Mentored by a Madman Page 3

  One day in November 1969, in rebellious mood I got hold of a Corgi paperback copy of Naked Lunch. The front cover had a stark image of Burroughs with eerie red irises and a blotchy cut-up montage that included a face and a monkey superimposed on his forehead. It suggested pulp detective fiction but the first lines had a spooky authority:

  I can feel the heat closing in, feel them out there making their moves, setting up their devil doll stool pigeons, crooning over my spoon and dropper I throw away at Washington Square Station, vault a turnstile and two flights down the iron stairs, catch an uptown A train …

  Naked Lunch was hard-boiled, clinical and detached, its characters shadowy and glacial with hollow voices. Burroughs told his readers that you could cut into its text at any intersection point; there was no beginning or end, just an infinite stream of consciousness. Reality and dream were illusory and neither could exist without the other. It was a mosaic of depravity, violence and cruelty driven by plain sexual desire, the Grim Reaper’s very own missive from Hell.

  It was also a tour through the school urinals with the musty smell of stale wank and jock straps and a prelude to my urology surgical dressership with descriptions of bifurcated penises, ejaculation on hanging (angel lust), and priapism. Burroughs’ writing spilt off the page in all directions and wallowed in excrement. It was a far cry from the drama of the kitchen sink.

  Doc Benway, the darkly comical Director of the Freeland Reconditioning Centre, made me laugh. He was an amalgam of all the bastard doctors Burroughs had ever encountered: the blinkered New York shrinks, the reckless blundering St Louis surgeons and the Mexico City prescription-forgers. Benway had been recruited as an advisor to the Republic of Freeland, a country given over to free love and communal bathing, and reputedly based on Scandinavia. Homosexuality is considered an infectious disease and in his laboratory he carries out aversive experiments on heterosexual rats that turn them into ‘fruit rats’.

  Benway’s unsettling bedside manner reminded me of my surgical teacher CT’s old-school gentlemanly demeanour combined with his penchant for drastic and fearless intervention. His punitive ward rounds, where terrified juniors and a simpering nursing sister would lead him on a sight-seeing tour of his condemned lung cancer victims, were an abomination. Many of his operated patients were in severe pain but nevertheless were expected to sit bolt upright in bed as the great man strode by. He rarely spoke directly to his patients. In theatre he threw scalpels and humiliated his assistants. His power was absolute and his decision-making infallible. He gave the impression that he had a visceral contempt for the frailty of the human organism.

  CT was a frightening hero renowned for his icy silences. There were several other practitioners and craftsmen with similar reputations at The London Hospital. A houseman on another of the general surgery wards told me how he had been forced to devise strategies to keep his boss away from incurable and dying patients’ colons. On ward rounds I learned the expression frequently used by surgeons that ‘the operation had been a technical success but the patient had died’, implying it was the anaesthetist who had committed manslaughter.

  Doc. Benway was medicine’s arch-enemy, a villain without a first name addicted to mind control surgery. He was enamoured by the abstract scientific process and unconcerned about who owned his research findings – he was on a quest for knowledge for its own sake. At Claybury Hospital, on my psychiatry elective, I saw insulin coma therapy, electro convulsive treatment and prefrontal leucotomies used to subdue the mentally ill but Benway’s fascination with electrical brain stimulators was still in the realms of science fiction. His mastery of brainwashing techniques, widely employed by the KGB and CIA, was all that was needed for now. This subversion of the medical model appealed to my rebellious streak. Benway was an operative of the State employed to find new ways of creating automatic obedience.

  Some of the black humour in Naked Lunch was implanted in my impressionable brain, along with textbook descriptions of diseases I had never seen:

  ‘They have no feelings,’ said Doctor Benway, slashing his patient to shreds.

  Did I ever tell you about the time I performed an appendectomy with a rusty sardine can? And once I was caught short without instrument one and removed a uterine tumor with my teeth.

  Benway’s confabs with his colleague Dr Schafer, the Lobotomy Kid, about creating a talking asshole that would improve human efficiency, were a chilling preview of a brave new world of genetic engineering, and his electrical stimulation of the mind did eventually become a surgical reality. Benway was grey and faceless and strode between Hippocrates and I, a disturbing third presence who could help me fail finals and free up time.

  London now dragged like an anchor. Burroughs had convinced me that rationality could only ever rule part of our minds. The phantasmagorical description of the Composite City in Naked Lunch, filled with infernal scenes and foreign landscapes, was the London where I now lived. Burroughs had opened a crystal door that led to the moon.

  3

  – Magic Bullet –

  My first house physician’s appointment was at St Stephen’s Hospital (now the Chelsea and Westminster Hospital) on the Fulham Road, where an acute ‘medical take’ consisted of five or six self-poisonings with sleeping pills like Mogadon and Mandrax, and a couple of bad LSD trips. Most of the ‘attempted suicides’ lived in bedsits and seemed to be seeking a holiday from the tedium of their mundane existence. A few had got into a mess and needed referral to the new breed of medical social workers that had displaced the hospital almoner. I was trying to get some proper medical experience under my belt and found it hard to be sympathetic. All I was doing was mopping up the wreckage of Swinging London.

  Blomfield, the Casualty Officer, had hair down to his back, called me ‘man’ over the phone and wore Release and CND badges on the lapel of his white coat. The disorientated dialogue of some of the addicts we talked down late at night reminded me of the string of disjointed ‘sets’ in Naked Lunch.

  In striking contrast to my ‘take nights’ in the newly built Accident and Emergency Department, the long wards in the old hospital were full of very ill elderly people with pneumonia, cancer and dropsy, collectively referred to in the doctor’s mess as ‘crumble’. I spent most of my mornings listening to their tales and ordering blood tests, electrocardiograms and chest X rays. Many were comfortably off but unlike the closelyknit East Enders they were isolated and lonely. When the time came for their hospital discharge, some didn’t want to leave. I prescribed heroin to palliate severe pain in the dying and Guinness as a bedtime tonic, but kindness and cheerfulness were my most effective nostrums.

  I had been in post for just three months when an elderly man who had worked on the London Underground was admitted from home. Parkinson’s disease had confined him to a wheelchair and he was now dependent on his family to feed, dress and bathe him. The first telltale symptoms had started six years earlier when he had noticed an occasional quiver of the middle finger of the right hand when collecting tickets at Fulham Broadway. Within a year, stiffness and awkwardness in his hands had forced him to retire. He could now only take a few shuffling steps and his handwriting had been reduced to an illegible spidery scribble. Saliva dribbled constantly from the right side of his mouth and both his hands quaked interminably.

  His reptilian stare suggested coldness and fear but he spoke warmly of his grandchildren and about his great love of pigeon racing. When he tried to take a few steps, he mumbled that it was like walking through treacle. He had told his wife that Parkinson’s was a death sentence and that he was pinning all his hopes on the ‘Dope’. He had read in the paper that the symptoms of Parkinson’s disease could now be countered by an amino acid called L-3-4-dihydroxyphenylalanine (L-DOPA) that worked by boosting the brain’s depleted levels of dopamine.

  Parkinson’s disease is the commonest neurological cause of chronic physical handicap in the elderly. It affects at least one in a hundred individuals over the age of sixty-five but can also stri
ke down much younger people. The cause of the malady is not known but one interesting finding is that it is twice as common in non-smokers as cigarette smokers. It usually begins with maladroitness in one hand, aches and pains in an arm and feelings of tiredness. Some of those affected are at first thought by their families to be depressed, fatigued or to have become old overnight. The emergence of a tremble is the sign that cannot be ignored and usually leads to specialist referral. A loss of sense of smell, uncharacteristic maudlin eruptions, constipation and the acting out of dreams (rapid eye movement (REM) sleep disorder) are recognised prodromes. If Parkinson’s disease is left untreated it deteriorates relentlessly, causing a quiet slurred speech, a hurrying shuffling gait and frequent falls. Progressive frailty, immobility and delirium lead to death within ten years of the first signs of the disease.

  Slowness and stiffness, which are the most disabling symptoms, are caused by severe damage to a small cluster of nerve cells called the substantia nigra (black stuff) located at the top of the brain stem. Under the microscope some of the remaining pigmented neurones contain bull’s eye inclusions called Lewy bodies which allow the pathologist to confirm the diagnosis after death.

  L-DOPA is a molecule found naturally in the pods of broad beans and in the pulses of the cowhage plant, a climbing legume used for centuries in Ayurvedic medicine. After it has been swallowed, it is actively absorbed in the upper gut and then transported by the blood stream, where a large quantity is broken down and excreted in the urine. A small proportion eventually crosses the blood-brain barrier and is then converted to dopamine. This Trojan horse approach to neurotransmitter replenishment is necessary because dopamine itself is not able to enter the brain.

  After routine investigations had been completed, I started my new patient on three large white tablets of neat L-DOPA (Larodopa) and over the next ten days gradually increased the dose up to 3 grams a day. The nurses were instructed to take his blood pressure lying flat and then standing up every four hours and report any changes in his mobility to me.

  On the fourth day it was obvious that his face had begun to thaw and he had started to blink again. After a week of L-DOPA he could use a knife and fork on his own and his voice had become much bolder. His handwriting doubled in size and no longer sloped upwards. On the tenth day he got out of his chair unaided and shuffled to the end of the ward. By the time he left hospital he had regained much of his independence. Parkinson’s disease had taken away movements that it had taken him a lifetime to learn. He told me that he felt as if he had cast off a heavy space suit and an iron mask and come back to life.

  L-DOPA had by now been heralded as a miracle cure but there had also been some sensational adverse headlines in the newspapers like, ‘New drug makes sick old man chase nurses round the ward’. There were concerns that this unprecedented sudden return of mobility to chronically paralysed patients could trigger falls and unmask angina pectoris. These negative reports gained the medicine an early, unwarranted reputation as being unsafe and difficult to use.

  For many years after its discovery, dopamine had been considered an inert intermediary on the synthetic pathway of the ‘fight and flight’ chemical messengers noradrenaline and adrenaline, and of no biological importance. By the early 1960s it was beginning to be more widely accepted that it was a chemical messenger and that its deficiency in the substantia nigra and corpus striatum (the basal ganglia) was responsible for the slowness and stiffness of Parkinson’s disease. It was also now understood that the tranquilisers that had been found to be helpful in managing schizophrenia blocked dopamine receptors and could cause parkinsonism and depression as unwanted side effects.

  The miracle of L-DOPA had turned me into ‘Molecule Man’ overnight. I was certain that further peptide and amine research would lead to cures for Alzheimer’s disease and all the other brutal brain degenerations within five years.

  4

  – Looking for Clues –

  A human brain looks like any other. Once it has been removed from the calvarium and the lining peeled away, it is a squelchy blancmange that dimples and blushes to the touch. After it has been fixed heavy with formalin it is putty in the hand, but holding it still feels momentous. It is not difficult to imagine that the walnut kernel I now rest on my palms used to spend hours watching ships sail down the river and was gifted in remembering faces. It is subtly asymmetrical with an intricate array of shiny fractals. From the sky its convolutions resemble a marshy wetland at low tide. There is no need to destroy it in order to communicate with the still life buried inside.

  Optical microscopy first drew me to the brain’s true beauty. Under high power magnification its silvered nerve cells resemble black leafless trees that have put down arborescent roots in the grey matter. Through my eyepiece I see climbing vines, grassy tufts, mossy tendrils and spiny shrubs. I observe how the pathology of Alzheimer’s disease spreads like a forest fire leaving behind it desolate tumbleweed glades and how Parkinson’s disease deposits ghost sunflower heads and twiners in the bleached nigra. Each sliver of inert tissue that becomes my focus appears like a microcosm of the Amazon valley. Inflorescences of unimaginable beauty nourished by rivulets of blood fill the gaps left by the dead trees. Dopamine and serotonin are the fluorescent butterflies of the soul, the sentimental amines that can never quite be pinned down. I am exploring death in inner space far below the brain’s surface.

  What I discover now alters constantly. Some of the trunks are draped with glial lianas. Ferns, air plants with rosaceous endings and dendritic thorns give way to an unforgettable flower-strewn landscape and then to an indefinable wood in which every charcoal tree is interconnected. I watch the forest metamorphose into an orchard of twiggy nerves and dying hyacinths. Empty, inaudible, and finally undone, the brain dissolves in the dim light and as I continue to pore down the microscope it opens my eyes to different but equally false unexplored dimensions.

  In 1972, after house jobs, I took a wanderjahre and ended up at La Salpetrière hospital close to the Jardin des Plantes, where as a part of my training I was taught the value of intuition and instinctive deduction in clinical decision-making. The French neurologists who taught me were even more picturesque, more colourful in speech, manners and dress than those who had impressed me so much during my undergraduate training at The London Hospital. Symptoms were the cries of a suffering brain, and through their intense study an idea of their cause could be reached. The words for the clinical phenomena I witnessed on the wards defied accurate translation into English.

  Careful observation of the external pathology was followed by a search for a physiological explanation. If this approach was not observed the image of the illness would become distorted and the patient lost from view. Jean-Martin Charcot, the father of neurology, taught me that nervous disease was very old and immutable. It was only I who would change as I learned to recognise what was formerly imperceptible. I discovered that even the classic nervous diseases like ‘maladie de Parkinson’ exhibited great diversity in their course, which seemed to render them less implacable. I was acquiring a feel for sickness and an appreciation of its intricacy.

  Much later I came across a footnote from William Burroughs in Ghost of Chance that seemed to come straight from the Leçons du Mardi:

  As any astute physician well knows the progress of disease to the classic symptoms is more the exception than the rule. Any combination of the expected symptoms may be observed, or any corresponding lack of them.

  The healing powers of L-DOPA had already pushed me in the direction of neurology but it was my experience at La Salpetrière in Paris that finally sealed my destiny. I seemed to be surrounded by the legendary ghosts of Joseph Babinski, Georges Gilles de la Tourette and Pierre Marie and yet some, like Charcot, still seemed to be alive.

  On my return to England in 1974, I started to attend the clinical demonstrations at the National Hospital, Queen Square. Many of the famous names of British neurology taught there on Wednesday afternoons at 4 p.m. and Saturd
ay morning at 10 a.m. to a rapt and incredulous audience. During these séances, silver-tongued senior students led us on a magical journey of inquiry. Some of these great men embellished their teaching with flourishes of showmanship but this was always backed up by a sound knowledge of semiotics. They condensed neurological mysteries into a problem and solution format and provided succinct statements of principle that provided us with a foolproof diagnostic approach that worked well in practice. Most taught off the hoof with no knowledge of the provisional diagnosis. On one occasion a man who had sustained a head injury and could only see half of everything was presented. The registrar then went on to demonstrate the half-field defect before his chief put the patient’s ability to name objects to the test.

  ‘What’s this?’ he asked, showing the man a half a crown. Quick as a flash and to gales of laughter the man replied ‘One and threepence’.

  When I began my specialist training on ward 5.2 at University College Hospital in the attic of the Cruciform building on Gower Street, British neurology was still a closed shop, with only 370 consultant posts in the whole of the British Isles. It was a highly competitive male-dominated ‘boutique’ speciality and the physicians at The National Hospital still exerted a strong influence on new hospital appointments and standards of good clinical practice throughout the land. Neurological apprenticeship could be compared in length and stringency to that required of a vestal virgin in Ancient Rome. Collective nouns used to describe neurologists included, ‘a synapse’, ‘a battery’ and ‘a twitch’ but the one I liked best was ‘a galaxy’. Many of the founding fathers of London neurology had gained knighthoods and Fellowships of the Royal Society and some had unassailable names like Sir Henry Head and Lord Brain.