Eyelid and insulation

Devotees of my Facebook page have noted that yesterday and today I changed the images appearing at the top. The confluence of rivers Eden and Eamont near Langwathby has been replaced by the family in 2007, so Hugh is there holding his young daughter, and Christine and I in Trafalgar Square in about 1953 have aged a few years in a portrait taken in (I think) Binns photography department in Carlisle, by which time I was stroppier and hated having my picture taken. Still not keen.

I remember that checked shirt. I remember mother fussing about its collar and my hair. She was a great fusser. Trained as a nurse in Wrightington Hospital and Bradford Royal Infirmary, her approach to motherhood was clinical in the extreme. Everything had to be just so. A woman from the village whom I’d not seen for half a century told me that she’d never seen a boy’s toy cupboard as tidy as mine. She obviously thought this reflected on me and I didn’t have the heart to disabuse her. Having said that, those that know me will understand that I am the tidiest of men: a place for everything and everything in something else’s place. The consequences of a free-spirited lad being thus regimented can for now be left to your imagination, for that is not what today’s billet doux is about.

Should you study the photos of the infant yours truly, you will note that my left upper eyelid droops. The jargon word is ptosis (πτῶσις: falling, dropped). A developing ptosis can point to a number of neurological conditions, and it may even signify a tumour of the apex of the lung which invades the neighbouring sympathetic chain, for the nerve supply to some of the eye apparatus reflects a fascinating evolutionary and embryological history that need not concern us today. In my case, ptosis was present at birth. It is congenital. Yes, girls and boys, I’m a freak, a force of nature.

Why a left ptosis? 

Who knows? Birth injury? Perhaps the forceps happened to press on the wrong place. But I think not. Ever since my left retina “detached” in 2006 and sight on the left deteriorated and then vanished, I’ve concocted another story about my beloved ptosis. 

I think my left eye and eyelid have always been substandard. Vision on the left has always been iffy. Looking back (yes, ha ha, very funny) I’ve always screwed my left eye shut to read. I’ve always had to turn my head more to the left than the right when taking in a view. I’ve never had a good aim in throwing or catching or kicking. Playground fights at Langwathby school never ended well for me so I Iearnt to fight with words.

My lack of hand/foot/eye coordination meant I was the last to be chosen for teams. Mercifully this didn’t happen very often for Miss Metcalfe of truly blessed memory had the extraordinary notion that school was for reading, writing, sums, geography and a bit of history. I have written about her in a previous blog https://ramblingrector.me/2013/07/19/the-happiest-days-of-your-life/

I was therefore hopeless at cricket and football. Penrith Grammar was a rugby school and the only bit of that I even mildly enjoyed, for I had good thighs, was shoving in the scrum – no aim needed once one’s grasp of the opponent’s scrotum was secure. In the main I thought, and think, rugby an incredibly silly game. All those rules – why?

Now, leaving behind the subject of eyes, this set me thinking about why some children are better than others at sporty stuff.

The spinal cord is like an electric cable containing bundles of wires (nerve fibres) each with its own insulation, some carrying impulses from the brain, others to the brain (never, note never, do wires sometimes carry impulses one way and sometimes another – unlike railway tracks that can be signalled bidirectionally). Now, hear this. It takes years after birth for insulation (myelination is the jargon term, myelin being the insulator) to develop fully – indeed in some cases it’s not complete until the late teens. This is one reason why teenagers can be so ungainly and need so much sleep; myelination must be very tiring. Actually, by this reckoning I’m living life backwards. But I digress. 

Here’s my theory, so. If myelination is early, then chances are you’ll be well coordinated early, good at sports and win the victor/victrix ludorum prize, your proud parents donating a cup to be awarded at subsequent sports days for other swaggering toads. If, on the other hand, myelination is later than usual, then you risk having the shit kicked out of you by the jocks for being a clumsy lumbering git.

The vagus nerve: a journey

A former student, now a Head and Neck Surgeon in Liverpool, has asked me to give a talk to his colleagues. Here it is. Even if you’re neither medic nor zoologist you might get something from it, particularly the way that words carelessly used can lead to erroneous inferences. 

This is the story of the tenth cranial nerve and me.

You won’t hear anything useful for your research project or your next paper. This is not likely to result in earth-shattering developments in head and neck surgery. It is rather a series of speculations and insights arising from half a century of asking “why?”.

As a clinical student 1972-75 at King’s College Hospital in south London it gradually dawned on me that medical practice was not to my taste, so in the final year I did some thinking. The things that took my fancy in Cambridge were, first, the introductory anatomy lecture in which the Professor of Anatomy told us about our place in nature with other primates (apes not archbishops); and, second, embryology, that is to say, how we come to be what we are. I guess our medical student cohort was one of the last to study embryology in any depth, examining serial sections of pig embryos every Monday afternoon for a term. 

But the most significant Cambridge influence was the person of Max Bull, the senior non-professorial anatomist, a gifted analytical teacher, and my supervisor. “If that is what an anatomist is and does,” I must have thought, “then an anatomist I shall be”.

In 1976 I started work as Anatomy Demonstrator (Temporary Lecturer) at the new medical school in Nottingham. I stayed for 11 years. In 1988 I took up the Chair of Anatomy at the Royal College of Surgeons in Ireland, which was and remains the biggest undergraduate medical school in Ireland, despite its name. After 16 years I came back to England as the foundation anatomist of the new Nottingham graduate entry medical school sited in Derby.

I was intrigued by a few things throughout this time: for example, the systematic arrangement of brain stem nuclei; that structurally we haven’t changed much since reptiles; and the ways that different species, different chordates even, handle the perception of vibration in the external environment (we call it hearing). But most of all, the vagus.

A motor nerve?

The tenth cranial nerve arises from the medulla by a series of rootlets posterolateral to the olive. The nerve passes through the jugular foramen and runs in the carotid sheath down to the mediastinum. It sends branches to ear, pharynx, and larynx, and forms a plexus around the oesophagus becoming ever more intimately involved with the gut tube as part of the myenteric plexuses of foregut and midgut – all the way to the splenic flexure of the colon.

Good Heavens, this is boring, isn’t it?

I could go on in mind-numbing detail that would have you reaching for the knife with which to slit your throat. But have you noticed that already our view of the vagus is coloured by that textbook account? The brain-to-periphery description implants in our minds the vagus as a motor nerve. 

This is reinforced when we hear physiologists and physicians tell us that vagal impulses slow the heart rate. That is how my undergraduate course first introduced the vagus to me. I heard that it is a parasympathetic nerve (motor), part of the autonomic nervous system that slows the heart (motor).

In 1969 I accepted this without question. After all, I was hearing it from eminent scientists – at least three of them Fellows of the Royal Society, and this 19-year-old freshman from remote Cumberland had other priorities surrounded as he was by the delectable delights of Cambridge.

But the vagus crept up on me. It has a role in the ear. It supplies the lateral line in fish, a system of receptors extending along the side of the body having something to do with picking up vibrations from the aquatic environment. This was intriguing.

Then I saw with my own eyes the asymmetry of the recurrent laryngeal branches – not only in the cadaver but also in serial sections of pig embryos. Thus I came to see how the branchial arch apparatus – fish again – stamped its presence on human anatomy. I began to appreciate that we carry our evolutionary history with us, and much of that history impinges on our structure and function. I began to ponder von Haeckel’s dictum “ontogeny repeats phylogeny”..

Being an Ear, Nose and Throat intern in 1975-76 might have stimulated further interest in the vagus, but keeping on the right side of irascible consultants, looking after patients some of whom I was pumping full of very nasty anti-cancer drugs, and coping with life in general meant there was no time for speculative thinking. Neither was there in Nottingham: I was learning the ropes, interested in university politics, doing a PhD and being a husband and father. 

It was in Dublin from 1988 onwards that I began seriously asking “why?”.

A shifting view

My view of the vagus was changing. I began to see that the vagal functions I’d first been introduced to by physiologists and physicians couldn’t be that important. How could they be when a transplanted heart does perfectly well without any innervation whatsoever? Can you imagine the surgeon suturing tiny strands of nerves and expecting axons to grow down them? So much for cardiac physiology as taught. And then there’s vagotomy (Helicobacter pylori hadn’t been invented then) – how did that affect the distal gut tube? 

You can see I was still in the way of thinking of the vagus as a predominantly motor nerve, reinforced by the appreciation of its role as the nerve of phonation and swallowing. Of course I was aware of its sensory functions, not least because of referred pain to the ear from pharyngeal disease, but they seemed somehow less significant.

I couldn’t see how to put all this together. Phonation, swallowing, external and middle ear, heart, stomach, foregut, midgut? No wonder the vagus is so-called. Why not hindgut? How do we know that vagal fibres go no further than the splenic flexure? In the words of Victor Meldrew, I don’t believe it. Is it merely inference, like so much else? How does it fit with the lateral line? 

Enlightenment

Then one night I had a light-bulb moment as I was soaking in the bath.

What does the heart do? Pumps nutrients round the body.

What do babies use their vocal cords for? To cry for sustenance.

What is the gut tube for? Absorption of nutrients. 

What does the vagus do to the pyloric sphincter? Relaxes it to allow food to move on for digestion.

What do we use our ears for? To pick up vibrations from the environment.

Why? In the search for food and to avoid becoming food for other creatures.

What is the lateral line in fish for? To pick up vibrations from the environment.

Why? Shoaling in the corporate search for food.

What might be the benefits of a slow heart rate?

Post prandial relaxation to aid digestion is one, but think in terms of diving mammals: the slower heart rate allows the dolphins or whatever to stay under for longer, handy when you’re hungry and hunting for the next tasty morsel.

What is the function of the pharyngeal musculature supplied by the vagus? Ingestion, swallowing of food.

The vagus is the nerve of nutrition.

All the structures it supplies are in some way connected to embryonic endoderm derived from the yolk sac. Can the vagus be summed up as the nerve of the yolk sac?

What about sensory?

As a result of teaching histology, I began to think about the myenteric plexuses. My passing interest in invertebrates of the aquatic deeps led me to realise that the plexuses function as a network of mini-brains – a gut brain – coordinating local reflex peristalsis, no motor impulses from the central nervous system being necessary. Also, there must be visceral sensory fibres from gut tube via myenteric plexuses to CNS for coordination and for such as emergency shutdown, and these must be joined by fibres from other abdominal viscera.

I began to see that distal to branches to laryngeal and pharyngeal musculature, the vagus was very significantly a sensory nerve. I had rid myself of the motor obsession. 

The vagus is implicated in a number of common conditions: oesophageal reflux of course, chronic hiccupping, gastroparesis and more. Here are vagal sensory functions working as it were too much or too little. As for the gut brain concept, this has blossomed over recent years. Having been regarded with suspicion as something promoted by sandal-wearing, yoghurt-knitting alternative medicine practitioners, it’s now right up there with the big boys and girls.

We talk of gut feelings, gut reactions. We know that the state of our guts affects our moods and feelings, the inference being that vagal inputs connect to the limbic system. As you may know, this is an up-and-coming research area in psychiatry. Certainly my gut is an effective warning system in all sorts of ways. Unfortunately, we know next to nothing about how visceral sensation in general and vagal inputs in particular are handled centrally – a recurring lament.

What about vagal stimulation for epilepsy? The question is really, I suppose, how do vagal sensory impulses reach the epileptic focus? As I say, our knowledge of visceral sensory central connexions is minimal, and I don’t know the answer. Judging from a survey of online publications, neither does anyone else: there’s a good deal of fudging. Perhaps this treatment regime arose, like many others, from a serendipitous observation.

Odds and ends

I don’t much care for the terms autonomic, sympathetic, parasympathetic, and I’m pleased to note that the US NIH agrees with me. They are pretty harmless when used of functions or modalities, but cause trouble when used, as they sometimes are, of structures – for example “the vagus is a parasympathetic nerve”, giving the impression that it is entirely a motor nerve. Autonomic means visceral motor, cell bodies of presynaptic (a better term than preganglionic) neurons being in the brain stem salivatory nuclei, the dorsal motor nucleus of the vagus, the sacral lateral grey horn, or for sympathetic impulses the lateral grey horn of the thoracolumbar region of the cord. 

So as terms describing modality I can just about live with them. But they lead to error if used of sensory fibres. One can fall into the trap of thinking that there are pre- and postsynaptic sensory fibres, as with visceral motor fibres. Not so. Sensory systems have no peripheral synapses. Primary sensory neurons, no matter what their origin or modality, are morphologically either pseudounipolar or bipolar with cell bodies in sensory ganglia (no synapses) just outside the central nervous system – dorsal root ganglia or the sensory ganglia of those cranial nerves that convey sensory fibres. 

What about the splenic flexure business? Is this really as the books say the limit of vagal gut tube territory? Such statements are often copied from text to text with no sources given. A survey of eighteenth and nineteenth century literature would be interesting to see when the story appeared. But assuming that the tale is true, perhaps the entire distal gut tube is a cloacal derivative with visceral supply from the lateral grey horns of the sacral spinal cord.

I find the sacral spinal cord quite fascinating. Did you know that in birds the terminal (sacral equivalent) spinal cord is separated from the rest of the cord by the glycogen body? Its function remains mysterious. According to Wikipedia (so it must be true) glycogen bodies may also have been present in dinosaurs from which birds are descended. But back to mammals where there is no glycogen body, but where there is nevertheless something different about the sacral cord. It develops not by folding of surface neuroectoderm to form a tube like the rest of the CNS, but by direct in situ differentiation. What to make of this I have no idea except that the sacral cord is peculiar.

Functionally, it is a cloacal brain responsible for sphincters and sex. So if you like, and I do like, we have one brain for controlling gut tube entry, and another brain for controlling gut tube exit. This cloacal brain does not need connexions with the rest of the CNS, as in patients with spinal cord transactions that isolate the sacral cord: it comes into its own with automatic sphincter control. How far back in reptilian/mammalian history this developed I do not know, but given the resonances between mammalian and avian sacral regions, perhaps it has something to do with laying eggs. It would be interesting to know more about the innervation of cloacal derivatives in egg-laying mammals. 

Finally in the nether regions of the trunk, vagal sensory fibres supply the uterus. What for? Why? They might account for the reports of women with spinal cord transection who nevertheless experience orgasm, the vagus being the afferent pathway rather than the spinal cord..

These ruminations lead me to think that we should consider, and teach, the nervous system as it evolves.

When we are simply tubes on the seabed waiting for currents to waft plankton our way for sustenance, we don’t need voluntary muscles at all. We need only the myenteric plexuses to deal with peristalsis. When we need to seek food and avoid being food for other creatures, then we need to move, so the body wall and its limb appendages need muscles and nerves. Thus we have the somatic nervous system.

Instead of teaching somatic first, then visceral, we should teach it as it (in my scheme) evolves. And when it comes to the somatic system, we tend to start with a reflex, so sensory first then motor. But functionally motor is more significant – we have to move to eat – so we should start with that.  But changing the minds of academics who are concerned only with their tiny area of interest is a bit like Northern Irish politics.

Drawing my thoughts together

I hear you say that none of this matters. It doesn’t help patient care, it doesn’t aid my research programme, it doesn’t get me a higher degree. 

It might, though. 

We are so busy scurrying around collecting data about detail that we ignore the big picture stuff. Who knows where seeing connexions might lead? If we’d never speculated about connexions we’d still be scrabbling round in caves, we’d not have penicillin, we’d have no smallpox vaccine, we’d have no theories of relativity. My big picture for the vagus is that it’s the nerve of nutrition, possibly even the yolk sac nerve.

Stepping outside the territory of anatomy, this kind of synthetic big picture thinking has relevance to fetomaternal immunology, still rather mysterious. Why is the fetus, a foreign organism, not normally rejected? One of the factors is that the immunology of the fetomaternal interface has things in common with that of colonial invertebrates that rub up against each other quite happily recognizing their sameness rather than, as in classical mammalian immunology, obsessing about their difference. 

Erroneous perceptions distort our capability for analytical thought. I ask for care in the use of words. As I hope I’ve shown, a lack of precision can so easily lead to fallacious conceptual thinking – for example confusion of fibres and nerves, ganglia and synapses. I hope too I’ve managed to let you see how easily we can be misled by the way information is presented in a text. It’s worth remembering that definitions and concepts are products of the human mind, and the human mind does not always see things clearly. 

As I said I’m probably one of the last generation of medical students to have studied embryology in any detail. I found it quite fascinating and I hope I’ve passed on that enthusiasm to some of my students. Is it useful? Well, it helps answer the “why?” question. It’s a pity that comparative anatomy and embryology have disappeared from undergraduate medical courses, for the more we specialize, the more limited our visual fields become and the more difficult it is to see connexions. We ignore our zoological history to the detriment of broadness of vision.

A plea

We need people who are paid to sit back and think big picture. We need people to make interdisciplinary connexions through blue-sky speculation that our increasingly frenetic research programmes have no time for, driven as they are by the need to satisfy grant-giving bodies, drug companies and the demands of publication. I suppose it’s a kind of academic relaxation I’m asking for – relaxation being something else that the vagus promotes. Regrettably, I don’t see that happening soon.

I have this feeling I was born a hundred years too late. Or too early.

The British Army: being thirded

Following my blog Avoid the stupid and hardworking about the Prussian Army types that Baron Kurt von Hammerstein-Equord encountered, a friend has written an updated version for today’s British Army. My correspondent is an Army Officer so is well qualified for the task.

Some thoughts from a more modern perspective – about 1952, which is where the Army is stuck. 

The Army is a firm believer in investing in people and maximising talent [pass the sick bag already], which mean that the MOD can pay a consulting firm millions to develop glossy on-message brochures, which they then roll up to sodomise you. The Army’s version of maximising talent is putting the big lads first to act as a human buffer against razor wire. 

The personnel appraisal system has mysteriously endured through successive defence reviews and budget upheavals, I imagine because it is now so entrenched in our language that the thought of changing it would have senior officers reaching for the sal volatile—or the nearest NCO to give him a good lashing. 

We in the Army are “thirded”. Top third, middle third and bottom third. All three are used as a form of introduction, though never in the presence of the subject. “Did you know that Capt Suchandsuch is joining us next month? I’ve heard he’s a solid middle thirder.”

Bottom thirders are referred to in a number of ways. Lizard, melt, creature, and cluster are the most common. In the officer’s cohort insults abound: “I wouldn’t follow him around a supermarket”; “he has all the depth of a car park puddle”; “he has the breaking strain of a soggy kit-kat”. These chaps tend to go to the logistics corps, although there is a smattering of them across the Army. They tend to have utterly unfounded yet deeply held self-belief, and often fall in to the bracket of the dangerously incompetent [von Hammerstein-Equord type 4]. The best thing you can say about a bottom third officer is that he’s bottom third but he knows it. Sadly, a lot of the senior leadership are bottom thirders. They have survived by dint of ‘staying on the log’ – more on that later – and have been promoted simply by remaining alive long enough, but certainly not through merit.

Some of the more progressive, or soft and “caring”, officers have pointed out that “bottom third” is a rather humiliating term – bad for morale – and have suggested alternatives such as “lower third” or “other third”. Needless to say this silly wokery hasn’t caught on, and those who suggest it are shunted off to bottom third jobs where they can’t do any more damage. 

Most people – 90% – constitute the middle third. Synonyms include “won’t set the world on fire”, “bit of a grey man” and “I honestly can’t remember anything he has ever said”. They won’t fuck-up but they bring no glory. They are officers who would make it through a war without firing their weapon or dying. They are generally content with their lot. They aspire to retire on a Lieutenant-Colonel’s pension somewhere in the Cotswolds with a spaniel, a couple of kids at uni and a spouse in a Barbour jacket, Alice band and solid employment. As soldiers, these are the guys you want: reliable, competent, and usually extremely good company. 

Top thirders are either extremely effective or the absolute worst. The worst are the thrusters, those who know how bum-snorkel like a champ, reliably absent when any actual work needs doing, but appearing like a shapeshifter moments before the CO shows up. As officers they epitomise the Sandhurst ethos of “run fast, shout loud”. You can have all the substance of candyfloss, but run fast and shout loud, and well, you’re in the top third, my lad. Thrusters know they are thrusters, and don’t care. They would happily sell their granny for facetime with the boss, and they would just as fast throw that boss under a bus for some crotch-sniffing with a general.

The good top thirders are referred to as genuinely good blokes, gleaming, or golden. They are rare and valuable, both extremely competent and self-aware, and for that reason usually lift the curtain of the Army sooner than most and have all left within six years of joining to earn gazillions in the City. The ones that stay do well, they are the ones who normally make Chief of General Staff level. 

Earlier, I wrote of “staying on the log”. This refers to the log run. On arrival in basic training every recruit is given the necessary kit to survive the impending course, including, ominously, a short length of rope. The purpose of this becomes clear a few weeks in – you knot with another, slip it underneath a horizontal telegraph pole, and as a team, all with your little rope holders, lift the log and run with it forever. There is always a rotating reserve and when your hands begin to bleed or you feel you cannot hold on for much longer, you rotate out and get a bit of a breather, until the next sorry sod raises their hand, at which point you rotate back in. If you fall back or fall over, you get the honour of a place in the jack wagon, the slow moving landrover which follows behind such activity for health and safety reasons. Going in the jack wagon is a heinous sin – you had best be dying, but more likely you are a malingering bottom thirder with an ouchy leg. Staying on the log at the front, setting a ridiculous pace and bellowing “keep it up, chaps” every few minutes is a top thirder’s role, thrusters and good blokes alike. But as long as you are still on the log by the end, even if that means getting out of the jack wagon because your ouchy leg feels a lot less ouchy now the end is in sight, then you pass. Hence the term, stay on the log.

Here ends my correspondent’s text. The parallels with the church are striking.

So there we have it, girls and boys. There are lots of ways to classify people. Perhaps you like von Hammerstein-Equord’s taxonomy. I do. Perhaps you see merit in the Army’s thirding. I do. Perhaps like me you can see lots of overlaps. Invent your own taxonomy. I used to classify people as fxxkers, wankers and buggers. Then I added tossers. But this isn’t really adequate since for me wankers and buggers (as in silly …) are terms of endearment, and none of them sufficiently describes the scabbiest specimens of the species.

In any case, have a good laugh. And for goodness sake, look in a mirror and laugh at yourself.

Avoid the stupid and hardworking

Baron Kurt von Hammerstein-Equord

I have recently – too recently – come across a rather splendid way of putting people into pigeonholes.

It’s based on the quite brilliant taxonomy of the Prussian officer class by Generaloberst Baron Kurt Gebhard Adolf Philipp Freiherr von Hammerstein-Equord (1878-1943).

“I distinguish four types,” he wrote. “There are clever, hardworking, stupid, and lazy officers. Usually two characteristics are combined. Some are clever and hardworking; their place is the General Staff. The next ones are stupid and lazy; they make up 90 percent of every army and are suited to routine duties. Anyone who is both clever and lazy is qualified for the highest leadership duties, because he possesses the mental clarity and strength of nerve necessary for difficult decisions. One must beware of anyone who is both stupid and hardworking; he must not be entrusted with any responsibility because he will always only cause damage.”

Marvellous!

Here is my take.

Clever and hardworking. Reliable, meticulous, imaginative, industrious. They get things done. Inclined to be workaholics. Good friends.

Stupid and lazy. They work to live. Don’t think too much. Not over bothered about standards: “it’ll do”. Good fun.

Clever and lazy. Strategists who see the big picture but have the sense and humility to know that masterly inactivity is often the way. They don’t need to bolster fragile egos by waving their willies about. They are aware of all possibilities, all the “what ifs?”, but they don’t waste their or anyone else’s energy by imposing silly tasks. They are aware of their own strengths and weaknesses and welcome wise advice – indeed they seek it. They can be firm and courageous in making difficult decisions, and neither stand nor impose nonsense. Without doubt, these people should be, but so rarely are, in charge.

Stupid and hardworking. The most dangerous. With their misplaced self-confidence linked to a combination of intensity and density, they fool people into appointing them to senior posts. Because of their arrogance and the ignorance of their own limitations, they wreak havoc and endanger others. They are like black holes, sucking the life force from all they come into contact with. They stifle initiative and surround themselves with even stupider yes-men so as not to be challenged. 

It’s not difficult to categorize people thus. The fourth group is stuffed full of politicians. I guess that most bosses fall into the first (good) and fourth (not good), whereas ideally they’d be in the third – clever and lazy. Doctors are easy to categorize too. And so are clergy. Use your imaginations, but suffice it for me to say that being a member of the fourth category seems to be a prerequisite for preferment.

Baron von Hammerstein-Equord was an interesting man. Aristocrat, Prussian then German army, and plotter against Hitler (how did the Baron survive?). At home he openly talked of planned anti-Jewish action so his many children could warn their Jewish friends. Two daughters passed information to the Soviet Union by means of the German Communist Party – indeed the whole family was somewhat cavalier about their own safety in the increasingly repressive Nazi state. He knew the Gestapo were onto him, but he bashed on.

He died of what might have been parotid cancer having ignored symptoms – typical man – for years. I suppose the cancer got him before the SS.

Two months before he died he said to a visitor “I am ashamed to have belonged in an army that witnessed and tolerated all the crimes”. 

A good and decent man, and clearly an extraordinarily shrewd judge of people.

A story for his birthday

at an Eton choral course

A summer morning in the early 1990s. He was about 15, a pupil at Wesley College, one of the rugby-playing* Protestant schools of south Dublin that both boys attended. (Victoria went to a girls’ school, Rathdown – not a rugby school unless there were some shenanigans that were well hidden.)

For some reason I was at home in Co Wicklow, skiving off work. Susan was elsewhere.

The phone rings.

Hello, is that Professor Monkhouse?

It is.

It’s Brian Duffy here, deputy head at Wesley.

What can I do for you, Mr Duffy?

Well, I’m ringing to let you know that I’ve suspended Hugh from school for the rest of the day.

Oh yes?

Silence.

Do you want to know why?

If you want to tell me, Mr Duffy, and I sense that you do.

This was not the response he expected. I had the impression that it enraged him.

He was talking and laughing in the library. I asked him to stop. I left for a few minutes and when I returned he was up to his old tricks. I didn’t care for his attitude, so I’ve sent him home.

Silence.

Well, Mr Duffy, thanks for letting me know.

Is that all you have to say? Do you have any response?

Since you ask, I think that’s rather pathetic. Infantile even.

He went ballistic. “I’ll have you know that I have only his best interests at heart … ” and more in similar vein. When he’d finished ranting I thanked him again and said goodbye.

The school was about 12 miles from home, and buses were not frequent in the middle of the day, but after a while Hugh rang me from a phone box in Enniskerry and I drove the 1.5 miles to collect him. He noted the hint of a smile on my lips. The rest of the day was pleasant enough.

Petty rules and irrational discipline in a school where prizewinners and pupils honoured at Speech Days often, inexplicably, had the same surnames as governors and members of staff. Incredible, isn’t it?

Not long afterwards Mr Duffy was appointed head of High School, another south Dublin Protestant school, though less rugby. Like Hugh, he has passed to life upon another shore. Perhaps they have met once again in that greater light.

* Before I sign off, let me tell you of an occasion when in the second form (age 13 I guess) Hugh collided with a huge sixth form rugby jock, Leinster trialist Eric Miller if memory serves. Little Hughie said, “hey you, watch where you’re going, you fat fecker”. Within seconds he’d learnt that alliterative skill does not overcome instant karma.

Psalm 119 verse 99 goes “I have more understanding than my teachers”, well known to Hugh from his chorister days. It was a maxim that he took to heart and made his own.

Happy birthday, big man.

Time traveller

Last night I dreamt about him again. 

I often do, at least once a week. He drops in on us quite unexpectedly, staying only a day or two as he takes a break from his world travels.

To say that it’s a delight to see him is a cosmic understatement. Such joy and hugs and laughter. I know that he’ll be off soon, and I know there’s no point trying to persuade him to stay longer. He does what he has to do, as always. I go with him to the airport to see him off.

Last night he turned up when we were in Bradford, a place that has pleasant associations from my childhood. Sometimes we’re in Nottingham, but mostly we’re in Co Wicklow. Of course in my dreams it’s not the real Nottingham or the real Old Longhill near Enniskerry, but that’s what my dream tells me. We’re all there – all five humans anyway: Petra the dog (he always said Petchra) hasn’t yet appeared. Despite his later adolescence in Dublin and his student days in Manchester, they haven’t yet featured, nor has Southwell where he was a chorister. 

He always looks well and is his bouncy cheerful self. I don’t know what his business is as he travels the world, but whatever it is I have no urge to ply him with questions about what he’s been doing or intends to do: I’m just ecstatic to be with him. He probably couldn’t tell me anyway, for he never was anything other than impulsive and spontaneous. 

The curious thing is that this time travelling son of mine is always somewhere between 8 and 15 years old. He’s very young to be so assuredly independent, but that’s entirely in character too. In my dream I wonder how he gets through airport red tape and security, but doubtless he charms the authorities as he charmed others.

He would have been 43 next Tuesday, and next Friday is the fifth anniversary of his death. 

Conversion: church and gym

A bit churchy but don’t be put off.

The Church of England is, to put it mildly, wetting its knickers about attendance. No punters, no moolah. In a bid to save money it’s dumping ordinary clergy and leaving posts unfilled. It’s still appointing bishops and administrators, but that’s modern management for you.

Church hierarchs – and let me assure you that I yield to no-one in my admiration for and loyalty to the church politburo – think that mission initiatives will sort it all out. There’s a whole series of blogs I could write on the idiocy of this, but though I’m convinced that there are too many people on the planet and humanity needs culling, death from boredom reading this blog is not the way to do it. So let’s move on.

In a recent Church Times piece, a senior cleric suggests that missions could be held in gyms and cafes. A retired colleague, Dean Henley, pointed out on the blog Thinking Anglicans some of the difficulties of this in a gym, bearing in mind “the sound of the thumping treadmills, the pop music, the grunting and the slamming metal of the weights machines” and that most of the participants wear headphones. “It might not be the right time to ask if someone is saved as they attempt the downward dog in a yoga class.”

He is absolutely right. I go further.

People who don’t use gyms often have a mistaken view of what goes on in them. Perhaps they see them as social clubs with people chatting, gossiping, making deals, arranging dinner parties, having a pint or a gin after sitting on a bike for 5 minutes in the latest designer gear, peering into mirrors saying “does my bum/belly look big in this?” Like a golf club, I suppose (I’m not old enough to play golf, so I wouldn’t know for sure).

I’ve been a gym rat for over 40 years on and off. What I see are people with focus, determination, discipline, and commitment to healthy living. They mind what they eat and drink, so church functions with their farinaceous and sugar-laden fare are for them (and me) evil. 

For us, gym = church. There are all sorts, conditions, faiths, races, ages, shapes and sizes. The atmosphere is businesslike and purposeful. No gossip, socialising or preening – there just isn’t the time when you’ve got to be back at work. The admiration of someone with a fine physique is not accompanied by snide remarks or by belittling those without, as would often be the case in equivalent circumstances in church where cattiness can be woeful. On the contrary, in gyms there is acknowledgement of the courage it takes to start a journey: mutual encouragement.

So I ask myself: what would anyone who takes physical wellbeing seriously enough to be a gym regular want or need of church? What does church have to offer that gym does not? 

Every good thing that church provides is available at the gym: companionship, common purpose, community, ritual, discipline, time out from the daily grind. People mind their own business but are happy to help when asked. No bossy interference.

And the gym provides one thing that church does not: a sense of achievement.

Does the church offer anything that gyms do not?

Yes. The threat of damnation. Indeed, the church harps on incessantly about this: after a good sing, it has people grovelling for being miserable sinners. Now, given that many of us use the gym as therapy for depression, anxiety and other mental health issues, being brought down low by this medieval control-freakery (control is what it’s all about) is not conducive to mental well-being.

Gym wins hands down.

The church politburo has it the wrong way round. If they are serious about spreading the message of Jesus Christ – life abundant – then rather than running mission initiatives in gyms, they’d be better off making gyms of all the churches. A different sort of conversion.

Cambridge exam memories 1975

I qualified as a doctor in June 1975. As I’ve explained before, since autumn 1972 I’d attended King’s College Hospital in south London but nevertheless remained a student of Cambridge, albeit one who was “using” King’s for the clinical course – a Cambridge cuckoo in a London University nest. At that time Cambridge didn’t have enough resources to look after all its own students (similarly for Oxford, but that’s a dump so we don’t mention that car factory on the upper Thames).

It was, therefore, to the city on the edge of the fens that I repaired for all exams – written, face-to-face, and exams with patients. In those days that meant taking the 36 minutes past the hour from London Liverpool Street calling at Harlow, Bishop’s Stortford, Audley End and Cambridge, then on to Ely and King’s Lynn. 

I have two vivid exam memories from summer 1975. 

The first is the Obstetrics and Gynaecology clinical exam.

“Monkhouse to the patient in bed 23”. I was instructed to take a history from her. So I did.  After about 10 minutes, the examiner hove into view to give me the third degree in front of said lady. The examiner – coincidence or what? – was one of the King’s consultants, Michael Brudenell, a descendant of the Charge of the Light Brigade Brudenells. If he recognized me, he didn’t let on.

Surprisingly, his first words to me were “why would Mrs X know more about her pregnancy than most people here?” A strange question, you might think. In those days I was a very quick thinker and I said without hesitation “because she is a librarian”. Think about that – he wanted to know if I’d been thorough enough to discover her occupation. I most certainly had – such attention to detail was drummed into us from the beginning. 

Then: “what advice would you give Mrs X about feeding her baby?” Without hesitation I said “breast, for breast is best.” “Come, come” said Mr Brudenell, “explain yourself”. “Because” says I “cow’s milk is for cows, and human’s milk is for humans”. Then I thought “you fool, Monkhouse, this is not the time for being a dick”.

Mr Brudenell looked at me for about three seconds – which is a very long time when your underpants are at risk of being soiled. “Haw, haw haw! Very good, Monkhouse. Off you go.”

And that was that.

He didn’t want to know if I’d read the latest research (I hadn’t), or knew the likely cause of a very rare disease found only in Papua New Guinea (I didn’t). All he wanted to know was that I was safe, thorough and coped under pressure. He evidently thought so. Perhaps he liked my impertinence.

By the way, I am right. Cow’s milk is more poisonous to humans than is generally acknowledged. Think snot, allergies, bellyache, bloating, belching, colonic dysfunction, farting, lactose intolerance, and more. As a child of the 1950s in a Cumberland village I had milk from an uncle’s cows poured down my throat. I speak from sad experience and numerous unnecessary hospitalizations. It was another hospital consultant at King’s – can’t remember the name – who said that cow’s milk should come in bottles labelled “poison”.

The other 1975 exam memory is being grilled by three eminent surgeons, all professors or Knights of the Realm. It went something like this.

Examiner: Good morning. Take a seat. Name?

Me: Monkhouse (no such thing as Christian names then).

Examiner: College?

Me: Queens’.

Examiner: And which medical school?

Me: King’s, London.

Examiner: Haw, haw, haw, a royal flush, eh? Haw, haw!

After I’d picked myself up from rolling around on the floor in fawning laughter, I was shown a radiograph (x-ray) of a wrist. There was a fracture of the bone at the base of the thumb where it meets the wrist. I recognized it.

Me: Ah, a Bennett’s fracture.

Examiner: Good, Monkhouse, very good. Pause. Tell me, who was Bennett?

Me, confidently, looking smug: a nineteenth century Dublin surgeon.

Examiner, surprised: Oh. Long pause. Quizzical look. Was he really?

Me: I’ve no idea. I was just guessing. There were so many eminent nineteenth century Dublin surgeons, so I thought the chances were good.

Examiner: Haw, haw. Very good.

Then followed a brief discussion of fractures that can result from falling on the outstretched hand, before I was dismissed. 

The irony is that Bennett was indeed a 19th century Dublin surgeon – in fact (how spooky is this?) he was one of my kind-of predecessors at the Royal College of Surgeons in Ireland. There must be a God after all. The commonest wrist fracture, by the way, is named after Abraham Colles, another of my Dublin predecessors – perhaps the most famous of all. See what I mean.

It was very entertaining. Comedy really.