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Sunday, September 27, 2015

Making of a Child Psychiatrist(24): Med School (2)

The next few days were full of expeditions to get to know the immediate vicinity to King’s, built between The Strand and the Thames Embankment (just a short walk down Surrey Street). Just across the road was India House, and there was public access to the basement restaurant and some of the hottest and cheapest curries I had eaten. Of course my mother had produced a great, if somewhat stylised, curry for numerous parties and occasions but somehow the ‘real thing’ came as a burning surprise immediately and two days later. Further to the west was Leicester Square, to the north of that Covent Garden, and in between all the London theatres that somehow we did not consider (and perhaps could not have afforded) in those early years. Walking east towards Fleet Street took me past Australia House and I have always wondered whether the repeated image of sun and surf and the promise of a £10 emigration somehow took up space in my mind. You either had to go round India House or Australia House to get to Aldwych to find Kingsway where, in Sardinian Arcade, there was a musty cramped little shop selling University memorabilia. Of course I needed a royal blue and red diagonally striped tie (which I still have) and, of course, a long cloth scarf in the same colours lengthwise (sadly long gone). They were worn with considerable pride. It was important to belong, to tell the world where I belonged. The shop also showed off an array of wooden plaques in the shape of a shield with the college insignia. I wanted one. I coveted one, but could not afford one at the time, and had to wait many years before getting one sent by post. It somehow remains a way of showing my heritage, and has sat on the wall in most of the offices in which I have sat. I have an identity: I was, and am still, a King’s man.
We had a list of prescribed textbooks for the main subjects (Anatomy, Physiology, Biochemistry, Pharmacology), and this necessitated repeated lengthy and fascinating visits to Foyle’s multistorey bookshop in Charing Cross Road. Having been a librarian at school, I was fascinated by the rows and rows of books from all round the world. Others were fascinated by the coffee shop; I never needed that. I was just happy with books, and happy to stay for hours, even though there was always an underlying purpose to each visit. There were other bookshops close by, and some of them antiquarian, but somehow they never had the fascination of Foyle’s. Perhaps not surprisingly (given my first day’s experience), I went a bit overboard in buying anatomy textbooks. I bought a copy of ‘Gray's Anatomy: descriptive and applied’, and a recommended guide for anatomical dissection – a brilliantly simple set of flip charts. Sadly I cannot remember the author’s name but, being a very visual person, I am eternally grateful for the ring back guides that were light enough to carry into the dissection room to assist. Somewhere along the line, I also acquired, and have retained, a copy of the very detailed and beautiful ‘CIBA Collection of Medical Illustrations’ by Frank Netter. These days, of course, it is easy to go onto the Internet, and find diagrams, photographs and MRI sequential scans of the whole body. But nothing compares with poring over a book, and turning time and again to a particular page until the whole thing is embedded in memory. Of course, exquisitely detailed anatomical drawings go back to the days of Leonardo da Vinci, and I am not sure anatomy has changed that much over the years. The new generation prefer the Internet; I prefer to hold a book, without the interruptions of email and other pop-ups.
We needed instruments, and almost furtively entered the recommended shop, whose name I now sadly do not recall. I do, however, have a visual memory of climbing some stairs in an elderly and slightly musty building. They were professional, never asking if any of us was a descendant of Burke or Hare, and responded quickly to our list of forceps, scalpels with spare blades, a probe, tweezers and surgical scissors, and a small boringly khaki canvas roll in which to carry them.
Dissection began on about Day 3, and we had directions as to how to proceed as well as an ever-present demonstrator to guide our thinking and hands. We began with the forearm of the upper limb, and no-one seemed awfully keen to make the first incision. I can still remember the discomfort of that first time; but then if you could not manage such an act on a long dead person, however could you manage on a live one when it might be a matter of life or death. So over the weeks we took turns uncovering the layers of skin, tracing muscles and the arteries and veins that had provided the blood flow to them, and eventually being able to lay out (and describe) the anatomy to please the demonstrator. This was real; it was important, and it left us all with a sense of wonder for the human body. I am sure that smell of formalin permeated not only my lungs, but also my clothes and perhaps my soul. If people moved away from you on the underground, there was always a thought that, perhaps, they knew what I had been up to.
Other topics had exercises in the lab, building from the very simple to the complex, but all providing a sense of how the body works. To this day I have my first Physiology exercise book, with its still schoolboy writing and the date of the first experiment (12th October 1962. Experiment 1 – Blood A: ‘Erythrocyte Count in Blood’). The reporting detail is like nothing I ever did at school; it was careful, precise and thorough. I wanted to do this; it was my future craft, and I was taking it seriously.
We built on examination of the various types of cell, quite literally counting them in squares under a microscope, to measuring heamoglobin levels. By the 27th October we were using an electric stimulator to get frog muscle to contract, and then practicing on each other’s palms. This was to become a way of life; practice on a partner and then they practice on you. On that day, I was working with ‘C. Lines Esq.’, my old friend Chris. Week by week we moved on, examining respiration and lung volumes and then the composition of exhaled air. We learned to use equipment like pipettes, microscopes and oscilloscopes. The experiments were always demonstrated first (see one), and then each of us would take a turn on our own specimens or on ourselves (do one). It was meaningful, grounding, and I gradually gained a sense of the pathway at the end of which I would be a doctor.
By February of 1963 we were doing group experiments which were randomized and controlled. For instance determining the effects of exercise, nicotine or pituitrin on renal output after taking on board a uniform water load. This was a feature providing a reality; we had to take small experimental amounts of all sorts of drugs through that first year to measure changes. When you have such an experience, you have a respect for medications that you cannot gain by reading a formulary and prescribing for some unsuspecting third party.
A weird thing happened one morning on my way to the refectory. I was passing a notice board close to the main entrance, and the word ‘Australia’ sprang out to hold my attention. I stopped, and looked closely. The ‘Inter-University Australia Committee’ (based at Oxford) was requesting applications from students interested in spending a summer holiday in Australia. A requirement was that the student had to have employment for three months, and had to arrange their own accommodation. But flights and transfers would be totally free - no obligation. After my initial disbelief, I read the notice again and again, checking details and dates and timing of applications. Then I wrote it all down. My parents and my sister had been in Adelaide, Australia, since March of 1962, and would be there for the full three-year posting. This might be a way of getting to see them. It might also be a way of getting Jan to myself for three months.

That night I rang Jan excitedly and discussed the possibilities. Then separately and later together, we discussed the ups and downs. She would be missing a whole summer season of contributing to her parents’ hotel. I would miss three months of working to supplement my grant. We discussed the whole thing with Reg and Bobbie, Jan’s parents, and I wrote an air-letter to Australia seeking a response as soon as possible. With agreement we put in our applications, not really believing our good luck, and with that faint sense of wondering about ‘the catch’.

Haiku on End/ Blow/ Deep/ Pound


Midnight one minute
Artificial end of day
In unending time

Don't want it to end?
Best there was no beginning
Just twiddle your thumbs

At a loose end, eh?
Just pop round to the neighbours
And offer to help


Yes I've had a drink
Blow into this bag, madam
'Twas a cup of tea

Article declined
A small blow to self esteem
On to next journal...

I never used blow
No need for mind enhancement
Quite the opposite


My feelings run deep
And have been there for ever
Underground river

Deep down in her womb
She felt the smallest flutter
The future of life

With deep sympathy
I honour those who have lost
That is, all of us


Fire in the fairground
We hide in the Ghost Train Bar
Nightmare headache pounds

Chopper blades pound night
Rockets fire enemy ground
We hide safe bar none

Scouting camp ground fire
Hide drum rhythm pounded out
Bar by noisy bar

Friday, September 25, 2015

Haiku on Might/ Flood/ Whine/ Travel


Mind is delicate
You might have to shut it down
For recovery

I can feel the draft
You might like to shut the door
As war closes in

Might is always right
Often for the wrong reasons
When minds are shut down


Washing machine floods
The flat is awash in suds
Time to move again

She wakes to red mist
Endorphins flood her tired brain
Bloody dream again

Post meditation
A flood of new ideas
He begins to write


Moaning and groaning
Fresh government ministers
Old whines, new bottles

Sunday afternoons
Languid garden mood broken
Next door's mower whine

We lay down to rest
Troubles over for today
Then the mozzie whines


Travel into space
From edge of eternity
Blue planet beckons

Living on the edge
Blue thoughts colouring my world
Need to travel on

Sharp blue horizon
Straight edge between sea and sky
Travels round the world

Tuesday, September 22, 2015

Making of a Child Psychiatrist (23): Med School (1)

The lecture theatre in the Medical School at King’s College London in the Strand (Founded 1828) feels ancient. It may partly be the darkish brown rows of seating, or cleaning materials used, or the polish on the floor, but there is a residual person smell that reeks of learning. It rises for two levels, with sloped seating rising into the Gods. I had followed the written instructions, and arrived in good time, choosing to sit about 8 rows back. I never did like sitting right in the front and, to be honest, was too lazy to climb right up the back just to gain obscurity and have a secret overview of the crowd. There was nobody out front controlling the crowd or guiding, nothing of interest to look at on the pristine green black boards, and so there was a rising hubbub as 9am arrived and passed, and people began to introduce themselves. There was some fidgeting and I guess others were, like me, wondering whether we had misread the notice. We had such a lot to learn about power and crowd control.
At thirteen minutes past nine, a diminutive man (I was later to learn his height was 5ft 4ins) walked into the theatre wearing a white laboratory coat over his suit. He was slightly portly, very unprepossessing and totally bald. He had a new piece of chalk, and in large letters slowly wrote ‘14%’ with a slight scratching audible in the silence. He turned to face us, and ran his eye over every face from left to right and then row-by-row from the bottom to the top. You could have heard a pin drop as 140 young souls packed into the theatre watched this man slowly walk up the left hand stairs, within inches of me, to about two rows below where people were sitting. He paused dramatically.
Then, enunciating clearly, in a broad Scottish accent, he spoke: “Fourteen per cent!” (pause) “Fourteen per cent fail Second MB…” (slight pause for impact) “… and this is where they sit!” There was silence as Professor of Anatomy Tosh Nicol strode down the steps to the front. We listened in wrapt awe over the next 40 minutes as he went on to describe the medical course over the next 18 months, the expectations overall and in his own subject. I can still capture the cadence of his voice when telling the story. In addition, I can still get the feeling of awe, if not fear of this small man who writ large. Unknown to me in my youth and naiveté, Professor Nicol in many ways reiterated the words of Robert Bentley Todd who, exactly 110 years before, had stood in the same spot and welcomed those new to studying Medicine at King’s (his lecture (1st October 1852) was published as ‘On the Resources of King’s College London’ – available free on Google Library). I suspect Todd’s address (judging from the transcript) had a certain gravitas, and would have lacked the aggressive directness of Nicol. I now have a certain fondness for Todd, given he focussed on neurological disease, writing several books about it. Five years later, I was to gain the Prize in Medicine for King’s, a bronze medal in the name of Robert Bentley Todd. I have always been curious about him, and his effigy cast on the face of my medal. But all that was a long way into the future.
As I remember it there were presentations from other academics introducing their topics and the structure of their courses. Strangely, I don’t have much memory for any of them. On reflection, this makes me think that Professor Nicol’s address was, for me, in the manner of a screen memory – an apparently aggressive man with enormously high expectations – someone we might never please, someone to be seriously avoided.
I suspect we were directed to a canteen for lunch, and spent some time making introductions and discussing the morning. Somewhat later on that first day, in groups of 12, we were taken up to the top floor by ‘demonstrators’. We entered a strange and open room with an awful smell I came to know as formalin (which did not disguise several other scents of unknown, but guessed at, origin). Shockingly, there were a dozen metal dissection tables in ranks 2X6, and on each of these was a preserved human body laying face down. I would guess this to be some device to lessen their humanity until we were used to the place and the processes. We were informed that these bodies had been freely given to the school for the express purpose of training future doctors; an odd privilege which has been mostly lost in today’s medical schools. We were assigned 10-12 to a body, with 5-6 to a side. We were given rosters listing the times we were expected to attend, and lists of the surgical instruments that would be required to do the job. A number of texts were recommended for purchase, to explain in some detail how we were to go about the exercise. Having been introduced, we were shepherded out.
In the corridor, while we were milling about coming to terms with our recent gruesome experience, a number of confident young people stood smiling with understanding next to small plain and unmarked cheap wooden boxes about a metre by 30cms by 30cms with a handle on the top. The young people were medical students who had successfully completed their eighteen months of pre-clinical training in the previous year, and wanted to sell their skeletons to the newbies for something between ten and fifteen pounds each. Having had the contents of a box demonstrated, and having been assured there was not one bone missing, I bought one; cash and no receipt.
Having collected some timetables and a guide to the med school, the day was complete and I walked with several new friends down The Strand to Charing Cross station, each of us hugging a cumbersome but surprisingly lightweight box. We arrived before the rush hour, used our newly purchased season tickets and sat reflectively on the underground, hugging our odd possessions until we got to Clapham South. From there, we walked the short distance along Southside to Halliday Hall, my home through to the spring of 1964.
In 1962 King's provided quality student accommodation for about £50 per term at Halliday Hall, on Southside at Clapham Common. This suited me eminently in my transition into the real world, as long as my parents were able to continue to supplement my KCCC quarterly grant. I was on the 4th floor, and had one of sixteen single rooms sharing two bathrooms. Luckily, there was a lift. It was full board with breakfast, dinner at night, and a cash bar with some snooker tables, and a television lounge. Rooms were cleaned and tidied each day. There were neatly kept lawns and tennis courts for the energetic.
In the first few days of living there I had been somewhat nervous of mixing with what turned out to be a lively (and naughty) mix of male Divinity, Engineering and Medical Students. I would eat quietly and quickly, watch a little television, and then retreat to my room where I had my record player. Day by day I made new friends who, of course, were in the similar situation of finding themselves living away from home in the big city for the first time.
After that first day of actually being at College, the group of med students began to grow close, and friendships were forged which certainly lasted strongly until the day we all qualified and went our separate ways. On that first day I wanted to retreat and examine my skeleton, looking at the markings and indentations on the whitened bones with curiosity. I had left the skull of this long dead person till last. Eventually I picked it out of the box and turned him round and upside down. He and I were to become old friends, so I thought the least I could do was to give him a name. In memory of my old school friend and mentor, I called him Fred. I hope whoever he was has forgiven me.

On about the third or fourth day, one of the med students asked me if I played Bridge; they were short of a fourth hand. And life began to take a pattern.

Monday, September 21, 2015

Haiku on Wave/ Specific/ Point/ Today


Floating on a sea
Waiting for the seventh wave
All an illusion

Noisy crowded room
I catch her eye, smile and wave
Too many people

Waves of nausea
First days human dissection
The future doctor


Random thoughts combine
Coalescing from nowhere
Specific answer

Man against nature
Builds everything in straight lines

Specific person
Correct in every way
Rigid and boring

Frog jumped out of pond
No real specific reason
Just needed a hand


It is rude to point
Even worse for you to grab
Find your manners

Point me to the aisle
So I can grab a six pack
If I can find one

Mental signposts point
Grab your pack journey ready
Go find your mountain


What is said today
May be forgotten tonight
But not forgiven

Today here at last
All we said in the past gone
Enjoy this moment

As I said my dear
I need you, mind body soul
Today forever

Tuesday, September 15, 2015

Transverse Myelitis and Neural Plasticity

I have just read Oliver Sack’s latest book (‘On the Move’), finishing ironically on the sad day he died a couple of weeks ago (30th August 2015). ‘On the Move’ was a brilliantly engaging autobiography that I could not put down, covering his medical history, his personal life, and the clinical background to all his books (think ‘The Man who Mistook His Wife for a Hat’ and ‘Awakenings’).
I had started reading Norman Doidge’s recent book about 3 months ago (‘The Brain’s Way of Healing’), having gone to a public interview with him in a packed auditorium. As soon as I began, I remembered having struggled several years ago to read his previous one (‘The Brain that Changes Itself’ which in many ways introduced the general public to the idea of ‘neural plasticity’). Doidge’s writing style is not engaging, and he tends to repeat himself frequently, going over and over the stories he tells – perhaps to defend himself against his critics. The problem is that he is saying some very important things in the latest book.
The primary story is that if we lose a part of the brain through whatever cause, it is possible to open up adjacent parts to counteract the loss. The first tedious and repetitive story in ‘Healing’ is that of an inspiring man with Parkinsonism who literally forced himself to walk again, over weeks and months walking further and further and faster and faster. If he slackened off his regular training, then he returned to his classic tentative steps and lost his animation. If he was ill for any reason he got a setback, and had to work hard to recover his progress. The message (as in Sack’s books) is that managing a chronic brain illness may not be best managed solely with medication; the brain needs to be retrained through exercise or listening to music to invoke a need to dance.
So over the last few weeks, Jan and I have been watching the US ‘So you think you can dance’ and marvelling at the athleticism and style, and wishing we could do anything that remotely resembled what happens on stage. We have also been addicted to the Australian ‘Dancing with the Stars’. This is closer to home, given Jan and I met at 14 in Ballroom Dancing Classes. Throughout our lives we have been dancers, taking every opportunity to move to the music. The last time is a painful memory of ‘doing the twist’ energetically and to collegiate applause at a Christmas party of Child Psychiatrists a few weeks before I became ill in December 2009. Watching DWTS, I twitch as if parts of me want to get back on the dance floor. The premise of the program is that a ‘star’ (usually someone of whom I have never heard) having never trained in dance before, is paired with a professional dancer for the weeks of competition. Week by week one of the stars leaves. One of the dancers this year was a young woman who had an above knee amputation with a high-tech prosthesis. She had never danced prior to her accident, and certainly never since. She was understandable tense and anxious, but week by week there was obvious improvement in her capabilities, her enjoyment and confidence, and her courage to try advanced moves. She was brilliant and, if an empathy vote counted for anything, she should have won. I watched gob-smacked at how much she could learn to better control her artificial limb to the point of obvious finesse.
OK, back to my current struggle. I noted in a previous post that I have an iPhone app that measures my daily strides. I questioned whether taking note of the app would have any impact on my walking over time. So here is the result to date. In January, I could not walk more than an average 1084 steps per day. This included two days a week being at work collecting patients from the waiting room etc. There were good days and bad; all very variable. Occasionally (like about once a week) I tried to go on the exercise bike for about 20 minutes, but it was a trial, and I was always exhausted afterwards.
Bit by bit I have pushed myself (the truth is probably that Jan has pushed me to push myself). She will often (on days I am not at work) demand we go for an early evening stroll. This began slowly, and just to the end of our road (about 600 metres return journey), usually with a stick to assist me to control my right foot placement. The frequency of exercise bike has now risen to at least twice a week.
As I have become a bit more confident, it feels like my muscles are a bit stronger and more toned. In fact we found out a precious fact. If I walk half way, and then stop for a rest for 5 minutes, admiring the view, I am refreshed enough to toddle home. I am consciously using this ‘exercise – rest – exercise’ in all that I do.
So what is the result? Over the last erratic and somewhat pressured month, despite struggling to recover from shingles around the head and eyes, I have averaged over 2000 steps a day. Admittedly this includes my more regular two days a week 20-minute exercise bike ride. In the last 6 months, I have gone from an average 1085 steps per day (over the week), to an average 2669 steps per day (over the week). This is the first week I have ever been able to exceed the 2500 average step marker on the phone.  I have to say generally that I am walking more confidently, though there are good and bad days.
I am generally more tired on bike days. I give myself a rest day before a work day. I recently had an odd viral illness over three days, and felt exhausted. I exercised very little for those three days.
I have a fantasy that my referred pain from T5-7 coming round to just below my right nipple, is less troublesome. I have bad days – for instance if I do too much reading or too much writing. Jan has continued to give me a back rub about once a week, and a foot and lower leg rub about twice a week (brilliant kind person that she is).
So, if the brain is plastic, is it possible that the spinal cord is plastic, too? Don’t know. Someone please tell me. I know that there are animal experiments that show an animal can regrow spinal fibres even after a transection; so why should that not be possible in humans?
The spinal cord is an extension of the brain, made up of the same kinds of cells and fibres. Can we teach our spinal cords to re-route signals past a damaged bit? Don’t know. Someone please tell me.
I suspect that regular massage, passive muscle movement, and gradually increasing exercise with physiotherapist or exercise physiotherapist support is far better for us than medications. You may like to check in with your doctor or neurologist.

By the way, in 2009, I had been teaching a karate class the night before I got my Transverse Myelitis. I very bravely wrote an email to friends a couple of days later asking if anyone would like to join me in ‘wheelchair karate’? I have done no karate since. However, three weeks ago I felt confident enough of my stance to do ten repetitions of a range punches and blocks looking at my style in the bathroom mirror. My legs were as steady as rocks, even when I increased the slight twist to increase the force of a punch. I have repeated that about twice a week. It did not make my chest pain any worse. I have a fantasy it may eventually recreate some old pathways in my spinal cord.
Do I want to go on ‘Dancing with the stars”? Not at my age. But I would like to improve my physical status as I age, and avoid being in a wheelchair for as long as my aching bones will allow.

Does anyone know any references to spinal recovery through neural plasticity? Please let me know. If I find anything, I will share it.