There have been moments in my life when I have been
genuinely scared. One of those occurred in about 1964, when several of us were
coming back from a rugby match (I think); we were somewhat worse for wear. As
we drove toward South London in the early evening, it got darker and murkier
and eventually we could barely see the streetlights, let alone the street
signs. It was pretty obvious we were in the middle of a classic London smog.
This was not supposed to happen since the Clean Air Act of 1956 several years
after the Great London Smog of 1952 when upwards of 4000 people are estimated
to have died as a direct or indirect result.But there we were, not able to see
much more than 15 feet in front of us; and that was coloured a murky yellow
brown. I can’t remember who was driving at the time but, whoever it was, he was
keen to get home for a date, and reckoned he knew the way like the back of his hand
– which continued to be visible at that point. Discussion followed, but the one
voice of reason was overruled. The other three of us were anxious, but retained
that sense of invincibility so common in young people, but even more so in
medical students. Jim Flower offered to walk slowly in front of the car,
watching out for obstacles, and I leaned out the window on the passenger side
giving a running commentary on how far away the kerb seemed to be.Occasional
car headlights cut through the gloom, and their owners crawled past, but most
of the traffic seemed to have stopped or perhaps been abandoned. Perhaps there
had been weather or news reports we had missed while we were raucously singing
songs with the radio turned off.I can’t really remember where we had been
playing rugby, but would guess it was down in Kent towards Bromley. You always
think of London as a flat place (after all, England is largely a flat place),
but that is not entirely correct. As we went through Forest Hill (106 metres
above sea level) we noticed that the smog cleared, only to deepen as we got
close to Dulwich. Finally as we drove towards Herne Hill (a whole 31 metres
above sea level), the smog once again cleared enough to allow us to drive at
somewhere close to 15 miles per hour (having picked up Jim, of course).So we
had a story to tell in the med student common room.
But then there are
always better stories, are there not? One of our rugby-playing colleagues,
Peter Macdonald (later to become a politician in New South Wales, I understand),
must have come from a reasonably wealthy background. He had an open topped
sports car (maybe a Triumph TR3, as far as I remember). He described going to a
rugby match one Saturday, and driving at speed through an English village. At
some point, a police car pulled out from a side turning with siren sounding.
Peter told us he picked up his med student’s stethoscope from the dashboard and
waved it in the air. The police car duly pulled out of the chase. The rider was
that Peter was returning later from the same rugby match, and driving through
the same village at about the same speed. A police car pulled out behind him.
So Peter tried the same trick, waving his stethoscope in the air. No result. He
tried again. No result. Then he looked in his rear view mirror and saw that one
of the police had a pair of handcuffs he was waving out the window. Peter was
pinched, smooth salesman that he was. Of course we all thought it was
hysterically funny, particularly compared to our own rather drab story of survival.
There
were ‘firms’ that I did not enjoy. One was a surprise.
You may remember that I
believe I can trace my career in medicine to watching the removal of my left
big toenail, and I had recurrent fantasies that one day I would be a surgeon.
In addition, my interest in psychiatry was still going strong, and I had
recently come across two bits of work that seemed to link the two.One related
to pain. I am not quite sure who recommended reading the article, or why, or
whether it was related to a current case on the wards, but in late 1965 an
article was published in Science called “Pain Mechanisms: a new theory” by Melzack and Wall (1). They provided
support for pain sensations being moderated by sensations from touch, pressure, vibration. So all of the sensations
interact to tell us (called ‘gate theory’) whether a pain is severe, or whether
we should not worry about it. Conversely, we have some conscious control, and
can reduce some pain by ignoring it (though of course this does not always
work), and in our peripheries, for instance, by rubbing. I actually have a
treasured collector’s item Victorian book called REP (Rubbing Eases Pain),
which discusses this issue at length.
I suspect I was intrigued with pain, in
part because some patients will describe as ‘severe’ what perhaps we might
think to be a lesser pain. Conversely there are patients who have broken a
bone, for instance their wrist, and describe the pain as ‘bearable’! Pain is so
subjective and personal, and there are some people who are naturally stoic and
put up with things, but others who are highly anxious, perhaps, and seem to be
over-reacting. The first may not seek medication when they perhaps could or
should. The second may take enormous amounts of medication with little
subjective relief.Context and timing are both important. In the heat of the
moment, for instance in a sport (being hit by a squash ball on the thigh, or
partially tearing lateral ligaments in an ankle during a crucial game of rugby,
are two personal experiences), we may wince but carry on – regretting later
that we had not been more kind to ourselves. So pain is one area of medicine,
where psychology interacts strongly with physiology, anatomy and personal
experience. It seems to me it is this complexity that continues to intrigue me.
This
interaction between brain and mind goes further. At about the same time as the
paper on pain, on a surgical firm, I ‘clerked’ a patient who had had chronic
intractable epilepsy that had not responded much to enormous doses a cocktail
of drugs taken over many years. His lifestyle was very limited, and he had had
many falls and resultant injuries. He was scheduled for surgery directly to the
brain. The idea was that the main area of hyperactivity that kept firing off
and causing his symptoms was to be ablated with an electric charge from probes
inserted using something called stereotactic surgery (2).
I was
excited. This is what I had dreamed I wanted to do with my life; I had had this
growing secret desire to be a neurosurgeon for many months.So here I was,
privileged to be party to the operation, all carefully scrubbed up, gowned and
masked in the theatre. I was very much an onlooker, needing to keep out of the
way of serious participants. I watched intrigued as the team began to carefully
attach the metal frame to my semiconscious patient’s head. It looked like some
mediaeval instrument of torture. We had all looked repeatedly at the cranial
x-rays, marked up to show the targeted area of brain through a complex process
relying on the patient’s EEGs (in those far off days prior to good MRI
scanners). The surgeons placed the probe according to the stereotactic
coordinates, and after what had seemed like hours of preparation, the dirty
deed was done. One flick of a switch, one minute area of brain death, and then
a lengthy process of dismantling the gear.Watching carefully, absorbing the
whole scene, I realised I was bored, and my legs ached. Wasn’t I supposed to be
ecstatic, or at the least satisfied?
But I was genuinely bored. I had noticed
this before on another surgical firm. I remember standing for hours on a raised
box assisting at the removal of some varicose veins in the leg. I had clerked
my patient, examined truly awful (and I am sure, very painful) varicosities,
sympathised with my patient and agreed surgery was necessary (as if it was my
decision!). The surgery was very clever, passing this long flexible wire down from
the femoral vein, carefully negotiating the bends, and attaching the head of
the instrument that would gather the vein. But overall it was boring! Alright I
was not the person doing the dirty (or at least bloody) deed. I was a tired
aching junior holding bits and pieces and wishing it was already over. Boring,
boring.
The same occurred when I was assisting at several other operations. You
stand there for what seems like hours, holding a retractor while someone else
removed my patient’s (what appeared to me to be a perfectly normal) appendix,
or in another case removed an obviously very infected gall bladder. Technically
brilliant, all based on the anatomy I had worked so hard at several years
before, carefully completed. But, boring. My dream of being one of the surgical
gods walking the hospital corridors began to slip away. Why would I choose to
do something technically challenging and highly skilled, but really only a
careful version of the butchering I used to see when I worked at Baxter’s
sausage factory?I know I am exaggerating. But the more surgical work I did, the
more boring it seemed, even when I was experienced enough to be asked to help
with suturing at the end of the operation.
And then the die was cast. And I am
grateful for this story to Jan who remembers the episode very clearly. We were
at a party, and talking with various people about where we might end up in
life. I volunteered that I had been playing with the idea of becoming a
surgeon. This elderly physician took my hands in his, turned them over and then
turned them back. “These are not the hands of a surgeon. These are the hands of
a General Practitioner, my lad”.
More later….
1. Ronald Melzack and Patrick Wall. Pain Mechanisms: A New Theory. Science, 19 Nov 1965: Vol. 150,
Issue 3699, pp. 971-979 DOI: 10.1126/science.150.3699.971
2. See https://en.wikipedia.org/wiki/Stereotactic_surgery#History
for details about the history and practice.
3. A. A. Milne, of course…
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