Every Third Thought Page 4

  Ageing Pessimist: ‘Better do something, you old crock.’

  Eternal Optimist: ‘A few swims and I’ll be fine.’

  AP: ‘You’re getting stiff. What about your fitness? You need to loosen up.’

  EO: ‘What’s the point? I had a brain attack, remember? Some of those pathways are dead.’

  The Ageing Pessimist might find physiotherapy routines boring and frustrating, but he also knows that, in the mantra of the physio, ‘if you don’t use it, you’ll lose it’. Besides, he has not lost his sense of curiosity about the interface of mind and body in the vogue concept of ‘plasticity’.

  AP: ‘Surely you’ve heard about “plasticity”?’

  EO: ‘What’s “plasticity”?’

  AP: ‘There’s a lot of new evidence that cerebral pathways can regenerate.’

  ‘Neuroplasticity’, to give its full name, is the exciting discovery that has transformed neurological rehab. practices in the last twenty years. It replaces the traditional view that our brains are physiologically static, and describes a process of neurological adaptability – changes in neural pathways and synapses – in the circuits of the brain that can result in dramatic ‘cortical re-mapping’. One high priest of this new orthodoxy is the Canadian Norman Doidge, whose bestselling book, The Brain That Changes Itself, is a landmark in discussions of neuroplasticity, promoting a now widely accepted phenomenon in the recovery from brain damage.

  The discovery that the brain is not an immutable organ but responsive to therapeutic stimuli has inspired some exciting initiatives, including Headway, in East London, a charity whose online writing programme ‘Who Are You Now?’ encourages brain injury survivors to tell their stories. Such writing projects can restore confidence, overcome communication problems, and enable patients to rethink their lives. From my own experience, I know that giving yourself the chance to be more like your old self is a good first step towards a fuller recovery.

  My decision to sign up for a programme of physiotherapy designed to stimulate plasticity was also driven by anxiety. That moment in June 2014 – my ‘fall’ – remained a piquant reminder of Time’s revenges. Even mild chronic disability has a way of reducing the patient, and closing off potential avenues of exploration. Perhaps it was inevitable that I should make my way back to the place where I had been first treated all those years ago in the summer of 1995. In retrospect, the National Hospital for Neurology and Neurosurgery, in Queen Square, has become my alma mater. Whenever I see the trim navy-blue tracksuits of the physio staff, I get caught in the crossfire of old memories. Negotiating the threshold to the gloomy Victorian interior of ‘the National’ is a difficult step back in time, troubled by many mixed feelings.

  One of the principal frustrations of physiotherapy, I’ve found, is that so few of the questions you are asked, as the patient, seem to connect to your immediate physical experience and needs. With such routine investigations as a standard (ten-scale) questionnaire designed to measure levels of pain or discomfort, I am inclined to deploy evasive strategies. The temptation to cheat and/or cover up becomes overwhelming. Usually, I come away from a physio session feeling looser – yes, of course – and fitter, but also – worse – mildly criminal.

  At first, then, it was strange and unsettling on this chilly November morning to return to the world of neuro-rehab., where I would begin an intensive and experimental two-week course under the direction of Dr Nick Ward, a pioneer for whom ‘plasticity’ offers possibilities of dramatic functional improvement.

  Today, on the first floor of the Albany wing in the National where, twenty years ago, I was wheeled in for physiotherapy with Sue Edwards, I found Kevin, the medical orderly from the 1990s, still in his navy-blue tracksuit, assisting a seriously disabled middle-aged stroke survivor. Kevin, a shy, good-natured Scot, had been present throughout my initial recovery. It was both comforting and slightly disturbing to find him still there. Twenty years on, his presence reminded me to acknowledge my convalescent status.

  Now Kate, one of the senior physios, was taking me through the paperwork. Arms. Upper body. Spine. Core. Left side. Right side. Feet. Sensation. Balance. So it goes . . . It was frustrating to rehearse stuff that must be in my notes, that inches-thick file. Had no one had time to read it? Inevitably, this reminder renewed some old rage about my affliction. Again, there was a persistent conflict – I was glad to be asked about my condition, but simultaneously resentful. I lay on my back, on my front, and on my side, and tried to find a moment of Zen. But that was hard: there are too many ghosts.

  After the induction procedures, Professor Ward and his expert physios subject their patients to a sustained programme of intensive physiotherapy – repetitive exercises involving the finely calibrated movement of a shoulder blade, wrist, or thigh. Their aim is to stimulate new pathways in the brain, to recover lost movement and to renew old mind–body connections. To recover even a tiny percentage of former skills is intensely thrilling. Stroke survivors get used to paralysed arms, legs that don’t move, words that won’t form, frozen hand gestures, and steps that fail. Ward’s programme sponsors an exploration of ways in which to break down these chronic prohibitions.

  In the generation since I had my ‘brain attack’, post-stroke treatment in the UK has undergone a revolution. It’s now linked to the best and brightest technology in the world. Ever so slowly, the brain is yielding up its secrets. We now know more than ever before about how, where, and why, in the cortex such an attack occurred. In several cases of stroke, among the survivors, it’s possible to treat the ‘brain-attack’ with drugs, and diminish its impact. In new stroke units, across Britain, it has become common practice to treat stroke sufferers with immediate physiotherapeutic programmes.

  And yet? We are still left with the human condition. We might live longer, but we are not immortal, and we certainly lose cerebral autonomy during these last years. Which brings us back to that ageing brain. Whatever the benefits of neuroplasticity, the brain remains the scene of more crimes against well-being than any other part of the body, as well as doubling up as chief suspect in the diagnosis of medical mystery.

  As the victim of a ‘brain-attack’, a cerebral mugging, I am still in thrall to the mystery of my assailant. From what dark corner did he or she emerge? Were they tall or short, desperate or casual? Who were they, and what were their motives? The fact that so much about the workings of the brain remains mysterious used to be a source of anxiety. Now I’m at peace with the enigma of the brain and its crime against my well-being. I survived, didn’t I?

  As I waited one day in the hospital elevator, I caught a glimpse of my reflection trapped between two mirrors. It seemed, at that moment, an apt summary of my insignificance. As patients, we sometimes feel as if we stand between neurological research on the one hand, and everyday consciousness on the other, with the image of a cerebral cure – better, an unequivocal explanation – regressing infinitely into the future. However much I want to acknowledge ‘insignificance’, at the same time I cannot abandon my quest for a better understanding of ‘brain attack’, and its impact on my story.

  5

  THE SKULL OF MAN

  Brain (n.): The convoluted mass of nervous substance contained in the skull of man and other vertebrates.

  Oxford English Dictionary, 2nd edn

  Scan my brain and you will find a fuzzy grey scar, the size of a thumbnail, but shaped like a tiny parsnip, indicating ‘the lesion’ in my cerebral cortex. On a computer screen, brilliant technicolour fMRI scans of the brain make an entrancing image, described by one scornful neuroscientist of my acquaintance as ‘neurological bling’. To such sceptics, the importance of fMRI is often over-sold. Does a scan suggesting in which parts of the brain a particular process occurs, they ask, tell us very much about the true meaning of that mental process? In black and white, which is how such images, transferred to ordinary computer screens, are often examined by consultants and their patients, the fMRI scan is not quite so enthralling, though still fascin
ating. Is that me? you think. Does that fuzzy scar represent the catastrophe that changed my life for ever?

  The brain is both banal and magical. In our prime, it weighs about 1.4kg, and looks like porridge. When the broadcaster Chris Tarrant suffered a stroke after a long-haul flight from the Far East, he became addicted to ‘the wonders of this extraordinary machine in your head’. He described to me how he had been going to a neuropsychologist. ‘One day she came in with this plastic model of a big, fat, crinkly, porridgy melon. And I went, “What!” I mean I had no idea. I did say, “Does this make you believe in God?” And she said, “No. But it does make you think.”’

  To the Oxford English Dictionary, the brain is the organ of soft nervous tissue ‘contained in the skull of man and other vertebrates’, which is fine, as far as it goes, but listen to the Norwegian writer Karl Ove Knausgaard, who, describing it as an object of surgery, captures the thrill of the brain:

  A landscape opened up before me. I felt as if I were standing on the top of a mountain, gazing out over a plain, covered by long, meandering rivers. On the horizon, more mountains rose up, between them there were valleys and one of the valleys was covered by an enormous white glacier. Everything gleamed and glittered. It was as if I had been transported to another world, another part of the universe. One river was purple, the others were dark red, and the landscape they coursed through was full of strange, unfamiliar colors. But it was the glacier that held my gaze the longest. It lay like a plateau above the valley, sharply white, like mountain snow on a sunny day. Suddenly a wave of red rose up and washed across the white surface. I had never seen anything quite as beautiful, and when I straightened up and moved aside to make room for the doctor, for a moment my eyes were glazed with tears.

  The living brain is an object of wonder and beauty, with a complexity which has always resisted a comprehensive description. Historically, awestruck by its mystery, we have approached the brain through analogy. Thus, in the ancient world, the brain was described by Aristotle as an organ for cooling the blood, and again, in the seventeenth century, by Descartes as a hydrostatic fountain (after the fountains of Versailles). The Victorians made a comparison with railway networks and, later, the telephone exchange. In our own time, we sometimes describe the brain’s activities in terms of computer technology.

  Whatever metaphor we choose, it can only be an approximation. The facts about the brain are dizzying. Andrew Lees, the neurologist who treated me in 1995, says that below the surface of the brain, there are the ‘100,000 million tiny nerve cells that make up the grey matter.’ The neurons of this ‘grey matter’, according to Lees, ‘form part of a kaleidoscopic Internet.’ In an ordinary brain, for instance, there will be about twenty billion neurons and each of those neurons makes on average ten thousand connections every nanosecond. The extraordinary computational power of a healthy brain holds the key to our lives as human beings.

  When you start to consider the brain’s many functions, you would have to be made of marble not to become enthralled by its complexity. In the fascinated words of the twentieth-century physicist Richard Feynman, atoms in the brain

  can remember what was going on in my mind a year ago – a mind which has long since been replaced. To note that the thing I call my individuality is only a pattern or dance, that is what it means when one discovers how long it takes for the atoms of the brain to be replaced by other atoms. The atoms come into my brain, dance a dance, and then go out – there are always new atoms, but always doing the same dance, remembering what the dance was yesterday.

  According to an old medical joke, the brain is the only part of the human body to have named itself. Each one of these extraordinary machines weighs less than a bag of flour, and you could hold it in your cupped hands with ease. To do this, neurologists will tell you, can be a most moving and extraordinary experience. That, perhaps, is because the brain is more than just an organ, more than your heart and your sight, or your sexuality and your instincts. It’s you, in every sense of the word – your HQ, your top-secret communications centre, your mobility, language, memory, and true self.

  Your brain is also your window on the world. Oscar Wilde once wrote:

  It is in the brain that everything takes place . . .

  It is in the brain that the poppy is red,

  That the apple is odorous,

  That the skylark sings.

  The novelist Jeffrey Eugenides puts it more prosaically: ‘Biology gives you a brain. Life turns it into a mind.’ How and why this happens is what Francis Crick, co-author of the breakthrough research into the structure of DNA, called ‘the hard problem’. It’s at the intersection of mind and brain that, as mortals, we can – and often do – live in denial about our future, until the fantasy of immortality disintegrates.

  *

  The tantalizing frontier between well-ness and ill-health is like Lewis Carroll’s looking-glass. We can step into a nightmare at any moment. On 4 March 2016, I received this email from my friend Ana, a Spanish publisher, describing the shocking irruption of such a crisis in her life. ‘I hope this email finds you well,’ she began.

  ‘These two past weeks’, she continued, ‘have been a little nightmarish for me, in fact rather verging on the surreal. In a span of six days my father had eye-surgery and both my mother and my husband had an “ictus”.’

  This ‘ictus’, I subsequently discovered, is the Spanish term for any kind of CVA or ‘cerebro-vascular accident’. Ana’s account continued:

  ‘After leaving the hospital’s neurology ward with my mother, only two days later I was going back in again with my husband! They are both now back at home and we can even joke about it, but it has been quite unbelievable . . . You know better than me.’

  Ana admitted that she had been shocked by her family’s brush with catastrophic neurological impairment. Most distressing for her was the experience of a neurological ward: ‘The reality you face in hospital is seeing people who are much worse off, and the worst of all, who are alone, with no family to care for them.’ Among those who are well, such stark reminders of the brain’s basic functions are distressing. Strangely enough, in everyday life, we forget to make these connections, a response which becomes an ironic illustration of the brain’s place at the centre of our selves: that we don’t, and can’t, understand how it works.

  Ana’s disturbing drama illustrates the tantalizing truth about the brain: it’s a puzzle wrapped in a mystery inside an infinity of consciousness. Indeed, despite the many incredible advances in neurological research – the scanning, the mapping, and the high-tech cortical examinations – the brain remains, as another specialist once said to me, the dark side of the moon in contemporary medicine. The miracle of the brain continues to frustrate human efforts to elucidate its hidden pathways. The neuro-physician remains like a person shining a pocket flashlight into a darkened ballroom, hoping to pick out a single precious stone. At this mysterious intersection of mind and brain, here’s one inexplicable bit of data. For twenty years, my sleep was dreamless, something I attributed to the events of July 1995. Lately, however, my dreams have come back. I have no idea what this means.

  But I do know, from my own experience, that the cortex is a part of our anatomy most of us take for granted, until it malfunctions. Among older people, there are many ways the brain can fail – Alzheimer’s, tumour, aneurysm, haemorrhage, Parkinson’s, motor neurone disease, and so on – with many routes into the third act of life’s drama afflicted by varieties of neurological impairment. The longer we live, it’s the failure of the brain that most threatens the tranquillity of old age. At the same time, it’s in the brain that most older people will conduct their continuing fight for a quality of life. This is a direct consequence of an evolution in the Western world’s mortality patterns.

  Life expectancy continues to improve. In 1776, the average American could expect to live for about thirty-five years. By 1900, this figure had risen to forty-seven years, and by the millennium it stood at seventy-seven. In
2013, according to some estimates, there were more than half a million people worldwide aged one hundred, a figure that’s set to rise to one million by 2030. A few snapshots: in Britain, there are now more OAPs than children under sixteen; approximately two million of over-sixty-fives suffer from depression; and one-third of all old people can’t cut their own toenails.

  Historically, the world’s population was pyramid-shaped, based on the numerical dominance of very young children. Now, in Britain and America, the predictions suggest that within thirty years, we shall have as many people over eighty as there are under five. Mankind is just not dying in the way, or at the rate, it used to do. Since 1950, the median age of the global adult has been somewhere in the twenties, a figure that has long been on an upward curve. But now, there’s a new milestone. In 2017, according to the most reliable estimates, the world’s median age will pass thirty, and is projected to rise to thirty-eight by 2050. In Britain during 2017, more people than ever before will turn seventy.

  Associated with these statistics, there’s a change coming in the ‘dependency ratio’, the number of dependants (retirees such as grandparents) relative to the number of working-age adults. Now that baby-boomers are ageing, 2017 will mark the moment at which the dependency ratio starts to rise again. An older world becomes a world worrying about imminent disruption and short-term instability. An older world is probably less interested than heretofore in climate change and population control.

  Traditionally, in books such as How We Die: Reflections on Life’s Final Chapter by Sherwin B. Nuland there were three main suspects in the demise of the elderly: cardiac arrest, cancer, and stroke. Cancer, the affliction that people euphemize as ‘the Big C’, and coronary heart failure are big killers; stroke remains an infinitely complex exit route. But the subject which has come to interest me the most is the one that’s less often explored, the cerebral dimension of ageing, and the decline of those little grey cells more than the grim march of heart disease or cancer.