A funny turn

3B10211C00000578-4002910-image-a-7_1480976584455As Facebook friends may have read, a couple of weeks ago I had a funny turn.

Out walking the dog I felt fuzzy headed, vision even more blurry than usual, unable to walk in a straight line, slurred speech. No drink taken. Transient ischaemic attack (ministroke) thought I as I was lumbering about. Or brain tumour, or cerebellar disease, or inner ear disease.

I sat down, minded by two kind passers by who said I was pale and unsteady. Susan walked the dog home, brought the car and off to hospital. I was in hospital a fair bit as a child for tonsils, nasal polyps (x 3), appendix, teeth and broken bones, so I dislike hospitals intensely. Not only that, people die in them. So the fact that I willingly went says something important.

A&E was quiet. I was tended with efficiency and good humour. I was given a mask and learnt that nobody knows how to stop them steaming up your specs. ECG normal, head CT normal, BP 135/75 – beat that, suckers, given the amount of salt and butter I consume.

High dose aspirin was administered, blood thinner and statins prescribed. Statins I don’t like. Doctors don’t always know the difference between good and bad cholesterol. and the evidence for the efficacy of statins is equivocal. Anyhoo, when I had them once before they didn’t agree with me so I stopped them PDQ.

There’s an MRI next week and they mentioned continuous ambulatory heart monitoring. But I feel as if I’ll be wasting their time. I’ve no idea what caused the symptoms, and they don’t fit into any recognised disease pattern.

You see, dear reader, we’re just machines, and machines have glitches. Sometimes we know what causes the glitch, sometimes we don’t. I’ve found that the cure for a computer glitch is usually to turn it off then on again; for a TV or washing machine glitch, a hard bash or three usually does the trick.

So on this well-established principle, my treatment for this funny turn (a recognised medical expression by the way) was: kill or cure. The very next day I took up running.

Back in the 1980s I was a regular runner – not particularly fast but I could go for ages. Often up at 5.30 am to run a few miles in north Nottingham to Bulwell and back from Sherwood (a suburb, not the forest). A friend and I often went for a few miles round Wollaton Park at lunchtime, showering afterwards in the Anatomy mortuary, much to the amusement of the staff if not the cadavers. I even ran three half marathons.

In the 1990s I was at it again at lunchtime in Dublin from St Stephen’s Green to Phoenix Park and back with a colleague (students were shocked to see that Professors had legs), and at home in Djouce woods in County Wicklow. I opened the car boot, in jumped Petra (a ridgeback/lab cross, a wonderful dog) and up to the woods. We had a great time on the tracks and pathways. The woods, opposite Powerscourt waterfall, were known as an IRA training ground, but we never saw or heard anything interesting. I was really quite fit and lean. Then life intervened and I became, let’s say, less lean. Weightlifting became my thing.

Now senza gym and provoked by a funny turn it’s back to running.

But gently—not because I might die, for I certainly shall, but because I wish to minimise pain. At the age of 70 next month, muscles are good but ligaments and tendons are much more brittle. It hurts when they tear or rupture.  Joint cartilages, too, need care.

Will I ever be back at the gym? When will it re-open? Will I at this age be allowed out of the house? Let me tell you, girls and boys, if the government says I’m not, I may well need to be visited in prison because doubtless some nosey parker reincarnation of an East German Stasi gobshite will report me for being a very naughty boy.

What if running provokes a catastrophic blowout? Well, that’ll be that. You’re welcome to the party after the funeral, if allowed. What doesn’t kill me makes me stronger, as my ole pal Fred Kneeshaw said.

But never mind. Her Majesty’s Government is in control. I have every confidence that they will act sensibly over gyms: reopen them now please. I have every confidence that they will raise money to pay for the largesse they’re doling out by making the super-rich pay more tax, by making multinationals like Amazon pay more tax, by stopping drug companies (they’re all evil) charging extortionately for things that are cheap to make, and by closing tax havens. Funds will cascade into government coffers. As I say, I have every confidence.

Meanwhile, back at the ranch, every day in every way it gets easier and easier. And the dog is having a great time.

Corona and Cassandra 2

Blue-COVID-BannerAn update of my previous blog.

“When we get back to normal …”

Not when, but if.

Coronavirus is the virus. Covid19 is the disease it causes. Coronaviruses have been with us a long time. The flu virus is one of them. Some common colds are caused by coronaviruses. Covid19 is caused by a new strain—hence the adjective novel. I dare say, dear reader, that you knew this. But I’m ashamed to say it hadn’t dawned on me until fairly recently. Now on with the plot.

I don’t see any prospect of controlling this pandemic until herd immunity has been achieved. Herd immunity comes from a combination of immunisation and recovery from infection.

  • A vaccine is at least a year away and anyway vaccines don’t always work. The first recorded influenza pandemic was in 1510. We haven’t yet fathomed the disease and a flu vaccine is as far away as ever. Furthermore, the common cold, sometimes of coronaviral aetiology, eludes all cures. The polio vaccine took decades to be usable, though we’ve moved on scientifically from then. I’m old enough to remember the polio epidemic of 1957/8. As an asthmatic child often fighting for breath, pictures of children in iron lungs terrified me.
  • For recovery from infection we need about 60% of the population to be infected, with the inevitable proportion having life threatening disease and dying. The trouble is that this virus has great propensity to mutate. Its mutated forms could be more vicious than the present one, and herd immunity, or vaccines for that matter, for the present strain won’t necessarily work for new ones. So we are faced with the possibility of wave upon wave of epidemic. Epidemics in general are occurring with increasing frequency (Asian flu, polio, SARS, foot & mouth, Ebola, now this … and more).

And of course there’s always the possibility that new viruses will emerge.

Viruses are clever. They use other creatures for reproduction—their only concern—remorselessly. Just as tectonic plates do the “things that come naturally” leading to quakes and tsunamis, so viruses do the “things that come naturally” leading to morbidity and mortality in vulnerable creatures including humans. It is the natural order.

Viruses are as much part of creation as we are. Praying to a sky pixie for delivery from the pestilence of viruses, as religious nutters do, is no more than human arrogance and hubris. We have viruses in our intestines, necessary for digestion, just as we have billions of bacteria living in us and on us, all necessary for an efficient bioeconomy. Are they asking the sky pixie to discern which bugs to zap and which to leave unhindered?

If covid19 were left unchecked, the best option scientifically, it would amount to survival of the fittest. The trouble is that the burden on the health services would soon be catastrophic. The strategy adopted, distancing and such like, spreads the load over a longer period. But no matter how we get there, herd immunity is needed—and may never be achieved. I suspect that governments have been informed of this, but dare not admit it publicly.

This brings me to the reliability of what we are told. Take today’s BBC news item “New data has added to growing evidence that the number of deaths linked to coronavirus in UK care homes may be far higher than those recorded so far.” Note the vagueness. “Deaths linked to coronavirus” – what does that mean? Deaths “may be” linked. They may not. Just because someone with a cough and pneumonia dies, it doesn’t mean they died of covid19, nor does it mean that the virus contributed to their death. Only testing will tell, so we need reliable tests. Not all tests are reliable. If one reads only the headlines, and many of us do just that, it’s easy to panic.

Ultimately—and I wish people would realise this—we’re all going to die, if not of covid19 this month, then something else later. And let me repeat that as someone with a great future behind him, I would expect a younger person who could get back to work to jump the treatment queue before me. I’m ready to die, though I don’t want to yet.

I don’t much care what others think this says about my morality: to me it’s pragmatic necessity. I acknowledge that I have a peculiar, even brutal, attitude to death. It comes from having seen death as welcome in severely ill people especially babies, having handled cadavers in anatomy dissection rooms for 30 years, and having suffered the death of one of my sons.

Turning from biology to economic and political affairs, the consequences of the pandemic could be serious in Europe, and cataclysmic elsewhere.

  • In the west, an economic slump of staggering magnitude is almost certain: some economic historians have said the worst in 10 generations (400 years), others 200 years, and certainly 100 years. As one commentator put it, it’s almost as if the virus were tailor-made to strike at capitalism. The financial markets are in turmoil. What will happen to the banks? Fewer people will be able to buy houses, house prices will plummet (a good thing you might say), savings wiped out, pensions destroyed. Power cuts, shortages, rubbish uncollected, unemployment, poverty, civil unrest, suicides. Back to the middle ages. Governments won’t be able to bail us out: national economies will be in the doldrums for decades after the financial largesse already being handed out. Taxes will rise. This economic reality is already fuelling demands for the lockdown to be lifted so that people can get back to work.
  • Elsewhere – a worst-case scenario
    • China is already buying up commodities now that the prices are rock bottom.
    • The US sees covid19 as China’s fault and demands reparations. China says no. The US refuses to pay back interest on its substantial loans from China. China sees this as an act of economic war. Then what?
    • The slump in oil prices destabilises the Middle East, especially Saudi. Oil supplies are cut. Dictators emerge.
    • The Russian economy being too dependent on oil, Putin invades Ukraine for food and the Baltics for minerals. Will Western Europe fight for the Baltics?
    • The peace since 1945 has been dependent upon economic prosperity. When that is taken away nationalism rises and fights are picked.
    • Africa is devastated. Infected migrants hammer at Europe’s doors. Shots are fired to keep them out: many will be killed.
    • I imagine something similar could happen in South and Central America – poor and populous.
    • The already creaking EU disintegrates.
    • Surveillance becomes intrusive (it’s getting that way already).
    • Totalitarian governments take over. Maybe China takes over. Or Russia.

Now, you may say that this is unduly bleak. But none of it is beyond the bounds of possibility.

I could be wrong. Part of me hopes I am. Part of me thinks that our lifestyle in the West is dissolute and decadent and needs sorting. But events that lead to correction of our lifestyle will likely lead to horrific, in human terms, sequelae for the third world—which now includes much of our inner urban areas.

Life is a terminal disease, its death rate 100%. People are going to die of this and other viruses. Measles is coming back. Polio and Ebola and Foot & Mouth lurk in the shadows ready to erupt unpredictably. The best thing we could do for one another is to help each other come to terms with uncertainty and mortality. I did my best from the pulpit and I do my best through my blog.

The fact is that there are too many people on the planet. There are far too many cooped up. Maybe the planetary ecosystem is resetting itself. I’m not a proponent of the Gaia theory, but I know that we reap what we sow. At present we are reaping. As far as creatures of the earth are concerned, apes like us are vulnerable, impotent and expendable.

But never mind. The sun is shining, the sky is clear, riverbeds visible, air cleaner. The night sky is spectacular. This virus is doing the planet a favour. Perhaps too it’s the scalpel that releases pus from the putrid abscess of aggressive capitalism.

I thank James Drever and others for help with this, but please don’t associate them with my prognostications.

Corona and Cassandra

Cass

Cassandra

Informed guesswork.

Even experts must be scratching their heads a bit in dealing with the pandemic. It can’t be otherwise, for this is a novel virus, and novel means novel. The virus is more infectious/contagious than was first thought (but not as much as say measles) and more virulent/fatal (but not as much as say Ebola). It’s difficult to plan in such circumstances.

I left full time medical practice in 1976, and I’m no political pundit, but I have a certain breadth of vision, so bear with me as I look ahead.

I don’t see any prospect of “controlling” this pandemic until herd immunity has been achieved. Herd immunity comes from a combination of immunisation and recovery from infection. A vaccine is about a year away, so in the meantime that leaves recovery from infection. We are faced with the prospect of more than half the population needing to be infected with the inevitable proportion having life threatening disease and dying.

If the disease were to be left unchecked, the burden on the health services would soon be catastrophic. The strategy adopted—distancing and such like—spreads the load over a longer period. But ultimately herd immunity is needed. I suspect that governments have been informed of this, but daren’t admit it publicly to a populace that has forgotten how to deal with uncertainty and mortality.

The trouble is that even if herd immunity is achieved, coronavirus, being an RNA virus, may well mutate, the new strain possibly more virulent than its predecessor. So back to square one. And of course there’s always the possibility that new viruses will emerge.

We’re a drop in the ocean compared to New York, Africa, India, the Far East, Central and South America. Economic and political consequences could be serious in Europe, and cataclysmic elsewhere. Read on.

  • China is already buying up commodities now that the prices are rock bottom.
  • US sees covid19 as China’s fault and demands reparations. China says no. US refuses to pay back interest on its very substantial loans from China. China sees this as an act of war. Then what?
  • The slump in oil prices destabilises the Middle East, especially Saudi.  Oil supplies are cut. Dictators emerge.
  • Vladimir Vladimirovich has economic problems in Moscow, the Russian economy too dependent on oil, and invades Ukraine for food and the Baltics for minerals.
  • Africa is devastated. Infected migrants hammer at Europe’s doors. Ammunition is deployed to keep them out.
  • The EU, already creaking, disintegrates.
  • Surveillance becomes intrusive (it’s going that way now).
  • Totalitarian governments take over. China takes over? Russia takes over?

As for the financial largesse being doled out at present, that will have to be paid for. Meanwhile, power cuts, shortages, economic hardship, civil unrest, back to the middle ages.

Now, you may say that this is unduly bleak. I admit I can be a bit of a catastrophist. But none of this is beyond the bounds of possibility. Interesting times ahead – a distraction from brexit anyway (remember that?). Don’t expect a quick resolution.

There are too many people on the planet – or at least too many banged up in cities. As far as creatures of the earth are concerned, apes like us are vulnerable, impotent and expendable.

Maybe the planetary ecosystem is resetting itself. A spring clean.

I thank James Drever, Andrew Paterson, and others for their help with this, but please don’t associate them with my prognostications.

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.