Sunday, 17 February 2013

Spinal Trap

It must be something of a record; certainly it is a personal best. In the first week of December I entered four different hospital buildings spread across two different hospital trusts in two different cities. The news from these different venues is mostly good.

Before all that, please let me share some happy news that is not related (yes, yes, I know EVERYTHING's connected) to my medical history or that of my family. Monday 3 December saw the Lord Mayor of London—not the flaxen-bemopped polymathic pretender to the Tory throne but the 685th holder of a much more ancient office, holding ceremonial sway in London's original Square Mile—coming through a doorway which I have had some part in reconfiguring. Here are some pictures: 

The north entrance lobby of St Olave Hart Street before improvement works.
Like walking into a cupboard and just as inviting!
In the foreground is a mayoral sword stand dating from the 18th century.

Ta daa!
Glass panels mean that people can see in and those inside the church can see, er, out.
Huge improvement, and with new stone steps and a levelled floor within in the lobby, making it safer.
New glass doors to Hart Street complete the improvements.
The door handles bear a design dating back to the 17th century.

The Lord Mayor's purpose in visiting St Olave Hart Street was to swear in the new Alderman of the Ward of Tower, in which the mediaeval church is situated. The City of London is a strange and magical place in many ways and it is a mistake to equate it in a simple and direct sense with blundering bankers and overweening skyscrapers (although the latter are currently, quite literally, in the ascendant, even while the former can expect yet more brickbats in the months to come). Talking of overweening skyscrapers...

The Guild Church of St Margaret Pattens on Eastcheap.
The view is from Fenchurch Street and has now been lost because the building
that is now filling the crater in the foreground is...
This monstrosity, nicknamed "the Walkie-Talkie" that bulges at the top
and looms over Fenchurch Street and Eastcheap.
Pedestrians walking past it are smacked in the chops by a fierce wind.
Another ghastly edifice, currently rearing its bulk above Leadenhall Street.
This one is called "the Cheese Grater".
It was a cause of celebration for me and my employers that the new north entrance to St Olave's was ready in time for The Lord Mayor's visit. Until the week before, access to the church was only available through the churchyard on the south side and the interior of the church bore a fine film of dust from stone cutting and cement mixing and, instead of the tinsel, baubles and fairy lights now twinkling over the Christmas season, it was host to a display of warning notices and builders' barriers. Through the clear new glass doors and down the pristine York stone steps they came: first was the Ward Beadle, his three-cornered hat embellished with gold braid, bearing the Ward Mace crowned with a model in silver of the Tower of London; next the City Marshal in plumed hat ; the Sword and Mace of the City—the latter assembled over several centuries and including elements, I was told, from the 14th century; finally, with forthright stride, walked the Lord Mayor in his red robe and wearing a black, plumed tricorn hat almost as wide as his shoulders;  Once the civic party was assembled at the east end of the church, the Beadle called the gathering to order with the ancient French cry "Oyez! Oyez!"

The Beadle of the Ward of Tower enters St Olave's at a stately pace.
The plumed hat of the City Marshal is visible behind him.
The Lord Mayor of London at St Olave Hart Street on 3 December 2012.
See what I mean about the hat?
Boris Johnson.
Growing his own plumed hat from scratch...
The formal gathering lasted no more than 30 minutes but was one more link in a chain that stretches back into the distant past, linking us to ancestors long departed and reinforcing patterns of service, obligation and culture that protect us from the passing whims of politicians, which are themselves perhaps amplified versions of our own fancies. Gross over-simplification, I know, which on the one hand glosses over the personal ambitions of the holders of ancient offices and on the other ignores the large number of dedicated local and national politicians. What I am arguing for is, I suppose, the virtue of a long view and the holding of conflicting ideas in tension. Freedom without law is a form of bondage and invention without structure is chaos; law without freedom is repression, while structure without invention is boredom. 

Time maybe to turn to matters medical. On 4 December I had my regular haematological check-up, currently taking place every three months. As regular readers will know, my outpatient appointments take place in the whizzy new Macmillan Cancer Centre, a short stroll from the main hospital building of University College Hospital in Bloomsbury, one of those areas of Central London that has been the cradle of much medical pioneering as well as of other scholarship and research. 

The mobile sculpture/artwork thingy, apparently made of "found" plastic components, that hangs above
the central reception desk at the Macmillan Cancer Centre.
Love it!
Some of the jobs that before would have been carried out by the receptionists are now in the voiceless care of computers. Or is it one computer, housed in its own secure enclosure, perhaps not even in the building—a lurking Shelob of a computer minding its web of a network in basement darkness? Whatever the digital underpinnings, volunteers are on hand to guide patients and carers through the reception process, which begins with scanning one's bar-coded appointment letter at one of the screen terminals standing at each of the four corners of the main reception area. Having been identified by hospital number and date of birth, the patient’s next task is to watch out for his or her name on one of a number of screens suspended above the floor of the reception, because also displayed there will be their next destination within the building: in my case the basement, for the blood test that precedes every meeting with a haematologist—other than the purely social, you understand! With all this high-tech receptionism in place it is almost disconcerting to find that I next have to take a numbered paper ticket (from a roll of these lying on the counter, not from the sort of dispenser you will find in the larger sort of post office) and write the number of that ticket against my name on a list in order to secure the brief encounter with a phlebotomist that soon follows. Soon enough the right amount of blood is drawn from my arm into the requisite number of sample containers and sent for analysis, so that the results can then be added to my computerised patient record. 

In the short time it takes me to take the staircase to the ground floor, my name has already been placed by Shelob on one of the suspended screens with a request that I present myself at haematology reception on the fourth floor. I have not been sitting there long before an opportunity arises to have a conversation with the person sitting next to me, who is waiting to see a different doctor for a different blood cancer. We compare notes, symptoms and side effects and agree that we are not very keen on the bold design of the flooring. The jagged, colourful pattern is artist-designed, although—in its resemblance to an impression I once saw of the aura that precedes a migraine—it seems out of place in an environment where calm is not only desirable but actively sought by most of those present. Not sure whether to congratulate those who commissioned it on bold thinking or to take them to task for error of judgment, I will try and remember to grab a picture of it for a future blog post, so that you, the reader, can decide...

My appointment itself goes well, with the general picture emerging of a stable state of good health. Shelob has not yet got round to placing the results of this afternoon's blood test on the doctor's screen, but I learn from the letter that she writes to my GP subsequently and copies to me that my haemoglobin and white-cell counts are a bit down. The latter is most likely explained by the fact that I was recently fighting off a chest infection while the former reading, as the consultant reminds me when I email her about it, has "bobbled about a bit" since last year's treatment. There is nothing in the latest readings to disrupt the picture of normality currently emerging and I am reassured.

Medical trip 2 that same week was on Friday 7 December, when I made my way to another node of the University College London Hospitals Trust, this time in a part of London unfamiliar to me, north of Holborn (although Holborn itself was once my stomping ground when I was training as a solicitor in the late 70s and early 80s). I was taking my troubled back and jangling sciatic nerve to the National Hospital for Neurology and Neurosurgery in Queen Square, just around the corner from the most famous children's hospital in the world, Great Ormond Street. The map provided with the appointment letter was very clear and it was easy to find my way to the imposing late Victorian red brick building. It turned out though that the spinal surgeon was holding his clinic that day in the former London Homoeopathic Hospital, now the Royal London Hospital for Integrated Medicine. I was able to form a good impression of the surgeon as we found ourselves going up in the same lift, he bearing an open, approachable manner as well as that staple of modern urban life, a takeaway coffee. 

The interior of the hospital was well lit and pleasantly decorated and the reception clerk had a wonderful manner with all those he dealt with: warm, compassionate and conversational and with no trace of "computer says no" about him. I did not have to wait very long to see the surgeon but there was enough time to note something of the difference between a neurology outpatients clinic and the environment of haematology that has become my home from home since 2010. Surely our ailments and sufferings shape and mould us, whether over a long time or—as in the case of trauma—suddenly. Haematology patients are often significantly pale and and lacking in energy, whether from the effects of disease or treatment,  carrying with them the memory or anticipation of numerous needle punctures, their emotions and mental equilibrium tied to regular cell counts. In the neurology environment that Friday were people dealing with issues of movement, gait or posture, dropped feet or shaking limbs. I find it helps to bear the extreme as well as the mundane consequences of disease and abnormality if one looks at the human frame and constitution in mechanical terms: blocked pipes, severed connections, bent or broken structures. With such a focus comes the engineer's hope of fixing problems: a little turn of the spanner here; there a restored connection or a brand new part, whether large or small. The really intriguing thing however is the interaction between what we can, for the sake of argument, call “mind” and what we can, by analogy with our own contraptions, visualise as “machine”. Thinking of us solely in mechanistic terms will not do: just think, for example, whether you would rather be thought of, nihilistically, as a "meat puppet" or, tenderly, as a "soft machine". Isn't it altogether wonderful and baffling, yet at the same time absolutely natural to us as humans, to find ourselves swayed and affected by such different arrangements of letters on a page or the sounds of variant sequences of words dropped into our ear?

A Cylon "Centurion" from Battlestar Galactica.
Definitely a "hard Machine", this one, but then the Cylons evolved, didn't they, viewers?
Before too long it was time for my consultation with the surgeon I had met earlier in the lift. Warned by my medical-student son that a surgeon on such occasions would not automatically have access to the MRI-scan images of my spine, I had taken steps to obtain a CD of the pictures from my GP, who in turn had had to request them specifically from the private company contracted to the NHS to conduct scans in my local area. I have to say that it seems odd to me that those whose job it is to tinker directly with the sensitive inner frameworks and systems of a human body are not supplied with such images as a matter of course. I imagine that the companies owning and operating the scanners are suitably paid for their services, so what is a little CD in this grander scheme of things. When I worked in property a plan was the golden route into understanding boundaries, rights and liabilities affecting plots of land. Verbal descriptions are also crucial, but to stint on piccies seems bizarre.

The surgeon was grateful for the disc, which he put it into his computer and in the digital version of a jiffy pictures of my backbone appeared on screen for us both to see. Here is one:

MRI image of my spine.
The surgeon has kindly aligned the mouse pointer of his computer
with the deformity that is causing my current discomfort.
Just to the right of centre in this shot you can see the displacement of lumbar-5 over sacral-1,
with the disc bulging out slightly to press on the nerve.
Otherwise, my spine is pretty straight, thank you very much!
The surgeon had a lively, even enthusiastic, manner as he outlined the nature of the deformity and what might be done to alleviate the trouble it was (IS!) causing me in the way of pain, stiffness and, sometimes, mildly impaired mobility. To my great relief, on seeing the problem and lining it up alongside my history of lymphoma and the energetic chemo that had been deployed against it, he pronounced that he would not be considering subjecting me to surgery. As I felt clutching anxiety release its grip on my shoulders, he said he was optimistic that a combination of physiotherapy and anti-inflammatory injection would be suitable in my case, although the duration of relief given by the injection could vary between years and mere months. In order to decide on the right course of treatment he would right away send me for an X-ray and a CT scan. Armed with those on our next appointment he would be able better to chart the way ahead. 

I had taken to this man instantly. To his open and informal manner was added a lucidity of expression, as well as an interest in me as a person, my work and my family. If surgery had turned out to be necessary I would have trusted that into his hands. When I thanked him for his time and the clarity of the information he had given, he made the memorable point that a doctor who does not communicate is forfeiting his most valuable asset, the intelligent and engaged patient. Lest I misunderstood what he meant by "intelligent", he added that the principle applied to patients of all levels of education, and whether or not they had much prior experience of medical matters. Powerful and energising stuff this was, and as I left his office it felt as if the bones of my lower back were already beginning to find a better alignment.

Before leaving hospital building no. 3 and returning to building no. 2 a quick word with the amiable reception clerk secured my next appointment with the surgeon. Building 2 was, you will recall, the red brick Victorian structure referred to some few paragraphs above and usually known simply as "Queen Square”—easy-peasy monosyllables replacing learned polysyllables derived from Greek.

Once you have passed the large commemorative plaques which name and celebrate the great (and presumably wealthy) individuals who set up and endowed "Queen Square" in its original form and which are of a type often to be found adorning the entrances of hospital buildings that pre-date the National Health Service, you find that the original innards of the fine old place have largely been replaced by glass, steel and modern flooring, all bathed in the pin-sharp clarity of halogen lighting. In this case all these replacements seem well conceived and executed, but what was more important than all the modern shininess was a similar personal warmth shown by the staff to that which had been so evident in the building I had just left. There was the cheerful receptionist who escorted me personally to the x-ray section, not wanting me to lose my way in unfamiliar surroundings; the radiographer who calmly explained the poses (for what else can I call them?) that I should hold in order to provide the surgeon with images of how my back was functioning (or, rather, wasn't); the CT technician with the neck tattoo who did not allow the efficient carrying out of his professional tasks to obscure either his humour or his genuine concern for my safety as I got on and off the scanner table.

At the moment I passed through the implacably smooth high-tech greyness and revolving lights of a CT scanner for the third time in my life I reflected on how far medical understanding, technologies and techniques had developed since the days of the two Tudor physicians I know anything about: William Turner and his son, Peter, both of them buried at St Olave's and whose combined lives spanned the period from 1508 to 1614. William was learned and indeed pioneering in close observation of the natural world and in the use of plant-based remedies and the therapeutic merits and demerits of wines, while Peter leaned more towards the chemical compounds deployed by Paracelsus and advocated the use of arsenic pendants ("plague-cakes") to avert the evils of the plague. Theirs was a world where the health of body and mind were maintained by balancing the "humours”—those classical entities associated with dryness and moisture, hot and cold, earth, air, fire and water—which survive into our age-millennia later-in the names given to four basic temperaments: sanguine and phlegmatic, choleric and melancholic.

In such a world, in 1612, the desperate royal physicians striving to save the young Prince Henry, the elder son of King James I (aka James VI of Scotland), from a ghastly death from what is now believed to have been typhoid fever, applied dead pigeons to the shaven head of their teenage patient and a split cockerel to his no doubt restless feet. The remedies were of no effect, which is why our nation has not so far had a King Henry IX and why the Throne,  instead of passing to someone groomed from his earliest years in the arts of kingship and in all manner of cultured, sporting and warlike pursuits, instead passed to his sickly younger brother Charles, in whom were allied a certain personal likeability and a catastrophic lack of suitability for guiding his people through particularly turbulent times-an inadequacy which led to the English Civil War and the shocking political expedient of his own death on the executioner's block. At its heart, this is a story of one young man's fatal illness, but just look at how the ripples spread in our human pool. The mind is identical with the individual brain? Somehow I don't think so.

The high-tech investigations done, it was time to leave the building.
My ruminations on the history of medicine and the role of plants in it were bolstered by the sight of plants in this plaque identifying the hospital that I saw on my way towards the exit.
In our techie world we do well to remember our roots.
Finding myself back on the streets of Holborn and the weather having improved in the several hours I had spent shuttling between hospitals, I decided to revisit old haunts and to pick up the Underground at Temple Station, which would mean walking through Lincoln's Inn Fields, that great square housing both Farrer & Co, the Queen's lawyers, and that monument to architectural experiment and eccentricity, Sir John Soane's Museum. From the square my walk took me into Lincoln's Inn, whose collegiate architecture from the 18th and 19th centuries exudes an atmosphere—no doubt partly deceptive—of calm, measured study, reminiscent of the quiet quadrangles of our ancient universities. The impression is reinforced by the hand-painted boards at the entrance to each set of chambers: black lettering on a white background in a style that has not changed for two centuries at least-bearing the names of the learned barristers within; here and there letters after the names and titles identifying those members of chambers who have reached judicial office. The building in which I trained as a solicitor is still there but has had a name change and is no longer occupied by the firm I worked for between 1979 and 1984. The firm itself has grown substantially since then, having merged with larger concerns—who swallowed whom? It has kept its name (dropping the dated "& Co." that marked it as a creature of the 19th century) and expanded its reputation beyond acting for substantial individuals, landed interests and charities to swim happily with the big boys in the corporate shark pool.

I walked out of the Inn and down the alley called Star Yard where you can still find an ornate Victorian metal urinal enclosure; although its entrances are blocked, preventing use of the structure for its original purpose, you can still marvel at its quaintness and rarity. I paused for a few moments by the window of Ede & Ravenscroft, makers of wigs, robes and shirts for the sort of lawyers who have to dress for the part. While admiring the craft that had gone into the making of a pristine wig, now on display atop its oval case, but which would one day perch on the learned bonce of some unknown barrister, I wondered—not for the first time and not alone in raising this question—how it is that styles of dress from the 18th century had been settled on for so long as the last word in how lawyers should appear in court. Once again, hallowed modes of ceremonial dress make an appearance in this blog post.

I emerged into Carey Street, which runs along the back of the Royal Courts of Justice—the name of the street being formerly synonymous with the state of bankruptcy—intending to make my way to the Tube via another barristers' enclave, the Temple. First though I took a short detour along the street of financial misfortune in search of the old narrow pub that faces south towards the Courts, frequented no doubt over the last couple of centuries by a mixture of those celebrating victories in court, those drowning their sorrows after defeat and those nerving themselves to do battle before the judges in their stronghold across the road. The Seven Stars is still there, looking neater now and having moved towards the upper limits of my price range after the gastronomic revolution that has swept these islands in the 30-plus years since I used to bolster my own wavering courage with a swift half.

The Seven Stars pub in Carey Street behind the Royal Courts of Justice.
In the window was this dapper festive cat.
Resuming my progress south to the Tube I entered the Temple through its discreet northern entrance on Fleet Street, my heart lifting once again to be within the boundaries of the City of London, whose proud dragon stands on its haunches in the middle of the road, itself named after one of the many, now diverted and buried, rivers of London.

17 Fleet Street, one of the few buildings in the City pre-dating the Great Fire of 1666.
The entrance to the Temple from the north is through the archway beneath the half-timbering.
Once inside the Temple, I looked into a recess in the wall to my right and noticed, as if for the first time, that the quaint-looking lamps inside it were powered by gas. So, at least this part of the legal enclave had taken to its bosom the technology of the 19th century. All this progress was too much for me, so I turned east and took refuge in the reassuring embrace of The Temple Church, its west end being originally a Norman round church, inside which are to be found tomb effigies of ancient knights, weathered over the centuries and rudely damaged in the aerial bombing of World War II. Drawn further eastwards into the newer (ha!) parts of the building by the sounds of a fine choir rehearsing music for Christmas, I found memorials of the Jacobean period, their painted effigies showing their subjects in poses of devotion or surrender to God.

Putting theology aside for a moment (although, I must confess, I cannot), many of the churches of London, and of course elsewhere, are truly remarkable in being buildings—or, at least, locations—that have been in continuous use for centuries: not only "use" in the mundane sense, either, but employment for the specifically spiritual purposes of prayer and worship; hospitality, healing and celebration. The mundane makes many appearances, to be sure—one of the reasons, for example, that memorials reward close study is that they vividly illustrate changing patterns of wealth in society, some of their initial purpose having been to remind of achievements in the knockabout realms of domestic and international trade and the entrée that worldly success gave to the courts of power and influence. However such ostentations become overlaid with a patina of alternative meanings and nuances even as the physical structures around them and the painted or plain stone effigies they contain change in appearance under the dust, grime and smoke of the passing centuries.

The continuing presence in a world city like London of such wonderful, sometimes very ancient, buildings is a call to stop and meditate on the deepest experiences available to us as humans. Seasoned readers of this blog will anticipate at this point that I am going to attribute a divine origin to these experiences and talk of God. If this is a step too far for some, perhaps you will allow, at least, talk of the "numinous”—that sense of mystery that we find in the sort of places our Celtic ancestors referred to as "thin", where the division we feel between our individual personality and what we share with each other, nature and the universe beyond falls away?

I stepped back outside into the jumble of centuries represented by the various buildings that make up the Temple, noticing again the faint glow of the gas lamps dotted around and then remarking—as I looked into the rooms of the barristers' chambers alongside my route to the Thames embankment, their comfortable spaces filled with shelves of law reports and other learned texts—that the Bar's tastes in office resources had moved beyond the 19th century and into the present one, as nearly every desk on it brandished a generously sized computer monitor. Lawyers—by which I mean the good ones—are valued for holding in creative tension the lessons of the past, the needs of the present and the anticipation of the future and somehow the collage of costume, architecture and the latest information technologies embodied this. Their services will cost you, mind.

This harmless window-shopping over, I walked along the riverside, into the Tube station and made my way steadily home, conscious all the time that my positive mood had been bolstered by the surgeon's confidence several hours before.

The fourth visit to a hospital that week was to see my mother, who was recovering from an operation. My brother had been staying in her house through the week and visiting daily, so was there to great me with a warm hug as my train from London pulled into the station. After a rather good Cornish pasty eaten alfresco, we spent the afternoon with Mum, who was recovering well, as she continues to do some weeks later.

Founded in the 19th century but now housed in the latest architecture, this final hospital of the week is a gleaming embodiment of the Private Finance Initiative, which I first saw flagged up in the commercial property press well over a decade ago, touted by those running pricey professional development seminars and conferences for chartered surveyors, lawyers and financiers as the Next Big Thing. Obviously those attending such events took careful notes, as the country is now dotted with nice buildings built by the private sector but the costs of which are being borne by John and Jane Citizen and succeeding generations into what seems like eternity.

On the way out my brother and I saw an eminent public figure accompanying an elderly relative into the hospital. The sight made me reflect on the benign centrality of the NHS, for all its faults, to our sense of social identity, even our patriotism. In recent days we have stood by our radios or sat in front of our televisions or with our newspapers before us, scarcely believing the horrors that emerged from the enquiry in Mid Staffs. It all seems miles away from what I have been describing of NHS excellence in this post and throughout this blog. I would just note at this point that in all of my hospital experiences since 2010 I have never knowingly seen an NHS manager on the shop floor, let alone spoken to one. Has anyone out there reading this spotted  one? I would love to know...

A brave soul entering Stafford Hospital.
It has taken so long to write this post, pecking away at the eentsy keyboard on my phone in snatched moments, that it is now nearly time to meet the spinal surgeon again and find out what treatment he is going to recommend. Before that, I am about to have another "NHS moment”, but this time of a different sort. After grumbling away for a few weeks, my left upper wisdom tooth has declared itself infected and therefore expendable. In a few minutes my brother will be arriving to drive me to the surgery a mile or so down the road. At some stage I am bound to give you some idea of how it goes. By the time you read this, it should be over at any rate!

Socrates, a wise man.
Wisdom teeth are so called because they typically make their appearance
when an individuals is between the ages of 16 and 25 and therefore
presumably more wise. Not necessarily.