The surgical memory

When senior citizens forget, we attribute it to old age. When they miss a step repeatedly, it’s what else, but wasting bones! In medicine, assumptions can be counter productive

I have come all the way from the suburbs for him,” Mahrukh aunty told me, pointing to her husband who was being manoeuvred by an attendant into my office on a wheelchair. She wore a floral scarf knotted under her chin and a simple, beige dress. He wore a big smile, typifying the oblivion of why he was here. For having lived to more than 80 years, he was robustly built: broad shoulders, steel frame, firm handshake. He was 5 feet 11 inches tall and weighed 110 kg.

“He is forgetting everything,” his wife started. “Can’t remember what he has eaten for breakfast, can’t remember the names of relatives who come to visit, and now he is even forgetting things of the past such as the name of his school, college, or where he worked,” she gave a detailed description of his memory impairment. “Do you remember your wife’s birthday?” I asked Rustom uncle, trying to engage him. There was silence. He stared at me blankly for a few seconds and burst out laughing. She gently stroked his forehead trying to calm him down. I can guarantee that no other wife in the universe would have had that reaction. “This is his behaviour to most questions,” Mahrukh aunty informed me of his plight. “Doctors tell me that this is Alzheimer’s and that he has to live with it,” she lamented.

“Why is he in a wheelchair?” I asked, not convinced about the Alzheimer’s diagnosis. “He cannot walk for more than a few steps; he tends to trip and needs help to support him,” she explained. “I used to walk two kilometres a day until one year ago,” he interjected following the conversation, not completely out of it. “What about passing urine?” I asked. “No control,” his wife stated. “He’s been on a diaper for the past nine months.” I made a detailed examination and concluded that before we could call this Alzheimer’s, we needed to rule out other treatable causes. “We should get an MRI of the brain done,” I insisted. “Doctor, please admit him and do whatever you want to because I’m 75 myself and can’t manage him at home,” she said exasperated.

The MRI done the next day showed what I had expected. The ventricles—the cavities that produce and contain cerebrospinal fluid or CSF—were distended beyond the normal, pushing against the delicate leg and bladder fibres of the brain, resulting in his imbalance and urinary dysfunction. Normally, ventricles look like two slender bananas backing each other. Dilated ventricles look like the bananas put on a Mickey Mouse hat. I explained the findings to the wife. “This looks like an entity called normal pressure hydrocephalus or NPH,” I got technical. “The pressure in the brain isn’t raised, but because the ventricles are distended or dilated, he has these symptoms.”

I explained that the logical thing to do was to drain some spinal fluid via the lower back, which communicated with the brain, and if there was an improvement in his symptoms, we could consider inserting a tube in the brain that would permanently drain CSF in a regulated fashion into the abdomen. We also tested for any vitamin B12 deficiency and thyroid dysfunction, which are the commonest causes of forgetfulness. His results were clear. “Is there a need to do all this at this age?” his wife asked. “Only so that he can remember your birthday,” I replied, putting my arm around her shoulder. “If he doesn’t get better after draining CSF via a lumbar puncture, we won’t do anything else for him,” I promised. She consented.

The next day, we stuck in a needle in his spine and drained about 40 cc of crystal-clear fluid from his spine. A few hours later, when we made him walk, his gait was remarkably better. He could walk longer distances simply with the support of one person. “How do you think he is?” I asked his wife. “He’s so much chirpier today than I’ve seen him in the past one year!” she said, beaming. I looked at Rustom uncle. “When is your wedding anniversary?” I asked. He gave me a blank stare. His wife looked away dejected. And then, three seconds later, he said, “12th, March 1975!” His wife turned around in disbelief. With a smile as sparkling as Julia Roberts’, she kissed him all over his bald head and face. “So, shall we go ahead with the shunt operation?” I asked with a smile. “Of course!” she said without any deliberation. When elderly people start forgetting things, the general tendency is to attribute it to old age or label it as the wearing out of faculties. When they have experience  imbalance while walking, it is mostly attributed to the withering of joints, muscles, and bones. When they have trouble peeing, it is assumed that it is most likely a prostate dysfunction. But we need to look deeper and identify if we can find something that is reversible. 

And when I’ve looked, I’ve found brain tumours, excess fluid, collection of blood pressing against the brain… all of which can cause the exact same symptoms. That’s why I always insist on an MRI for anyone who’s unreasonably forgetful. The next day, we made a tiny hole in Rustom uncle’s skull and tapped his dilated ventricle. The tube was attached to a valve that would regulate the pressure at which the fluid was drained. We then tunnelled the tube under his skin and inserted it into the abdomen, performing a sophisticated plumbing job. Now, all the excess fluid that was produced by the ventricles would drain into the abdomen and get absorbed by nature’s magnanimity. The day after surgery, he was sitting up and eating alone—something he hadn’t done in months. Two days later, he indicated an urge to pass urine and walked to the washroom on his own.

“Now I have no work left to do; otherwise, I was changing three diapers a day!” his wife joked. She also told me the story of how, when she was in hospital and diagnosed with breast cancer a few years ago, he was there to take care of her round the clock. When they got discharged, the hospital staff cut a cake with the words, “Best husband ever” iced on it. The next day, we decided to get another cake with the date ‘30th July’. When he was told to cut it, he instantly recognised the date as his wife’s birthday. Tears rolled down her wrinkled cheeks. Memory allows us to have a meaningful life.

“I feel like eating French fries from McDonald’s,” Rustom uncle told me. “Will you help me smuggle them into the hospital?” he winked. “French fries are for eight-year-olds, not 80,” I chided. “Just get rid of the zero after the eight. I’m enjoying my second childhood,” he reminded me, paraphrasing Shakespeare.

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals mazda.turel @mid-day.com

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