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 The confluence of rivers Eden and Eamont near Langwathby has been replaced by the family in 2007, so Hugh is there holding his young daughter, and Christine and I in Trafalgar Square in about 1953 have aged a few years in a portrait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.

NHS encourages irresponsibility?

For Church Magazine, November 2020

You might remember Terry Waite, adviser to a former Archbishop of Canterbury, who was captured and kept in solitary confinement for over three years in Lebanon. He speaks with some authority about how to survive in difficult times. 

He has in no uncertain terms told us to stop being so pathetically wuss (my words not his) about dealing with the privations arising from efforts to stop the spread of covid. We should stop moaning and be constructive about organising our lives. We could read more, be creative, use technology to chat to people. However bad we think it might be, it has to get a lot worse before it compares with being on your own in a Beirut shithole for years. In short, we should take responsibility for ourselves and not expect someone else to come along and sort us out.

Amen, amen.

It applies to every aspect of life, not least health.

Actions have consequences. If you stuff your face with cream cakes from the rising of the sun unto the going down of the same, don’t be surprised if you get fat, develop diabetes, have a heart attack, and suffer from joint disease because your joints weren’t expecting to have to support a ten ton truck.

Part of the blame lies with the NHS—or rather the way we have allowed it to develop. Having it as a safety net is one thing, but now we expect it to deal with the consequences of our stupidity. We think that we have a right to feel as good at 70 as we did at 30. We refuse to take responsibility for ourselves in the expectation that the NHS will sort it out for us.

It’s a bit like praying to a sky-pixie to sort out problems that we have brought on ourselves. Indeed, it is exactly like that. The Dalai Lama has pointed out how silly it is: “humans have created this problem, and now we are asking God to solve it. It is illogical. God would say, solve it yourself because you created it in the first place.” 

And so with health.

Make a weekend visit to a casualty department (after covid, if it ever ends). Wade through the vomit on the floor caused by alcohol overconsumption. Is this what the NHS is for? Why should doctors be non-judgmental? When I was a teenager, my GP told me I was too fat and should do something about it. He was right, and I did. 

None of this is easy to manage. Some of us eat to make us feel better about ourselves. At least the food loves us even if nobody else does. Some of us have genetic predispositions to certain conditions and there is little we can do other than manage them. Life is difficult. We are at the mercy of our obsessions and addictions – and don’t kid yourself that you don’t have any because we all do. Here’s a list.

Nicotine/tobacco. Alcohol. Exercise, Porn. Golf (I’m not old enough to play golf, but I’m told that it’s popular amongst the brain dead). Recreational drugs (cannabis is less dangerous than alcohol; cannabis rice krispie cakes are delicious). Religion: ecstatic trances of mystics are orgasmic, and for some people religion is merely a prop like smoking or drugs or booze to help them get through the day. Some people are 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.

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

You hear people compare themselves to others: “if she can eat it, why can’t I?” The sad truth is that as with everything else, our bodies and our metabolisms are unpredictable. We are not all the same. Swallow a handful of paracetamol and see what happens. Some of you will have no detectable symptoms; some of you will die. Or covid: some people have mild or no symptoms, some have serious symptoms that last ages; some die. 

And all of you will die sooner or later. The longer you live, the more likely you are to die. Life is not fair. Life is uncertain. Get over it. 

One of the first things that medical students do is study a dead body. It is a ritual that helps define them as trainee doctors. All their patients will die, and so will they. As a priest, at every funeral I took I pointed to the coffin and said “every single one of you is going to go in a box like that, and it might be later today, so get your affairs in order, make peace with those you need to, and if there’s something you need to do, do it now. And stop moaning”. I had more complimentary remarks as a result of that stark advice than ever I expected.

My reading of Scripture tells me that we are to be responsible for ourselves. You are no good to your neighbour if you don’t look after yourself. The NHS encourages some of us NOT to take responsibility for ourselves, instead remaining as infants expecting nanny (NHS staff) to deal with the consequences of our idiocy.

You could say that the NHS is UNChristian in tolerating irresponsibility.

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.

Sarf London medic

In previous posts, I’ve explained why going to see the doctor can be dangerous, and why we should treat mental illness with compassion without embarrassment. This piece is much more personal.

The Cambridge medical course was and is six years long, three in Cambridge 1969-1972, three on the wards 1972-1975. In my day the hospital at Cambridge couldn’t cope with 250 medics each year, so it was the custom for almost all of us towards the end of second year to apply for a clinical place in another medical school for years 3-6. Most of us went to one of the London schools, and I ended up at King’s College Hospital on Denmark Hill (Camberwell), not too far from the Peckham of Del-boy. Peckham has now been well gentrified, but it most certainly was not so then.

In late summer 1972, a couple of weeks before the course was due to start, I arrived in London on the overnight sleeper from Carlisle, and met up with David and Steve, two more Cambridge medics, in search of student bedsit(s). We stayed in north Clapham with another friend who had already begun work in the Bank of England. I remember most vividly the invertebrates slowly sliming across the “bathroom” wall. Salubrious, huh? 

King’s was in south London but my two mates were attending more central medical schools: David in Whitechapel, east London, and Steve in Hammersmith/Fulham, so wherever we ended up, we would have to travel. We allotted ourselves search areas: mine was Paddington and north Kensington (think Grenfell but long before).

After a few days up and down the smelly and stained staircarpets of shifty letting agents, we settled on renting a basement flat on the South Circular road between Clapham Common and Balham (gateway to the south). It had its good points. It was a short walk to Clapham South tube, the living room and bedroom were spacious, and the gaff had its own side entrance. Less good were the fact that the bathroom and bog were just an incompletely partitioned area of the kitchen, culinary and other smells blending appetisingly, and the second bedroom was actually a cupboard under the stairs up to the ground floor. 

We were not in the least put off by any of this, not even by the flock wall paper that I see in my mind’s eye in the living room with its scenic eye-level view from the bay window of discarded cans and dog turds on the pavement. We invited a nonmedic friend of Steve’s to share the rent. He was a Nigel Planer (The Young Ones) type – lanky, lugubrious, long black hair – and was supposed to be at some college or other but as far as I could see spent most of his time on a mattress in the tiny, smelly, windowless under-stair cupboard with his girlfriend, doubtless engaged in mind-improving activities with mind-altering substances.

This meant that David, Steve and I shared the bedroom. Three blokes. We got to know each other pretty well. Single beds before you ask.

I had a daily commute across town of 3.5 miles each way. No car in those days. I knew nothing about London buses, but as a rail nerd I had a working knowledge of tube and rail networks, so my journey was 100 yards walk to the tube, two stops on the Northern Line to Clapham North, across the road to Clapham railway station, two stops to Denmark Hill station, 200 yards walk to King’s. I did it on foot sometimes along Acre Lane through Brixton – pleasant enough if I wasn’t pressed for time.

My first student attachment was at Dulwich Hospital, a couple of miles from King’s, up and over Dog Kennel Hill, one of the steepest in south London. A year later, after Susan and I were married, I cycled a fair bit, and up and over the hill got me quite fit.

Three things I remember quite clearly from my time at Dulwich.

The first is that there’s nothing new under the sun. Peter Friedlander, a most delightful and gentle consultant physician in his late 60s, told us that his first line treatment for any stomach upset was liquorice. “Oh sure”, thought we, “what would an old codger who was at medical school in the 1930s know of modern all-singing-all-dancing medicine?” Well, boys and girls, he was absolutely right in this as in so much else. Liquorice root is indeed the active ingredient of several therapies. Just because it comes from a plant and not a laboratory doesn’t mean it’s no use—the opposite in fact. Also from plants come aspirin, morphine and digitalis, and from mould, penicillin. Dr Grundy in Cambridge drilled into us that these drugs are four of the five essentials you need to have if stranded on a desert island. The fifth is insulin. (By morphine people actually mean heroin – diamorphine – but they have a fit if you call it that.)

Dr Friedlander also taught us that for patients on a lot of drugs, it’s often wise to stop the lot and see what happens. You see, the trouble is that drugs interact with each other, and when several are taken together they have unpredictable effects that make things worse. That message—keep it simple—still informs just about everything I do.

The other Dulwich realisation was that sometimes—often in fact—the best thing to do is let someone die. Too often I saw patients suffer unnecessarily just for the sake of being kept alive for an extra week or two or month or two, often in great distress. Why? Well sometimes it makes the doctors feel they’re doing something (doctors like you to think they’re omnipotent), but also sometimes—and I saw this in ordained ministry too—because family members use someone else’s pain as a weapon to score points off each other.

It was while I was living in Clapham South that Susan and I rekindled our school friendship. By then she was a primary school teacher in Droylsden, east Manchester, and one weekend in late 1972 she came to visit the grubby basement. An evening walk to Clapham Common found us in the Windmill tavern. I, then a junior clinical medical student, asked her to marry me. The wedding would have to wait four years, said I, until I was earning. 

So, dear reader, we were married within months in August 1973.  But all that’s another story. Until then, I leave you with this vignette from my bachelor social life at that time.

The year is 1973, the time Friday evening. The story concerns four young men attending King’s College Hospital Medical School who were taking an evening stroll. As they proceeded from Camberwell in a north-westerly direction towards The Oval, a thirst descended upon them somewhere in salubrious north Brixton.

“Behold, seest thou yonder hostelry?”
“Yea, verily. Let us hie thither and slake our thirst.”
“Aye, aye. Come, let us make haste.”

It was the Skinners’ Arms on Camberwell New Road. The four knights did enter.

“If it be thy pleasure, fair wench, we parchèd wanderers each desire a tankard of thy most toothsome nectar.”
“Most certainly, wandering knaves,” quoth she.

Some time and several flagons later, behold the lights did dim. Music rang forth and lo, a lady materialized on the podium. The knaves salivated in eager expectation. The performing lady gradually divested herself of her habiliments until she stood before the assembled company in a two-piece bikini that didst cover only the barest of essentials. She had a midline scar below the umbilicus.

“Ah, comrades, spiest-ye the scar?” saith I (for yes, I was one of the four). “Perhaps the lady hath undergone an hysterectomy.”

It was not that the utterance itself was foolish, but rather the volume at which it rang forth, for the intended whisper cameth more as proclamation. If thou understandest that, thou dost apprehend the nub of the issue.

“Thou art mistaken, fair friend,” quoth the lady, “for ‘tis an appendix scar.”

And having uttered those very words the bikini-clad performer hied herself to the bench at which the knaves sat, and reclined on the knee of the writer, and polished his spectacles with one of her removèd undergarments.

Now, the knaves were, admittedly, very junior medical students, but they possess’d enough anatomical knowledge to know that appendicectomy requirest not a midline incision but rather a right-sided incision. Nevertheless, they sensed that circumstances were not propitious for elucidation. They felt that discretion was in their interests, and without further quaffing or quoting they legged it back to their lodgings. The young men were lucky, methinks, not to have been set upon by the lady’s supporters. 

The moral of the story? To draw conclusions from observations is good, but proclamation of same should be judicious if one wants to avoid getting one’s head kicked in.

In the dark?

Burton Hospital Eye Outpatients, 26 June 2020

Exchanges between hospital staff (HS) and me.

Me            Good morning. Outpatients, 9.30.

HS            assumed: can I have your name please?

Me            Sorry I’m deaf, can’t hear.

HS            still not loud enough: can I have your name please?

Me            I need to see your lips move, so please can you take your mask off? 

This does not go down well. After giving the requested information:

HS            We don’t seem to have your phone number. Can you let me have it?

Me            after having given it: that’s odd, you know, because somebody rang me last Monday to tell me about the appointment, and somebody rang me yesterday to confirm that I would attend.

HS            bluster bluster.

Me            Upstairs as usual?

After an affirmative nod, up I go. Upstairs is laid out differently from last time. I normally sit on the left to be near the place where staff call for patients, since none of them speaks very clearly. After about 20 minutes having been ignored:

Me            Am I in the right place?

HS            Have you had your temperature taken?

Me            No.

HS            Well, you should be over there in a red chair.

Me            after moving: It might be a good idea if the receptionist were to tell people that.

HS            There are notices in the lift and on the stairs.

Me            thinking: Notices? Notices? In small print? FFS, this is an eye clinic.

But I merely smile and relocate my backside.

Before long my sight has been tested, my right retina scanned, and in I go to the consultant. All very pleasant, though taking longer than usual. The consultant is very gently spoken and not easy for me to hear.

HS            What sort of surgery have you had?

Me            perplexed since he has the notes in front of him: Well I had the procedure that fries the ciliary apparatus last year and in 2018.

HS            Here? In the theatre downstairs?

Me            Yes.

HS            You had retinal surgery (not a question).

HS            No, not here, that was in Derby in 2008 by Mr Chen.

Him           So what was the operation here?

Me            after dredging my memory: cyclodiode laser treatment.

HS            Here?

Me            Yes, twice. You have the notes there: is there no record?

HS            Well, I can’t find them. Those records are digitized and kept offsite. We are completely in the dark.

Boom boom!

Me            trying to keep a straight face: that’s crazy ridiculous.

HS            shrug of the shoulders: That’s the way it is. Tell me when you had the cyclodiode.

So I did, and he wrote it down.

Ocular pressure on both sides is good. Glaucoma on the right is under control. It turns out I have a substantial cataract on the right, as well as glaucoma. Because that’s my only functioning eye, and surgery carries the risk of my being left totally blind, his advice is to live with the cataract until normal daily activities become impossible. I’m happy enough with that. I ask if successful surgery would mean that I could drive, to which the response is probably not.

After these moderately entertaining exchanges, he rationalises my seven lots of eye drops to five.

This is good, except that he insists that the drops I use should be from individual sachets without preservative, rather than with preservatives from a plastic bottle (cheaper). It seems the preservatives are damaging my corneas. He tells me that I must insist that the GP prescribes the individual sachets and not the generic drops in plastic bottles. Knowing as I do how difficult it is even to get a GP appointment, I express doubt that this will work and tell him why.

HS            Oh well, that’s the problem we all have to deal with. Good luck.

Then I’m dismissed with cordial farewells and I pootle off to hospital pharmacy to get the first new prescription. Do you know it takes 50 minutes to find two boxes, put them in a plastic bag, and give them to me?

I don’t fault the treatment one little bit. Burton Hospital has been very good to me. But I do wonder about administration, record keeping, the ability of one computer system to talk to another, and the difficulty people seem to have in imagining what it’s like from a patient’s perspective. 

All hail the NHS!

Mental illness

For the church newsletter, a sequel to “Should I go to the doctor?” https://ramblingrector.me/2020/05/16/should-i-go-to-the-doctor?/

If you have a broken arm, you go to hospital where it’s dealt with. If it happened playing sport or doing something heroic, your injury will be a badge of honour. If you’re a schoolboy whose arm was broken in a rugby match, you’ll be unbearable as you flaunt the evidence of your manliness. I don’t know how schoolgirls regard bones broken in, say, a hockey match because I’m not a girl.

If you have a faulty electrical circuit in your brain and become depressed, or self-harming, or in any way unable to cope, chances are you will not consult a doctor, but will soldier on, telling nobody, sinking deeper into the doldrums. If you tell someone else you run the risk of being patronised or ridiculed as odd, inferior, inadequate, even possessed by evil spirits—yes, that view is still held by some and is common in some cultures.

We can see, touch and understand a broken bone or a leaking blood vessel or a blocked tube. But we’ve little or no idea about what goes on in the brain. We talk about and are even proud of our broken bones, but we are embarrassed about and even ashamed of our broken minds. It should not be so.

Why do people become mentally ill? 

Maybe because some people don’t produce quite enough of a certain brain chemical which is used for one nerve cell to communicate with another. Maybe because some people produce too much of a different chemical. The one might result in depression, the other in mania or overactivity. Maybe some mental illness arises because repeated traumatic childhood experiences result in the development of electrical networks in the brain that enabled us to cope then but are unhelpful now. Maybe some people develop such networks in the brain as a result of genetic inherited patterns. It’s all a bit of a mystery.

If you use your imagination you might be able to see that some of these conditions can be helped by learning to think differently: counselling and cognitive behavioural therapy (CBT). Believe me, these are hard work and take time. Other conditions can be helped by chemicals. Sometimes a bit of both is good, with drugs kick-starting a longer period of counselling or CBT.

Recognising mental illness is difficult. We all have different personality types. Some people are prone to depression, others to overactivity. When does an exaggerated characteristic become illness? 

Sometimes such instability is productive. You may have heard of Tourette’s syndrome in which people have a mind that fizzes with ideas and a mouth given to uttering a constant stream of shocking profanities. If you are, for example, a jazz musician who is most productive when Tourette’s is at its height, the last thing you need is for the symptoms to be taken away with drugs, especially if it’s the jazz that puts bread on the table. Being “abnormal” in this way is no bad thing. There have been studies showing that the most original and creative scientists and artists can in some way be regarded as not quite mentally “normal”.

Please remember that there is in truth no such thing as “normal”: it is merely a statistical definition. To give one example, “schizophrenia” is used in different ways in different societies. In totalitarian states the chances are that if you are critical of the way society is organised, constantly sniping at government policy, you’ll be declared schizophrenic and confined to an asylum (for “protection”) or prison camp. Our society is highly critical of this, but hypocritical in that we do the exact same thing using different criteria. I leave you to think about that. Perhaps “normal” means “able to cope with society”. But what if society itself is abusive and oppressive? We need to fight for justice.

It’s also true that the brain receives information from all parts of the body and we know little about how this affects mental health. There is growing evidence that what goes on in the intestine affects our mental wellbeing – the “gut brain” sending information to the “head brain”. You know about gut feelings – this is what I’m on about. So, eat well, treat your intestines with respect, and if your diet upsets you in any way, change it. Don’t be a fool.

Similarly, exercise. It releases brain chemicals that improve the mood. It gives a sense of achievement. The best medicine is your own sweat produced by exercise. Just do it. 

Let me give you my theory about how some mental illnesses arise. We need to start with some evolutionary history. 

As you pass forwards (upwards in apes like us) from the spinal cord you come to the brainstem. In simple terms this deals with automatic things, control of breathing and heart rate, balance, coordination, awareness of position in space – stuff that we need but have no real control over. Next come the paired structures, right and left cerebral hemispheres. These are where awareness and thinking occur: we process information in order to make decisions. Part of the hemispheres deals with urges (sex, hunger, fear), memory, mood and emotion (these are linked) and another part with logical thinking, analysis, reasoning. 

I’m pretty sure that some mental problems result from tension between these two parts. For example, I might in a fit of anger feel the urge to punch your teeth down your throat, but the thinking part of my brain tells me that if I do, there will be undesirable consequences for me, and therefore I override the urges and refrain. Too much of this kind of repression results in a building up of frustration that, if not dealt with by exercise or kicking the cat or some such, is not good for mental health. Learning to recognise and cope with anger is a good thing. Anger, by the way, is good. It spurs us to improve what needs to be improved.

This is only a theory and it can’t be proved, but neither can it be disproved.

I said above that counselling was useful therapy, and to my mind it would be better named “listening”. Every single one of us is capable of being a listener. It’s one of the things that people with mental illness need. They do not need to be judged. They do not need to be told what to do. They do not need to hear your opinion or why you think they’re in the position they’re in. What they need from you is simply companionship. Look at that word “companionship”. In the middle of it is panis, Latin for bread (pain in French). Bread together. What they need is for you to take them for tea and something to eat. Sit with them. Listen to them. Keep your ears open and your mouth shut except when eating and drinking.

If you do that you’ll be increasing the amount of delight in the world. There is no better thing to do.

Men suffer disproportionately from depression. It is said that Staffordshire has the highest rate of young male suicides in the country: you will know how often the A38 is closed and the rail service disrupted for undisclosed reasons. Men are less likely to talk about their feelings than women who often need no encouragement. 

In Burton there’s a charity supporting men’s mental health. It deserves your support. 

Nobility in lockdown

At first, the virus signalled the end of the world. Now we know it to be neither particularly lethal nor particularly infectious.

We have been led to hysteria.

Opinions differ about the lockdown. Evidence is equivocal: its effects, however, are not. The economic consequences will be felt for generations, and the geopolitical maelstrom is only just beginning. 

But whatever about the big picture, the lockdown has been desperately cruel for many, especially the chronically ill, the dying, the grieving, and those in sheltered accommodation and care homes. 

The purpose of this piece is not to provoke discussion about the handling of the pandemic or the nature of the lockdown, but rather to let a dear and longstanding friend tell the story of how it has affected him and his wife. They are examples of the heroism that has emerged from this terrible wound that our society has inflicted upon itself. 

Over to you, friend.

I already look with horror at the misery caused not by the virus but by our response to it. My wife, sadly, has dementia and Parkinson’s disease, and has lived in a care home for over three years. I was excluded from visiting her altogether from the day lockdown started and left her the day before that wondering if I would ever see her again. Her capacity precludes any meaningful contact by telephone or video calling. 

The home has been visited by the virus with proportionate fatalities, but she has not so far been infected as far as I know. But over the first two months she gave up eating and drinking properly, lost more than half a stone in weight and has not been out of doors other than to make two trips to A&E following falls with injuries. Without saying how, I have found my way round the restrictions on visiting though I am limited to one visit per week at present. She is now showing more interest in eating and her mood has lifted at least some of the time.

I am slightly nervous, as lockdown is lifted, that my access may perversely be blocked again for reasons of preventing virus spread in the interests of others. The national policy has been one of panic rather than reasoned risk assessment with measured responses.