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Tuesday, February 2, 2016

Making of a Child Psychiatrist: (38) Settling Down Sort of… (1)

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”.
“And that…” said Pooh, “is that!”

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 for details about the history and practice.

3. A. A. Milne, of course…

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