brief, my father married her and brought her to England, a few weeks before the Second World War started.

My mother’s sister was an enthusiastic supporter of Hitler and the Nazis, and her brother joined the Luftwaffe, although from a love of flying and not from any political conviction. I do not know how my mother knew that Hitler’s regime was evil. It is only since her death, by reading about Germany at that time (in translation, given my shameful lack of German) that I have come to understand just how remarkable was her defection. Her decision to leave Germany – a country with the deepest respect for authority and on the brink of war – would have been seen by many as treason. It seems obvious and easy in retrospect, but how I wish she was still here so that I could talk to her about this.

Sixty years later, I asked my parents about their decision to get married. My first marriage was falling violently apart, and sometimes I went to speak to them about my unhappiness. I should not have burdened them with this, but it was a strange experience to converse with them both almost as equals, as fellow adults, about the difficulties of married life. I learnt that the decision to marry my mother had been a difficult one for my father, although he did not specify exactly why. My mother suggested he was on the verge of marrying somebody else in England, but my father did not confirm this. He told me that he was in such a state of despair that one day, working as a young lawyer in London, he was walking up Tottenham Court Road and saw a doorway with a sign advertising a counselling service. I think it was some kind of Christian mission – whatever it was, my father said that he went in and found a man there who helped him greatly.

In Nepal marriages are still arranged. My Nepalese friends tell me that it usually works. Sometimes it seems to me that my parents’ highly successful marriage was, in a way, also arranged – arranged on the basis of the rule of law, morality and liberal democracy. They were closely involved from the 1960s onwards in the creation of Amnesty International, and my mother ran – in her quiet and wonderfully efficient way – the registry of political prisoners in dozens of countries. At the beginning the offices were in the chambers of the lawyer Peter Benenson, who had come up with the idea for the organization. I would go in sometimes to help – mainly to lick and stamp envelopes. I would like to say these were for letters sent to dictators all over the world, but they were mainly newsletters to the small groups of volunteers – organized in cells like revolutionaries – who adopted particular prisoners and would write in protest to the dictatorial regimes that had imprisoned them.

By the time that I was born in 1950 my mother had developed a strange, disabling condition which resulted in excruciatingly painful bruising over many of her joints. She consulted a wide number of specialists but none could come up with a diagnosis. One suggested it was allergic, so they had the family pets put down. The only treatment that seemed to help was arsenic (from which she developed a rare skin cancer called Bowen’s Disease many years later).

Eventually in despair – I think I was only a few months old at the time – they sought a psychiatric opinion and my mother was admitted for six weeks’ inpatient psychoanalytic treatment in the Park Hospital in Oxford under the care of a fellow German émigré. He was, she once told me, very much like her father, who had died quite suddenly in 1936 from metastatic bowel cancer when she was nineteen. As a fellow émigré, he must also have understood her deep sense of loss – of her family, of her past and much of her identity. Her mother had died from breast cancer during the war and her sister perished in a British air raid on the city of Jena. Her sister had been an enthusiastic Nazi and she and my mother had parted on bitter terms when my mother left for England, although my mother was told after the war that her sister had changed her mind before her death. And perhaps, although I never asked her directly, she also felt that she had betrayed her principles by fleeing from Germany and by not standing up for them and her colleagues in court.

The treatment worked and the stigmata-like bruises disappeared. There is no way of knowing whether it was the psychoanalysis which helped, or whether it was the way in which my father, by his own admission, became a more considerate husband because of her illness, or whether it was simply the rest in hospital from bringing up four children with minimal help and from a husband who was completely dedicated to his work. My parents once told me – as a joke – that my own personality, which at times caused them great problems, was partly to be explained by the famous child psychologist Bowlby’s work on maternal deprivation. This may or may not be true, but only as I reach old age myself have I come to understand just how completely I am my parents’ creation, and whatever good is in me came from them.

Thirty years later, by which time I was a medical student, my mother’s purpuric swellings, or ‘bumps’ as she called them, reappeared, much to my parents’ alarm. ‘You must be stressed and anxious about something!’ I remember my father saying to her, close to despair, as she lay on her bed in severe pain. But on this occasion a specialist prescribed the drug dapsone – a drug normally used for leprosy – and the bruises immediately disappeared. I still do not know what the underlying diagnosis might have been. If dapsone, a mere chemical, had been available in 1950, perhaps I would not be the person I am now, and I might not be sitting in a remote Nepalese valley, at the foot of Mount Manaslu, writing about my parents as I listen to the water of the glacial River Budhi Gandaki, rushing noisily past over its many rapids on its journey from the Himalayas to join the River Trishuli and then the Ganges, to end in the Indian Ocean.

My father was a tremendous optimist – even as his memory deteriorated he would express the hope that things would get better. Before his dementia became profound, while he was still living in the grand eighteenth-century house overlooking Clapham Common, I once engraved a brass plate with the family name to go by the bell push for the front door to distinguish it from the bell for the basement flat, which was now rented out. My engraving was very clumsy and the letters became smaller as they went from left to right. ‘Like my faculties,’ he said sadly as we looked at it together after I had screwed it in place. He still had some insight then, into what was happening to him. ‘But I think things will get better.’

On my second trip to Nepal I accompanied Dev to a Health Camp he had organized in a remote corner of the country. The metalled road ended at Gorkha, and we then took three hours to travel the thirty-six kilometres over the mountains to the small town of Arughat on a wildly uneven dirt track – though not uneven enough to dissuade large trucks and buses from crawling along it as well, throwing up huge clouds of ochre dust. In places there was barely room for the vehicles to squeeze past each other, often with a precipitous drop, only a few centimetres away, to the valley below. On a clear day we would have seen Mount Manaslu at the head of the valley, one of the most beautiful of the great Himalayan peaks and the eighth-highest mountain in the world, but the haze was intense and there was no view at all.

The Health Camp took place in what had been a brand-new primary care hospital, but which had been badly damaged in the earthquake a few days before it was due to open. It had been abandoned until Dev had come to inspect it and found that most of the building was serviceable, although in a terrible mess. An advance party had arrived a day before us and I was very surprised to find a clean and tidy building – although with great cracks in the walls and one wing partially collapsed – when we arrived. The Neuro Hospital team of over thirty doctors, nurses and technicians had come with enough equipment to run two operating theatres, a pharmacy and five outpatient clinics, with plain X-rays and ultrasound and a laboratory. It was an impressive piece of organization – but they had done similar camps elsewhere before, especially after the earthquake, and had learnt from experience.

Next morning there was a long queue of patients – several hundred, mainly women, all dressed in brilliant red – waiting outside the hospital. All the treatment would be free. They were sheltering under equally colourful umbrellas, as the temperature was soon in the 90s. They were held back at the hospital gates by armed policemen and allowed in, one by one, to be registered at the entrance and directed to the appropriate clinic – such as orthopaedic, plastic-surgical or gynaecological. Fifteen hundred patients were seen in three days and many, relatively minor, operations performed, some under general anaesthetic. Difficult cases were advised to go to larger hospitals long distances away. Patients came from far and wide – the Health Camp had been advertised for many days in advance.

‘Some patients are coming from the Tibetan border,’ I was told.

‘How far away is that?’

‘Four or five days’ walk. No roads. Ten days if you or I tried to do it.’

Sick patients arrived on stretchers. Several old people arrived carried piggyback.

Although I was treated like visiting royalty, and presented with bougainvillea garlands and silk scarves at the lengthy opening and closing ceremonies by the local people, and a framed certificate entitled ‘Token of Love’, I was completely useless. My days of general surgery and general medicine are long behind me. I was disappointed to find, as I watched Dev happily operating on inguinal hernias, hydrocoeles and similar lesions, that I had completely forgotten how to do them, even though I had spent a year doing dozens of such cases when working as a general surgeon. Thirty-five years ago, a year of general surgery had been a necessary part of qualifying for the final FRCS examination, which I had to pass before I could train as a neurosurgeon. I sat in on some of the Health Camp clinics, and I found that the junior doctors knew much more than I did.

Dev is doing a clinic – a chair has been put next to him for me. A tidal wave of patients now flows in: an old woman with elaborate gold ornaments in her nose and a rectal prolapse, old men with inguinal hernias, old women with haemorrhoids, many patients with varicose veins – cases which remind me why I was pleased when my year of general surgery came to an end almost forty years ago, and I could devote myself to neurosurgery. But it also reminded me how modern medicine is not just about prolonging life – it has probably achieved as much good by finding treatments for all the chronic non-fatal conditions from which we would otherwise suffer and from which people in poor countries like Nepal still suffer.

I remembered a rectal clinic I had done on Friday afternoons when I did my mandatory year of general surgery. Neither I, nor my patients, enjoyed the experience. They knew, and I knew, that I was going ‘to give them a ride on the silver rocket’ – the medical procedure of sigmoidoscopy, where an illuminated long stainless steel tube is used to examine the inside of the rectum. But I was happy enough when I was in the operating theatre.

There is a young woman with unilateral proptosis – her right eye is bulging outwards; we will send her to Kathmandu for a scan. There is a girl with what are probably pseudo-seizures, hurried in by her anxious mother. If people have fits in front of the doctor – which is what is happening here – it usually means, although not always, that the problem is psychological rather than epileptic. Dev prescribes the antidepressant amitriptyline. There’s no question of any follow-up in such a remote country area. It is impossible to know what will happen to the patients. Many of them – most of whom are illiterate – produce plastic bags full of the many medicines they have been taking.

It’s all in Nepali, of course. I am half asleep, lulled by the sound of hundreds of voices outside and the whirring of the ceiling fan. The temperature outside must be in the high 90s. The patients at the front of the queue are pressed up against the metal gates, and the police guards push themselves into the crowd from time to time to stop fights breaking out, or to allow urgent cases to be brought into the hospital. But inside the building everything is highly organized.

There is a man with huge, wart-like growths on his hands and feet. Next we see a five-year-old boy and his ten-year-old sister, who both went blind at the age of two. They are led into the room and sit sightlessly while my colleagues thumb through the stained and dog-eared pieces of paper that comprise their medical notes. All we can do is confirm that there is nothing to be done. I ask whether there are schools for blind children in Nepal and am told that there are, but that it is unlikely that these children, from a remote mountain village, could go to one.

At lunch on the baking-hot roof, sitting in the shade of a bright-blue UNHCR tarpaulin left over from earthquake relief, I talk to the gynaecologist.

‘How many PVs [vaginal examinations] have you done so far?’

‘Over five hundred.’

‘Do the women know any anatomy?’

‘Most know none at all. It’s a waste of time trying to explain anything to them. A few of them can understand. But usually I just say take the medicine and this is the name of your illness. The women in the queue outside the room,’ she adds, ‘were starting to fight each other, trying to get in…’

One room is reserved for people who are too weak to sit or stand. There is a young woman with diabetes who is now in severe ketoacidosis. She lies on a stretcher, with dulled eyes and a deeply resigned expression on her face, coughing and retching into a plastic bowl from time to time. The MO fails to get a drip up on her and I reconfirm my uselessness by also failing. One of the anaesthetists succeeds. We give her IV fluids and find some insulin from another patient.

‘What’s her outlook?’ I ask.

‘Not good. Poor peasant in a remote village. Can’t afford insulin. Diabetes is still a fatal disease here for many people. But we’ve told her husband to take her to the nearest big hospital. They may be able to help.’

I find an empty room in the ruined part of the hospital. There are large cracks in the wall from the earthquake. The many windows look out onto some tall mango trees and the room is full of the sound of the wide River Budhi Gandaki rushing past, coming down from the glaciers of the invisible Mount Manaslu. I sit there quietly for a while, trying to write, until two playful Nepali boys find me and peer over my shoulder at what I am doing and will not leave me alone, so I return to the clinic to watch more patients come and go.

After three days, Health Camp comes to an end. By the early evening there are only a few patients left waiting outside the entrance. I sit outside on a white plastic chair looking at the dim, blue hills around me. It is still very hot, and there is a strong wind, so the giant mango trees wave and shake. A noisy wedding party passes on the nearby road, dust swirling about them, the women all brilliantly dressed, with two men at the head of the procession blowing on long, curved horns. The bride is carried in a palanquin, and is veiled and dressed in red and flashing gold. The groom walks behind, his face heavily made up, wearing an elaborate and decorated coat. Three young girls are playing in the hospital courtyard and come up to me. We exchange a few words, which we don’t understand, and they happily laugh and dance around me for a while, before running away. I so wish I spoke their language and could talk to them. My inability to speak any language other than English is the deepest of all my regrets. So I sit by myself and watch dust devils spiral up off the dry ground, driven by the wind, as the light slowly fades.