There is a curious irony in medicine. We spend our lives worrying about tumours, clots and bleeding, yet sometimes the greatest trouble comes from something as innocent as water.
Not water exactly, but cerebrospinal fluid—a crystal-clear liquid that bathes the brain and spinal cord. Nearly half a litre of it is produced every day, although only about 150 millilitres are present at any one time. It is continuously made, circulated and absorbed, washing over the nervous system like an invisible river. Hidden deep within the brain are four interconnected chambers called the ventricles. They are not hollow voids waiting to be filled; they are carefully engineered waterways, carrying this fluid through the brain before it returns to the bloodstream. Most of us will live our entire lives without ever knowing these chambers exist. Yet when these quiet rivers stop flowing, they can slowly erode memory, balance and independence.
Rustomji was 85 when I first met him. He arrived holding his wife’s hand with the easy familiarity of two people who had stopped counting anniversaries decades ago. They had been married for almost 60 years. She answered most of my questions before he could, not because she wished to speak for him, but because they had long ago become experts at finishing each other’s sentences.
Over the previous year, she had watched subtle changes creep into his life. He had begun walking more slowly. His feet seemed reluctant to leave the floor, as though invisible magnets had been placed beneath them. He had developed embarrassing urinary urgency and occasional accidents that chipped away at his dignity. More painfully, he had become forgetful. Names escaped him. Conversations dissolved midway. Familiar stories were left unfinished.
Many families assume these changes are simply the price of growing old. Sometimes they are. But occasionally ageing is blamed for something that is, at least in part, treatable.
A scan of his brain revealed enlarged ventricles. The brain’s rivers had become lakes. The condition is called normal pressure hydrocephalus, one of the more deceptive disorders in neurology. Unlike the dramatic hydrocephalus seen in children, the pressure is often deceptively normal. The ventricles enlarge gradually, stretching and compressing the delicate white matter fibres that surround them. These fibres carry messages responsible for walking, bladder control and aspects of memory. It is less a flood than a slow tide, quietly pushing against the brain’s wiring until everyday tasks become unexpectedly difficult.
The French writer Antoine de Saint-Exupéry wrote, “What is essential is invisible to the eye.” Few structures embody that thought more than the ventricles. They are almost invisible in our awareness, yet without their gentle circulation the brain cannot function as it should.
After careful evaluation, we decided to insert a ventriculoperitoneal shunt—a slender tube that diverts excess cerebrospinal fluid from the ventricles into the abdomen, where it is safely absorbed. It is an elegantly simple idea: restore the flow, relieve the pressure, and give the brain room to breathe again.
Recovery after shunt surgery is often gradual, almost imperceptible. Family members notice the difference before the patient does. His wife noticed first. “He walks faster now,” she smiled. Then she added, almost shyly, “He sleeps through the night again.” The urinary urgency had improved. The hesitant, magnetic gait had loosened. He no longer seemed anchored to the floor. It was as though someone had quietly released the brakes that had been holding him back.
Memory, however, is a more complicated traveller. At his follow-up visit, I decided to test it in a way no textbook recommends. “So tell me,” I asked, “where did you first meet your wife?” He frowned in concentration. His face brightened with confidence. He proudly announced an address. Before I could congratulate him, his wife burst into laughter.
“Doctor,” she said between giggles, “that isn’t where we first met.” I looked from one to the other. “That’s the red-light district next to his old house!” The clinic erupted.
He looked mildly offended, then amused, while she laughed with the effortless affection that only 60 years of marriage can produce. Perhaps the shunt had nudged open a few old filing cabinets in his brain but misplaced some of the labels.
Marcel Proust famously wrote, “Remembrance of things past is not necessarily the remembrance of things as they were.” Memory is not a recording. It is a reconstruction, endlessly edited by time, emotion and imagination. Neuroscience can restore the pathways through which memories travel, but it cannot always guarantee where those journeys will end.
As they left my clinic, he reached instinctively for her hand. She squeezed it without a word.
His steps were steadier. His confidence had returned. His dignity had been reclaimed. And although the geography of his memories remained delightfully unreliable, the geography of his heart was perfectly intact. Sometimes that is the most meaningful recovery of all.
The author is consultant neurosurgeon at Wockhardt Hospital, Mumbai.
mazdaturel@gmail.com @mazdaturel
