“A palimpsest of thousands of painful, shocking memories”

“As a doctor you can never forget. Over the years you become a palimpsest of thousands of painful, shocking memories, old and new, and they remain with you for as long as you live. Just out of sight, but ready to burst out again at any moment”.

This quote from Cecil Helman’s “An Amazing Murmur of the Heart”, a book I was somewhat tepid when I reviewed, has been resonating with me lately. I have also posted here about Helman’s disparagement of   “Technodoctors”:


Like may other doctors of his generation – though fortunately still only a minority – Dr A prefers to see people and their diseases mainly as digital data, which can be stored, analysed, and then, if necessary, transmitted – whether by internet, telephone or radio – from one computer to another. He is one of those helping to create a new type of patient, and a new type of patient’s body – one much less human and tangible than those cared for by his medical predecessors. It is one stage further than reducing the body down to a damaged heart valve, an enlarged spleen or a diseased pair of lungs. For this ‘post-human’ body is one that exists mainly in an abstract, immaterial form. It is a body that has become pure information.

I have been re-reading passages of “An Amazing Murmur of the Heart” lately. While the reservations I have  about Helman’s use of medical anthropology being at times, a little glib, and the “technodoctor” something of a straw man, remain, it is a rewarding text. Here he quotes Dr L, one of “six great doctors I have met in my life”, “an old family doctor, battle-weary and cynical after decades in practice. He’s a traditional, no-nonsense type of doctor, stern and impatient, though he has a warm and kindly core.”

Cecil Helman, from here

Helman has Dr L impart words of genuine wisdom, beyond medical practice:

Every time I see him at work, he reminds that medical practice is about all those tiny, trivial, almost invisible things. They’re the ones that really make a difference. And Dr L is full of advice about them.

“And don’t ever forget about time, ” he says. “Always pay attention to time – and the ways it can affect your patients’ bodies and their minds.” He warns me that time is never linear, and that in emotional terms it can loop and curve back upon itself, at any particular moment. And that some traumatic memories can act like time-bombs, set to go off at some unexpected time in the future.

Helman recalls this in 1994, when the 50th anniversary of D Day sees sudden post traumatic issues, physical and mental, amongst veterans, and again in 1995 with the 50th anniversary of the liberation of the concentration camps.Dr L also impresses on Helman the importance of touch, of human connection.

Of the three books I reviewed for the TLS in 2014, I thought Henry Marsh’s the best as a purely literary work. Heimlich’s memoir was entertainingly grandiose (and, indirectly, led to my discovery that Heimlich’s own son labels him a fraud, a circumstance entirely misses from Heimlich’s book) Helman’s was the book I was most tepid about, and yet it is now the one which has stayed with me most.



The world under water. Nthposition.com October 2007

I don’t think I’ve ever self consciously set out to write a “medical story”, but some of my fictive efforts have had as their germ an idea derived from medicine, taken to an extreme (I was going to say “logical” conclusion)
This is a good example. I have taken the opportunity to remove an awful howler – you can peruse the original here if you wish to find out what it is.

Now, the twist seems rather forced, rather too pat. “MicroApple” also seems dated, the way “FaceGoogle” probably will be in a few years.

The world under water

“Now Mr Marks, I’m just going to ask you a few questions. Some of them will be very easy. Some of them will seem very easy. Some of the others may seem a little bit harder. The important thing to do is no to worry about it, just do your best. If you get some wrong it isn’t the end of the world. So just give it a go.”

“Yes doctor, yes,” Mr Marks nodded enthusiastically. He smiled. This was familiar, the smile seemed to say with confidence, and Mr Marks seemed new to the experience. He wasn’t.

“First of all,” Dr Duggan said, “can you tell me today’s date?”

“The sixth… The sixth… Or is it the seventh? No, the sixth. June. Twenty … twenty twenty-four.”

Dr Duggan drew a cross, then a tick, then another cross. It was the fourth of June, and on the date Mr Marks was not far enough out – but on the year his mind was not merely a few years in the past but several decades. Dr Duggan knew that a mistake in the year, especially of such magnitude, did not bode well for the rest of the test.

“Can you tell me what building this is?”

“It’s the clinic, isn’t it?”

“But what is the name of it?

“The clinic… the clinic in MicroApple.”

“Can you tell me where this building is? What town?”


“And what county is Exeter in.”

Silence. Embarrassment. The smile still there. But was there fear in the eyes now? After three seconds: “I don’t know, Mister, I really don’t. If you got me another time.”

The test went on.

“Could you please subtract seven from a hundred for me?”

“Ninety three”

“Now could you subtract seven from ninety three, and keep subtracting seven from that total, giving me the total each time.”

“Ok Doctor.” Again the look of confident familiarity. “Eighty… eighty three. Seventy-six. Sixty… sixty-five.”

“That’s fine Mr Marks, why don’t we try another one? Here we are – can you spell the word “world” backwards for me?”

“World backwards?”


“D. D. R. Or is it L? Is it L?”

Dr Duggan couldn’t help saying “it’s L”, even though this was a breach of the protocol.

“Thank you doctor. D. L. O. W. R. L. D.”

Dr Duggan made one tick and four crosses.

At the end of the test, Dr Duggan thanked Mr Marks for his patience. “We have to add up the scores, and look at the scan, and talk to a few other people here, and we will talk to you then.” He pressed a button hidden just under his desk. A bald man dressed in a suit that was angular and sharply cut, yet seemingly bearing no relation to his figure came in. “Will you take Mr Marks outside for a little while, please?” asked Dr Duggan. The bald man nodded and put his arm out to the side. For a few seconds all three men remained frozen in their position – Dr Duggan looking absently at the ceiling, his ballpoint pen gripped in his right hand; the bald man with arm outstretched, like life model illustrating a deceptively challenging pose (except fully clothed in the sharp yet formless suit); Mr Marks just sitting there.

Dr Duggan was first to break this eternal instant.

“Mr Marks, Mr Johns is here to take you outside.”

Mr Marks smiled and nodded.

“Mr Marks, please…” Dr Duggan trailed off.

“Mr Marks,” interjected Mr Johns, kindly yet commandingly. “I am Mr Johns. I am here to take you away for a little while. The test is over now. Come with me.”

Slowly Mr Marks rose. After they had left, Dr Duggan went to press a button on the keyboard on his desk. Suddenly he sniffed slightly. He sighed at the familiar smell, and to confirm what he already knew looked over the computer at the chair recently vacated by Mr Marks. A pool of urine had gathered on the plastic surface.

He looked at the monitor, casting his eye over the brain scans. He tapped at the keyboard to bring up different images – occipital slices, sagittal slices, views of Mr Marks’ brain from every angle.Who am I trying to fool? he thought to himself. I am no radiologist. He moved the ageing mouse and clicked for the radiologists report.

That damn mouse is on its last legs. Still, they don’t make them like that anymore, do they? He smiled and thought of how baffled they had been that day in the journal club. That very day. It was only ten years ago, when he presented the Stratford paper. Or rather Stratford, PH, Myles FO, Drury FG, Tokmeninova DA, Redefining cognitive impairment and dementia: A needs-based strategy for optimising function for utilisation in the workplace. New Journal of Applied Psychology, Vol 15, Issue 3, pp 145-54, 2049. Paul Stratford’s great contribution to the gaiety of humanity. Dr Simon Duggan remembered trying to set up the laptop and projector that day in 2049, and all the difficulties getting the mouse to work. What was the joke he had made about mice? Damn, my memory is as bad as any of theirs. Whatever it was, all those young doctors looked at him blankly. It took a while to realise that they had no idea that a “mouse” was anything other than the device to control the cursor on screen, one that had been made many years ago and had to be taken care of – as only very inferior quality mice were made now. Just as computer monitors, keyboards, the scanning machines that only a select few knew even existed – all had to be protected, as no-one could make them now.

How ironic that it was on the day that the last really significant biomedical paper had been published. The torrent of papers of the late twentieth and early twenty-first centuries had dwindled to a trickle, mainly surveys and audits and reviews of the increasingly incomprehensible journal articles of the past. The past! As a child, Simon remembered books full of history as they called, all about the past. Books! Books in special shops, books in places called libraries, which had been the forerunners of digital information centres, books everywhere.

Peter Stratford, only three years Simon’s elder, and his team – all of whom disappeared into obscurity, but then again wasn’t that where most of us ended up, Simon thought – had a simple idea. From reviewing the literature, they found that in the early twenty-first century, thirty years before, people had known what was going to happen. They knew about the flood – though they vaguely called it “climate change”, it was clear that everyone knew exactly what would happen. And they knew that they were all getting older, with less and less younger people to follow. Or rather, they suspected both these things, but never but them together.

Perhaps they thought one thing would happen, and not the other. It seemed that many people thought the answer to the “ageing problem”, as it had been called, would be that people could invent new things to solve the problem. Or some people thought that things like the flood, or “climate change”, would mean that people wouldn’t live longer after all, so the problem would be solved. They didn’t realise that the flood didn’t actually kill many people, just crowded them into less land. And that people just stopped inventing new things, and just forgot how to make old things. It just happened, sometime around twenty years before Stratford’s paper.

There were still journals and papers, all of which looked back to the past, and politics and the professions continued as if nothing much had happened. In places the structure of the old civilisation remained. But no-one, or no thing, could grasp it, could really go back to the days when people found new ways to do things.

Except Peter Stratford. The problem was, everyone was seeing the millions of people becoming what had been called “demented” as needing care and help, as being helpless and hopeless. And even the great scientists of the early twenty-first century, whose heirs had been so oddly disinterested, had not managed to find any cure. So with no cure, care was the only option. The only option? Stratford wrote (and anyone who knew he knew that he really did write this part) that there is never only one option. Why not put these supposedly helpless, hopeless people to work? He argued, using statements from old ethics textbooks, that in the absence of capacity to consent to work, assent could be assumed. He referred to clinical experience that people with cognitive impairment could perform repetitive tasks, sometimes even quite complex ones, effectively. He proposed a hierarchy of tasks which people unfit for other work could do. And as the machines built by the generation before began to break down and could not be replaced, those formerly classed as suffering from dementia began to appear in factories and offices, assembling under supervision, sometimes requiring physical encouragement but generally diligent and hardworking.

The issue ten years ago had been ethical for Dr Simon Duggan. He remembered that, once he finally got the mouse to work and presented the paper on that old magic program PowerPoint, he had expected his junior colleagues to join him in seeing the obviously unethical nature of what he dubbed, with sarcasm no one picked up, Dr Stratford’s modest proposal. There had been nods of assent as he outlined Stratford’s claims – all the better to demolish them, he had thought, and blank incomprehension as he railed against Stratford. He solemnly warned that the medical profession had to consider carefully if it would it co-operate with Stratford’s idea – for it depended on them to identify which levels of dementia were compatible with which types of work.

There had been no debate, no consideration. All over the world the system came into place and existed. No one said no. And here was Dr Duggan himself, doing assessments for the Allocations Board.

Poor Mr Marks! His happy smile and confident manner masked a disastrously low MMSE. The Mini Mental Score Exam, despite the caveats the old doctors who had developed it had about it themselves, was the key test. Incontinence of urine and probably faeces as well, if the odour Duggan had detected towards the end of the interview was what he suspected it was. He really wasn’t able to continue in any appointment that involved working with others. Yet he had such a good social fa�ade. For some reason Mr Marks reminded Simon of when he used to go to the swimming pool as a child. Simon used to try and sink to the bottom of the deep end. Then he would walk, for a few seconds before buoyancy and the need to breathe made him rise. He found it a strange feeling, try to move underwater just like moving out of water, and found it fascinating how slowed down and clumsy he was. For Mr Marks, thought Simon, the whole world must seem like being underwater.

Simon sighed. It was a dilemma. He never knew whether to certify someone as Not Fit For Further Employment. On one level, enough of his old training and reservations about the whole Stratford scheme remained to encourage him to get as many of these fundamentally vulnerable people out of work as possible.

On the other hand, no one knew what happened when you were deemed Not Fit For Further Employment.

To hell with it. He pressed the same button he had used to summon Mr Johns. After about five minutes, Mr Johns and Mr Marks, still smiling, came back in. Dr Duggan had stood, and gestured at the chair. Mr Marks stood there. Dr Duggan gestured again, and this time Mr Johns made a larger, more emphatic gesture. Mr Marks still stood. Mr Johns began to advance on Mr Marks, but Dr Duggan put up his hand. “It’s OK, Mr Johns. Mr Marks, thank you. Thank you for coming here today. Thank you for doing the test so well. Mr Johns will take you now. Thank you.”

He took a stamp from a drawer in the desk, stamped in large red letters “NOT FIT FOR FURTHER EMPLOYMENT” on the form Mr Marks had brought with him, and smiled. He handed it to Mr Johns, while putting a hand on Mr Marks’ shoulder.

“Thank you,” said Dr Duggan again.

A few minutes later Dr Duggan stood at the window as the Allocations Board van left the clinic grounds. What would happen to that man now? Where will they take him? Who was that man? What did he do before? Where did he come from? Who was that man? What was his name? What am I doing here? What am I looking at?Simon Duggan stood there and stood there while the buzzer on his desk kept buzzing.