To digress immediately, have you read Saturday, by Ian McEwan? Of which more anon.
Day 7, post aura, and I awake migraine-free.
It started last Sunday morning while taking a shower, a rather abrupt onset of frontal headache, shortly followed by a disturbance in the left visual field. That is unusual for me; usually the visual disturbance precedes the headache. Then I developed a left upper quadrantic hemianopia – I lost a quarter of my visual field altogether. I noticed it while watching the Andrew Marr Show. If I focused on Mr Marr I lost the paper reviewers completely. I didn’t panic. I just self-diagnosed migraine and swallowed two paracetamol.
Generally I find the visual disturbance lasts about twenty minutes and then reverts quite suddenly to normal. In Click, Double-Click, Dr Alastair Cameron-Strange suffered a classical episode. On Sunday my hemianopia was slow to resolve and then was superseded by two further discrete episodes of aura, shimmering wavy lines and “fortification spectra”. The headache persisted. I still entertained the notion of sitting at the back of Dunblane Cathedral but by 10 am I had abandoned this ambition and, by 11.30, with the onset of nausea, I had made a phone call to cancel lunch in Glasgow. I then spent a miserable day lying on a couch with a bucket parked beside me.
My migraine attacks are infrequent and usually mild. Sometimes they consist of little more than 20 minutes’ aura then the dullest of headaches. If I’d been born a woman, I would not have been able to take the combined oral contraceptive pill; it would have been “contraindicated”, not because of the migraine, but because of the aura. By the way, the charismatic Professor of Family Planning at UCL, John Guillebaud, describes a clever method of deciding whether or not sufferers of migraine should take the pill. You sit directly opposite the patient and ask her about her vision. If she lifts up one hand and flutters her fingers, don’t prescribe the pill.
The last time I had anything as severe as this was in 1984. I was a GP registrar in Edinburgh. It came on after morning surgery. My boss sent me home at lunchtime, and with great kindness actually carried out a home visit on me that evening. Earlier that year when I was a paediatric senior house officer I was similarly sent home at lunchtime with, I’m ashamed to say, a hangover. These were the only two occasions when that happened, and indeed I have been incredibly fortunate in that throughout my entire medical career, knock on wood, I never took a day off owing to sickness. I had a week’s compassionate leave in 2005, and again in 2008, with the passing of my parents. There is something of a tradition in medicine of dragging yourself into work because if you don’t, you know your hard-pressed colleagues are going to have to absorb even more pressure. This probably isn’t very wise. Maybe a doctor with an upper respiratory tract infection dispenses more harm than good. I used to get episodes of acute low back pain and would take about an hour to get up in the morning. I would conduct morning surgery looking like a half-clasped knife. I wonder if I didn’t gain some perverse satisfaction in observing that I looked much worse than some of my patients. Interestingly, now that I no longer practise, I don’t get any back pain at all. Maybe it was all psychosomatic.
Monday was almost as miserable as Sunday. But I never seriously entertained the notion that migraine might be a misdiagnosis, that this might be something more sinister. Like most doctors I am in a state of denial; illness is something that happens to other people. There is a famous image of a world-famous cardiologist who was found dead in his hotel bedroom at a medical conference, with a bottle of antacid sitting on the locker. Of course he had had a myocardial infarction.
Some doctors don’t like headache. It presents a diagnostic dilemma. Which headaches are benign and which sinister? We call the majority of benign headaches “tension headaches” which I suppose implies they are caused by – well – tension, maybe tension in the musculature of the head and neck, or psychological stress. It may or may not be so. Medicine is full of instances of attributing low-echelon symptomatology to guesswork without much of an evidence base. Irritable bowel, lumbago, chronic fatigue… Maybe it would be more honest if we were to put our hand up and say, “I don’t know what’s causing this, but I can tell you what it’s not.” So I was pretty sure my prolonged headache was not due to meningitis, subarachnoid haemorrhage, or a brain tumour.
Or at least I was pretty sure, until this week I read Admissions, A life in Brain Surgery, by Henry Marsh (Weidenfeld & Nicolson, 2017). I’d already read and greatly enjoyed Mr Marsh’s Do No Harm, so when I stumbled on Admissions in Waterstones Dunfermline, I snapped it up. I notice that Mr Marsh acknowledges his wife Kate for coming up with the title. I like its ambiguity, referring as it does not only to hospital admissions but to admissions, nay confessions, of remorse, regret, and guilt. Believe me this is very unusual in a doctor. I have heard senior consultants at Morbidity & Mortality meetings pay lip-service to the need for honesty, humility, and candour in owning up to professional error, and then proceed to lead by example in presenting the biggest load of sanitised, cosmetic eyewash you could imagine. It’s rather like the old job interview chestnut, “What is your main strength, and your main weakness?” Those who are groomed for high office know to present a main strength, followed by another main strength, disguised as a weakness. “I’m very impatient. I need to learn to listen to others, to try to understand where they are coming from.” Yadda yadda yadda. Candour is professional suicide. “I’ve got a tremor. I find alcohol helps.” I don’t think so.
Mr Marsh is extraordinarily candid. Admissions is a series of reflections on a lifetime of neurosurgery by a surgeon on the cusp of retirement. And what a roller-coaster ride it is. Triumph and tragedy, at home and abroad. He writes with great vividness. I’m not surprised there is an endorsement on the sleeve from Ian McEwan – “a great achievement”. Ian McEwan’s novel Saturday describes a fictionalised day in the life of a neurosurgeon. Mr McEwan has always been interested in professions, and the wider lives that professionals lead. I imagine Admissions must have seemed a rich seam to him. Descriptions of Kathmandu, Ukraine, and a decrepit lock-keeper’s cottage in Oxfordshire are as vivid as those of awake craniotomy, the medicolegal world, and the domination of the NHS by absurd managerial pseudoscience.
For me, the narration of events in theatre, ICU, and on ward rounds are the most vivid. Mr Marsh is not always kind to himself. He describes an episode of visiting a patient post-operatively in ICU to find that somebody had inflicted him with a nasogastric tube. He asked the nurse to remove the tube but the nurse refused because it contravened some written protocol. Mr Marsh lost his temper and assaulted the nurse. He does not come out of this episode well, and he knows it. (I couldn’t help wondering, why didn’t he just remove the tube himself?) I’m not sure that I would have enjoyed working for him.
Yet his humanity shines through. It takes an extraordinary personality to be a neurosurgeon and to inhabit this dark world in which so much can go wrong and so many outcomes are bleak. Of all the specialties, there is surely none so bizarre as neurosurgery and there can be no activity as extraordinary as that of literally entering somebody else’s head. In undertaking awake craniotomy, that is, carrying out brain surgery on a patient who is not anaesthetised, Mr Marsh asked his patient if he would like to see his own visual cortex on the television screen. (My dentist even looked dubious when I asked to see the wisdom tooth she had just extracted.) To look at your own visual cortex is to look at yourself looking at yourself, a metaphysical experience, I imagine, akin to inhabiting a hall of mirrors where your own image recedes endlessly to infinity. The patient looked and said, “Crazy!”
Much of Mr Marsh’s memoir is an intimation of his own mortality and a contemplation of the inevitability of failing faculties and a running out of time. So. All week I was weak as a kitten, waking each morning to a dull nagging headache, and moving in the obtunded twilit world of the migraineur. Did I have the dismal terminal diagnosis of one of Mr Marsh’s patients? I gave myself the piece of advice I have given patients thousands of times: “I think we should hold our nerve, and keep a watching brief.” And here we are, Saturday, and I am well. But it did cross my mind – one of these days, I will suffer an illness from which there will be no recovery. I’m not dwelling on it. Mr Marsh professes to be terrified of dementia, partly because his father developed it. I’ve never seen much point in trying to predict the future, other than in a ribald way. I think of myself in the care home, disinhibited, making inappropriate advances to the nursing staff. “That’s enough of that, Jimmy. Just keep your hands to yourself, you old lech!” My experience of looking after “the worried well”, ever vigilant for the approach of the grim reaper and trying to cut him off at the pass, is that they seldom see the direction from which he comes. Best just to take each day at a time, and live it with faith, hope, and love.
Yet I did find myself wondering, if I were to receive a sudden call, should I have any abiding regret? Would it be regret of a sin of omission or of commission? Should I try now to rectify it?
But of this I cannot speak. I’m not admitting anything!