Admissions: A Life in Brain Surgery

7

AN ELEPHANT RIDE

We set off for the Terai – the flat lowlands in the south of Nepal, bordering India – early in the morning, just after dawn, the air very still and humid and hot. I was in a cheerful mood: the day before, I had received the pathology report on the skin tumour I had had removed before setting out for Nepal. The tumour was indeed cancerous but the ‘excision margins were clear’ – in other words, I had been cured and would not need further treatment.

There is an entire tourist village centred on elephant rides adjacent to the Chitwan National Park. Tourism in Nepal had suffered badly because of last year’s earthquake and the nearby tourist town of Sauraha, with many bars and small hotels, looked almost empty when we drove through it.

‘What will they live off?’ I asked Dev.

‘Hope,’ he said, with a shrug.

There were only a few Western people to be seen, easily identified by their baggy shorts and T-shirts. I always wear a long-sleeved shirt and trousers, not just to be different but because the Catholic missionaries I lived with in Africa fifty years ago, when I was working as a volunteer teacher, taught me that this shows respect for the local people.

We were taken to the government elephant station at the edge of the jungle. We walked beneath tall, widely spaced trees, through patches of sunlight. It was remarkably quiet. There was a group of elephant-high, ramshackle shelters – roofs of battered and rusty corrugated-iron sheets on four posts, surrounded by tattered electric fencing. In the centre of each shelter there was a massive wooden pillar, with heavy chains and shackles hanging down. There were no elephants to be seen.

‘They used to keep the elephants chained at night but an Englishman showed them they could use electric fencing,’ Dev told me.

Beyond the sheds were a few low buildings, and in one with an open front two European teenage girls were sitting cross-legged in very short shorts on the ground next to a dark-skinned elderly Nepali man. They were rolling up handfuls of rice mixed with sweets – the plastic wrappers were carefully removed – into a ball, wound around with long grass, a packed lunch for elephants. They held the ball with one foot and used their hands to bind the long grass around the rice. The girls were very absorbed and everybody was silent. When I asked them where they came from, they smiled and said they came from Germany. I wasn’t quite sure what to think about seeing these children of the affluent West playing at being peasants.

And then, slowly, coming out of the surrounding jungle, a huge elephant appeared with a mahout perched high on her neck, his feet behind her ears. The creature was enormous, solemn and stately, and strangely graceful for such a massive beast. The last of the megafauna on land to survive mankind.

‘That’s the one we’ll be going on,’ Dev told me.

The mahout brought the great creature to where we were waiting, and the elephant bent her huge knees and settled awkwardly down on the ground, back legs pointing backwards and front legs forward. The mahout and his helpers then spent some time fitting a wooden frame over a mattress onto the elephant’s back, kept in place with a wide girth, which they heaved on with ropes to get it tight. While they did this I walked up to the elephant and looked into her small, thoughtful eyes and she looked back at me. She had elegantly curled the end of her trunk over her left foreleg. The day before I had been reading about elephants – of the 40,000 muscles in their trunks, and of their great brains, the largest brain of all land mammals. They are intensely social, with a complex social life. They can console each other, mourn the dead and have a language of sorts. They can also recognize themselves in mirrors (which is generally considered to mean that they have a sense of self).

Nobody knows how many brain cells are needed for consciousness. Recent work on insects suggests that even they might be capable of it; their brains show similarities to the midbrain of reptiles and mammals, where some authorities think conscious experience arises. To ask if a creature is conscious is equivalent to asking if it can feel pain, and nobody knows at what point pain arises in nervous systems. If you deliver a painful stimulus to one of a lobster’s claws, it will rub the painful area with the other claw. Is this a mere reflex? It seems more likely that it feels pain. We boil lobsters alive, of course, before eating them.

When patients are unconscious, for instance after a head injury, we assess the depth of their coma by hurting them. You either squeeze the nail bed of one of their fingers with a pencil, or press very hard with your thumb over the supraorbital nerve just above one of the eyes. If they respond purposefully to the pain – trying to push you away or, just like the lobster, trying to get one of their hands to the painful area – we assume there is some kind of conscious perception of pain going on, even if the patient has no memory of it afterwards. On the other hand, if the patient is in deep coma, they do not move in response to the pain at all, or move their limbs in a reflex, purposeless way. We assume, then, that there is no conscious element to the response and that the patient is deeply unconscious.

And then there is the wonderful mystery, at the other end of the scale from insects, as to why whales have brains which are so much larger than ours. It is true that there are structural differences (whales lack our cortical layer IV and most of them have a much higher ratio of supportive glial cells to neuronal cells than we do), but nobody knows why they have evolved such massive brains, and to what use they are put. In recent years the floodgates have opened with new research into animal intelligence: cows have friends among other cows, pilot whales (a species of dolphin) have more neuronal cells in their brains than any other creature, manta rays can recognize themselves in mirrors, fish can communicate and work together when hunting. We are moving further and further away from Descartes’s separation of mind from matter, and his dreadful claim that animals are mere automata.

Self-consciousness, however, to be aware of one’s own awareness, to think about thinking, is probably a more complex phenomenon. I first discovered it at the age of fourteen on a school expedition to the ruins of Battle Abbey on the South Coast. With the other boys, I ended up larking about on the nearby shingle beach. I ran fully clothed into the sea and stood with the waves lapping about my knees, soaking my school uniform. As I stood there, I was suddenly struck by an overwhelming awareness of myself and of my own consciousness. It was like looking into a bottomless well, or seeing myself between a pair of parallel mirrors, and I was terrified. We returned to London in a coach and I came home in a state of considerable distress. I tried to explain what I felt to my father as he sat in his book-lined study. I started to shout about suicide, but I think he was rather confused by my hysterical outburst, as was I.

Clearly this sudden self-awareness was a philosophical version of the awkward self-consciousness which comes to boys with adolescence, when testosterone levels rise. I remember the shock I experienced on seeing my first, solitary pubic hair. Over the next two years I had a series of what are best described as mystical experiences – feelings of profound illumination and unity associated with intense visual effects, where shadows and colours acquired an extraordinary depth and beauty. My hands, and the veins on them, would look especially profound. I would gaze at them with wonder.

When I was a medical student many years later, studying anatomy, I was particularly fascinated by the anatomy of the human hand. There was a large polythene bag in the Long Room – the room with corpses for dissection – full of amputated hands in various degrees of dissection. The hand is a wonderfully complex mechanism, with a series of tendons and joints and muscles, a device of articulated levers and pulleys. I drew and painted careful and elaborate watercolour studies of these hands, but to my regret lost my anatomy notebooks many years ago. I subsequently discovered in Aldous Huxley’s writings that my mystical experiences were identical to those he described while taking mescaline. There is a form of epilepsy, known as limbic epilepsy – Dostoevsky is thought to have had it – where people have an intense feeling of unity and transcendence, and often interpret it as being in the presence of God. The limbic system is part of the human brain involved in emotions, and in ‘lower’ mammals is mainly involved in olfaction – the sense of smell. When I was at Oxford University most of my friends were experimenting with LSD, but I never dared. I smoked cannabis occasionally but disliked the complacency it produced.

The mystical experiences faded as I grew older, replaced, perhaps, by sexual desire and sexual anxiety. While my contemporaries at school were going to parties and learning to kiss girls, I sat in my room at the top of the large house in Clapham, reading voraciously. I kept a diary which I destroyed in a fit of embarrassment and shame a few years later. I rather regret that: I suspect that many of the questions and problems that trouble me now, as I face retirement and old age, were already present then, when I was also trying to find a sense of purpose in my life, but had much more of it ahead of me. It would also amuse me to see what a prune I was when young, and how seriously I took myself.

My father recommended many books, ranging from Raymond Chandler to Karl Popper’s Open Society and Its Enemies – this latter book, I think, had a great influence on my later life. Popper taught me to distrust unquestioned authority, and that our moral duty in life is to reduce suffering, by ‘piecemeal social engineering’ and not with grand schemes driven by ideology. This, of course, is very close to the Christian ethics and belief in social justice inculcated in me by my parents, and the understanding of the importance of evidence and honesty that I learnt as a doctor. Yet doctors get paid – usually very well – for their work, and we cannot but help people (unless singularly incompetent). So our work need not call for any particular moral effort on our part. It is easy for us to become complacent, the worst of all medical sins. The moral challenge is to treat patients as we would wish to be treated ourselves, to counterbalance with professional care and kindness the emotional detachment we require to get the work done. The problem is to find the correct balance between compassion and detachment. It is not easy. When faced with an unending queue of patients, so often with problems that we cannot help, it is remarkably difficult.

My experience as a hospital operating theatre porter had resulted in my deciding to become a surgeon. I had returned to Oxford to complete my degree before trying to get into medical school. My arrival back at Oxford was shortly followed by my first, and unsuccessful, attempt at sexual intercourse (with a sweet girl in Leicester who took pity on me). This precipitated a further crisis. I started to suffer from manic pressure of thought, seeing all sorts of wonderful connections between disparate things – at first rather exciting, but then very frightening. My ideas started to spin out of control, and the feeling of brilliant omniscience was replaced by a fear that there was some kind of evil presence beside me. I can see now that part of me was trying to force another part of me, through fear, to seek help. There is another form of limbic epilepsy, it is interesting to note, where people experience the presence of evil rather than the presence of God. At a friend’s suggestion – another person to whom I am deeply indebted – I got in touch with the psychiatrist my father had unsuccessfully tried to persuade me to see a year earlier, when I had abandoned my degree. I was admitted for a short time to a psychiatric hospital.

I had a room to myself and lay there on the first night feeling miserable and tense. A friendly West Indian nurse came in and asked me if I wanted a sleeping pill.

‘No, I don’t need one,’ I said defensively.

‘Well, I’m called Charlie and I’m at the end of the corridor if you change your mind,’ he said with smile.

I could not sleep. I had sunk so low that I had no future whatsoever. I had reached the bottom of a bottomless well, and there was no way up again. I had become a mental patient. I was utterly and completely alone. I cried and cried, but even as I cried I felt something frozen in my heart thawing, just like the fragments of the evil magician’s mirror in the boy’s heart in Hans Christian Andersen’s story The Snow Queen. I had been fighting myself for so long, and for so long I had viewed other people only as mirrors in which I tried to see my own reflection (I am, alas, still prone to this). Was it that I had tried to freeze my heart, trying to suppress my hopeless and inappropriate love for the woman who had kissed me? I do not know, but I got out of bed in the early hours and walked down the dark hospital corridor to where Charlie was reading a newspaper, spread out on the table in front of him, in a little pool of light from a desk lamp. I asked him for a sleeping pill – it was Mogadon in those days, now banned. I fell asleep exhausted, and next morning I was rather pleased to see in the bathroom mirror that my inner suffering had finally become real, at least visible. Much better than trying to lacerate my hand and its veins with broken glass, I now had two enormous purple bruises under my eyes.

The next week I spent an hour a day with a deeply sympathetic elderly psychiatrist, unburdening myself. The feeling of being reborn, of being in love with everybody and everything, was intense. When I was discharged I drove up into the Chiltern Hills. It was a perfect autumnal afternoon. My body felt so stiff that it was as though I had run a marathon. I remember the difficulty I had climbing over a padlocked field gate. It was the happiest day of my life.

Research has shown that the ecstasy of being in love rarely lasts more than six months. It fades, and comes to be replaced by the more mundane practicalities of maintaining a successful relationship, but at least it fades a lot more slowly than the ecstasy I felt when I started to take cold showers. The intense feeling of illumination and optimism, of being part of a coherent whole that I felt after leaving hospital, was identical to many accounts I have read of religious conversion and revelation, except that I did not for a moment believe in any kind of divine presence in my life, or in the world. These intense feelings obviously involve the same cerebral mechanisms as when you are in love with a person, with the feeling of joyful unity, beauty and coherence all focused on that one person.

Zebra finches and other birds can grow new brain cells when the mating season begins, when they need to start singing to attract a mate. I wonder whether similar processes go on in our brains when we are in love. I also wonder whether other animals experience ecstasy. It has been suggested that the huge brains of dolphins and whales, creatures who also show great playfulness, mean that they do. It is easy to believe this if you watch a pod of dolphins swimming and leaping through the sea. I did not find God with my ecstatic experience, but instead I learnt that my own mind was a profound mystery, and that the sacred and the profane are inextricably linked. There must be a neural correlate for this, whereby the deep and basic instinct to procreate, present in almost all living things, becomes interwoven with the complex feelings and abstract reasoning of which our larger brains have evolved to be capable. This feeling of mystery about my own consciousness, but without any ecstasy, has grown stronger and stronger in recent years as my life starts to unwind and descend to its close. It is, I suppose, a substitute for religious faith and, in part, a preparation for death.

On one of my trips to the Sudan I had been taken to a small zoo in a huge sugar plantation in the desert, on the banks of the White Nile, a few hundred miles to the south of Khartoum. There was an enclosure with five Nile crocodiles, who eyed me thoughtfully – they prey on humans – half submerged in their concrete pond. Next to it was a cage with a single young elephant in it. Deprived of its mother and its highly developed social life, it had clearly gone mad, and showed the same disturbed behaviour of grotesque and repetitive movements as severely autistic children, or the chronic schizophrenics I once cared for as a nursing assistant. And next to the poor elephant’s cage there was a small enclosure with a young chimpanzee who seemed to have gone as mad as the young elephant. My Sudanese colleague – whom I greatly liked – roared with laughter when he saw my dismay.

‘You English! You are so tender-hearted!’ he said.

The look the Nepali elephant gave me, with her small, red-rimmed eyes – or so it seemed to me – as the girth was tightened round her was of deep and infinitely sad resignation.

We were taken to a twelve-foot-high mounting platform, with a staircase of rotten treads, overgrown with moss and climbing plants. The elephant was positioned alongside it, and Dev and I and two guides clambered into the wooden frame on her back, each of us sitting in a corner, facing outwards, our legs straddling one of the four corner posts. There was a thin cushion and it was less uncomfortable than I expected.

It was quite disconcerting at first, the slow, rocking movement, twelve feet off the ground, with the elephant gently placing her huge feet on the uneven track as we headed back into the jungle. This is going to be a bit boring, I thought, once I had got used to the swaying motion – there is nothing to do. But after a while I started to enjoy it, although I still wondered what the elephant thought about it all.

The mahout carried a sickle and a stick, and he used the sickle from time to time to clear the way, as did the elephant with her trunk, coiling it expertly around branches and snapping them off. The sickle, I had read, could also be used to cut the elephant’s ears if it became difficult to control. I have also read that training young elephants can involve considerable cruelty, although people also write of the close relationship between the mahouts and their elephants and of the benefit to conservation from the tourist income generated by the elephant rides.

Apparently you cannot get an elephant to do something it doesn’t want to do, and watching the mahout and the animal as they chose which way to go through the dense jungle, it was clear some kind of negotiation was continuously going on. The mahout used his feet to kick gently behind her ears to steer her, like the pilot of an airplane using a rudder bar, but it was obvious that the elephant did not always agree with his suggestions. We crossed a river, the elephant effortlessly climbing the steep bank opposite, and went deeper and deeper into the tangled trees of the jungle, along paths that were almost invisible. In a small clearing we saw a herd of spotted deer which took fright and quickly disappeared, bounding with great elegance back into the trees. Apparently there are tigers and leopards in the reservation as well, but they are rarely seen. After an hour of this slow, rhythmic plodding between trees, the leaves brushing our faces, we emerged into grassland, some of the grasses almost as tall as the elephant. The mahout pointed out an area of flattened grass and said something to Dev.

‘Rhino’s bedroom,’ Dev translated, and shortly afterwards, near the riverbank, we came across a rhino with a young calf, which quickly hid behind its mother as the monstrous shape of the great elephant with five human beings on top of it approached. Its mother took little notice of us, continuing to graze, as we admired the studded armour-plating of her skin and her single horn which the Chinese and Vietnamese so stupidly prize, ground up as an aphrodisiac or as a cure for cancer, resulting in the near-extinction of the creature from poaching.

‘Why can’t they use Viagra?’ I complained, as we left the rhino and her calf behind and crossed back over the river. ‘I’m sure it’s cheaper.’

With Dev as translator, I asked the mahout about the elephant as we plodded majestically through the tall grass. He told me that she was forty-five years old and would probably live to seventy, but recently they had lost several elephants to TB. This elephant had had four calves, but three had died before they were three years old.

‘When are the calves taken from their mothers to be trained?’ I asked.

‘At three years old,’ I was told.

I asked if all the elephants were kept alone and was told that they were. As we crossed back over the river on the return journey the elephant suddenly let out a great trumpeting cry.

‘What was that about?’ I asked.

‘She smells another elephant,’ Dev translated.

Back at the elephant station, we climbed off our elephant’s back and had to wait for a while for Dev’s driver and bodyguard to appear. We sat in the sunshine outside a group of huts which clearly had been financed by some well-meaning foreign charity – a lopsided and mildewed notice announced that this was the Children and Women Promotion Centre. The notice was so faded that it was difficult to read, but there was a long list of projects and among these I could just make out ‘Computer Letchur’ (sic), ‘Sports Coachers (any)’, ‘Environment’, ‘Caring Wildlife (injured)’ and ‘orphan animal’, ‘HIV/Aids awareness programme’ and other projects funded by foreign aid. ‘Unskill volunteers’ were accepted. There was another notice, also worn and partly illegible, announcing a Vulture Recovery Programme, with the icons of all manner of international bird charities at the foot of it. The buildings were all dilapidated, with rusty corrugated-iron roofs. The shop was almost empty apart from some cheap imports from China and a single woman in attendance who, most unusually for Nepal, did not smile when I entered. All the world wants to help Nepal and vast sums of aid have been lavished on the country, yet much of it seems to have disappeared without trace, leaving only faded signs and notice-boards behind.

I cheerfully volunteered to join Dev operating on a large brain tumour in an eight-year-old boy and was soon regretting it. The tumour bled like a stuck pig right from the start and there were extraordinarily large arterialized veins running in it that bled furiously and too heavily for the diathermy to work. I started sweating. The problem is that when you worry about the patient bleeding to death you rely on a close working relationship with the anaesthetist, and she didn’t speak English and was very uncommunicative. As I struggled to stop the child bleeding to death from a blood vessel in the centre of the tumour, I despaired of ever managing to train Dev’s juniors to do such operating. It becomes almost impossible if you are trying to train your junior and you have to watch passively while they fumble and stumble, putting the patient’s life at risk. It is easy to see why so often trainees are left to operate on their own, learning the hard way, on the poor and the destitute, who are unlikely to complain if things go badly. In all the countries where I have worked over the years, people with money or influence will make sure that they are not trained upon.

In poor countries such as Sudan and Nepal, there has been an explosion of private clinics and hospitals. The professional associations, largely based on the old British model, have become sidelined, and there is less and less effective maintenance of professional standards. Money and medicine have always gone together: what could be more precious than health? But patients are infinitely vulnerable, from both ignorance and fear, and doctors and health-care providers are easily corrupted by profit-seeking. It is true that socialized health care, as the Americans call it, has many faults. It tends to be slow and bureaucratic, patients can become mere items on an impersonal assembly line, clinical staff have little incentive to behave well and can grow complacent. It is often starved of resources. But these faults can be overcome if high morale and professional standards are maintained, if the correct balance between clinical freedom and regulation is found, and if politicians are brave enough to raise taxes. The faults of socialized health care are ultimately less than the extravagance, inequality, excessive treatment and dishonesty that so often come with competitive private health care.

Dev took over and I was able to go and have a sandwich. In fact the worst of the bleeding had stopped by then, but it was rather wonderful to be able to pause and have a break. And I thought, imagine running a practice like this single-handed for thirty years, with nobody to help out or relieve you – day in, day out and on call every night.

When I saw the boy on the ITU round next day he was awake and crying, and at first I thought that all was well. But something troubled me: his eyes were open, roaming and unfocused. I had missed it at first, but when I came back to see him after looking at the other patients it was clear that he was completely blind.

‘What was his eyesight like before surgery?’ I asked Dev.

‘Not good,’ he replied.

‘He must have had severe papilloedema from the severe hydrocephalus,’ I said. ‘We know that some of them wake up blind after surgery.’

When I saw Dev later in the day he told me that he had seen the boy’s mother.

‘She said his eyesight was very bad indeed before the operation.’

‘I have seen that happen twice before,’ I said, ‘it can’t be avoided.’ It was better not to think of the boy’s future.

One of the first operations I did on a child, when I was a junior registrar, was on a nine-year-old boy with an acute subdural haematoma – a severe traumatic head injury – from a car crash. A neighbour was taking him with his own children to the zoo when another car drove into them. The neighbour was killed, as was his five-year-old daughter. The brain of the child I operated on became so swollen during the operation that I could scarcely get it back into his skull and I even had difficulties stitching the scalp back together over it. This can happen occasionally with acute subdurals. It turned out he was an only child, conceived after years of fertility and IVF treatment. There was no question of the mother having any further children. I had to tell his mother that he was going to die. I watched her as I told her this and realized I was delivering a death sentence, on her as much as on her child. It is not a good feeling to destroy somebody like this. The hospital where I was training was a high-rise building in the north of London, and the ITU had large windows with panoramic views of the city below. I remember how the light from the windows was brightly reflected on the ITU’s polished floor as I led the mother to her son’s bed, where he lay on a ventilator, a large, lopsided bandage hiding my rough stitching. I thought of how difficult it is to believe in a benign deity intervening in human life when you have to witness suffering like this. Unless, of course, in the words of the famous Victorian hymn, there really is a friend for little children, above the bright-blue sky, who will right all the wrongs we suffer in this life on earth in an afterlife in heaven.

But I am a neurosurgeon. I frequently see people whose fundamental moral and social nature has been changed for the worse, often grotesquely so, by physical damage to the frontal lobes of their brains. It is hard to believe in an immortal soul, and any life after death, when you see such things.

The outpatient clinic is usually finished by six in the evening. Dev’s bodyguard will always materialize, as if by magic, at exactly the right time, and we are driven the short distance home. We then sit in the garden, drink beer and talk.

The kidnappers who had kidnapped their daughter six years ago had come up from the valley, poisoning one of Madhu’s dogs with a piece of meat they threw over the fence, before climbing over the spiked fencing that surrounds the garden.

‘It wasn’t just being held at gunpoint and having your daughter kidnapped. There were extortion attempts as well. I used to carry my own mobile phone until I was telephoned one day. “You have heard of the Black Spider group?” the voice said. “You remember how we killed Dr So and So?” They wanted money but I took no notice, and now my driver Ramesh always carries my phone. And during the Maoist insurgency the Maoists often came demanding money. I always refused but said I was happy to give them free medical care.’

‘But the deputy leader of the insurgency was a schoolfriend of yours, wasn’t he?’ I asked.

‘Not exactly a friend,’ he said, ‘but we were at school together. He was very popular with the Christian missionary teachers. I wasn’t.’

‘What we call a little swot?’ I asked.

‘Something like that.’

I asked him what had happened to the men who had kidnapped his daughter.

‘She was so brave!’ Dev said, almost with tears in his eyes. ‘When the kidnappers said they were going to take one of us away, she immediately got up and volunteered. My sixteen-year-old daughter! I felt so helpless. It was really very difficult for me. Why should she be tortured because of my success?’

‘What happened?’ I asked.

‘I had to pay a ransom. But Medha had noticed some details of the place to where she was taken in Patan, because her blindfold had slipped. There was a big police operation and they caught the whole gang. But there was no established sentence for kidnapping – maybe just a year or two in prison. But then the police found drugs on them and they all got fifteen years.’

Dev knew well enough that I was longing to see the high Himalayas, but for much of the time that I was there both the foothills and the mountains beyond them were obscured by mist. We eventually managed to see them in the distance – briefly in the morning before the clouds moved in – from a town called Dhulikhel, after an hour’s drive from Kathmandu at the crack of dawn.

The snow-covered mountains seemed to float in the sky, above the mist-hidden foothills and valleys, serene and celestial, and entirely detached from the world below in which I lived. It needed no imagination to think that gods lived there. I wept silently with happiness that I had lived long enough to see them. And then the clouds rose up from the west and in a matter of minutes the mountains had disappeared from view.

On a later trip to Nepal, I took a few days off work to go trekking in the mountains with my son William, who came out to join me for two weeks. We walked for five days, the first day ascending from Nayapul – a typically scruffy, dusty and rubbish-strewn Nepali town – up towards the foothills around Annapurna South, one of the several peaks of the Annapurna range. After a few miles the dust track ends, and from then on you climb up a path paved with rough-hewn stone and what feels like an endless flight of stone steps. We climbed more than 1,000 metres on the first day like this, the temperature in the 80s. William and our guide Shiva – a delightful man, both solicitous and discreet – climbed imperturbably while I streamed with sweat and had to stop at regular intervals to catch my breath. I had assumed that my daily exercise regime meant I was very fit. I am getting old, I thought, and remembered how so many of my elderly patients in England would protest when I explained that their problems were due to old age. ‘But Mr Marsh, I still feel so young!’

As we climbed, the villages at first were all formed around small subsistence farms. Shiva would point out the various crops being grown – rice at the lower levels, potatoes and corn as we slowly climbed higher. Annapurna is a conservation area, and entirely free from the rubbish of the towns. There are medieval scenes to be seen – a farmer with a pair of oxen ploughing a sloping field, with steep hills and mountains in the distance, old women carrying firewood in large baskets on their backs, mule trains going up and down the stone steps. As you climb higher the hillsides become too steep and cold for any farming. The entire area is now based on the trekking industry, a very important part of the Nepalese economy. It is a little strange to see the local Nepalis slowly walking up and down the stone stairs, carrying enormous baskets on their backs or tree trunks or building materials, alongside the wealthy Westerners in their shorts and T-shirts and backpacks. I saw a couple of German tourists at one of the guest houses, slowly walking barefoot on the sharp gravel of the footpath outside our guest house. Later I saw them setting off with a group of trekkers all carrying yoga mats, so I suppose they were seeking enlightenment in the high mountains as well as on gravel. A grey-haired English woman, travelling alone, told us she was heading for a remote village.

‘It’s said that there are old lamas there,’ she said with a note of awe in her voice, and then added, ‘But they might not talk to me.’

‘Twenty per cent houses now empty,’ Shiva told us, pointing out yet another empty dwelling. Rural depopulation continues apace, with more and more people leaving for the nearby city of Pokhara. The houses in the mountains are usually built of stone, with wooden balconies, and some still with stone roofs. They can be very beautiful. The roofs are increasingly being replaced with incongruous bright-blue corrugated metal. His own house, Shiva told us, had been badly damaged in the earthquake. He had young children and elderly parents to care for, so he had to spend much of the year guiding trekkers, trying to accumulate enough money to build his family a new home. His life, he said, was rather difficult at the moment, and I thought he looked old and careworn for his age of thirty-three.

We passed many mule trains going up and down the trail, the patient creatures carrying gas cylinders, concrete blocks, sacks of cement, food and crates of beer. They carefully picked their way over the rough stone steps, their neck bells daintily ringing. We longed to see the high, snow-covered mountains, but they remained stubbornly hidden in cloud and the view was only of the tree-covered foothills – mountains themselves by European standards, and thousands of feet high.

The guest house on the second night was at the trekking village of Ghorepani, at just under 11,000 feet in altitude. It seemed that William and I were the only guests. Our bedroom was like a large tea chest with just enough room for two hard beds, with walls made of plywood and the original manufacturers’ stencils in black ink still in place. We spent a friendly evening sitting round a large stove with Shiva and our hosts. The stove – it was quite cold outside by now – was made from an oil drum with a flue going up through the ceiling, with metal bars welded to it for drying clothes. There was a tremendous thunderstorm, the first rain of the season. William and I fell asleep in our tea chest of a room to the sound of the rain beating a stereophonic tin symphony on the roof above our heads. Shiva had expressed the hope that the rain would clear the clouds and we would see the Himalayas in all their glory from nearby Poon Hill at dawn, before the clouds rise from the valleys and hide the mountains. So we had to get up next morning shortly after four.

Although our guest house was empty, many other trekkers – dim and silent figures in the pitch-dark night – suddenly appeared in single file, heading for the hill. We joined their silent procession; it felt more like a dark stampede and was a strangely sinister experience. At the foot of the stone stairs leading to the summit two dogs, snarling and fighting furiously, locked together, came tumbling down the steps in the dark and almost knocked me over. I was gasping for breath in the thin mountain air within minutes and felt as though I was having a panic attack. But I felt compelled upwards by the silent figures in the night around me. They seemed to be climbing the 300 metres of stone stairs to the summit quite effortlessly. All I could hear was my own panting breath and I was soon soaked in sweat. Or perhaps it was my deeply competitive nature that forced me upwards – the thought of being overtaken by anybody being unbearable, even though I was probably the oldest person on the hill. So I hurried, gasping, upwards.

It felt like an ascent to hell, rather than the more conventional descent. We hoped to see the sun rise over the high mountains but they would have none of it and had promptly wrapped themselves in dense cloud. William and I quickly left the crowd on the top of the hill, most of them clutching their smartphones and cameras, hoping to see the mountains. At the height of the trekking season, Shiva told me, there can be many hundreds of people on Poon Hill at dawn. There was some consolation in passing the late arrivals as we descended, and now that we could see them in the daylight, toiling up the stairs, they looked as breathless and tortured as I had felt.

The day was spent walking along a high ridge through a rhododendron forest. The trees were as large as oaks, with mottled and flaking trunks, and must have finished flowering a few days earlier, so we walked over a path of pink and red petals. The next night was spent in a guest house which was supposed to have fine views of the high mountains, but when we arrived there we could only see cloud and foothills. Our bedroom had unglazed windows with elaborately carved, black wooden shutters. I woke in the middle of the night. I could see a few stars through a half-open shutter and so could hope to see the mountains in the morning. I listened to my son’s quiet breathing as he slept in the bed next to mine. I thought of his birth thirty-seven years earlier. How he had been placed on his mother’s stomach and how he then opened two large, thoughtful blue eyes as he saw the outside world for the first time. I thought of how within a few months he had almost died. Years later we had come close to becoming estranged. He had gone through a difficult time, and I felt paralysed, knowing that I was part of the problem and that the past could not be undone, for all my regrets. His sister Katharine proved to be of much greater help than me. But that terrible time was also now in the past and I soon fell asleep again.

In the morning I woke from my one recurring nightmare – that I am back at university about to take my Finals, after my year of truancy working as a hospital theatre porter, but I have done no work whatsoever. I am filled with dread and panic. I am told anxiety dreams about examinations are quite common, but I find it curious that it is so locked into my subconscious. When I was allowed back to the university after running away, and after my brief stay in the psychiatric hospital – I continued to see my psychiatrist once a week – I worked frenetically hard and got a good degree, so I do not know why this fear of failure so often haunts me when I sleep.

I got out of bed to find that the mountains of the Annapurna range had miraculously appeared, where before there had been only cloud. It’s more as though they had suddenly arrived, in complete silence, from somewhere else, that they had descended from heaven. They towered above us, brilliant white with ice falls, snow fields and glaciers, against the blue sky. They looked so close that you felt you could get to them with a walk of only a few hours, when in reality Annapurna base camp, at the foot of Annapurna South, is four days’ walk away.

There was then a long walk downhill back to Nayapul, at first along a little-used track in a steep and peaceful wood, with the great mountains still to be seen between the trees, before the clouds rose up from the valleys and the mountains disappeared. We had to stop at regular intervals to kick the leeches off our boots. Later we rejoined the stone path and steps, passing many mule trains climbing up in the opposite direction. As we slowly descended we were accompanied by the sound of the glacial grey and white River Modi Kholi, rushing over rocks far below us.

‘Twenty-two-year-old fell thirty metres. Caesarean section. On examination no movement in lower limbs and weak upper limbs.’ The MO rattled and stumbled through the presentation.

‘Oh, come on!’ I shouted. ‘That’s a hopeless presentation. How much movement does she have in her arms? What’s her spinal level?’

We worked out that she had only partial movement in her biceps and none in her triceps, that she could weakly shrug her shoulders and bend her elbows, but that everything below this – her hands, her spinal and abdominal muscles and her legs, her bowels and bladder – was all completely paralysed.

‘So her spinal level is C5/C6. Yes? And don’t you have any curiosity as to what’s happened to your patients? Thirty metres? How can one survive that? Was it suicide? And was this after the caesarean section?’

‘She fell off cliff while cutting grass with sickle. Foetal death, so caesarean section. Then she came to Neuro Hospital.’

‘How many months pregnant?’

‘Seven months. Husband working in Korea.’

‘Ah,’ I said, appalled. ‘Well, let’s look at the scan.’

The MRI scan showed fracture and complete translocation of the spinal column between the fifth and sixth cervical vertebrae. The spinal cord looked damaged beyond repair.

‘She’ll never recover from that,’ I said. ‘What’s the next case?’

Dev and one of the registrars operated the next day, screwing the girl’s broken spine back together again, although this could not undo the paralysis. Surgery would at least mean that she did not need to be kept flat on her back in one of those horrible cervical collars, and it would make the nursing and physio easier.

I saw her on the ITU next morning as Dev and I went round.

‘Presumably here in Nepal she’ll get bedsores and renal infections if she ever gets out of hospital?’ I said.

Dev grimaced.

‘She’s unlikely to survive long. Christopher Reeve was a millionaire and lived in America and he eventually died from complications, so what chance a poor peasant in Nepal?’

I looked at the girl as we talked – at least she couldn’t understand what we were saying. She was very beautiful in the way that so many Nepali women are, with large, dark eyes and high cheekbones and a perfectly symmetrical and outwardly serene face. Her eyes moved slowly, she spoke a few words when spoken to. Her head was immobilized in a large and uncomfortable pink plastic surgical collar. Dev agreed with my suggestion that it could be taken off now that she had her broken neck screwed and plated back together again.

‘I put a locking plate in,’ Dev said. ‘Very expensive. Thousands of rupees.’ He then launched into a tirade once again about the way the foreign equipment companies charged First World prices in Third World countries and how most surgeons using implants would be paid a 20 per cent kickback by the suppliers, the extra cost being passed on to the patient. He said he had always refused to get involved in this widespread, but thoroughly corrupt, practice. You can find it in many European countries as well, despite being illegal, although there the inflated extra cost can often be passed on to the taxpayer and government rather than to the patient.

‘Well, medical-equipment manufacturers are businessmen, not altruists,’ was all I could say.

After a few days on the ITU the paralysed girl was discharged to one of the wards, but shortly afterwards her breathing deteriorated – which often happens in these cases – and she had to be readmitted and put on a ventilator.

‘I spoke to her husband again yesterday,’ Dev told me. ‘He’s flown back from Korea. I think he is coming to accept that she might die. But it’s very difficult in Nepal. If you are too honest and realistic it causes terrible trouble. The family will be shouting and screaming all over the hospital and causing all sorts of problems. You just can’t tell them the truth straight out. I told him he was young. I said that if she dies he could at least start again.’

‘It’s easier now that she’s on a ventilator, isn’t it?’ I replied, because it would be kinder if she died anaesthetized on a ventilator than from bed sores and infection on a bed in the hospital or back in her home – not that she was likely ever to get home.

On the morning round next day I noticed a group of doctors and nurses round the girl’s bed. She was groaning terribly as an anaesthetist pushed a flexible, fibre-optic bronchoscope down her trache tube. Her chest X-ray looked awful. We watched the intriguing view of the ringed and ridged inside of her lungs’ bronchi on the small monitor attached to the bronchoscope, while she groaned piteously as the anaesthetist tried to clear the fluid from her lungs. We agreed she was better off dying, but Dev was in an impossible situation. Should he have refused to operate and left the woman with her dislocated, broken neck untreated, leaving her to die without any treatment? The family would almost certainly have refused to accept this. Should he have left them to take her to another hospital where she would have undergone surgery that probably would not have been done as well as it would have been in his hospital? I had never had to face problems like this in my own career.

We get so used to most of our patients having brain damage and being unconscious that we forget that some of the paralysed patients on ITUs are wide awake, suffering horribly but unable to show it. Or perhaps it is wilful blindness on our part. I was painfully aware that I had found some of these cases so distressing during my career that I tended to avoid them and walk past them on the ward round. What do you say to somebody who is completely paralysed from the neck down, but awake, on a ventilator, so that they cannot talk?

I remembered an identical case in Ukraine many years ago. My colleague Igor was still working in the government emergency hospital at the time. He was very proud of the fact that he had managed to keep the patient alive, but on a ventilator.

‘First case of long-term ventilation in Ukraine,’ he declared.

The young man was in a bleak little side room and lived there for three years. Many religious icons surrounded him on the otherwise bare walls. He was equipped with a speaking tracheostomy tube and each time I visited Igor’s department I would go and see him. His brother looked after him and spoke some English, so I communicated with the patient through him. Each time I saw him he had wasted away a little more. At the time of the injury – breaking his neck diving into shallow water – he had been quite heavily built, but by the time he died he was skin and bones. At first I was able to have quite rational conversations with him, but it became more difficult with each visit. At least, he started to ask me about religious miracles and salvation, which he spoke about with intense passion (to the extent that you can speak passionately with a speaking tracheostomy tube), to which I had no answer. I was relieved on a later visit to see that the little side room was empty.

The young Nepali woman had fallen and broken her neck during Dasain, the most important of the many Nepali festivals, when upwards of fifty thousand goats and hundreds of buffalo are sacrificed to the goddess Durga. Blood is smeared everywhere in honour of the goddess, including, I noticed, on Dev’s gold-coloured Land Rover. Animal rights activists, I read in a local newspaper, have recently suggested that the goats be replaced with pumpkins.

The festival goes on for two weeks. Two days earlier Dev had told me to accompany him to the gates in front of his house. A police jeep was parked there with a uniformed policeman standing beside it. Another policeman appeared, leading a beautiful goat with long, floppy ears on a rope from behind the garage.

‘I give the local police a goat every year for Dasain,’ Dev told me. The goat was bundled into the back of the jeep but immediately jumped out. So it was put back in, but now with a police escort. They drove away with the goat looking mournfully out at me over the tailgate, the policeman beside it.

‘That goat will feed a hundred policemen,’ Dev said approvingly.

‘Nobody is in the mood for Dasain, this year, what with the earthquake and now the blockade and fuel crisis,’ Dev commented as we drove back to Kathmandu from a visit to a nearby town. Yet in several places we passed the beautiful high swings – known as pings – which are a traditional part of Dasain celebrations. They are made simply of four bamboo poles lashed together, more than twenty feet high and decorated with colourful flags. I saw Nepalis – both adults and children – laughing ecstatically as they swung happily to great heights, although I thought the pings looked a little precarious.

The next day I sat in the library teaching the juniors and discussing how we could improve the MOs’ jobs.

‘I am going back to London tomorrow,’ I told the new cohort of MOs, freshly out of medical school and, it seemed to me, pretty well out to lunch.

‘You are good doctors. We want to make you better. I hope the registrars’ – I looked pointedly at them – ‘will try to continue the morning meetings in this spirit. Teasing, yes, but no bullying.’ Pleased with this little speech, I then went down to Dev’s office and was about to go downstairs to start the clinic when there was a sudden flurry of activity in the corridor outside.

I found Dev, looking grim, surrounded by several of his juniors at the theatre reception desk, all looking equally serious.

‘The girl with a broken neck has just died,’ Protyush told me. ‘The husband is very angry.’

‘Is Dev waiting to talk to him?’

‘Yes, but we need backup – here in Nepal the families can assault us. We’re waiting for the security guards.’

Thirty minutes later, I stood in a corner of the theatre reception area where I had a view into the counselling room, and I could see Dev, but not the angry husband. Dev listened to a long outburst in silence and spoke quietly in reply. I crept away, not liking to eavesdrop on so much tragedy and unhappiness.

‘I wish I still worked for the NHS,’ Dev said to me that evening, as we sat in the garden. ‘Or at least that I was still the only neurosurgeon here, or that I didn’t have to worry about keeping the hospital afloat financially. It’s yet to make a profit, you know, even after ten years. Twenty years ago I could simply have said that there was nothing to be done and the family would have accepted it.’

‘How did the meeting with the family go?’ I asked.

‘Oh – the usual stuff. It happens now every few months. Never happened in the past. The husband said I had killed his wife by doing a tracheostomy. Nonsense of course – and in fact, in six months’ time, he’ll probably have a new wife. If she had survived it would have been terrible for both of them. And I spent so long, every morning, trying to explain. And he was so polite, as though I was a god, but now I’m a devil. But I’m sure you’ll find there’s another neurosurgeon in town who’s told them that if he had treated her she’d have been OK.’

‘You can’t expect people to be reasonable immediately after a death like this one,’ I said, trying to be helpful.

‘Nepal is different,’ Dev replied. ‘I worry for the boys, when they become seniors, having to work in a country like ours where the people are so uneducated – they won’t have my authority. All the hospitals have a permanent plainclothes policeman stationed twenty-four hours a day because of problems like this. They said they would get all the other patients’ families to blockade the hospital. Said they would burn it down. They want money. I know a lot of other doctors here who have had money extorted from them. That’s the problem with having to run a private hospital – “We paid you to treat her,” they said, “and now she’s dead.” It was so much easier in the past when I worked at the Bir. But the government medical service here now is terrible, almost completely broke. And so when I first see a patient the initial question is not what treatment would be best for them but “What can you afford?” You’re so lucky to work in the NHS.’

‘Well, she’s better off dead,’ I said.

It was sad to see Dev – usually so cheerful and enthusiastic – suddenly silent, looking grim.

‘You can’t really share it with anyone. It would only upset and frighten my wife,’ he added.

‘Only neurosurgeons understand,’ I said, ‘how difficult it is to be so hated, especially when you haven’t even done anything wrong, and only tried to do your best.’

I remembered one of my first catastrophes as a consultant. A child who died as a result of my postponing an operation that should have been done urgently. I had thought it was safe to wait until the morning, but I had been wrong. I had to attend an external investigation. I did not have to meet the parents face to face but passed them in the corridor. The look of silent hatred the mother gave me was not easy to forget.

‘You start,’ he said, pointing to the bottle of beer I had already got out. ‘The woman’s MP might come round to the hospital – I don’t want to smell of alcohol.’

I was summoned to supper two hours later. To my surprise, all the managerial team of the hospital were present – six people including the driver, all there to support Dev. I was rather touched. I’d never had support like this for my disasters.

Over a large Nepali dinner there was much animated discussion, most of it lost on me as they spoke in Nepali. But I was told that the family were threatening a hunger strike and a press conference, and planned to get the other patients’ families to join them.

‘Seven point five,’ I heard the manager, Pratap, suddenly say – he had been looking at his smartphone. This, it turned out, was the strength of an earthquake that had just hit Afghanistan and Pakistan. The catastrophic earthquake that had hit Nepal six months before my visit had been 7.8. This was discussed for a while, and then they resumed the conversation about the dead girl’s family and what might happen.

‘It’s all because we now work for money,’ Madhu, who was sitting next to me, said. ‘We didn’t want to, but had no choice. We can’t provide free treatment to everybody.’

Next morning, the morning of my departure from Nepal, I sat drinking coffee in the garden, in Dev and Madhu’s little Shangri-La. The pigeons were cooing and gurgling, the cocks were crowing, the hooded crows were quarrelling again in the camphor tree, although in truth for all I knew they might have been discussing their marital problems or the presence of the brown mongoose which can sometimes be seen, sinuous and graceful, running swiftly across the garden. Or perhaps they were excited about the prospect of the first day of the festival of Tihar in two weeks’ time, the day of kaag tihar, when crows are worshipped and little dishes of food are put out for them. I probably understand as much about the crows as I do about the impenetratable complexities of Nepali society. Two birds with feathery trousers I couldn’t identify waddled busily about on the small lawn in front of the gazebo.

I set off for work as usual but as it was the tenth and most auspicious day of Dasain, there was little traffic on the road. I passed women wearing their finest clothes – brilliants reds and blues and greens, decorated with gold and silver and paste jewels which flashed in the sunlight. They picked their way cautiously over the puddles and around the rubbish and stinking, open drains. When I got to work I found that there were twelve uniformed policemen with long iron-shod sticks in front of the hospital, sitting in the sunshine on the grass mound by the magnolia tree. The dead woman’s family and supporters stood nearby. Dev and I looked down at them from his office window.

‘How much longer will this go on for?’ I asked.

‘Oh, until the weather gets colder,’ he said with a laugh, his cheerful good humour having returned.

‘I’m not even sure the story about cutting grass on a cliff was true. Her husband has money – it’s unlikely she’d be out gathering grass off a cliff,’ he said. ‘I’m pretty suspicious that it was another ping accident.’

We had admitted a sixty-five-year-old man two days earlier, also completely paralysed, with a broken neck, who had fallen from a ping.

‘Happens all the time during Dasain,’ Dev said.

I noticed that behind the policemen, the waiting outpatients and the dead woman’s angry family, in the rice paddy next to the hospital, people were harvesting the rice – a picturesque and medieval sight, although in the background there was a long queue of dirty old trucks waiting at the petrol station. In the distance, the high Himalayas, beyond the foothills, were hidden.