The unreal real story of a couple separated and united by one of the world’s worst tumours there is

Sam and Anita sat in front of me in my clinic. They were a couple in their early forties. He was a gym instructor and she was a teacher. Their physical appearance said they had little in common on the outside. They looked like the king and queen on opposite sides of a chess board, but were on the same team in life. Seeing them I realized that true love sees no caste, creed, religion, or race. After I heard their story, I figured, cancer doesn’t either.

“Sam was diagnosed with a glioblastoma in his right frontal lobe a year ago,” his girlfriend started, holding his hand as she spoke, while I noticed his eyes welling up with silent tears. A glioblastoma is grade 4 brain cancer. It is a ghastly diagnosis to live with. The median survival of this tumour is 1–2 years. “He had surgery by another surgeon and followed it up with 34 fractions of radiation and 6 cycles of chemotherapy,” she gave me the lowdown. The previous surgeon had done a perfect job with interim scans showed an immaculate resection and a wonderous initial response to therapy, but as expected in these ghoulish tumours, it had recurred.

“For 2 weeks, I noticed I was dragging my left foot and finding it hard to button my shirt,” he described, getting up from his chair to show me his gait. “That’s when we repeated an MRI and found that it had all come back,” Anita continued. I examined him to find his left arm and leg slightly weak. As I peered through the MRI, it showed a large growth in the right frontal lobe that was pushing against the motor cortex, thus responsible for his weakness. It had also spread to the opposite side through fibres that connect the two halves of the brain. “The tumour’s not only come back, it’s done so with a vengeance,” I announced. “We know,” they said in unison, a gnawing sadness permeating the room.“Our previous surgeon simply said, ‘Nothing can be done about it.’”

I recalled those being exactly the same words a dermatologist had used for me the previous day when I’d asked her if something could be done about my premature balding, but I didn’t think it right to mention this at this time even though I have always believed that honesty and humour are the two greatest weapons in the face of helplessness. She had also advised me to ‘accept it gracefully’, and I wondered if that, perhaps, would be the appropriate thing to say here. They were an empowered couple who had done their research and were fully aware of the finality of this diagnosis. “You could do more chemotherapy or attempt another surgery, but I’m unable to assure you or confirm if this will alter longevity and improve the quality of your life. Sometimes it could make you worse,” I said, agreeing with the previous surgeon.

“We have a date to get married in three months,” Anita said, looking into Sam’s eyes, surrendering to the anguishing anxiety of an uncertain outcome. These are such deeply personal choices that I refrained from making any comments, although I did briefly wonder why she wanted to marry a dying man. “We’ve been dating for 8 years, and a few weeks before my diagnosis, we’d set this date. We want to go ahead with it,” Sam said with a depth I was unable to fathom. Who among us would have the will to marry someone we know is going to die shortly thereafter? The answer to most things comes in not looking for one.

We discussed all the technicalities, and much to my reluctance, I agreed to another operation; I couldn’t help but remember it was Voltaire who said, ‘Every man is guilty of all the good he did not do.’ I had to keep any personal judgement aside because if we didn’t operate, I was pretty sure he wouldn’t make the date.

A few days later, we opened up the right side of his head. Everything about this tumour was macabre. It was dark and ugly. The veins in it had thrombosed and there were pockets of necrosis or dying tissue. There were engorged arteries feeding the tumour with the blood haemorrhaging in its core, which I buzzed and cut, buzzed and cut, and buzzed and cut again.I kept removing it until I saw some semblance of normal-looking brain around, ensuring I had relieved the pressure on his motor cortex. The monstrosity was demolished, and the brain once again looked illuminatingly beautiful under the brilliance of the microscope. We had restored some normalcy and hoped we had added a few checkered days to the duo’s black and white lives. He woke up the next day with improved arm and leg function, but I was unsure of how long that would last. We scheduled him for some more chemotherapy as he got discharged. “We’re going to go for a holiday before we start chemo,” Anita smiled, giving me a hug to say thank you. They had transformed their suffering through their irrepressible vitality of spirit.

Cancer has been around for centuries. We have done so much to find a cure and yet, in the larger scheme of things, it has proven to be so little. It indeed is a great leveller. It respects nothing. But recently, I came across some research that elephants don’t get cancer. The answer is, at least partly, that elephants’ cells have an astounding 20 copies of p53, a cancer repair gene. Humans just have 1. In a world where we see everything in black and white, it sometimes helps to be grey. “The war against cancer,” noted physician and writer Siddhartha Mukherjee in his epic novel – The Emperor of All Maladies “continues to oscillate between being profoundly distressing to relentlessly exhilarating.”

Three months after they were discharged, Anita sent me enraptured photos of them at their Bali destination wedding. She was dressed in bridal silver. He wore adark tuxedo. They were amidst flowers and friends of a myriad hues and glows. They were singing and dancing and living their dream. Several weeks later, I heard from her again. He hadn’t made it.  Everything once again was back and white.

The fault in our stars is the fault in our cells

“This is a very unusual-looking tumour you have there in the lower part of your spinal cord,” I told Nilesh as I displayed his MRI scan films against the brightness of the viewing box. He was a high-performing executive in his late forties and wore a conventional white shirt and khadi pants. He came in being supported by his doting wife, walking with a limp that typified spinal cord compression. “I have been in agonizing pain over the past few months and am simply unable to lie down,” he said, clearly struggling, the creases on his face doubling up on each other. “Last few weeks, he’s been sleeping on a chair at night,” his wife interjected in Gujarati.

“Is it cancer?” he asked, worrying about a diagnosis that most patients would be disquieted by. “I can’t be a hundred percent sure, but it doesn’t look like it,” I said, studying the morphology of this growth on half a dozen films. Whenever I peer through each of the MRI sequences longer than usual, I wonder if my patients begin to think that I am as clueless as they are, but I have no qualms in expressing my uncertainty in front of them. “I think this is a dermoid cyst in the spinal cord,” I finally declared, wondering if using technical terms would make any difference to them. “But doesn’t ‘derm’ have something to do with skin?” he asked, confused. A surprisingly intelligent question, I thought.

So, I went on to explain as simply as I could that when an embryo is formed, there is something called the neural tube from which the brain and spinal cord develop. This tube then folds over, leaving intact the outer covering which forms the skin. If, owing to some glitch in the process, that outer covering is also incorporated in the folding, cells from which skin, hair, and teeth grow then get incorporated in that particular organ and we call it dermoid or skin-like. Some patients thrive on technicalities and he was one of them. “So that means they can grow in any organ of the body,” he said, wisely. I nodded, saying we often remove them from the brain as well. “Why do I have so much pain on lying down and relatively much less on walking?” he continued. I explained briefly about spinal fluid dynamics and how its buoyancy is affected, and I realised that my answer was a bit confusing. “I wonder if this is a fault in my stars,” he lamented, looking at the three dazzling gemstones on his hand that were in stark contrast to his subdued pastel outfit.

We went through the perils and perks of surgery in even more detail and fixed a date for a few days later. After she gently escorted her husband out, the wife came back in. “I just want to let you know he’s addicted to heroin for his pain, and I hope it won’t affect the operation in any way,” she said, leaving without waiting for an answer. No wonder he was asking so many questions, I thought to myself, and then, just as quickly, remembered something I had read: Judge people by their mistakes and it’s we who lose almost as much as they do.

Three days later we ‘opened him up’ – a crude phrase we use, I know, but at least we did it with finesse. We sawed the bone covering the spinal cord and opened it up like a French door, to close it once we were done. His dermoid extended across eight segments of the spinal cord starting from a few segments above the tapered lower end of the spine called the conus (cone like). All the nerve roots that come off the tip and provide function to the legs were ensconced by the dermoid. When not afflicted by a tumour, this region (called the cauda equina) resembles a horse’s tail, more specifically, that of a white stallion, with a bunch of glistening nerve roots bearing resemblance to the rump of this gorgeous hoofed mammal. And even though I wasn’t an accomplished equestrian, we had to preserve the tail.

We opened the dura, the layer covering the spinal cord and nerve roots, and the dermoid almost leaped into the interstice. I cut into it to find it was filled with sebaceous putty material (the kind that our sweat glands secrete), some hair follicles, and dead skin. We also found a tooth in it. There were some fat cells and crystals of cholesterol refracting radiance. I felt like a little child looking through a kaleidoscope. It is spectacular how grungy looking remnants of skin, hair, and teeth lodge themselves between pristine nervous tissue, almost akin to the slums of Mumbai encroaching amidst fancy high-rises. After emptying the dermoid of all its contents, I adroitly peeled off its capsule from each nerve it had pushed to its edge and removed it completely. The stallion was back in the race. We closed the dura with a fine prolene suture and fixed back the bone of the spinal column with some miniature some plates and screws.

He awoke from surgery howling in pain and no amount of opioids would help calm him down. We waited a few hours hoping that once he was back to his room with family he would feel better, but it seemed like there was no recourse; the yelling only turned more turbulent. His wife took me to a corner. “I have some of his heroin, and if he gets that he’ll be okay!” she advised me, knowing he was clearly in withdrawal. I didn’t say anything but gestured to her with a slow blinking of my eyelids, the kind that allows one to communicate without having to say a word. The beauty of silence, as Richard Rohr points out, is that it frees you from the burden of thinking that your judgement is needed or important.

The next day, coincidentally, I did exactly the same operation on another patient who, strangely, had the same tumour in the same location, and she was okay post-surgery with the regular pain medication we administer. I always wonder how different people perceive pain differently and where the fault lies.

Three months later, he walked in with his wife, his gait having completely recovered. His MRI looked clean. His loving wife had doubled up as his physiotherapist and helped bring the strength back to his legs. He was completely pain-free. “I hope you’ve given up your addiction now that you’re not in pain?” I asked him. “I’ve left heroin thanks to my heroine,” he said in Gujarati, beaming while holding his wife’s hand.

A 20-minute commute on the bicycle turned into a lesson in humanity

A couple of weeks ago on Dussehra, I decided to revive riding my bicycle to work. I had started cycling during the pandemic and occasionally indulged in for short spurts whenever my weighing scale issued a warning. It’s a sublime 20-minute ride to work, where you sweat just enough not to require a shower on reaching, the air conditioning in the operation theatre evaporating the perspiration from your pores in a jiffy.

I chose a public holiday (Dussehra) because it was my first time cycling after the monsoon and I didn’t want the bane of the city’s traffic to interfere with my joy. Also, I simply needed to round on all my admitted patients and was to be back by lunch. There was no surgery or patients in the clinic to be seen. So, I cleaned the desolate domestic dust of the indoors that had settled on the bicycle, pumped the tires with air, put on my helmet, and took off.

Whenever I take a different mode of transport on the exact same route, I always notice multifarious things. Walking allows you to soak in the smell of a place and have conversations with random people, cycling gives you room to interact with the city at a medium pace, and taking the bus alters the vantage point of everything you survey.

Halfway through my journey, as I sauntered along jovially in the left lane thinking about what needed to be done for each patient who was admitted and planning for the next day’s surgeries, a truck cornered me, forcing me to press hard on the brakes. Nothing happened to me, but I’m guessing that the unused-for-a-while disc brake jammed the back wheel. So, effectively, the bicycle wouldn’t cycle. I tried to loosen some wires and tighten some knobs with my surgical hands, but the bike needed to be operated upon by a specialist.

At our home with our two daughters, if a Barbie doll’s head falls off, I can glue it back. If a soft toy gets injured, we suture it with a needle and thread. We spent all of the pandemic removing tumours from toys at home. There is nothing that cannot be fixed by a small operation – is what all surgeons like to believe. So, I picked up my bike and rolled it on its front wheel in search of a cycle surgeon on the streets of Mumbai. Within walking a kilometre, I was drenched by the sweltering October sun. I tried to hail a cab, but no one was willing to lug a cycle along, until a taxi-walla in a particoloured shirt and reeking of alcohol abruptly halted in a kaali-peeli that looked like it would fall apart any time. My destination was just a few minutes away, so I was willing to risk it. “200 rupees!” he said, with a gentle sway and a sharp slur. I’m usually the bargaining type but both of us were a little disoriented, me from dehydration and he from overhydration.

I hoisted the cycle on his overhead carrier and he secured it with a rope that looked more like a thread. We both settled into the crumbling cab. One of his hands was on the steering wheel while the other was holding the cycle on the carrier. I clenched the door to ensure it wouldn’t fall off. My intention was simply to reach the hospital, but the driver had other plans. “There is a cycle-walla in the lane behind the hospital,” he suggested in Hindi, infusing the car with an intoxicating whiff each time he spoke. I agreed, hoping to fix the problem so that I could use my cycle to ride back. The shop he had in mind was closed, but he made a few enquiries and took me to a dilapidated lane close by. I was beginning to wonder if this was going to turn into one of those scams we keep hearing about. At this point, I thought, my cycle was likely to bring more than his cab.

We reached the spot to find a bunch of scrapped cycles strewn around. There were a few sharp tools and rubber tubing lying on the ground. Bhajjans played on a speaker with incense emanating from agarbattis stuck into a crevice on the wall. It seemed like the prelude to the perfect crime scene we see in the movies. There was a sandwich maker adjacent to the make-believe cycle shop who said that the main repair guy had gone for breakfast and would come in sometime. He suggested I leave the bike and that the taxi-walla would bring it to the hospital. My suspicion grew even stronger. I said I’d wait.

I asked them to call the repair guy urgently using the line doctors always use to their advantage. “Hospital mein emergency hai,” I told them. The chief surgeon arrived to perform the operation that the cycle needed. Looking at the other cycles lying around in various states of disrepair, I very much doubted he would be able to fix anything. He took a spanner and released some bolts. The wheel was still jammed. He shook his head to signal this was a difficult task. I was familiar with that gesture because as surgeons we do the same. Now I began to calculate how much money he was going to charge me. Because that is what patients do when surgeons tell them that things are not straightforward. Today, I was a patient’s relative and my patient was half dismantled in front of me. I was at the mercy of this doctor and I was certain he was there to fleece me.

After spending a considerable amount of time tightening and loosening stuff, he removed the cable, oiled the channel within and reinserted it. He then readjusted the nuts and bolts and spun the back wheel to ensure it was smooth and then pressed on the brake to make sure it worked fine. He spent about 30 minutes on the entire assembly. All this while my one hand was on back pocket to ensure the taxi-walla didn’t flick my wallet off my scrubs.

“Yeh lo,” he said, handing the bike over to me. Knowing he was going to charge me a bomb and ready to bargain, I asked him in a brusque, haggling voice, “Kitna hua?”

“Twenty rupees,” he said with a straight face. I was ashamed of myself. He gave me his number and told me that the next time there was a problem, he would come himself to the hospital to fix it. I gave him a much bigger amount than what he’d asked for, but it still left me feeling very small.

I thanked the cabbie for going out of his way to help me. I paid him and told him to stop drinking, and that if he had any health issues, he should call me; I would help him. I gave him my number and asked him to send me a “Hi” on WhatsApp (one of the weirdest things people do, I know) so that I could save it.

Instead, he sent me a Dussehra forward.

“The demon is always within. The God is always within. The battle too is also within. And so is the triumph of one over the other. Which one over which one? That choice is also, somehow, always within.”

When you’re caught in a conundrum and have to take decisions to avoid hurting your patient’s sentiments

“We were lying in bed, fast asleep at night with our backs facing each other,” started Peter, wanting to narrate exactly what happened to his wife. “That is how we usually sleep since we’ve been married for 12 years,” he continued, not wanting to spare any details. “Suddenly, I heard her make a grunting sound that partly woke me up, and I, in my deep sleep, simply thought she was snoring, so I kicked her to keep her quiet. And usually, this works!” he explained, giving me an insight into the dynamics of their relationship. “But the sound continued, so I turned around to pinch her nose and found that my hand was wet. I immediately turned the light on and saw her frothing at the mouth. Her eyes had rolled up and she was breathing heavily,” he gestured with animated hands, “and then the breathing stopped!”

I nodded, listening patiently. “I tried to wake her up but there was no response. I didn’t know what was happening. I called my kids from the bedroom next to ours and she didn’t awaken to their calls either. She was dead, we thought. The three of us were simply holding hands and crying profusely, saying our final prayer…” he trailed off. I nearly sported a ridiculously goofy smile on my face. I could afford to grin because his wife was sitting right next to him in perfect health while he was narrating something that happened 2 weeks ago.

“While we were wiping our tears, we heard a moan from her,” he continued. “It was as if Christ had heard our prayers! She was back to life, but still not conscious,” he heaved, “so, we decided to rush her to the hospital.” Peter went on to narrate that somehow, they managed to seat her in their car and drove 20 minutes to get to the nearest hospital in the middle of the night. As soon as they reached, she opened the door to get out and asked “Why are we here? What happened?” with no awareness of what had happened to her.

“When the doctor in the ER examined her, he found nothing wrong. He explained that what she had was a seizure,” he looked up at me and saw me nodding in agreement. “For you it seems ordinary,” he countered, looking at my nonchalant expression, “but for us… we’ve never seen something like this and still don’t know how to deal with it!” he exclaimed, shaking his head. I comforted him and told him that the good news was that his wife was fine and that was all that mattered at the moment.

He handed over the whole bunch of blood reports and MRI films of the tests they had been asked to perform in the city from where they had travelled to come see me. “You do know you have a big brain tumour in your head,” I confirmed with one glance at the scan. “But we were also told that it is not malignant,” they counterchecked with me. I agreed. I explained to them that it was a meningioma, a growth arising from the meninges covering the base of the brain near the temporal bone and extending to the orbit. It measured 5 cm and was stuck to the internal carotid artery, the body’s most important blood vessel that supplies that nourishes half the brain. I also explained that these are extremely vascular tumours and bleed profusely and simultaneously instructed my colleague to arrange for three bags of blood instead of the usual practice of reserving only one every time we open a head.

“Doc,” the husband held my hand. “There’s one problem.” I waited for him to continue. “We can’t give her any blood,” he said, pulling the rug from under my feet.

I allowed for the depth of that statement to seep in before reacting. “Are you a Jehovah’s Witness?” I asked, having seen a few in the United States where I trained but none so far in India.

Jehovah’s Witnesses are a Christian denomination with beliefs distinct from mainstream Christianity. A staunch conviction of theirs is the refusal of any blood transfusion, considering it to be a violation of God’s law. “We believe that life is blood, and if God wants me to live, he will do so with my own blood,” the wife spoke for the first time in this conversation, calmly and clearly standing her ground. I respected her belief but couldn’t help but wish she had an easier tumour to remove; this one was sure to need a blood transfusion. “How about we draw your own blood, allow your haemoglobin to build up over a few weeks, and then operate so that we can transfuse it when you need it?” I suggested, coming up with a brilliant plan that I had implemented previously for someone with a very rare blood group. “Not allowed,” they vetoed it instantly.

“You go ahead with the surgery, doc. I’m willing to consent for death on table but I won’t take the blood,” she said, emotionless, while my emotions were playing football in my chest. We are so entrenched in our beliefs that what seems completely logical and straightforward to one person seems outrageous to the other, and yet, surprisingly, neither is wrong. Two surgeons had refused to operate on her, and we could do the same thing. The question was, what did I want to do?

I excused myself for a bit and went out to discuss with the team. “Even if the patient is willing, I don’t want a death on MY hands,” I justified. “How will she know if we’ve given her blood? Just don’t tell her,” innocently reasoned a colleague. “If she gets the blood of a Parsi, she’ll be cursing for the rest of her life and then she’ll know!” I laughed, trying to make light of the situation.

Trying to make up my mind, I decided to speak a little longer to the courageous woman who was willing to die for what she believed in. A few conversations after, she convinced me to do the operation. The evening before surgery, she held my hands and said, “I have two little kids to go back to.” I nodded and quipped, “Thank you for adding more pressure to an already intricate situation!”

As we wheeled her into the OT the next morning, she was happy to see the pleasant wallpaper view of a scenic beach and mountains that adorned the of walls of the OT. “If this is the last thing I get to see before I die, it’s worth it,” were her last words before the anaesthetist put her to sleep. “Does this lady want to live or die? I’m very confused,” I said aloud, while everyone got to doing their part.

From the moment we opened her head, it started bleeding. We used all the tricks in the book to stem the blood flow, ably assisted by our anaesthetists, who reduced the blood pressure for us so that we could minimize blood loss. We quickly drilled the bone, and in a set of coordinated moves, cut off the blood supply to the meningioma by buzzing with a bipolar cautery all the vessels feeding it, turning a red ball of fire to its ashen counterpart. Coring out the inside, I kept shrinking it until only a shell remained. I held the shell with an instrument and with the other hand peeled it off the internal carotid artery, removing the tumour completely without needing a single unit of blood. I must have aged a few years in those few hours.

She was fully awake by the time we wheeled her out of the operation room. “I hope you didn’t give any blood?” was the first question both she and her husband asked me in sync. Back to my usual filmy self, I replied, “The only blood I gave her was mine!”

Prashanti Patel, a budding scientist (and a prolific writer) from Israel with a keen interest in neuroscience spent a day at the hospital with Dr. Mazda Turel and wrote this poetic piece.

Ever since man became conscious of himself and the environment, he has turned increasingly wondrous (and a little fearful) of the prowess of the seething electric activity that sits in his skull and directs his body. After all, an entire human community laid a stronghold upon Earth simply through the transformative powers of higher cognitive centres, even while, in contrast, another reptilian set of connections still persists and unfailingly elicits comic hysterics upon encountering a bemused cockroach. The demons of Hiroshima and the Holocaust arose from brains wired differently and a disastrous paucity of empathy, while the flood of oxytocin explains, in part, the propensity of the working professional to watch silly cat videos during lulls in Zoom meets. The human brain continues to be an object of wonderment in itself, as a harbinger of both genius and stupidity.

I was recently given the unlikely opportunity to have a dekho at this “thinker of thoughts” up close and personal and was predictably knocked out of mental breath. As an introductory aside, I am an aspiring fledgling scientist working with the calm, stoic plant kingdom but nursing an oddball fascination for blood and gore and a particular appetite for neurosurgery. I have long yearned to be admitted into the ranks of the neurosurgeon. However, being wooed by diverse interests and woefully dissatisfied with any one of them ensured that I finally careened my career off the railroads of medicine and into the metro of applied research. Nevertheless, I continued to harbour this yearning in secret, much like the typical soap opera vamp nurtures a cobra in her bosom.

A column by Dr. Mazda Turel, a renowned Mumbai neurosurgeon in the Sunday Mid-Day, caught my eye. I began to devour his writing. Much reading, wringing of hands, and a few email exchanges later, I let spring the proverbial snake I’d been nursing. He very kindly caught the non-biting end and suggested I come observe a typical day in his life. It was thus that I found myself at the doorstep of operation theatre (OT) no. 5 on floor 11 of the hospital he works at, my heart thudding, acutely aware of being a distinctive misfit in the seamless whir of a slew of pre-operative preparations. A quick change later, I stared at myself garbed in the clinical freshness of blue OT scrubs, cap, mask, and oversized Crocs, suddenly officious and tingling with excitement.

My first impression of neurosurgery was that of a cold, stern, but wondrous dance theatre act, with the anaesthetized protagonist cloaked in sterile drapes, sanitized, and centrally immobilized under a massive robotic pincer bearing a sterile-bagged scope and two giant lamps. With the exception of the two neurosurgeons and scrub nurse who are relatively restricted in movement as they fuss about the patient, the others perform graceful terpsichorean moves about the room, a coordinated orchestra of tearing open saline drip packs and fine instrument bags, adjusting levers and valves, helping dress the surgeons in scrubs, and generally maintaining order for what’s to come. Masking up means that communication is Kathakali-style, with a spectrum of expressions finding voice in the eloquent movement of ocular muscles, conveying exasperation (scrub nurse to principal surgeon), frustration (principal surgeon to scrub nurse), and joint responsibility (principal surgeon to assistant surgeon). The neuro anaesthetists are at home, nonchalantly strolling in place amidst the hum of beeping monitors and tangled wires, but with watchful eyes on the screens, ever so gently tuning gas flow and ensuring uninterrupted anaesthesia. I, as the fourth wall, had such an earnest desire to be useful that I occasionally assisted by pulling shut the OT door every time someone went in or out, earning myself a quizzical yet kindly glance of acknowledgement from the scrub nurse.

While neurons themselves are largely quiescent, some cell groups in the nervous system are occasionally rebellious, shoving past cell division checkpoints like commuters in a Virar (fast) local and enthusiastically foundering dynasties that disrupt normal function. Some of these tumours in the brain present additional challenges of inaccessibility, infuriating the surgeon and distressing his colleagues. I watched Dr. Mazda manoeuvre through two excruciating surgeries with the able aid of the assistant neurosurgeon and a sprinkling of colourful language. Both surgeries had contrasting aspects: one patient had a right frontal lobe tumour and the other had a tumour arising from the tentorium cerebelli, a glistening protective sheet that separates the cerebellum from the cerebrum. One could do with the relatively simple opening of the frontal cranium, but the other needed a tortuous inroad through the retromastoid route. Both procedures involved a lot of noisy suctioning, blood vessel cautery to stem bleeding, and copious requirements for absorbent patties, which the scrub nurse artfully arranged along with the other instruments on her trolley. No matter what the strain, Dr. Mazda in an avuncular fashion treated me to explanations of the origin and consequences of the tumour, readouts of the MRI scans, and the use of the silvery hemostatic pads that dammed the rivulets of blood seeping into the gaping cavities that once housed the angry engorged tumour. No textbook or video, though, could have prepared me for the sight of the brain itself, softly pulsing in synchrony with the heart monitor, every detail of its topography starkly visible through the scope and reminding me that the entire intangibility of my life’s experiences was wholly contingent on the smooth corporeal functioning of this organ. As the ‘good doctor’ controlled the last bit of torrential bleeding, the room too was silent, the obvious vulnerability of the patient weighing heavily on everyone’s shoulders, the only sound being a prodigious sigh from Dr. Mazda, who had just swallowed an expletive.

Once all patties that had gone in were extricated and tallied, the surgery culminated with a silent prayer under his lips and I followed Dr. Mazda into the OPD, where a string of patients with interesting symptoms and even more interesting descriptions of the same filed through. Here, too, I co-studied scans, read through histories, and understood that body language – not only words – instantly puts the sufferer at ease. It had been a full twelve hours since I’d left home when I finally pulled off the cap and mask, donned street clothes, and prepared to leave, adrenaline still coursing through my body as I yanked open the taxi door, while both starving neurosurgeons stayed on to observe the patient until she was wheeled into intensive care. A full week elapsed before I ceased looking at people as brains with bodies and resisting the urge to pry open their skulls.

Do as the doctor says, always, especially when it involves matters of the back

Benny walked into my room with an obvious limp and a grimace on his face. Taking one look at his visage, I knew he was in excruciating pain. As he sat down, his lips pursed into an O, but what he really wanted to say was ouch. “Would you rather lie down?” I asked, already having made my diagnosis. He agreed and warily made his way from the chair to the examining bed amidst a few more moans.

He was in his 50s. He wore a tight-fitting black polyester shirt whose microfibers were stretched to their limit by his underlying paunch. “Do your friends call you Pot Benny?” I joked, pointing to his belly. He was jovial enough to acknowledge it needed to go, gesturing it with a tap downwards. “I have severe back and right leg pain,” he continued running his hand down the distribution of the pain along his cargo pants as he lay in bed. It had been 2 months now. He had tried the usual medication masala that we doctors prescribe for sciatica, a pain that radiates from the back along the path of the sciatic nerve in the leg. “I need to get back to duty, I can’t take any more leave!” he finished, exhausted.

“What do you do?” I asked. “I work in the army,” he said matter-of-factly. “Really?” I asked, the question emanating from genuine surprise given his physique. “I have a desk job in the army,” he laughed, taking the suspense away. “Don’t worry, I’m not on the battlefield!” he guffawed, putting me at ease.

“If you hadn’t clarified, I would be worried for our country!” I said in jest, but I also apologized for judging him so abruptly. “We are so programmed to make assumptions based on how we must look the part if we are in a certain profession,” I thought aloud. “I wonder what people imagine doctors to look like…” I mused, throwing open the question. “Certainly not like you,” pat was his reply. As he saw my crestfallen expression, he softened the blow by adding, “Because you are still so young!” It seemed like we were already friends.

I was reminded of a ‘sports’ theme party we once had in school. It was a classmate’s birthday and everyone had to come dressed as playing some game. Some children wore cricketing gear, others wore shorts and carried badminton, tennis, or table tennis racquets. A few wore boxing gloves or got along a football or a basketball. One boy came dressed rather formally and all the other kids mocked him for being a party pooper and not taking the trouble to dress the part like everyone else did, until he said, “I’m playing chess.” From then on, he was the hero of the party.

I examined Benny to notice that his right foot was slightly weak compared to his left, and that when I raised the right leg off the bed, he had a jagged pain down his leg from the disc in his spine that had prolapsed and was pinching his nerve. I showed that to him on his MRI film, holding it up against the twilight of Mumbai’s skyline that came in from my window. “So many people in this grungy yet gorgeous city must be having what you have,” I told Benny, “and so many just plod along in their suffering.”

I pronounced that he needed surgery. In his heart, he too knew that there was no other recourse. “A large portion of patients get away without an operation,” I explained, “but your disc is just too big, deeply indenting the nerve, which appears swollen on the MRI,” I said, rationalising my decision. “The fate of the Indian army’s accounts is in your hands,” he said in his self-deprecating humour, poking fun at himself and at the desk job he needed to get back to. I explained to him that it was a minimally invasive surgery and assured him that he would be fine.

The next afternoon, we made a small incision in his back, and, using a set of tubular dilators, which only separate the muscle without cutting it, I got to the bone. I drilled a sliver of the lamina and bit off the ligament covering the dura. The disc had lifted up the nerve root, causing it to look angry and inflamed. I cut into it and with a forceps, grabbed the fleshy piece and wriggled it out. It was like unearthing a pale slug from the soil. The nerve root went instantly lax and retreated to its place, almost as if it were saying ‘thank you’. We made sure there were no free fragments of the disc before we closed.

When he woke up, his pain had dissipated. He tested it by bending his knee and hip and rehearsing the movements that had caused him pain earlier. “You must lose weight before you can try any stunts with your back,” I warned him when he got discharged the next day, giving him permission to resume work in a week. He was eternally grateful.

Two weeks later, I got a call from the emergency saying Benny was back with the exact same pain. My heart sank; perhaps it was something ominous. When I saw him, he was in greater agony than the first time we met. “Did you do something silly?” I asked, knowing that his disc had probably popped out again. “I was feeling so good all these days that this morning, I lifted a bucket full of water and poured it over my head while having a bath, and that’s when the pain started,” he said, shaking his head and tapping his forehead this time instead of his belly. “Courage is knowing it might hurt and doing it anyways. Stupidity is exactly the same thing,” I said, pulling out a quote from my armamentarium. “And that’s why life is hard,” he said, completing the saying for me.

In my earlier days, on the few occasions when someone whom I had operated upon for a slipped disc returned with pain within a short span of time, I would always blame myself for possibly a sub-optimal job done, until a surgeon, probably in witticism, once told me, “Always blame the patient first. Only if you can’t find fault with them, blame yourself.” I could never resonate with that until this day.

We did an MRI and saw that he had a large re-herniation of his disc. I told him it was best to bite the bullet and redo the operation. “Do I have a choice?” he asked. My usual philosophical response would have been, “We always have a choice,” but this time I bluntly said “No!” I assured him that we would be done in 30 minutes. I went back in and removed that fleshy little monster of a disc that had exploded in his spine. The nerve once again said ‘thank you’ for what I hoped would be the last time.

We discharged him the next day, completely pain free as if nothing had ever happened. “So, what should I do now?” he asked perplexed. My reply was to maintain ‘Status Quo’… and I then went on to paraphrase and sing a song by a band with the very same name.

 Now you remember what the doctor said,

Nothing to do all day but stay in bed

You’re in the army now

Oh-oo-oh you’re in the army now!

One man’s refusal to undergo surgery could have led to a lifetime of overwhelming pain and distress, but a change of mind changed everything for the better.

“Please, could you turn off the air-conditioning?” an elderly gentleman requested me in Urdu as he gingerly sat on the chair in front of me, his wife helping him make the final adjustments. I instantly obliged by switching it off and he acknowledged the act by placing his hand on his heart and nodding his head. He was in his sixties and adorned a white kurta. His eyes looked troubled and were brooding with grief that I wanted to know the source of. “I have an intense pain over the left side of my face,” he mumbled keeping his mouth half closed. “If he opens his mouth more than this, he gets an electric shock down his jaw, sometimes his nose, and even his forehead,” his wife explained.

A few medical students interested in neurosurgery were sitting in my office, and I asked them to pay close attention to the patient’s history, as I had already made my diagnosis. “He can’t touch the left side of his face,” his wife continued. “He can touch his right forehead, can rub his right eye, dig his right nostril, but nothing on the left,” she narrated as her husband performed all these actions. It was like watching an elderly couple play dumb charades. “He hasn’t washed the left side of his face in a while,” she concluded. “I haven’t shaved in months,” he added,  pointing to his long glistening silvery beard. “Even the air of the fan bothers me, and that’s why I asked you to turn off the air-conditioner. It sends shivers down my spine even if it whiffs past the left side of my face,” he said in Urdu, to which the above English translation does no justice.

I wanted to examine him, but he didn’t allow me to touch his face. He had poor oral hygiene because he couldn’t brush on the left. I turned my gaze to the medical students who had just completed their final year and raised my eyebrows, asking them for a diagnosis. “Trigeminal neuralgia,” one of them jumped. “Correct,” said the patient’s wife having heard this term umpteen times since they had made the diagnosis three years ago. “He takes 14 pain killers a day, 4 in the morning and afternoon each and 6 at night,” she said. Even I was shocked. They had tried an injection into the trigeminal nerve, which hadn’t worked, and even had a single shot of radiation to the nerve 2 years ago. Both of these are valid treatments of this condition, but as I studied the MRI in detail, I explained to them that surgery seemed to be the only resort. I pointed out a loop of a dilated and tortuous artery pressing against the trigeminal nerve, and with every heartbeat, it was pulsating against the nerve, sending a current down the distribution of the nerve which was the entire face.

“We will do everything but we won’t have surgery,” he gently placed both his palms on the table. “We have lived with this pain, we will die with it,” he ordained, as if it was the will of God. The medical students, one of whom was from Ukraine and the other from Kenya, were surprised. I explained to them that India is a vast country and its citizens had varied religious and cultural beliefs, which we must regard and accept respectfully without being judgmental. But I really wanted to help this man, so I came up with an explanation in Hindi that hit close to home.

“Imagine that someone has placed a humongous rock on your chest because of which you can’t breathe. Any amount of oxygen or intravenous pain medication is not going to help unless I physically lift that rock of your chest,” I simplified. The artery pressing against the nerve was the rock on his chest. Most of us carry that rock metaphorically, and I wanted to say that but I didn’t know how in Hindi. I’m guessing you might try to do that too, as you read this.

Amidst the explanation, he had another attack of sharp-shooting lancinating pain but was unable to wipe the tears that rolled down the left side of his face. We waited till they stopped. After 3 or 4 minutes of silence, he said. “We will do the operation.” The medical students were excited because they would get to watch what they were googling on their phone. We admitted him the very next day, lest he changed his mind.

Two mornings later, we fixed his head on a clamp and positioned him on his side so we could make an incision behind his ear. I made a bony window and opened the covering over the cerebellum, which I gently retracted after draining some holy water, more specifically and technically called cerebrospinal fluid. I exposed a little more than usual because I wanted to show all the cranial nerves to the medical students who were watching on a screen what I saw through the microscope.

“That’s the hypoglossal nerve,” I said, pointing to a thin glistening structure at the base of the skull. “It helps you move your tongue. If it comes into my suction, he’ll have half his tongue paralysed.” I moved up to the vagus nerve. “That’s the nerve that makes your heart skip a beat or race furiously when you’re in love,” I continued, adding some spice to keep them glued. “I wish I could burn mine,” muttered one, who was just recovering from heartbreak. I quickly moved up to the facial nerve. “That’s what makes you smile,” I pointed, and then, finally we reached our target.

“And that’s the trigeminal nerve. Look how it is pushed up from below almost like a tumour sitting within it.” I gently teased all the arachnoid strands around the nerve and painstakingly mobilized artery from the nerve, making sure nothing snapped. After having separated the two structures that, until a while ago, looked like conjoined twins, we placed a pad of Teflon to make sure the artery didn’t bounce back onto the nerve. I inspected the nerve with an endoscope to ensure nothing else was touching it. “And we’re done,” I pronounced at the students still gawking at the screen with their mouths wide open.

“Dr. Peter Jannetta invented this operation in the 1960s,” I told them as we closed. “Often, patients go first to dentists with this problem and sometimes get cavities filled and root canals done with no pain relief. Most dentists nowadays are very astute and instantly identify this condition correctly for what it is. But in the past, I’ve even had a patient who was advised a jaw replacement surgery to relieve this pain,” I told them, as they listened, engrossed, to how tricky the diagnosis can be.

I went with the entire entourage to see him in the ICU a few hours later, when he was fully awake. His pain had gone completely. He dug his palm deep into the left half of his face, rubbing his eyes and forehead to prove it. The medical students were in awe. “It’s one of the most rewarding operations in neurosurgery and we have Dr.Jannetta to thank for that.”

The next morning when we walked into his room, he sat reading the newspaper after having brushed and shaved for the first time in months. “You’ve given me a new life,” he burst out in tears, but this time, he was able to wipe them off on his own without a worry. I embraced him. “It was the will of God that we could do this for you,” I said prophetically in Urdu.

In a world where you can be any kind of parent (helicopter, dragon, tiger, dolphin) –  some parents just simply choose to be entertaining.

I have two daughters, one each in the first and second grades. They go to school by their school bus, a convenient way for them to travel, and that is more than enough for me. But if you go by the WhatsApp chats of their respective class groups, it is clearly not enough for some of my fellow parents. These chats are also the sole reason for my phone reaching its maximum storage capacity thrice a day.

I wonder why so many parents are disgruntled with so many things. I thought that the children being out of the house for half the day – this simple fact – would bring joy to the faces of most mothers. On the contrary, from the time their kids leave home to the time they return, they are complaining about the school on WhatsApp.

The kids have a tracking bar on their ID cards that is coded to an app, which you can download on your phone to know where the bus is in transit. “The tracking system doesn’t work!” the parents moan daily. If the bus leaves 5 minutes late from school, WhatApp crashes, because the parents have no clue where their precious poodles are for those 20-30 minutes between school and home. I wonder how many children didn’t get home when these devices were not present. I remember spending a couple of hours at my neighbors’ after getting off the bus before going home. Today’s parents would freak out because the app would show that their child has reached home but is nowhere to be found!

On the days it rains heavily for a bit, some parents will send photos of the puddles outside their homes, protesting that school should be online that day. And if, by any chance, the school goes ahead as planned and their children’s feet get a little wet, WhatsApp starts brimming with pictures of their wet toes and crinkled ankles – the kind you’d get if you had spent an hour in the pool. “Can’t the school make provisions for the children to change into new socks? Why can’t we wear Crocs to school? How can we expect 6- and 7-year-olds to have wet feet?” they fuss. When we went to school – and it was the same school – we splashed happily in every single puddle on the way and back and no one was bothered.

“My child got bitten by a mosquito in class,” fretted one parent, and followed it up with pictures of the bite from different angles so that we, a captive audience, could get an idea of the correct amount of redness and pain. To gain some momentum, a few other parents followed this up with pictures of mosquito bites on their kids, making my WhatsApp slow down tremendously once again. Demands were made that the furniture should be checked for bugs and termites and why couldn’t the classroom be airconditioned. I was surprised no one suggested that the monsoon be cancelled. When we were little, we got cut and bruised. We were bitten and sometimes bit back. No one knew, no one cared. As long as we were alive, we were okay.

“The benches are not the right size for my kids,” grumbled some other parents. “When my child comes home, they (which, in case you didn’t know, is the correct pronoun to use in today’s gender sensitive times) complain that their back hurts and legs have cramped.” “My child can’t even do karate class properly,” bemoaned another. If everything hurts so much, I thought, then perhaps the karate class needs to be changed, not the bench. Parents are worried that their progeny, sitting on hard benches, will have osteoporosis when they grow up. I’m worried if these parents will ever grow up. I always sat on the last bench, and I have very long legs. My teachers were lovely to have allowed me to put my bench out of the class while the table remained inside; problem so easily solved.

“My child came home with some yellow paint on the uniform,” was the topic of another day. Apparently, some of the newly painted benches hadn’t dried completely. Parents objected about the school’s apparent lack of concern. “The lead in these paints is so toxic, it can affect their nervous system and cause them to have nerve problems,” was a common opinion. My WhatsApp started flickering on its own with these comments. The school was accused of jeopardizing the future potential of children who would otherwise make brilliant advances in science were it not for the stains on their uniform, the fumes from which they were actively inhaling. I didn’t complain because my daughter is in the yellow house and the yellow stains were easily camouflaged.

I had a complaint of my own, but not for the WhatsApp group. “My daughter doesn’t like to do homework with me,” I lamented to a friend of mine. She responded with, “Which child likes homework? Send her to me. Kids usually study well with someone they can’t make excuses with. I teach some underprivileged children and she can join us.” “Do you teach overprivileged children?” I joked, because our kids today are in that category. She rolled her eyes back at me. “You can’t expect to raise your children like you were raised, Mazda, because the world that you were raised in doesn’t exist,” she retorted.

“Why do you not care about the problems these little kids face?” a bunch of parents asked me recently, when I told them about how trivial their issues were and that the school was doing a great job and my kids always come home happy (even though, on most days, they haven’t completed their homework). “Why do you live as if none of this stuff matters?” they cornered me. I mulled over that for a while, and I have an answer. I think it comes from being in the profession I am in. I regularly see children with brain tumors, hydrocephalus, blindness, and retardation. I see children with malformations of the spine, those who can’t sit, stand, or walk. I see children with epilepsy who have 5, 10, 15, 20 seizures a day. Most of these children once went to school and can’t anymore, while some of them never did. Some may not see their next summer vacation and their parents are acutely aware of it; somehow, they still smile. Where I trained in neurosurgery, in Vellore, people used to sell their farm produce, cattle, and sometimes even their homes to seek help for their children. Every time I operate on a child, I ask myself, “What if this was my daughter?” And then I’m thankful it isn’t.

So, this Parsi New Year, please, let’s not complain, at least not about the things that are paltry or inconsequential. Life is too short to be little. And so is the storage on my phone.

Happy New Year.

A tiny tumour within the pituitary gland, discovered nearly a century ago by Harvey Cushing, continues to be the bane of existence for many women

“I have put on an incredible amount of weight in the past two years,” said 38-year-old Tanya Patel, plonking herself on my office chair after barely managing a few steps on her own. She was bruised all over. “Even a minor bump causes my skin to discolour and swell,” she said showing me her arms that had the words ‘today I escape’ inscribed in Sanskrit. “I’ve had three fractures and two miscarriages and now I can’t even conceive,” she lamented, her eyes welling up. “I have hair growing all over my body and I am ashamed to even look at myself in the mirror,” she burst out crying, covering her acne in the palms of her hands.

“I’ve had PCOD (polycystic ovarian disease) for years, and doctors are attributing all my symptoms to that. My periods are irregular and I’ve been on hormonal medication forever but I’m tired and exhausted and annoyed and irritated and depressed!” she exclaimed, as she emptied a bag full of pain killers, oestrogen and progesterone tablets, drugs for diabetes and hypertension, and mood elevators for her bipolar disorder. “My sugars are all over the place, my wounds don’t heal, and I bleed profusely if and when my period decides to come!” she said, exasperated.

I examined her thoroughly after some more questioning. She had a very typical physiognomy. Her obesity was mainly truncal, while her arms and legs were lean. Her face was round like the moon. She had a bulge on her upper back where fat had deposited – in medical jargon we call this a ‘buffalo hump’, classical of a certain ailment. I held her hands in mine and noticed that certain parts of it were very darkly pigmented. My suspicion grew stronger. “I think you may have Cushing’s Disease,” I decreed.

“It’s a condition where you get a bunch of these symptoms because of a tumour of the pituitary gland producing excess cortisol. You can also see several of these features in people who are put on long-term steroids for either asthma or rheumatoid arthritis. But as you’re not taking any, it’s probably your body over-producing cortisol from either your brain or your adrenal glands. We must do some testing and get an MRI of the brain. If it is what I think it is, we’ll have an answer to all your problems,” I left her with hope. After all that she had been through, that was the least I could provide for the time being.

She came back with her extended family a few days later, completing the myriad tests that had been ordered. “Bingo!” I snapped my fingers. The MRI showed an 8 mm tumour within the pituitary gland, off to the left. I pointed to it with a pen. “That’s the enemy,” I smiled. “That tiny thing is doing this to me?” she asked, aghast. I nodded, confirming after checking all the biochemical tests to collaborate my findings. “We’ll remove this via the nose using an endoscope and you’ll be cured. In the place I trained, we probably did more of these than anywhere else in the world,” I said to boost her confidence. She looked at me with incredulity, still unable to believe that such a tiny thing can cause so much havoc.

A few days later, along with my ENT colleague, we made our journey through the nose. Navigating our way through the turbinates, we broke the posterior part of the nasal septum and entered a cavernous structure. “That’s the sphenoid sinus,” I demonstrated in 4k on a giant screen to some medical students interested in neurosurgery who were visiting us, standing on their toes with excitement. I had gotten them to see Tanya before surgery and explained her MRI to them. They were shocked to know that a brain tumour can be removed through the nose.

I drilled the floor of the sella, the bony saucer that cradles the pituitary gland. “You have to be very careful while you drill,” I cautioned them, “as on either side of the sella are the carotid arteries, the main blood vessel of the brain, and if I damage it, the patient could die in an instant,” I narrated to add some shock and awe value and keep them engaged. “Shubh shubh bolo, sir,” my assistant prodded. I cut the dura covering the gland widely and there it was – 8 mm of a cheese ball that we curreted fastidiously and removed completely. “That’s the normal pituitary gland to the right, pinkish and fleshy, a stark contrast from the tumour, which is soft and squishy,” I explained.

“Do you know who Harvey Cushing was?” I questioned the medical students while we closed in a meticulous fashion. “He was the father of modern neurosurgery,” one of them replied. I was impressed. “Cushing called this condition the ‘diabetes of bearded women,’” I enlightened them further. “And do you know what his contributions were besides naming this disease over a 100 years ago?” They remained silent.

“He was the youngest of 10 children who augmented neurology and neurosurgery to the respect it has now. He used X-rays to diagnose brain tumours at the time and introduced to the United States blood pressure measurement that he saw being practiced in Italy. He described a definitive condition of raised intracranial pressure where there is a triad of bradycardia, hypertension, and irregular breathing and named it Cushing’s Reflex. He worked at both Johns Hopkins and Harvard, writing numerous papers on several important discoveries he made, designing several surgical instruments, describing new procedures, teaching surgical trainees, and maintaining detailed records of his 2,000 brain tumour surgeries,” I lectured.

Harvey Cushing was nominated for the Nobel prize in physiology and medicine 38 times, but never won. However, he won a Pulitzer Prize in 1926 for the biography of Sir William Osler. He died of a heart attack. Interestingly, his autopsy revealed a tumour-like cyst in the brain.

After Tanya was discharged, her care was taken over by an endocrinologist to finetune her medication. But we stayed in touch over the phone and became friends. She came to me for a follow up a year later looking unrecognizable. She had lost 30 kg and looked well-toned, with glowing skin and dazzling hair. “I’m 2 months pregnant and I only have you to thank!” she said, holding hands with her husband. “Please don’t thank me, the nose was the only orifice I entered,” I joked. “Either thank him,” I said, directing my gaze to her husband, “or thank Cushing, without whom we’d still be treating you for PCOD.” “Cushing Zindabad!” she cheered, and gave me a tight hug.