Admissions

by Henry Marsh

  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 w
hen 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.