What’s your little helper?

drugs-and-addictionSo, girls and boys, out we go for a walk with Bella the Staffy.

As we approach the Trent and Mersey canal, a young man walking purposefully in the same direction overtakes us. We exchange pleasantries. Then, surprisingly, he stops. We catch up with him just as another young man approaches from the opposite direction. With sleight of hand the two guys exchange something. They retreat whence they came.

User and supplier, we mused? Which was which?

What does it take you to get through the day?

  • Nicotine/tobacco. The sense of calming and release can be blissful, I gather.
  • Alcohol? At a funeral of a wealthy 40-something year old who died of alcoholic liver disease, I said from the pulpit that anyone who ever encouraged him to “just have one more” was complicit in his death.
  • Exercise, fitness? The endorphins released are addictive.
  • Sex? Porn? Likewise.
  • Golf? I’m not old enough to play golf, but I’m told that it’s quite popular amongst the brain dead.
  • Other drugs? Cannabis is less dangerous than alcohol. Cannabis rice krispie cakes are delicious.
  • Religion? Yes. The ecstatic trances of mystics are well known to be comparable to—even equate to—orgasm.

Am I saying that for many people religion is merely a prop to help them get through the day, on a par with smoking or drugs or booze?

Yes. That’s exactly what I’m saying.

Here are some other things we can be addicted to: money, power, controlling others, pleasing people, wanting to change people, gambling, internet, social media, books, buying stuff you don’t need, gossiping, criticizing, moaning, being miserable.

Some are financially more expensive than others, but there isn’t one that’s any worse than any other. They can all destroy us. It’s as hard for you to let go of your addiction to new clothes, or whatever, as it is for someone else to put down the drink or the syringe.

They’re like demons. They steal our personalities and stop us being ourselves. They deny us our freedom. They make us obsess about ourselves instead of serving others.

We’re all wounded because of stuff that’s happened to us. We all need something to dull the pain. We develop patterns of behaviour to protect us from these hurts. Whatever “pain relief” we choose—substances, attitudes, activities, religion—can be dangerous. We become addicted to them.

We’re all addicted to something—several things in my case. Look at your addictions. If you think you haven’t any, you’re blind.

All the vain things that charm you most—accept that they are part of you. Think of them as controlling different versions of yourself. Then give that version of yourself a cuddle. You begin to love the hell out of yourself. You might have to accept that some will stay with you till you die.

This is not easy. But even beginning the process is a kind of renewal. Nobody is perfect. Nobody has a perfect upbringing.

We are all in recovery.

Clearing out stables?

2AP1TD2-b598c7937e0cb7c3ddb3d98f6d897d82Isolation, distancing, handwashing

I understand some of the reasons for what we are told to do.

I understand the vague concept of herd immunity, but not the ins and outs of it in this Corona virus phenomenon, which, I gather, is not like other viral epidemics. As a medical student, I never took to epidemiology. It is mathematical in a way that probability and statistics are mathematical, and they always provoked mild panic in me.

In the mid-1970s, virology wasn’t much in evidence on the medical course. As for handwashing, the Professor of Microbiology, one P A Boswell, told us that since urine is sterile but hands are most certainly not, men should wash their hands before having a piss, not after. That has stayed with me.

But …

In an idle moment in Dublin several decades ago I did one of those personality questionnaires that appeal to vanity. It told me that I was more than a little fatalistic. Oddly enough, for such questionnaires are often drivel, I could see that there was truth in that verdict. I am indeed.

So despite my unwilling, chuntering conformity with most instructions from on high at present, a large part of me thinks we should remove all restrictions and let nature take its course.

People will die.

People will die anyway. Part of the present hysteria stems from the expectation that “I can live for ever”. The NHS panders to the notion of immortality and to the notion that at 70 I should feel as good as I did at 20. And it encourages irresponsibility in that people think they can do what they like in the expectation that the NHS will sort them out. In this regard, the NHS is complicit – but that’s another story.

People say “we should protect the vulnerable”. Why?

Both Susan and I are in the at-risk category, or soon will be. One of us is 70, the other 69. One of us has diabetes-2, the other asthma with a propensity to chest infections. One or both of us might die. But that’s going to happen anyway.

If treatments must be rationed, I can’t see why I should be favoured more than younger people with dependants. I have a great future behind me: theirs is in front of them. There is a discussion to be had on the allocation of resources in hard times, but it seems nobody will have it. Instead it all comes down to unexamined “motherhood and apple pie” sentimentality.

Earth cleanses itself

I’ve never had any doubt that there would be some catastrophic event that culled humanity. I’ve wondered about an eruption of the Yellowstone caldera such as may have wiped out dinosaurs; or an extraordinarily large eruption of sunspot plasma that would completely disrupt the earth’s magnetism, electrics and electronic communication; or wars over the availability of water; or MRSA; or viruses.

There are too many humans on the planet. Nature will deal with it.   One thing I’m sure of is that if humanity is wiped, viruses and bacteria and archaea and insects and … will still be around, so evolution can get to work again.

It’s extraordinarily arrogant of humans to expect that other creatures of this earth, including viruses, should stop doing the what-comes-naturally for the sake of human comfort.

I am in control of nothing. Thou art in control of nothing. He/she/it is in control of nothing. We are in control of nothing. You are in control of nothing.

They, viruses, have the future in hand.

I can probably survive like this for a week. The prospect of 12 weeks makes me reach for a sharp knife with which to slit my throat. Of course it’s possible that economic factors will mean no pensions, lootings, hyperinflation, supermarket fights, no food, so I could well have died before then through inanition.

It will do me no harm to live day by day without expectations, even though I find that extraordinarily difficult.

Sex

image

Lunar landing

As some of you will know, the church has its knickers in a twist about sex.

The church—be in no doubt about this—talks bollocks. One of the reasons it can’t recognize balls is that it’s stuck in the past (“surely not” I hear you say) and it ignores biology, the most fundamental thing of all.

So to get the juices flowing, and in preparation for things to come, I offer you this.

Structure

The gonads of the early embryo can develop into either testes or ovaries. It seems that the ovary develops unless hormonal conditions at a certain stage of development ‘switch’ on the testis, as it were. The female is the default setting. Very rarely (1 in over 80,000 births), an individual may have an ovary on one side and a testis on the other, or a gonad may contain both ovarian and testicular tissue.

The ovary stays more or less where it started, but the testis descends into the scrotum. Undescended testes, this descent having been arrested, are common: about 3 in 100 male births. In a sense, an undescended testis signifies incomplete male development.

The clitoris and penis both develop from the same embryonic precursor. The female, again, seems to be the default setting. Penile congenital anomalies such as hypospadias, where the opening is on the under surface of the penis, are surprisingly common (some say 1 in 300 male births). They can be regarded as varying degrees of reversion to the female anatomy. How small does a penis have to be before it is a clitoris? If you’re interested, there are websites (so I’m told) that show all sorts of penile anomalies and how some people have them modified.

The scrotum and the labia majora develop from the same structures: the scrotum is the two labia sewn together. You can see the ‘seam’: you’ll need a mirror unless you have a tolerant friend. How large do labia have to be before they become scrotum-like?

Every adult male prostate gland contains a vestige of the precursor of the uterus.

Every adult female has structures that in males develop into the tube conveying spermatozoa from testis to penis.

Some people are born with external genitalia of one sex and internal genitalia of another. Or a person may be born with genitals that seem to be neither one thing nor the other—a girl may be born with an abnormally large clitoris, or lacking a vaginal opening, or a boy may be born with a small penis, or with a divided scrotum, like labia.

Structural anomalies in the male are more common than in the female, though you may recall the fuss about the South African ‘female’ athlete who was reported to lack both ovaries and uterus.

Chromosomes

Normal male: XY chromosomes. Normal female: XX chromosomes. The incidence of newborns that are neither XX nor XY has been put at about 1 in 1700. Here are some examples:

    • XXX: 1 in 1000. Female, often no other manifestations.
    • XYY: 1 in 1000. Male, often no other manifestations.
    • XXY: Klinefelter’s syndrome. 1 in about 1000, often sterile, males with female fat distribution. May never be diagnosed, so may be commoner than we think.
    • XO: Turner’s syndrome. 1 in about 3000. Appear female, nearly always sterile.
    • Mosaic, some cells XX, some XY. Very uncommon.

Psychological sex – ‘what do I feel or experience?’

We know very little. It seems that a part of the brain may be switched on to ‘I think I’m a male’ at a certain stage of development. It seems, again, that the female is the default state. There are reports of people who feel as if they have been born into the body of the ‘wrong’ gender. There are reports of an area of the human brain that in homosexual men is more like that of heterosexual women than that of heterosexual men: male body, female brain perhaps.

  • If a man admires or envies the muscularity of a male athlete, does that mean he is homosexual? Do rugby players who grab their opponents’ bollocks in the scrum have something else on their minds?
  • If a woman admires a Rubens lady of generous proportion, does that mean she is lesbian?

My view is that we are all on a sliding scale of sexuality, and we move to and fro. But the unfashionable truth is that we don’t know much for certain.

Defining man/male and woman/female

We simplify sex categories into male, female, and sometimes intersex, for cultural purposes. This is unsubtle. There is much scope for naturally occurring structural and chromosomal anomaly, and a spectrum of psychological sex.

Pleasure

To what extent did ancient writers associate procreation with sexual intercourse? In Biblical times, the roles of ova and spermatozoa were not as we know them today. It was held at one stage that semen merely initiated the development of the embryo in the mother, and at another stage that a spermatozoon contained the miniature human and that it was ‘injected’ into the mother, who was merely the vessel (oven) in which the embryo grew. (As an aside, both these shed interesting light on notions of virgin births in Biblical times, even accepting that virgin as we understand the word is the correct translation – which it isn’t.) This matters to the same-sex debate, because it is relevant to whether or not the ancients recognised the importance of pleasure in sexual intercourse—what we might term the psychological “reward” effects that come from the flood of endorphins released in orgasm.

If we say that sexual pleasure is banned, and that intercourse is only for the purpose of procreation, then intercourse must be restricted only to those times in the menstrual cycle when conception is possible. This turns current Catholic teaching on its head, for using the safe period for the avoidance of conception should surely be just as much a ‘sin’ as using a condom. Catholic teaching logically should restrict intercourse to the unsafe period.

So, how do we define man and woman?

  • Inspecting genitalia mightn’t give a definite answer, and who would be daft enough to suggest it?
  • Chromosomal tests might not be a reliable indicator of what gender the person feels.
  • Assessing the ability to engage in vaginal intercourse might do the trick. Doubtless assessors could be appointed by the state – a job for voyeurs (what’s wrong with voyeurism?). If one or both partners were infertile, then intercourse would be only for pleasure, so there might have to be pleasure police.

Conclusion

If we say we are certain, we deceive ourselves, and the truth is not in us.

British Association of Clinical Anatomists: origin and future

srgry02A paper for the meeting of the British Association of Clinical Anatomists at the Burton on Trent meeting, 14 December 2017

In the beginning was the Word, and the Word was with God, and the Word was the Anatomical Society and the Journal of Anatomy. They were in the beginning with God, and without them was not anything done in anatomy that was done. And the Professors of Anatomy saw themselves as the Lord Almighty. They terrorise and pulverise. They march through the breadth of the earth to possess the dwelling places that are not theirs. They are terrible and dreadful, their judgment and their dignity proceed from themselves. And lo, it came to pass that the people rebelled inwardly in their hearts. They cried to the Lord “wilt not thou deliver us from these bitter and hasty foes?” And the Lord raised up prophets, Coupland of Nottingham and Scothorne of Glasgow. And through them the Lord came to the aid of the oppressed. And lo! BACA was born.

It’s fun to see the formation of BACA in these Biblical terms, and it is not inaccurate. But there’s a bigger story to tell, and since this year marks BACA’s fortieth birthday, I shall do so. Of course, I’m not an historian, but I’m one of the few people alive who witnessed BACA’s birth in 1977 just along the corridor from my office in Nottingham. My recollections are thus first-hand and are as reliable as memory ever is.

First, a brief autobiographical sketch. I was at Cambridge for preclinical studies and then King’s College Hospital in London for clinical training and preregistration house jobs, as they were then known. I went to Nottingham as anatomy demonstrator in 1976 then Lecturer in 1977. In 1988 I began as Professor of Anatomy at the Royal College of Surgeons in Ireland, in Dublin—a medical school as well as a postgraduate college—and then in 2003 was appointed to Nottingham’s Graduate Entry Medical School at Derby. In 2006 I was ordained into the Church of England, becoming Vicar of Burton in 2014.

The origins of BACA are intertwined with two main medicopolitical trends: first, the decline of anatomy as a discipline in the medical curriculum, and second, the loss of medical graduates from departments where they had been predominant. I know that I am talking today to a mixture of scientists, physios and medics, and I apologize if what follows seems irrelevant to many of you, but it is important in the embryonic development of the society, so bear with me.

The decline of Anatomy

I enjoyed undergraduate anatomy. I was riveted by the first lecture in October 1969 concerning lemurs and lorises and thumbs, part of a series on the evolution of Man. Subsequent anatomy memories centre on Max Bull, the doyen of Cambridge anatomy teachers, who gave us a definition of anatomy that has stayed with me: “the study of the structure and function of the growing and changing living organism, not necessarily human”. It’s not elegant but, like a thong, it covers the essentials, especially, as Max was at pains to emphasize, the growing and changing bit.

I was fortunate in the Cambridge anatomists of that time, who with one exception were affable, approachable and interested in students. So when during clinical years I realised that practising medicine was not for me, I thought that if being an anatomist involved what Max Bull did—welfare and nurturing of students using the vehicle of a subject that interested me—then an anatomist is what I would be.

In the third clinical year I approached several professors of anatomy about a job, and ended up in Nottingham because it was a lovely day when I visited and Rex Coupland, the professor, was charismatic. It was a good decision. I immediately saw the value of the brand new systems-based course that resulted in anatomy being significantly trimmed down, with much less time spent on dissection.

Listening to colleagues who had done time at other places, I realized how fortunate I’d been in Cambridge. I heard that more than a few Professors of Anatomy elsewhere were belligerent and irrational, and bullied their juniors and students. I witnessed it in external examiners

This is relevant to the decline of anatomy. In the 1970s and 80s, all the influential people in medical schools had had to endure hours wasted on dissection, all had been made to learn anatomy in excessive detail, and a fair few had suffered from the bad behaviour of some anatomists. Not surprisingly, they resented anatomy and they resented some anatomists. They were determined to cut anatomy down to size. They were abetted by the new discipline of Medical Education, then on the march, many of whose enthusiasts stated openly that doctors no longer needed to have facts at their fingertips. There was growing opposition to what they, wrongly, called didactic teaching

Things did not get better. The systems-based curriculum developed in many places in a way that may have suited metabolic processes but all but wiped out regional anatomy. The understanding of human biology as a product of evolution and adaptation, as imprinted upon me by Max Bull, sank without trace. I must be one of the last medical students to have enjoyed a term studying serial sections of pig embryos as part of an undergraduate course.

What was to be done?

With their clinical training and their clinical eyes—Coupland had begun to train in neurosurgery—BACA’s founding fathers were certain that only medically qualified staff were capable of teaching clinical anatomy. But there were hardly any left. So the question for them, given the image problem and the brain drain, was: how can we in anatomy recruit and retain medics?

The answer, they thought, was twofold: money and status. Rex told me that he saw BACA as a trade union that would lobby for preclinical medics to be paid more. Furthermore, the founders saw it a means of having medical anatomy recognized as akin to a clinical specialty. The trouble was that Rex and Ray didn’t know how to achieve these aims—indeed, given that they were both adept medical politicians in university life, they displayed surprising naivety.

First, money. Formerly, medics in preclinical departments had been paid more than non-medics doing the same job, but this differential had been abolished some years back. No salary committee in its right mind would reverse that decision for the sake of a miniscule number of peculiar medics. Perhaps the founders were thinking in terms of a salary enhancement, for Rex was the recipient of a hefty NHS merit award for which he attended at most one ward round a week. If he thought that that arrangement would catch on with NHS administrators, he must have seen pigs with wings. As for payment for clinical duties undertaken by anatomy staff, of which I was for over a decade a beneficiary, the resentment created by my not being available for university duties for one session a week was considerable. That wouldn’t have survived in the increasingly regulated NHS.

Second, status. I’m afraid Rex and Ray were living in cloud cuckoo land in imagining that clinicians would support any proposal to give senior anatomists clinical privileges. Unless the definition of clinical was twisted to mean what it patently does not, anatomists could never be clinical. At that time I became a member of the BMA Medical Academic Staff Committee, and believe me I know just how little support there was for such an idea. The clinicians simply laughed. In any case, Rex and Ray were wrong. Neither money nor status would have dealt with the image problem. Medics in anatomy were in many cases rightly considered maimed, unable to cope clinically, or, like me, deranged in turning their backs on clinical practice and salary.

It was all too late. King Canute couldn’t stop the waves, and neither could BACA.

Consequences

In the eyes of junior staff, BACA was compromised from the beginning. It was snobbishly hierarchical. For full membership you had to be a medic, and a senior anatomist to boot. Anything else meant a lesser category. And right at the bottom—sorry about this, all you scientists—were the ‘mere’ PhDs. The Association looked like an exclusive club for Rex’s and Ray’s friends and relations. My non-medic colleagues were outraged. The powers that be eventually relented, and this discrimination was abolished, though not soon enough. It left a bitter taste, and non-medic anatomists shunned BACA in favour of other scientific societies, leaving BACA meetings in the early days with little of great worth other than a good meal.

How did clinicians view BACA? I can only go by what I deduced from meetings. I should say that I was never a great meetings enthusiast. As a teacher I felt an impostor as scientist. As someone who did one ENT clinic a week, I felt an impostor as clinician. I was at home with students, provoking them to explore, to think, to imagine, to learn, and to ask questions, but to be on the receiving end of a comment from an eminent scientist which began “Dr Monkhouse, I listened to your paper and I have a question” was to render me incoherent in the sure and certain knowledge that evisceration was imminent. But to proceed. Many of the presentations at early BACA meetings came from only a handful of research groups—we’re back to the private club. Most surgeons looked elsewhere to flex their academic muscles, and few were enthusiasts for BACA or indeed anatomy. I was astonished to hear a Professor of Surgery tell me, the Professor of Anatomy, that he didn’t care what a structure was, or what it was called, or how it developed: all he cared about was whether or not he could cut it.

For these and other reasons, BACA was viewed by non-medical staff as elitist, and by clinicians as not really kosher. BACA meetings and the journal Clinical Anatomy came to be regarded by some in both camps as second or third best. It was fighting for its life as soon as it was born.

The future

I’ve been off the game for over a decade, so what value my comments have is for you to judge. However, as Max Bull remarked over 45 years ago, I have an analytical brain, added to which the view of the forest is better from the edge than from the middle.

The organization I work for at the moment is run by yesterday’s people making decisions for tomorrow without heeding the concerns of those that will have to bear the consequences. Is this true of BACA? Judging from your website, I think not, indeed I have the impression that you have worked hard to move on from those incestuous and hierarchical early days.

The future of an organization depends upon its capacity to be of service to others. So I suggest that you continue in that direction in the knowledge that you are on the right course. The future of BACA depends not on juniors tugging the forelock to grand old men, but on the extent to which those with experience can be useful to those trying to acquire it.

You rightly offer yourselves as a forum for gaining experience to anyone who wishes to explore clinical anatomy, no matter how tangentially. Find out what trainees need and work with them to provide it. Help them build their portfolios, and gain skills in presentation, writing and editing. Think back to when you were young and ask yourself what made you anxious. Help trainees to master these things.

Your committees will need to include more than a token trainee, so sling off the superannuated. If trainees are hard pressed to find time to serve, then organize things to suit them. I don’t want to get overly theological about this, but didn’t someone once say that the first would be last and the last first?

Many of the scientists among you will know more embryology than the medics. Teach them! It is hugely important in several clinical and scientific areas. How can anyone understand the function and layout of the cranial nerves except in terms of evolution and embryology? How can anyone understand how a weak voice might signal a mediastinal tumour except in terms of evolution and embryology? The medics among you can help nonclinical staff get to grips with some of the more obscure consequences of regional anatomy in terms of diagnosis and treatment. Work with the Anatomical Society—after all they are wealthy while you, I understand, are merely comfortable.

Is there anything to be gained by working with the Royal Colleges in training programmes? I know it’s difficult to work with surgeons, especially those who are big in the Royal Colleges, for as with Yorkshiremen, you can’t tell them anything: they are multitalented and omniscient. But there are other disciplines …

Another flight of fancy. Alternative medicine is on the up. See if you can cooperate with some of its more anatomical branches. I was in terrible trouble early in my Dublin days for having conversations with osteopaths and physical therapists about how we could help with their training. My knuckles were well and truly rapped by protectionist surgeons. I still see nothing wrong with those conversations and remain unrepentant, especially since they had money to pay us. One of the things I learnt from osteopaths was the way in which neglected ideas from the past surface years later. For example, the gut brain, once sneered at, has a new lease of life. It was an osteopath that directed me to a book entitled “The Autonomic Nervous System” by the unfortunately named Albert Kuntz, published in 1929. There are some prescient nuggets in there that might repay imaginative thought.

Now there’s a word: imaginative. Imagine how you could serve. Imagine how things might develop and plan for them. Maybe that’s the best advice anyone could give the Association as it looks towards the next forty years. You’ve done well to come from a precarious postnatal period to the state you’re in now, so keep your eyes open and your antennae alert and let your imaginations flower. You can be proud of yourselves.

Finally

When I saw that BACA was coming to Burton, my first thought was “perhaps they’ll give an honorary member, or whatever I am, a free dinner”. And so you did, last night. It pays to be cheeky: “ask and you shall receive” is a phrase I read somewhere. It’s lovely to meet you, to renew friendships, and a real pleasure to begin to get to know Neil Ashwood. When we first met he asked me if I knew any connexions between Burton and Anatomy to which he could refer in his speech. I said modestly “not really, only me.”

Friends, thank you for your invitation, for feeding me, and for listening to me. May the Lord light up your life ….

…. any scholar of Carry on up the Khyber knows that the correct response to this is: and up yours.

Placentas and pizzas

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Placenta

Mrs Windsor née Middleton is pregnant. It’s in the newspapers so it must be true.

First, I have to get this hobbyhorse off my chest. The correct spelling of fetus is fetus, not foetus, the word being related to felix, femina, etc. The incorrect spelling occurs first in the late writer Isidorus (570-636 AD) who fancied that the word could be derived from foveo (I cherish) instead of feo (I beget). So there.

Now to the hard stuff.

Is it an embryo that is taking root in Mrs Windsor’s genital system? Yes indeed. Is a fetus? Is it a baby? Is it a child? Embryo and fetus are defined by convention: you can look them up if you like. Baby is a meaningless term. Is it a parasite? Well, it steals mama’s nutrients and dumps its rubbish on her. It guzzles into her flesh so that its placenta can plug itself in to mammy’s tissues and get up close and personal with her blood vessels. It consumes the contents of parental wallets for at least two decades. Make up your own mind.

Some people worry about when the fetus becomes human. Not I. It’s human because the spermatozoön and ovum that produced it came from gonads belonging to humans. Reputedly. Anyhoo, however royal this fetus may be, it’s also a chordate, a vertebrate, a mammal, an ape and a primate. This is much more important than royalness.

The royalness will doubtless induce the Church of England to produce a prayer for the royal products of conception—it may already have done so—the usual crass, meretricious, tendentious, wordy drivel that comes from Lambeth. Products of conception include placenta, amnion, chorion, umbilical cord. Are they royal too? Are we to have a prayer for the royal placenta? Will a specially consecrated pair of scissors be used to cut the royal umbilical cord?

Killing the fetus

When do you think it should be permissible to kill the fetus? Or perhaps, when should it no longer be permissible? Well here’s the thing as I see it. Despite what the law may say, there is no single moment during the whole course of pregnancy at which the fetus is significantly different from what it was the moment before. There is no event that takes place that sufficiently differentiates what the fetus was before that event from what it is after the event. Fetal development is a continuum. From this point of view, if it’s permissible to kill a fetus at 18 weeks, then it’s permissible to kill a postnatal child or an adult. For those of us who have a little list of people not one of whom would be missed, this is comforting.

Why are we born when we are born?

The short answer is nobody knows. Brain size must have something to do with it. If we stayed inside any longer, our heads would grow so big that we wouldn’t be able to get through mama’s pelvis. But like I say who knows?

We are born very immature. A newborn horse can canter off pretty soon after birth, but not a newborn human. Unfortunately. Neurologically (spinal cord tract myelination—look it up), some of us mature more quickly than others. If earlier, we shall be better at physical activity and sport at an earlier age. If later (like me, dear reader), we shall have the shit kicked out of us at school for being physically inept.

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Pizza

Placenta

Placenta in Latin means flat cake. It is a most interesting organ, much under-researched. Its evolution is fascinating. Some mammals have lots of little placentas. Some, like mice and humans, have a single placenta. A primate (therefore human) placenta is about the size of a small pizza. Looks like one too. Some twins have separate placentas, some share.

A mouse placenta is similar in size to the head of a small drawing pin. Believe me, I know. I’ve dealt with hundreds of them in my time. When our three products of conception were little, the eldest drew a picture of me at work with the caption “my daddy studies mices kidneys”. Adrenals, actually, and fetal ones at that, but the gist was spot on. She had not mastered the apostrophe by that stage (like an increasing number of adults, but don’t get me going), but had grasped that plurals are normally formed by the addition of a terminal s, and that in conjugating the verb ‘to study’, y sometimes becomes ies. Pretty good, huh?

Please understand, dear reader, that the placenta is fetal. Entirely fetal. The only bit of maternal tissue that comes out with the placenta is that which is torn away from the uterine lining when the placenta detaches itself, hopefully after birth. This is why bleeding may occur.

The placenta, like the infant that it nourishes, is a foreign organism as far as the mother’s immune system is concerned. Why is the placenta, which comes into intimate contact with maternal tissue, not rejected? Well, sometimes it is. And so arise spontaneous abortions and other obstetric headaches.

A bit of history

In the fourth, fifth and sixth Egyptian dynasties the placenta was held to be the seat of the external soul. There existed the ceremonial position of Opener of the King’s Placenta. Some have suggested that in Abigail’s flattery of King David (1 Samuel 25:29) she calls on this image, the ‘bundle of life’ (KJV) being the placenta, though this is not mentioned in recent Biblical commentaries. Some societies suppose the placenta to be ‘the twin brother or sister of the infant whom it follows at a short interval into the world’ — and in a way, it is. In central Africa a belief in reincarnation leads to the afterbirth being buried at the doorway, or under the threshold of a hut, practices connected with the divine doorkeeper and the widespread custom of carrying the bride over the threshold.

The great fry up

And now, children, finally for today’s “Listen with mother”, remember that the placenta is a most nutritious organ. It’s not that different from black pudding: blood, connective tissue and other bits and pieces.

Fried with eggs, mushrooms bacon and tomatoes it would make a right royal breakfast.

Four in 10 students say university not good value

drainWhat a surprise!

During my quarter of a century teaching at the University of Nottingham and the Royal College of Surgeons in Ireland I’ve seen the growth of ‘educationalists’. They purport to improve teaching standards by fostering an interest in the ‘discipline’ of ‘pedagogy’ (why do they insist on pronouncing this ‘pedagodjee’?)

Have they done so?

No.

They manufacture more and more hoops for those at the chalk-face to jump through.

They spin all sorts of guff about improving the student experience. They do this by giving the students questionnaires to fill in every week about this, that and the other. They are asked to grade individual staff on the basis of quality of handouts, or use of technology, or approachability, and much more.

They write garbage such as:

  • purposeful reflection (thinking, but at €100 an hour);
  • impactful research (difficult, since Medical Education Journals are pretty risible);
  • student centered e-portfolios (students do something online, the teachers ignore it);
  • the flipped classroom (getting students to read ahead and then asking questions during a ‘lecture’);
  • dynamic/personalized/bespoke Learning Environments (A place online to dump powerpoints);
  • student-led teaching, peer teaching (letting the students do the work while the staff do experiential research into different varieties of coffee);
  • interprofessional education (talking to each other).

As sociology was once defined as the study of those who don’t need to be studied by those who do, so medical education is the study of those who teach by those who can’t, won’t, and certainly shouldn’t.

And the sad thing is that the tail now wags the dog. Educationalists now call the shots. The result is that students are not now taught anything much. Students must reinvent the wheel for themselves. They are lectured about the ‘science’ of learning—in truth not a science at all, merely tendentious opinion.

University ‘teachers’ are appointed to lectureships on the basis of knowing a great deal about hardly anything. What matters for their career advancement is how many publications they produce, and in what journals. Chances are that to them the teaching and nurturing of students is a distraction. The ability to distil complex concepts as an introduction for the neophyte matters not one jot.

Students pay fees. At the College of Surgeons medical school (despite the name, for undergraduate medics not just surgeons), a medical student now pays over €50K a year. Just think what could happen if the students started to use this power. Oh yes, of course, silly me, what would happen is that they would not get their degrees, so they would not be able to earn enough money to pay off their student loans.

What is the solution?

Simples, as Aleksandr Orlov might say:

  • separate teaching and research and fund research separately;
  • abolish student fees.
  • let students pay teachers directly, on the spot: they would flock to the good ones who would be suitably rewarded.

O taste and see

Camel_in_Singapore_ZooAnother avenue of pleasure closed off. The World Health Organisation tells us not to drink camel’s urine.

I was wondering why I was tired. I’m overweight. I was 64 (65 now). It’s very tiring to have people dumping their expectations on one—the lot of the Vicar. Then, listening to SWMBO, a type 2 diabetic (when I say listening, I mean being aware of faint buzzing sound somewhere to the left), I wondered if I was developing diabetes. That would account for tiredness. It would mean that I was drinking a lot. Now, I’m a copious tea drinker, though not in Bennite quantities, so how would I know? It would mean I was peeing a lot, and given the amount I drink, I don’t. And it would mean that my urine would taste sweet.

O taste and see. So I did. Nothing really. A bit salty perhaps, but I am a salt lover. I’ve never been a sugar lover. As a child I was known as the odd one who likes sandwiches not cakes. So no diabetes. Why bother with expensive tests when taste buds come free?

As a medical student I learnt the importance of always checking piss (in the Bible, don’t moan at me) and dung (also there, but less likely to provoke moaning). Here, boys and girls, is what to look for.

First, blood. This might be pinkness or redness or blackness from huge quantities of the stuff. Mind you, chances are you’ll already be at death’s door if it’s black—unless you’ve just returned from a night on Arthur’s best in Dublin. Blood in wee means something wrong with kidneys, bladder or connecting tubes. Blood in poo means something wrong with large intestine. Blood on poo means probably piles, which are kind-of blood blisters. Don’t sit on radiators or you’ll get thermopiles. Blood is a danger sign. Blood is good, but only confined to blood vessels. End of.

Now urine: colour, smell, pain. Note any change in what’s normal for you. I drink a lot, so mine is anything between clear and a delicate Piesporter. It doesn’t smell. Smelly dark urine often means infection, unless you’ve been perilously convivial the night before and have a head like a constipated turnip. If you’ve recently partaken of asparagus, your pee will smell pretty vile. It soon passes. If you’ve recently had a bum-burner, it might well sting a bit to pee. Don’t fret unnecessarily: use your common sense, should you have any left after last night.

Poo: colour, consistency, pain. Again, note any change from normal for you. Poo colour comes mainly from bile, which digests fats. If bile is unable to flow into the intestine, fats will not be digested so poo will be fatty, chalky coloured, smelly, and will float. In such cases, the bile is excreted from the body not in poo but in urine, so urine is dark. Pale stools and dark urine—always bad news: bile tubes are blocked. You’d be amazed how many doctors miss this, though not if they’ve been through my hands they shouldn’t.

Consistency: the function of the colon is to remove water from stools. So runny poo means that stuff is hurrying, or being hurried, through. There are several reasons why this might happen, often an infection by some of God’s non-human creatures. I once had a dreadful episode at Johannesburg airport that made the check-in lady enquire if I was well enough to board. I crossed my legs I can tell you. Read about it: Letter from Malawi. Parishioners who have had part of their colons removed have always responded well to being addressed as semi-colons (“oh no, it hurts to laugh”). I could go on, but maybe you’ve had enough for today. I shall deal with the ear next, I think. Quite fascinating.

From now on, look and sniff before flushing. Leave the tasting to others. Or machines.