Admissions Page 3
‘Look, there’s the sphenoid wing,’ I said to Samih. ‘We should go in just a little above it, but you’ll have to go deeper into the brain than you think from the scan as his brain is bulging out a bit.’
We returned to the table and Samih burned a little line across Mr Williams’s brain with the diathermy forceps – a pair of forceps with electrical tips that we use for cauterizing bleeding tissue.
‘Let’s bring in the scope,’ I said, and once the nurses had positioned the microscope, Samih gently pushed downwards with sucker and diathermy.
‘It looks normal, Mr Marsh,’ Samih said, a little anxiously. Even though there are all manner of checks and cross-checks to make sure we have opened the correct side of the patient’s head, I always experience a moment of complete panic at times like this, and have to quickly reassure myself that we are indeed operating on the correct side – in this case the left side – of Mr Williams’s brain.
‘Well, the trouble with low-grade tumours is that they can look and feel like normal brain. Let me take over.’
So I started to cautiously prod and poke the poor man’s brain.
‘Yes, it looks and feels entirely normal,’ I said, feeling a little sick as I looked through the microscope at the smooth, unblemished white matter. ‘But we’ve got to be in tumour – there’s so much of it on the scan.’
‘Of course we are, Mr Marsh,’ Samih said respectfully. ‘Would Stealth or a frozen section have helped?’
These are techniques that would have reassured me that I was in the right place. Rationally I knew that I had to be in tumour – at least in brain infiltrated by tumour – but the man’s brain looked and felt so normal that I could not suppress the fear that some bizarre mistake had occurred. Perhaps the wrong name was on the brain scan, or it hadn’t been a tumour in the first place and the problem had got better on its own since the brain scan had been done. The thought of removing normal brain – however unlikely – was terrifying.
‘Well, you’re probably right, but it’s too late now and, having started, I can’t stop,’ I said to Samih. ‘I’ll have to remove a lot of normal-looking brain to stop him swelling and dying post-op.’
The brain becomes swollen with the least provocation, and Mr Williams’s brain was already ominously enlarging and starting to bulge out of his opened skull. At the end of a craniotomy – the medical name for opening a person’s head – the skull is closed with little metal screws and plates and the scalp stitched back together over it. The skull becomes once again a sealed box. If there is very severe post-operative swelling as a reaction to the surgery, the pressure inside the skull will become critically raised and the brain will, in effect, suffocate and the patient can die. Surgery, especially for tumours within the actual substance of the brain like Mr Williams’s, where you cannot remove all of the tumour, will inevitably cause swelling, and it is always important to remove enough tumour – to create space within the skull to allow for the swelling. The pressure in the patient’s head after the operation will then not become dangerously high. But you always worry that you might have removed too much tumour and that the patient will wake up damaged and worse than before the operation.
I can remember two cases – both young women – from the early years of my career where my inexperience made me too timid and I failed to remove enough tumour. They both died from post-operative brain swelling within twenty-four hours after surgery. I learnt to be braver with similar cases in future – in effect, to take greater risks when operating on such tumours, because the deaths of the two women had taught me that the risks of not removing sufficient tumour were even greater. And yet both the tumours were malignant and the patients had a grim future ahead of them, even if the operations were to have been successful. Looking back now after thirty years, having seen so many people die from malignant brain tumours since then, these two tragic cases do not seem quite as disastrous as they did at the time.
This is about as bad as it gets, I thought with disgust as I started to remove several cubic centimetres of Mr Williams’s brain, the sucker slurping obscenely. What’s the glory in this? This coarse and crude surgery. This evil tumour, changing this man’s very nature, destroying both himself and his family. It’s time to go.
As I watched my sucker down the microscope, controlled by my invisible hands, working on the poor man’s brain, teasing and pulling out the tumour, I told myself that I wouldn’t have panicked in the past. I would just have shrugged and got on with it. But now that my surgical career was coming to an end, I could feel the defensive psychological armour that I had worn for so many years starting to fall away, leaving me as naked as my patients. Bitter experience of similar cases to Mr Williams’s told me that the best outcome for this man would be if the operation killed him – but I felt unable to let that happen. I knew of surgeons in the distant past who would have done just that, but we live in a different world now. At moments like this I hate my work. The physical nature of our thought, the incomprehensible unity of mind and brain, is no longer an awe-inspiring miracle but instead a cruel and obscene joke. I think of my father slowly dying from dementia and his brain scan, and I look at the age-wrinkled skin of my hands, which I can see even through the rubber of my surgical gloves.
As I worked the sucker, Mr Williams’s brain started slowly to sink back into his skull.
‘That’s enough space now, Samih,’ I said. ‘Close please. I’ll go and find his wife.’
Later in the day I went up to the ITU to see the postoperative patients. The young Romanian woman was well, though she looked pale and a little shaken. The nurse at the end of her bed glanced up from the mobile computer where she was inputting data and told me that everything was as it should be. Mr Williams was three beds further down the row of ITU patients. He was sitting upright, awake, looking straight ahead.
I sat by his bedside and asked him how he felt. He turned to look at me and said nothing for a while. It was hard to know if his mind was blank or whether he was struggling to organize the thoughts in his disrupted, infiltrated brain. It was hard even to know what ‘he’ had now become. Once I would have waited only a short time for an answer. Many of my patients have lost – sometimes permanently, sometimes transiently – language or the ability to think and there is a limit to how long you can put up with waiting. But on this occasion, perhaps because I knew that this would probably never happen again and perhaps also as a silent apology to all the patients I must have hurried by in the past, I sat quietly for what felt like a long time.
‘Am I going to die?’ he suddenly asked.
‘No,’ I said, alarmed at the way he seemed to know what was going on after all. ‘And if you were I promise I would tell you. I always tell my patients the truth.’
He must have understood that because he laughed – an odd, inappropriate sort of laugh. No, you are not going to die just yet, I said to myself, it is going to be much worse than that. I sat beside him for a while longer but it seemed he had nothing further to say.
Samih was waiting for me as usual at 7.30 the next morning at the nurses’ desk. He was a junior doctor in the traditional mould and could not bear to think that he might not be in the hospital when I was there. When I was a junior it was inconceivable that I might leave the building before my consultant, but in the new world of shift-working doctors the master-and-apprentice form of medical training has largely disappeared.
‘She’s in the interview room,’ he said. We walked down the corridor and I sat down opposite Mrs Williams. I introduced myself.
‘I’m sorry we haven’t met before. Tim was going to do the operation but I ended up doing it. I’m afraid this is not going to be good news. What did Tim tell you?’
As a doctor you get used to patients and their families looking so very intently at you as you talk that sometimes it feels as though nails are being driven into you, but Mrs Williams smiled sadly.
‘That it was a tumour. That it couldn’t all be removed. My husband was pretty bright, you k
now,’ she added. ‘You’re not seeing him at his best.’
‘In retrospect, looking back, when do you think things started to go wrong?’ I asked gently.
‘Two years ago,’ she said immediately. ‘It’s a second marriage for both of us – we married seven years go. He was a lovely man, but two years ago he changed. He was no longer the man that I had married. He started playing strange, cruel tricks on me…’
I did not ask what these might have been.
‘It became so bad,’ she went on, ‘that we had more or less decided to go our separate ways. And then the fits started…’
‘Do you have children?’ I asked.
‘He has a daughter from his first marriage but we have no children from our marriage.’
‘I’m afraid I have to tell you that treatment won’t get him better,’ I said, very slowly. ‘We can’t undo the personality change. All we can do is possibly prolong his life and he may yet live for years anyway, but he will slowly get worse.’
She looked at me with an expression of utter despair – she could not have helped but hope that the operation would undo the horrors of the past, that her nightmare would come to an end.
‘I thought it was the marriage that had gone wrong,’ she said. ‘His family all blamed me.’
‘It was the tumour,’ I said.
‘I realize that now,’ she replied. ‘I don’t know what to think…’
We talked for a while longer. I explained that we would have to wait for the pathology report on what I had removed. I said it was just possible I might have to operate again if the analysis showed that I had missed the tumour. The only potential further treatment would be radiation and, as far as I could tell, this had no prospect of making him any better.
I left her in the little interview room with one of the nurses – most of my patients’ families prefer, I think, to cry after I have left the room, but perhaps that is wishful thinking on my part – perhaps they would prefer me to stay.
Samih and I walked back down the corridor.
‘Well,’ I said, ‘at least the marriage was coming to an end, so I suppose it’s a bit easier for her, but how can anybody know how to deal with something like this?’
I thought of the end of my first marriage fifteen years earlier and how cruel and stupid my wife and I had been to each other. Neither of us had had frontal brain tumours, though I wonder what deep and unconscious processes might have been driving our behaviour. I look back with horror at how little attention I paid to my three children during that time. The psychiatrist I was seeing at the time told me to become more of an observer, but I simply could not detach myself from the raging intensity of my feelings at being forced to leave my own home, so much of which I had built with my own hands. I feel that I have learnt a certain amount of wisdom and self-control as a result of that terrible time, but also wonder whether it might in part be simply because the emotional circuits in my brain are slowing down with age.
I went to see Mr Williams. The nurses had told me, when I had come onto the ward, that he had tried to abscond during the night, and they had had to keep the ward door locked. It was a fine morning and low sunlight streamed into the ward through the east-facing windows, over the slate roofs of south London. I found him standing in front of the windows in his pyjamas. I noticed that they were decorated with teddy bears. His arms were stretched out on either side as though to welcome the morning sun.
‘How are you?’ I said, looking at his slightly swollen forehead and the neatly curved incision behind it across his shaven head.
He said nothing in reply and gave me a vague, cryptic smile, slowly lowered his arms and shook my hand politely without saying a word.
The pathology report came back two days later and confirmed that all the specimen I had sent was infiltrated by a slow-growing tumour. It was going to take a long time to find any kind of long-term placement for Mr Williams and it seemed unlikely he could be managed at home, so I told my juniors to send him back to the local hospital to which he had first gone after the epileptic fits had started. The doctors and nurses there would have to find a solution to the problem. The tumour was certainly going to prove fatal, but it was impossible to know whether this would be a matter of months or longer. When I went round the ward early next morning I saw that there was a different patient in his bed and Mr Williams had gone.
2
LONDON
I had decided to resign from my hospital in London in a fit of anger in June 2014, four months before I came across the lock-keeper’s cottage. Three days after handing in my letter of resignation I was in Oxford, where I live with my wife Kate at weekends, running along the Thames towpath for my daily exercise. I was panic-stricken about what I would do with myself once I no longer had my work as a neurosurgeon to keep me busy and my mind off the future. It was in exactly the same place, on the same towpath, but walking, not running, many years earlier, in a much greater state of distress, that I had decided to abandon my degree in politics, philosophy and economics at Oxford University – much to my parents’ distress and dismay when they got to hear of it.
While I ran beside the river, I suddenly remembered a young Nepali woman with a cyst in her spine that had been slowly paralysing her legs. I had operated on her two months previously. The cyst turned out to be cysticercosis, a worm infection common in impoverished countries like Nepal but almost unheard of in England. She had returned to the outpatient clinic a few days earlier to thank me for her recovery; like so many Nepalis, she had the most perfect, gentle manners. As I ran – it was late summer, the river level was low and the dark-green water of the Thames seemed to be almost motionless – I thought of her and then thought of Dev, Nepal’s first and foremost neurosurgeon, more formally known as Professor Upendra Devkota. We had been friends and surgical trainees together in London thirty years ago.
‘Ah!’ I thought. ‘Perhaps I can go to Nepal and work with Dev. And I will see the Himalayas.’
Both decisions, separated by forty-three years – to abandon my first degree and to resign from my hospital – had been provoked by women. The first was a much older woman, a family friend, with whom I was passionately and wholly inappropriately in love. Although twenty-one years old, I was immature and sexually entirely inexperienced, and had had a repressed and prudish upbringing. I can see now that she seduced me, although only with one passionate kiss – it never went beyond that. She burst into tears immediately afterwards. I think she had been attracted by my combination of intellectual precocity and awkwardness. Perhaps she thought that she could help me overcome the latter. She probably later felt ashamed, and perhaps embarrassed, by my passionate, poetic response – the poems now long forgotten and destroyed. She died many years ago, but my intense embarrassment about this episode is still with me now, even though the kiss resulted in my finding a sense of meaning and purpose to my life. I became a brain surgeon.
I was confused and ashamed by the pangs of my frustrated and absurd love, and overwhelmed by feelings of both love and rejection. I felt there were two armies fighting within my head and I wanted to kill myself to escape them. I tried to compromise by pushing my hand through a window in the flat where I had student digs beside the Thames in Oxford, but the glass would not break or, rather, a deeper part of my self showed a sensible caution.
Unable to translate my unhappiness into physical injury, I decided to run away. I made the decision while walking along the Thames towpath in the early hours of the morning of 18 September 1971, having fortunately failed to hurt myself. The towpath is narrow, in summer dry and grassy, in winter muddy and with many puddles. It passes through Oxford and past Port Meadow, the wide flood meadow to the north of the city. My childhood family home was a few hundred yards away. I might even have seen it as I walked miserably along the river – the area was deeply familiar. If I had gone a little further and followed a narrow cut, linking the river to the Oxford canal, I would have come across the lock-keeper’s cottage, but I think I had already t
urned back by then, having made my decision. The old man, though young at that time, would already have been living there.
I abandoned my university degree for unrequited love, but it was also a rebellion against my well-meaning father, whose belief in the virtue of attending Oxford or Cambridge university was an article of faith. He had been an Oxford don before moving to London. He deserved better from me, but such rebellious behaviour is buried deep within the psyche of many young people; and my father, the kindest of men, but who had himself once rebelled against his own father, resigned himself to my decision. I left my predictable professional career path to work as a hospital theatre porter in a mining town north of Newcastle. I hoped that by seeing other people suffering with ‘real’, physical illness I would somehow cure myself. My subsequent life as a neurosurgeon was to teach me that the distinction between physical and psychological illness is false – at least, that illnesses of the mind are no less real than those of the body, and no less deserving of our help. A friend’s father, John Maud, was the general surgeon in the hospital, and although he had never met me, at his daughter’s request he got me a job in his operating theatre. I find it quite extraordinary that he did this, just as I find it remarkable that my Oxford college agreed that I could return after a year’s truancy. It is impossible to know how my life would have developed without so much help and kindness from others.
It was my experience as a theatre porter, watching surgeons operate, that led me to become a surgeon. It was a decision that came quite suddenly to me, while talking to my sister Elisabeth – a nurse by training – as she did her family’s ironing, when I returned to London for a weekend. I had gone to visit her to hold forth at great length about my unhappiness. It somehow became clear to me – I can’t remember how – that the solution to my unhappiness was to study medicine and become a surgeon. Perhaps Elisabeth suggested it to me. I took the train back to Newcastle on the Sunday evening. As I sat in the carriage, seeing myself reflected in the dark glass of the window, I knew that I had now found a sense of purpose and meaning. It would be another nine years, however, when I was already a qualified doctor, before I discovered the all-consuming love of my life – the practice of neurosurgery. I have never regretted that decision, and have always felt deeply privileged be a doctor.