by Henry Marsh
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 an
d 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 horribl
e 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.’