Author: jamescalumcampbell

There is a character in Dashiell Hammett’s The Maltese Falcon named Charles Flitcraft.  In this piece of detective fiction set around 1930 on the west coast of America, Flitcraft makes a brief cameo appearance which seems completely irrelevant to the rest of the narrative.  Hammett’s private detective Sam Spade meets a potential client, Miss Wonderly, aka Brigid O’Shaughnessy.  Miss O’Shaughnessy is a femme fatale of the type so powerfully depicted by Barbara Stanwyck in 1940s Hollywood noir, like Phyllis Dietrichson in Double Indemnity.  These ladies breeze into the office of the private dick, and describe some terrible fix they’ve landed themselves in, with that beguiling mix of vulnerability and sexual allure.  “I was frantic!”  Apropos of nothing at all, and without any preliminary introduction, Spade tells Miss O’Shaughnessy about Flitcraft, a man he was once hired to find.  Mr Flitcraft was an unremarkable real estate agent in Tacoma, married with a family, successful, well off, and quite content, who one day was walking past a building site during his lunch break when a large beam fell from a great height and landed on the sidewalk right beside him.  It might have killed him, but all he got was a scratch on his cheek from the ricochet of a fragment of pavement.  This apparently entirely random event changed Flitcraft’s life completely.  He had briefly been permitted to open up the lid on life, peer in, and see how the machinery worked.  What he saw disturbed him.  He had thought that he was in harmony with life; now he realised that he had hardly been living at all.  Subsequently, he vanished without trace.

In fact, he drifted to the northwest and – now that beams had stopped falling on his head – took up a life in Spokane which was really a replica of the life he had abandoned.  He found another job, another wife, a way of life not dissimilar to the one he had abandoned, and he started another family.  When Sam Spade tracked him down, Flitcraft expressed no remorse for what he had done, and indeed he did not consider his behaviour to be in any way remarkable.  He had left his previous wife and family comfortably off, and in any case his first wife did not want him back.  So he simply carried on with his new life. 

Flitcraft never reappears in The Maltese Falcon, and his significance to the overall structure of the book remains obscure.  In the Humphrey Bogart movie, Hollywood stuck closely to Hammett’s dialogue.  Yet I don’t recall that the Flitcraft episode appears on film.  I would have loved to have heard Bogie recount that story. 

The idea of the reinvention of a life is a recurrent theme in literature, and indeed it seems to conjure a deep yearning experienced at least once by most of us.  I will go to bed a caterpillar, slough off this noxious, slimy integument of my personality, and wake up a butterfly.  Nicodemus visited Our Lord by night, to ask what he had to do in order to turn his life around.  It turned out that he had to be born again.  In Twelfth Night, Shakespeare casts Viola ashore after a storm, like a piece of jetsam, on the edge of the unknown land of Illyria.  She turns herself into Cesario.  Here is the ice cold shock of recognition of the chance for a complete metamorphosis.   In Julius Caesar Act IV Scene III, Brutus says

“There is a tide in the affairs of men,

Which, taken at the flood, leads on to fortune

Omitted, all the voyage of their life

Is bound in shallows and in miseries.”

We are beguiled by the narrative of a person who has recognised an opportunity, embraced it, and turned his life upside down.  “It was such a small thing.  And yet, it changed everything.  I discovered my meaning and purpose, and I never looked back.”  But can we really tell the difference between fortune on the one hand, and shallows and miseries on the other?  Recall Robert Frost’s The Road not Taken, the idea of a crossroads, and a choice.  In The Unbearable Lightness of Being, Milan Kundera makes the point that you can never know whether, faced with a binary choice, you chose the better option, because you can never know where the other choice would have led you. 

But you know, Milan Kundera was wrong.  I have this odd notion; I find it difficult to articulate.  You see, I took the other path.  The path not taken. 

When?

After I finished my degree in English Language and Literature, I was completely at a loss as to what to do.  The obvious thing was to do a year of teacher training.  After all, if I were at a loose end, I might as well accrue another qualification, and leave at least one option open.  I got the admission forms for the local teacher training college, and sat down, pen in hand.

I never filled that form in.  I went off at a complete tangent and became a medical student.  I sometimes wonder how I would have turned out if I had gone to the teachers’ college.  Where would I be now?  I decided one night to track myself down.    

I wasn’t very hard to find.  I’d barely moved fifty yards from the family home, a terraced house in a handsome tree lined avenue in a leafy west end suburb of our town.  I noticed I’d crossed the road from the grey sandstone in the west to the rather swanky red sandstone in the east.  I rang the doorbell and my alter ego opened the door.

“It’s me.”

“I had an idea you might turn up.”

“Like the bad penny.”

“You’d better come in.” 

Parquet flooring in the hall.  The familiar layout of the living room with its high ceiling and peripheral frieze.  A fireplace with a wood burning stove.  He bade me sit down.

“Tea?”

“You wouldn’t by any chance have anything stronger?”

He handed me the squat crystal glass with its puddle of gold.  I took a sip.  Rich and mellow, with warm notes of baked apple and toffee.  Cardhu.  I glanced about me at the family photographs on the mantel, the Bösendorfer in the bay window, and flowers, the picture rail hanging a few of the Scottish Colourists; and books, but no clutter.  I sensed a woman’s touch. 

“I see you’ve prospered.  What did you do?”

“I was a teacher.”

“Ah.  You filled in the form.  I didn’t. That must have been where we diverged.  What did you teach?”

“English.”

“Of course.  Where?”

“The High School.”

I put down my glass so sharply that I cracked its base.  “The High School?  You mean you went private?  You perpetuated that ghastly network of ‘useful acquaintance’ whereby the great and the good order the world according to their own requirements?  How on earth did that come about?”

He smiled good-naturedly.  “I got an attachment there as a probationer.  I found I liked it, and I guess they liked me.  So I ended up staying.  Then I became principal of the department, then deputy head, and, before I knew it, the headmaster.”

“You perpetuated the status quo.”

“I don’t know about that.  I hope I taught my students to love letters, and to be prepared to look at the world in a different way.”

“Like John Keating in Dead Poets’ Society?”

“Something like that.”  

“I recall Mr Keating left a trail of death and destruction, and got the sack.”

“Through no fault of his own.  He was hung out to dry by an angry and misguided parent, and a monster of a headmaster.  Keating was a fabulous teacher, though I guess he was a little naïve.  That Scottish dominie who taught Latin – was it Mr McAllister? – he tried to warn him.” 

“The High School.  Do you remember, at the summer orchestral courses, the High School boys had their own dorm?  Stuck up bastards.”

“Since you raise the issue, I put a stop to that.  So while you are content to rant and rave” – he added with a hint of mischief – “I made a difference.  Besides, the school is co-ed now.”

“I beg your pardon.  I have no right to berate you.”

“Who can you berate, if not yourself?” 

“Did you marry?”

“Jennifer Marsden.”

“Sensible fellow.  The most beautiful girl in the west end.  Children?”

“Two.  Elizabeth and Barbara.  Lizzie is a journalist and Barbara a human rights lawyer.  Two grandchildren, Oscar and Emily, and a third on the way.  What else can I tell you?  I ran the Literary & Debating Society at school.  They gave me a gong, an MBE for services to children’s literacy, I am an elder in the cathedral and sing in the choir.  Jennifer and I have a subscription for the Symphony, and we like to holiday in the South of France.  You see, it’s all very conventional.”

“You always wanted to write.”

“Yes.”

“Did you publish?”

From the bookcase he selected a slim volume in hardback.  He handed it to me. Faber & Faber. 

“Verse!”

“Doggerel.”

“You are a poet.”

“A poetaster.” 

The publication was entitled “Life’s Obverse”.  I leafed through it and caught just a few broken lines.

“…to wrestle the best of three falls with words…”

“…acres of wordage of doubtful intent…”

“…a device of patient lacklustre…”

I closed the volume.  “Are you going to publish more?”

“No.  It is no longer important to me.  I no longer introspect.  And now you.  What did you do?”

I told him I had been the Director of a hospital emergency department in Australasia. He gave a low whistle.  “Where did that come from?”

“I have no idea.”

“Mum once found us reading Somerset Maugham’s Of Human Bondage.  Do you remember?  She asked what it was about, and we said it was about a man with a club foot who wanted to lead the Bohemian life of an artist, who suffers terribly from an unrequited love, and who eventually becomes a doctor.  Mum said, ‘Wouldn’t you like to be a doctor?  It would suit you.  You have kindness.’”

“Yes.  And I said, ‘That’s the last thing I will be!’”

“Did you marry?”

“Not as such.  I co-habited.  It didn’t work out.”

“Children?”

“Not as far as I know.”

“Hobbies?”

“Aviation.”

“Another surprise!  I thought the University Air Squadron was bloody murder.”

“We weren’t at home in the military.  But flying is more relaxed Down Under.  Oddly enough, it was for me the ideal antidote to the blood and thunder of the emergency department.  I would take the aircraft up to ten thousand feet over Dairy Flat, put it into a spin, and say to myself, “The only person who can get you out of this mess is you.’  After that, the department didn’t throw anything at me I couldn’t face.”

“Sounds like you constructed quite a life for yourself.”

“D’you know, it’s been completely chaotic.  The idea of ‘building a life’ is totally alien to me.  There’s the difference.  You are committed.  I am a comedian.”

“Regrets?”

“I wish I had realised that I didn’t have to take on the whole world on my own.”

“Are you still living Down Under?”

“Oh no.  I threw it over.  I did a Flitcraft.”

“Excuse me?”

“I flitted to Camustianavaig on the Isle of Skye and wrote a book.”  And I told him I had written a trilogy about the life of a troubled doc.  You write about what you know.  And oh yes, a nuclear farce. 

“So there you are,” he said encouragingly.  “You always wanted to invent a character and construct a world in which he moved, in a series of adventures.  Sounds like you did it.  You ‘built a life’, as you put it, in fiction.  Can I freshen your glass?  Jennifer will be home any minute and she will be thrilled to meet you.”

But I was already on my feet.  “A step too far I think.  But it was nice to meet you again.”

He stood up and took my glass, and together we went back out into the hallway.

“You know, we could do a swap.   Why don’t you stay here, and I will walk out into the night?”

Much as I was tempted, I declined.  “Impossible.  Life’s vicissitudes change you.  You go down a path and you think you are an immutable personality merely accruing experience, the way the hull of a boat accrues barnacles.  But it is the experience itself that creates you and defines you.  And maybe, at the end of the day, we all attain the way of life which we fundamentally desire.”

“Maybe.  Call again.”

But I think we both thought that unlikely.  “My love to Jennifer.”  I stepped back out into the cityscape.  So, my Doppelgänger had not been a sinister individual, although he may have thought otherwise of me.  I remembered Schubert’s Doppelgänger in his last song cycle Schwanengesang – utterly terrifying.  But there is a song in Schwanengesang even more horrific than Doppelgänger.  Die Stadt.

Am fernen Horizonte

Er scheint, wie ein Nebelbild,

Die Stadt mit ihren Thürmen,

In Abenddämm’rung gehüllt…     

…und zeigt mir jene Stelle,

Wo ich das Liebste verlor.

In the stillness of twilight, the distant tower-capped city appears out of the mist… and shows me that place where I lost the most beloved of all.   

You might suppose a setting of such words to be nostalgic, wistful, perhaps melancholic.  But spine-chilling?  Schubert, like Flitcraft, must have been permitted to open up the inner workings of life and briefly look in.

One last fragment from Life’s Obverse stuck in my head.  A haiku:

These well-trodden streets,

Grow less substantial to me.

Else I am the ghost. 
 

It started insidiously.  I first noticed it about a decade ago while carrying out a respiratory examination, and percussing a patient’s chest, by laying my left hand prone on the patient’s back and tapping the middle phalanx of the middle finger with the tip of my right middle finger.  I couldn’t rest my left hand flat because my little finger had developed a mild contracture and was sitting at about ten degrees of flexion.  That is in fact the acid test for Dupuytren’s Contracture – this inability to lay one’s hand, prone, flat on a surface.  The condition was described by Baron Guillaume Dupuytren (1777 – 1835), surgeon to Louis XVIII.  A thickening of the subcutaneous palmar fascia forms a cord which pulls the finger into flexion.  It’s quite common.  They say it’s down to a Viking gene that can skip generations.  I’m not sure about that, but I’m having lunch with a Viking next week so I will ask her about it.   

One pays less attention to the chronic than to the acute.  That is why the insidious is – well, so insidious.  I developed the same thing in my right hand.  Bilateral Dupuytren’s of the little finger.  But I was too busy to pay much attention; I had lots of medicine to practise, and books to write and so on.  I was deft from an early age at the typewriter, “Qwerty-adept”, but I never properly learned to touch-type so never used my pinkies.  I quietly let the thing progress. 

The first time I really had a sense of loss was when I realised, having previously been able to stretch a tenth on the piano, I couldn’t even stretch an octave.  Well I could, having a broad stretch, with thumb and any other finger, but not the pinkies.  O well, I was never a pianist, although I did like to tootle (I won’t say tickle the ivories – the ivory police will be at my door) – now and then. 

The crunch came quite recently, when I realised I couldn’t lay my left little finger down on the viola finger board.  Now the viola can lie dormant in its case for months on end.  But human nature being what it is, I thought, “This is intolerable.  I must play my viola!”  The time had come to seek the help of my erstwhile medical colleagues.

I consulted privately.  I knew that there was no way the NHS, with its current inevitable backlog in elective surgery, would prioritise Dupuytren’s Contracture. The NHS would not be aware that failure to play the viola is a medical emergency.  I phoned my GP and asked her for a referral to a hand surgeon in our local private hospital, and I emailed a couple of pictures of my hands.  I myself have often referred patients to this hospital, and although I frequently walk past its front door, I’d never previously entered.  Nice place.      

The surgeon saw me the following week, and, one week later, he carried out a needle fasciotomy on my right hand.  He just popped in some local anaesthetic and then picked the fascial cord apart with a hypodermic needle, and then pulled my pinkie into hyperextension.  The cord came apart with a resounding snap.  It was very satisfying, as much for the surgeon as for me.  Then he put a dressing on the wound and left it to heal “by second intention”.  It is a remarkable procedure, with a huge gain from minimal intervention.  I left the hospital with a straight finger, and, two days later, I could depress Middle C on the piano with my right thumb, and, with my little finger, the E of the octave above.  Honestly, it was like a miracle.

The left side was a little more complicated.  The proximal interphalangeal (PIP) joint was involved, so the surgeon opted for a subtotal fasciectomy.  I preferred to be awake throughout the procedure, so the anaesthetist put in a regional (brachial plexus) block.  It was spectacularly successful.  I lost all proprioception – the perception of a limb’s position in space.  The limb lying on the table to my left could not be mine, because I could feel my left arm, where it had previously been, resting across my tummy.  In a bloodless field the surgeon made a series of interconnected zig-zag incisions, exposed the neurovascular bundles, and excised redundant cord around them.  Then he closed up.  There was some canned music playing quietly in the background.  Michael Bublé.  Fortunately, I am a fan of Michael Bublé.

Now the stitches are out and everything is healing apace.  And I can stretch a tenth with my left as well as my right hand.  In fact, the piano has become the chief instrument of my post-op physiotherapy.  I started with Bach’s C Major Prelude from the first book of the 48.  Then I moved on to the first movement of Beethoven’s Moonlight Sonata, useful because the left hand mostly holds down octaves.  Then Mozart K 545, making sure not to be lazy but to play the arpeggios of the left hand mostly with the ring, and not the middle finger, to facilitate flexibility between little and fourth fingers. 

It’s funny; barely conscious of the matter, I’d resigned myself to a future without a piano.  The recovery of the ability simply to depress the keys has made me determined to stick with it, as much in order to stop these cursed fascial cords from reforming, as to make some semblance of music.  Use it, or lose it.  I think that’s true across the board.  Maybe we should never give anything up (with a few notable exceptions, such as cigarettes, unkindness, and minimalism).        

I’m very grateful to my surgeon, and the whole team at the hospital.  Today, I got out the Archinto Strad and played a C major scale, avoiding the open strings and using my newly revitalised little finger.  It worked.  Now that really is a miracle. 

What a relief, that for a month now, the BBC Proms have been back.  Not only that, there has been an audience in the Royal Albert Hall, although, with the subdued lighting across the auditorium, you would hardly know.  Aside from the stage, the hall is in darkness.  Sir Simon Rattle evidently thought so too.  Twice I saw him put a hand to his forehead as if to shield his eyes as he peered out into the abyss, to see if he could see anybody.  His all Stravinsky concert, with the LSO, was magnificent.  Fortunately, though invisible, the audience, ever attentive during the music, made its presence felt with applause and cheers.  The Proms audience has always been appreciative, but never more so than now, as it has been starved of live music for nearly a year and a half.   

A month ago today, on the first night, the BBC Singers and the BBC Symphony Orchestra performed Vaughan Williams’ setting of words from The Merchant of Venice, The Serenade to Music.

The man that hath no music in himself,

Nor is not moved with concord of sweet sounds,

Is fit for treasons, stratagems, and spoils.

The motions of his spirit are dull as night,

And his affections dark as Erebus.

Let no such man be trusted. 

How true!  And yet, perhaps somebody cursed with the blight of tone deafness might take me to task for such prejudice.  Add to ageism, sexism, racism, homophobia, transphobia, snobbery, and xenophobia, the charge of “atonalism”.  We might organise a Prom especially programmed for the harmonically challenged, in order to “level up”.  A celebration of discord.  Some might argue that contemporary classical music is precisely that. 

I can’t remember the last time I heard a contemporary orchestral work that was greeted by the audience with enthusiasm.  Usually the response is in the form of a polite smattering of applause.  The world première becomes a world derrière.  I can remember the last time I heard a contemporary work being greeted with catcalls and boos, and a shout of “Rubbish!”, and it was during a Prom in the Albert Hall.  It was a work for percussion.  Pleiades by Iannis Xenakis.  I have to admit I whispered to my neighbour, “Life’s too short” and took myself off to the bar, not because of the discord, but because of the sheer volume. 

Of course there are plenty of works, initially incomprehensible to the audience, which have become standard repertoire.  Bach’s music was too complicated for his church congregation, Mozart’s too elaborate for the aristocracy (“Too may notes, Mozart!”), Beethoven wrote one of his string quartets “for a later age”, everybody thought Berlioz’ Symphonie Fantastique was just bonkers, Cesar Cui thought Rachmaninov’s First Symphony came from a conservatory in hell, and wrote a crit so damning it nearly sent Rachmaninov over the edge, there was a riot at the première of The Rite of Spring, and so on.  Even Charles Ives’ Three Pieces in New England (Proms, August 8th), its middle movement a soundscape of shifting cacophony, has become mainstream repertoire.  I love the atmosphere of the third piece, The Housatonic at Stockbridge.  So you never can tell.  Yet it would be good if somebody wrote tuneful music.  I think it would be greatly appreciated.  Yet, despite the fact that people hunger and thirst for a tune, composers and critics seem to have turned their noses up to the sound of melody, as if melody were banal and naïve.  Malcolm Arnold, a great tunesmith despite being a troubled man, began to lose popularity in the 1960s precisely because he wrote melody.  At least the Proms performed his fifth symphony on August 27th.  A revelation.

Contemporary composers take themselves very seriously.  “In my work Concatenations, I wanted to capture in sound the idea of a series of ideas bouncing off one another and causing reverberations that ripple to the horizon and return once again to re-interact with one another in a metamorphosed form and shape.”  Give us a break.  Rodgers and Hammerstein never had to explain Some Enchanted Evening like that.  Ronald Reagan once remarked that if you have to explain yourself to the electorate, you’ve already lost.

(Don’t Google Concatenations.  I just made that up.)

Still I try to keep an open mind.  Maybe the next time I hear a première I will be blown off my feet.  So I will return to the Royal Albert Hall full of buoyancy and hope.

Here will we sit, and let the sounds of music

Creep in our ears.

Talking of the sound of music, last night I greatly enjoyed, not the family von Trapp, but the equally numerous and prodigiously talented family Kanneh-Mason play Saint-Saëns’ Carnival of the Animals.  The Swan was beautifully played.  I heard Sheku Kanneh-Mason play the Elgar Cello Concerto a couple of years ago at the Edinburgh Festival.  My neighbour in the Usher Hall whispered, “He’s not quite ready for it.”  But I reckon he just meant that Sheku didn’t sound like Jacqueline du Pré.  I thought he was magnificent.  Like Kiki Dee, he has the music in him.       

Strangers & Brothers Volume 2, C. P. Snow (Macmillan 1972, Penguin 1984)

The Masters (1937)

The New Men (1939 – 47)

Homecomings (1938 – 51)

The Affair (1953 – 54)

I read these four C. P. Snow novels last week in quick succession.  I found them to be compelling, and the last of them, The Affair, unputdownable.  They are a part of a series of eleven novels concerning the life and times of one Lewis Eliot, born 1905 (the same year as Snow), trained as a lawyer, an academic and fellow of an unnamed Cambridge college, later a civil servant influential in the world of affairs, and the corridors of power.  Eliot is also an author.  These books clearly have a strong autobiographical element, for Snow himself was an academic and an advisor to government.  But he himself trained as a physicist.  He was something of a polymath, then, but he didn’t cast Lewis Eliot as a Renaissance Man.  Eliot is rather ignorant of science.  It is his brother, Martin, who is the scientist. 

The BBC dramatized Strangers & Brothers and I have a vague recollection of seeing snatches of it, the way you pick up on something on the TV as you pass through a room.  Shaughan Seymour played Lewis, and Cherie Lunghi Margaret Eliot. 

These books capture an age, now gone.  I find them in some ways reminiscent of the novels of Nevil Shute, born 1899, who trained at Oxford and became an aeronautical engineer.  Politically, Shute wrote from the right, Snow from the left.  Both are profoundly English, though Shute became disillusioned with the way he saw Great Britain moving after the Second World War, and took himself off to Australia.  For both, science is a constant preoccupation in their fiction.  They would each have instantly recognised the manners and mores of the world they both describe.     

Yet for all these books are of a period, I don’t believe Snow is dated.  He is concerned about politics, and the motivations, the psychological undercurrents, the ambitions, passions, and jealousies of men aspiring to high office.  And it is mostly men who bestride the corridors of power.  Women fulfil a prominent role, but the role is supportive, domestic and subsidiary.  That too is of its time.  But the way Snow delves into the minds of high flying academicians, scientists, politicians and civil servants, I find to be entirely convincing. 

The Masters concerns the canvassing for support for two Cambridge men vying to be the next Master of their college.  The incumbent is terminally ill, but his doctors have withheld this information from their patient.  (That, too, is of its time.  The idea of wheeling and dealing to fill the shoes of a man who does not know he is on the way out strikes us now as being positively macabre.)  The contest is close, the outcome never predictable until it comes about.  This study of internal academic politics is revisited in The Affair, in which another closely contested college matter hangs in the balance until the last page. 

The New Men are the scientists, and their struggle throughout the war is the attempt to build a fission bomb.  The next novel, Homecomings, covers broadly the same period, but is concerned with marriage, family, and childhood illness.  Interestingly, the fictions of The New Men and Homecomings hardly overlap.  These books hardly touch one another.  Is this a literary device, or do we really thus compartmentalise our lives?  I don’t recall reading another dynastic saga, a long chronological account, which separates areas of life off in this way.  Yet that too is of its time, a time when you might strive neither to bring your private life into work, nor to take your work home with you.   

In The Affair, a young research scientist is accused of faking his results, as a result of which he is stripped of his fellowship.  There is a minority opinion that this man has been unjustly treated.  Eliot is approached to champion his cause.  He is at first dismissive, but then, convinced of the man’s innocence, takes the case on.  It’s a bit reminiscent of the Dreyfus affair – one of the characters says as much.  The accused man, and his wife, are not sympathetic characters.  I won’t say whether Eliot manages to get his man off, but I don’t think it is a plot spoiler to say we never really find out if he, or anybody else in the matter, is innocent or guilty.  But, throughout the book, I found myself on tenterhooks to know.

I’ve always enjoyed reading C. P. Snow.  The ability to make you willingly turn the page has to be admired.  Of his non-fiction, I highly recommend Variety of Men (Macmillan, 1967).  Variety indeed – Rutherford, G. H. Hardy, H. G. Wells, Einstein, Lloyd George, Churchill, Robert Frost, Stalin, Dag Hammarskjöld – Snow had met most of them.  Also The Physicists (1981), a celebration of the giants of twentieth century science, which Snow wrote from memory. 

Of course, I must mention The Two Cultures, Snow’s Rede Lecture of 1959, in which he posited that scientists and artists didn’t understand one another and couldn’t communicate with one another.  Famously, the distinguished Cambridge literary critic F. R. Leavis took exception to this and set out to carry out a hatchet job, a demolition, not just of The Two Cultures, but of Snow himself.          

“Snow is, of course, a – no, I can’t say that; he isn’t; Snow thinks of himself as a novelist…  Snow not only hasn’t in him the beginnings of a novelist; he is utterly without a glimmer of what creative literature is, or why it matters.”     

I guess Dr Leavis didn’t care for Strangers & Brothers.  He called The Affair “that feeble exercise”.  But then, Dr Leavis had fairly restrictive ideas about what constituted a novel.  Hard Times apart, he didn’t think much of Dickens as a novelist.  Sometimes I think that the most compelling piece of evidence that Snow was right, that the faculty of science and the faculty of arts don’t impinge on one another, is F. R. Leavis’ Richmond Lecture of 1962, Two Cultures?  The Significance of C. P. Snow.  Could Dr Leavis conceivably have been something of a literary snob?  He would say that he saw through The Affair, but maybe he just didn’t get it.   

Red lips are not so red

  As the stained stones kissed by the English dead.

Greater Love

Wilfred Owen

There is a wonderful passage in Michael Ondaatje’s The English Patient (Bloomsbury 1992) in which a series of Eastern winds are named, in a kind of half-elegiac, half-intoxicating prose poem: the aajej, the africo, the alm, the arifi, the bist roz (which buries villages in Afghanistan), the Ghibli, the haboob, the harmattan, the imbat, the khamsin, the datoo, and a secret desert wind whose name has been erased, and the nafhat, the mazzarifoullousen, the beshabar, the Samiel, the simoom, and the solano.  Herodotus wrote of the simoom, that one nation was so enraged by it, that they declared war on it, and marched an army out to confront the wind in the desert, only to be completely engulfed by a sand storm, and never seen again.   

I remember that when President Bush declared war on terror in 2001, this passage came unbidden to my mind.  The idea of choosing to wage war on “terror” seemed as nebulous as declaring war on a desert wind.  How would you ever know that such a war had come to an end, win or lose?  How indeed would you ever know that you had come to grips with the enemy?

9/11, the destruction of the twin towers in New York, has been, to date, the defining event of this century.  Mr Blair apprehended its overriding importance, if not necessarily its significance.  Remember, “The kaleidoscope has been shaken…”  Everybody remembers what they were doing on 9/11.  Oddly enough, I was flying an aeroplane.  A Cherokee Warrior.  I landed on an airstrip just outside Glasgow and somebody in the Aero Club told me a plane had flown into a high rise block in New York City.  I just assumed it would be a light aircraft like a Cherokee Warrior, gone astray.  Then the other tower was struck and it became evident that something utterly extraordinary was happening.  I went home and saw the horrific pictures on TV.  I have extended family in New York.  One of them left his office block in Manhattan and didn’t stop running until he was over the Brooklyn Bridge.  Later I got a call from his mother to say my American cousins were all safe and well.  The next day at the Aero Club we had a visit from the slightly upmarket gumshoes of the Special Branch, anxious to find out if anybody had joined the club, in order to learn how to steer an aircraft, but not necessarily how to land it.  The following day we were all grounded.

Mr Blair crossed the Pond with extraordinary rapidity, to cement the Special Relationship and to reassure Dubya that we were standing “shoulder to shoulder”.  The President looked bemused.  How do you respond to an atrocity, when its perpetrators all died in its execution?  You go after the masterminds.  You do all in your power to prevent another attack.  You identify the terrorist cells and their training camps.  You posit that such activity must be at least tolerated, if not condoned, if not sponsored, by a hostile state.  Thus you declare war on terror and occupy Afghanistan.   

In 2003, Mr Blair persuaded Parliament to attack Iraq.  He told us that Saddam held weapons of mass destruction and he had the capability of deploying them and attacking us within the space of forty five minutes.  A delegation led by Hans Blix was carrying out a methodical search for Iraq’s putative WMDs but so far had turned up nothing.  Reports of the search were usually accompanied on the BBC news by television pictures of pieces of rusting ordnance lying in the desert.  They resembled the jetsam of decaying munitions I remember encountering quite commonly as a kid on west coast Scottish beaches, remnants, perhaps, of the huge munitions dump in the Irish Sea’s Beaufort Dyke.  My father warned me they might still be live and never to touch them.  The detritus in the deserts of Mesopotamia looked just as decrepit.  I don’t think the British public ever felt seriously under direct threat from Saddam.  Robin Cook, who had been demoted from Foreign Secretary to Leader of the House, was similarly not persuaded.  He could not support the invasion, resigned from the government, and delivered his very eloquent resignation speech from the back benches.  

Saddam’s statue was toppled with great rapidity, and the man himself discovered hiding out in a cellar, and apprehended.  President Bush declared “Mission accomplished!”  But it soon became evident there was no plan as to what to do next.  Iraq dissolved into anarchy and chaos.  The WMD were never found.  A large part of Mr Blair’s memoir, A Journey, is a justification, if not an apologia, of the decision to go to war.

One early morning on BBC Radio 4 a journalist suggested that the case for going to war had been “sexed up”.  All hell broke loose.  Mr Blair’s communications advisor gate-crashed Channel Four News and conducted an angry tirade with the presenter Jon Snow.  A subsequent enquiry found in favour of the government, and various BBC people, including the Director General, had to resign.   

Yet it is irrefutable that, even supposing the government were acting in good faith, the intelligence upon which the invasion went ahead was flawed.  The association of Iraq with 9/11 was very tenuous, but the invasion of Iraq was certainly strategically a part of the war on terror.   

Twenty years on from 9/11, the Taliban have once again, with remarkable rapidity, taken control of Afghanistan.  The sight of helicopters conveying US personnel from the embassy to the airport is reminiscent of the evacuation of Saigon in 1975, but Secretary of State Antony Blinken has said, “This is manifestly not Saigon.  We went into Afghanistan 20 years ago with one mission in mind, and that was to deal with the people who attacked us on 9/11, and that mission has been successful.”  So, once more, “Mission accomplished!”  I wonder if the mothers of the 453 British servicemen who died during the campaign will be convinced. 

At the dawn of this millennium, the Presidency of the United States depended on a hanging chad.  On the recount, Mr Bush took Florida, and the White House.  If it had fallen the other way, I wonder how Mr Gore would have responded to 9/11.  In the history of the world, has a powerful nation-state ever responded to an expression of hate with an expression of love?  No doubt any statesman who suggested we love our enemies would be ridiculed, persecuted, and reviled.  Yet I don’t think Our Lord was half so naïve as he sounds.  He knew perfectly well that it is well-nigh impossible to love your enemies, and he said as much, quite explicitly.  “Greater love hath no man than this, that he should lay down his life for his friends.”  So directing an act of love towards one’s enemy is more an act of pragmatism than of selflessness.  Love drives out hate.  It leaves hate with nowhere to go.                    

The United Nations Intergovernmental Panel on Climate Change (IPCC) has today published a report stating that global warming, undoubtedly due to human activity, is occurring even faster than anticipated, and its devastating consequences are even now with us.  COP26, scheduled to take place in Glasgow this November, is the last chance for the world to avert a total catastrophe.  Fancy that!  Armageddon turns out to be, of all places, Glasgow.  Glasgow is the last chance saloon for Planet Earth.  Who’d have thought it?  It might be hard, on the day, for the COP26 delegates to conjure the idea of an overheated planet.  Glasgow in November, can be dreich (good Scots word) not to say gruamach (even better Gaelic word).

I was in Glasgow, my home town, for lunch, yesterday.  It’s only a forty five minute drive from my Trossachs fastness on the edge of the Highland Boundary Fault Line.  Where the M80 merges with the M8 I was aware of a huge expanse of cumulonimbus – we call such clouds a “MacGregor” – towering like a gigantic black anvil over the city.  The heavens opened as I drove west along the Clydeside expressway past the Scottish Event Campus (SEC), formerly the Scottish Exhibition and Conference Centre (SECC), where COP26 will be held.  Even with the wipers going at full pelt, visibility was so poor that I wanted to pull over, but there was no place to stop, so I just had to slow down and brave the storm.  The Audis and BMWs (don’t get me started) hurtled on, lemming-like, into the opaque monsoon.  I thought of the poor people in Greece; they would have loved it.

There are two sides to Glasgow.  There is the down-at-heel, litter-strewn, alcoholic, drug-addicted Glasgow of poverty, hopelessness and despair, the Glasgow of Shuggie Bain, the east end enclaves where male average life expectancy is 54 years.  I can’t help thinking this is the Glasgow depicted in the city’s coat of arms with its associated enigmatic quatrain which, come to think of it, could hardly be more inappropriate in the fight to save the planet.  I quote it at the end of this piece.   

The city’s motto is “Let Glasgow flourish” but the better known strap line is “Glasgow’s miles better”.  It is evident this has the alternative meaning “Glasgow smiles better”, reflecting Glaswegians’ reputation for being warm-hearted and generous of spirit.  But less evident to all save the locals is the true meaning of the tag: “Glasgow’s miles better than Edinburgh”, reflecting Edinburgh’s “You’ll have had your tea” attitude.  Whether these stereotypical characterisations have any evidence base I couldn’t say.         

My school motto (in Glasgow’s west end) was “Spero meliora”.  I hope for better things.  We were trained from the earliest age to look at the world from a position of disadvantage.  If any ambition was to be nurtured, it was the ambition to get out. 

The down-at-heel side of Glasgow is decrepit, untended, and overgrown with weeds.  There is a close association in Glasgow between dilapidation, and fire-raising (no arsonists, note, north of the border, only fire-raisers – just as there are no Scottish burglars, only house-breakers).  An unoccupied sport’s club pavilion of some antiquity in Glasgow’s Victoria Park recently went up in flames, and has now been demolished.  It occupied a position quite close to another decrepit pavilion that has been shut for years, housing the Fossil Grove.  These remarkable eleven Lepidodendron tree stump remnants have been there for 325 million years.  Maybe I shouldn’t tempt fate, but it would not surprise me if the building in which they now shelter went up in a puff of smoke.  Two of the most tragic fires in Glasgow’s history have resulted in the destruction of the St Andrew’s Hall (a discarded cigarette butt after a boxing match in 1962), and of The Mack, Charles Rennie Mackintosh’s striking School of Art (cause unknown).  It took thirty years for the city fathers to replace St Andrew’s Hall.  At the time, they were too busy ripping up the rail tracks and the tram tracks and replacing them with huge motorways and fly-overs to accommodate the great god of the automobile.  From our present vantage point that seems short-sighted.  As for the Mack, nobody knows if the Mack will be restored or replaced.    It was wrecked by fire, not once, but twice, in 2014 and 2018.  Now once is unfortunate; twice is carelessness.    

Yet, on the other hand, Glasgow is a city of tremendous character.  Glasgow can look terrific.  This is why Hollywood chooses to shoot blockbusters here, shutting of St Vincent Street and turning it into downtown Philadelphia.  Glasgow’s west end is very stylish.  Glasgow University campus is stunning.      In so many ways, the Glasgow of today is a far better place than it was when I was a boy.  Indeed the better side to Glasgow is evident in the environs of the SEC.  When I was a youngster, an evening stroll down here by the Clyde would have been tantamount to an act of suicide.  Now, a favourite walk of mine is down by the river, crossing to the north and south banks by the suspension bridge, the Squinty Bridge, the Millennium Bridge, Bell’s Bridge, passing the Hydro, the Armadillo, BBC Scotland, the Science Museum, the Transport Museum, and the Tall Ship.  I would recommend such a stroll to the COP26 delegates, though I don’t expect to see President Biden walking over the Squinty Bridge any time soon.  But you never know.

The SEC is a good conference centre.  Recently the Royal College of General Practitioners has held its annual conference in a three year cycle in Liverpool, Harrogate, and Glasgow.  Whenever the RCGP conference came to Glasgow I was aware that local issues were given some prominence.  Why is Glasgow such an unhealthy place?  Is there an unknown malign “Glasgow factor”?  Yet despite this worthy attention, I was always aware that the RCGP conference was being masterminded by 30 Euston Square.  The RCGP meeting in Glasgow is like the Lloyd George Cabinet of 1921 held in Inverness.  Quirky.  COP26 in Glasgow might be similarly quirky.  It is to be noted that the masterminding of COP26 is primarily a reserved and not a devolved matter.  When the First Minister suggested she have some involvement in Glasgow in November, did not the Prime Minister pass some remark concerning “that bloody wee Jimmy Krankie woman”, and that she would have a role in COP26 “over my f****** dead body”?  One of the more admirable characteristics of our Prime Minister is that occasionally he tells you exactly what he thinks, and hang the consequences.  This can be insightful.   

Once you are cocooned in the bubble of a conference, I don’t suppose it much matters where in the world you are.  I don’t imagine Team GB, inside the Olympic Stadium, were particularly aware they were in Tokyo, and the Japanese authorities went to great lengths to keep the population well away from the games.  I expect COP26 will be similarly cocooned.  (The Olympics, incidentally, have ended on a sombre anniversary which has passed unnoticed by the media.  The atomic bomb was detonated over Nagasaki on August 9^th, 1945.)

You can never predict what will happen at a conference.  I had a ring side seat for the G7 held at Gleneagles in 2005, because I was doing some work for a pre-hospital care educational body headquartered nearby, tutoring ambulance personnel and paramedics.  The great unexpected event coming out of left field on that occasion was not President Nixon falling off his bike, but, of course, the 7/7 attack in London.  Mr Blair had to make a hasty exit and fly home.  So we may plan for Armageddon and draw up the battle lines in Glasgow, only to find that the conflict is taking place elsewhere.  The first rule of engagement is this: be present at the battle.   

Which side of Glasgow will be reflected in any agreement arising from COP26?  An ambitious worldwide accord, and hope, or a breakdown in talks, and despair?  If the former, then “Let Glasgow flourish” can become the motto for the world; if the latter, then that enigmatic quatrain associated with the Glasgow coat of arms can become the world’s epitaph:

 This is the tree that never grew

This is the bird that never flew

This is the fish that never swam

This is the bell that never rang.

There is a recurring story that appears in The Herald with dismal regularity.  It relates to “A & E waiting times” in Scottish hospitals.  If the numbers quoted vary each time this story comes up, the variations are not statistically significant; so the story is always essentially the same.  X% of patients were “not seen” within four hours.  The opposition parties at Holyrood make a tremendous fuss, saying that the statistics demonstrate conclusively that the government is destroying the NHS, and that therefore the Health Minister must “consider his position”.  They don’t really expect the Health Minister to resign, and they are not as aghast at the statistics as they purport to be; their outrage is faux-outrage.  They are merely doing what opposition political parties do – chipping away at the government in an attempt to topple it.  Whether or not they have a better idea as to how the NHS should be run is open to question, and indeed hardly seems to matter.

This issue came up again in The Herald last week and as usual I spluttered into my cornflakes before writing the following letter, which they published the following day:  

Sir,

 I write to beg The Herald to stop referring to the time patients spend in the emergency department (ED) as a “waiting” time, or a time “to be seen” (“A & E targets record third worst week on record”, Herald, July 28).  These expressions are inaccurate, sloppy, and misleading.  The patient’s initial point of contact on entering the emergency department is, or should be, with the triage nurse, and triage, or rapid assessment of a patient’s emergency status is, or should be, immediate.  Most emergency departments then assign a time within which the patient must be seen by the emergency physician.  This might only be a few seconds, but in any case, all true emergency patients will be assessed within “the golden hour”. 

The medical consultation comprises history, examination, investigation, diagnosis, treatment, and disposition.  To describe this as a “waiting” process is quite wrong.  Of course there can be delays to disposition, notably access block to the ward, but this is beyond the control of the ED. 

A patient on the waiting list for a hip replacement might wait, truly wait, for years.  This rather puts the ED “time to disposition” (my preferred terminology) in perspective, and shows up the absurdity of turning ED “performance” into a political football.  It suits opposition politicians to talk about “waiting times” and “time to be seen”.  Annie Wells for the Scottish Conservatives said, “Over a fifth of patients are not seen within the SNP’s target time of four hours”, and Jackie Baillie for Scottish Labour said, “A & E waiting times are spiralling further and further out of control”.  Either they are ill-informed, or sleekit. 

Emergency physicians are not interested in the four hour rule.  Instead, they try to ensure the patients in the department are in a safe environment, and they do their best for the patient in front of them, however long it takes.  Politicians should stop trying to micromanage an environment they don’t necessarily understand.  They would be better to visit the ED staff, not to tell them what to do, but to ask them, “What do you need?”

Yours sincerely…

I was published verbatim, or nearly so.  They took out the word “sloppy”.  That’s fine; at least they kept “sleekit”, an expressive Scots word meaning sly, or cunning. 

Health Ministers come and go.  South of the border, there was Mr (now Baron) Lansley, then there was Mr Hunt, then Mr Hancock, and now Mr Javid.  I heard Mr Lansley speak a couple of times at the annual conference of the Royal College of General Practitioners.  It was all about “GP commissioning” but I was only listening with half an ear, since health is devolved.  The GPs were suspicious of the government of the time and thought they were trying to privatise the NHS by stealth.  Mr Hunt, I recall, got offside with the junior hospital doctors by trying to impose a contract on them, thus driving them to go on strike.  He got offside with the consultants by suggesting hospitals were dangerous places at the weekend.  Mr Hancock definitely got offside with me when he suggested that GP consultations should be, by default, online.  And already, Mr Javid has got offside with the public by telling them, with respect to Covid vaccination, not to “cower”.  Health Ministers, by and large, don’t know a great deal about medicine.  But why should they?  Baron Lansley studied politics, and Mr Javid politics and economics, both at Exeter, Mr Hunt and Mr Hancock both studied PPE at Oxford.  If I were a Health Secretary with a background like that, I don’t think I would wish to tell doctors and nurses how to do their job.  Instead, I hope I would represent them in Cabinet in order to get them a bigger budget, then I would hand it over to the professionals and tell them to get on with it.      

You can’t understand medicine until you practise it.  I started my first medical house job, in wards 29 and 30, Edinburgh Royal Infirmary, forty years ago yesterday.  I’m still trying to figure it out.                                     

Ever since I heard Her Majesty announce to her Lords and Commoners that her Government was intent on “levelling up” society, I have been puzzling over this bizarre utterance.  The Queen is expert (nearly always) at keeping her opinions to herself.  But I couldn’t help feeling that the total lack of expression with which she read this announcement held within itself an encrypted message: if my dearly beloved husband were only here, he would raise his eyes to the ceiling.

“Levelling up” seems to have taken over from “social mobility”.  All the political parties bought into social mobility.  The idea is that society affords everybody an equal opportunity to make use of whatever talents and abilities they possess, no matter how lowly the station from whence they start.  It was not always thus.  James Mason’s last film, The Shooting Party, is a depiction of life in upper class England on the eve of the First World War.  While the toffs are slaughtering pheasants on a weekend shoot, Mason’s character, a landed gent, notices that a young lad, one of the beaters and the son of a gillie, is a very talented artist.  He looks at one of his sketches and says, “You have it to the life!”  He then suggests to the boy’s father that he will pay his son through college so he can further his talent.  The boy’s father says, “No thank you, sir.  I don’t want him to get ideas above his station.”  Mason does not argue the point, albeit with evident regret. 

The Great War changed all that.  But there remains a problem with the idea of social mobility.  If you think it propitious that people should strive to be upwardly mobile, then by implication you endorse the class system.  A miner might wish that his son does not have to go down the pit, and may strive that he have a better life, but he might not wish that the colliery be closed down.

I suspect that the pandemic has altered our collective view of social values.  What are the occupations that really matter?  Who have we not been able to do without?  Farmers, nurses, carers, grave diggers, and refuse collectors.  (This list is not exhaustive.)  We need people to undertake tasks that have heretofore been deemed “lowly”.  Did not Our Lord demonstrate this when he washed the disciples’ feet?  The reason why our politicians have replaced “social mobility” by “levelling up” is that they have belatedly realised that it would be a disaster if all our refuse collectors became hedge fund managers.

Of course “levelling up” has been politicised.  It is really a Tory idea.  We want to level up, they say, while the Labour Party want to level down.  The Labour Party points out that “levelling up” is a scam, because it has no relationship with reality.  The gap between rich and poor is ever wider, families are reliant on food banks, and even people in employment are officially in poverty because they are on ill-paid zero hours contracts.  It is clearly absurd to think that the Tories want to turn a state comprehensive school in the east end of Glasgow into Eton.  Is “levelling up” mere lip-service?  Is it a sop?  If it actually exists, even in embryonic form, you might expect people from “humble” origins to have aspired to positions of power and influence.  I undertook a review of the make-up of the current British Cabinet. 

The Cabinet currently has 23 members, including the Prime Minister.  For the most part they have come from prosperous affluent backgrounds.  The majority were educated in private schools.  Most went to university, a couple to Agricultural College, and one to Sandhurst.  Twelve went to Oxford or Cambridge.  While “up”, they read most commonly the humanities, economics qua PPE (politics, philosophy, and economics) or a similar course, history, and law.  Only two read a science, one physics and one chemistry.  I don’t see too many glass ceilings being broken.  Boris: Eton, Balliol Oxford (Classics); Rishi: Winchester, Lincoln Oxford (PPE), Kwasi: Eton, Trinity Cambridge (Classics and History), Jacob (non-cabinet minister who attends cabinet): Eton, Trinity Oxford (History) and so on. 

As slogans go, I think “social mobility” is more honest than “levelling up”.  The Tories have a profound distaste for the idea of amorphous mediocrity.  On the other hand, British High Society is reasonably open to people who wish to join the club, so long as they are prepared to abide by the club rules.  But, in terms of the dispensation of slices of cake, “levelling up” is in defiance of the laws of thermodynamics.  You can’t conjure wealth out of thin air.  If you really are going to go even some way to redistribute wealth, there’s only one way to level, and that is down.  That fact may be unpalatable, but at least it’s on the level.       

Parked at the supermarket last week for a quick shop (in, oot, nae hingin’ aboot), and on returning to my vehicle, could not help noticing it had suffered a prolapse (I think diagnostically in medical terms).  Something was “hanging down” at the front, off-side.  I thought it might be a foreign body, but alas, it was integral.  I phoned the garage, and struggled to describe the pathological appearance.

“Sounds like the under-tray, sir.  Can you bring it in tomorrow morning?  8.15 all right?”

“Perfect.  Should be a quick fix.  Just a loose screw.”

Ha!

I got there in plenty of time, handed the keys over, and went for a walk.  I always experience a sense of liberation when I relinquish the automobile and become a pedestrian.  The tempo of life necessarily slows down.  I cut a swathe across an industrial estate in the direction of the city centre, noticing the way those of us on foot (I already felt a sense of moral superiority over the motorist) sometimes eschew the pavement and take a more direct route that has forged a path across the grass expanses and through the hedgerows.  The birdsong never ceased.  I enjoyed the sensation of walking the still quiet streets of Stirling waking up.  Commuters paused at newspaper racks and coffee shops.  I nodded and said hello to them, like Crocodile Dundee on New York’s Fifth Avenue.

I left the city centre and walked south west, parallel to the railway line, and into unfamiliar territory.  It occurred to me that if I kept going, rather than turn back, I would sooner or later come to a bridge that would let me cross the railway and thus afford me a round trip.  So it turned out.  There was a rather handsome footbridge, with extensive ramps for cyclists, as well as pedestrian stairways.  I crossed over and found myself in a quiet country lane surrounded by green fields populated by contented cows chewing the cud and apparently enjoying the sunshine.

Still no word from the garage, so I extended my walk through a wooded area in the direction of Bannockburn, coming eventually to Ladywell Park, a very beautiful area of grassland in an extensive hollow on the edge of the town.  Ahead of me was a remarkable structure, a bridge across the burn, carrying the town’s main thoroughfare, a double arch, the lower arch inverted so as to form an apparent wide circle in the centre of the bridge’s superstructure.  It was very eye-catching.  It turned out to be a creation of the great engineer Thomas Telford, erected in 1819.  When I saw it I was reminded of a recent brief report in The Herald, announcing that the footbridge above Callander crossing the Bracklinn Falls, which had been swept away in a violent storm a decade ago, and was replaced by an apparently robust and sturdy structure, has now been deemed unsafe and irreparable, and is to be demolished and once more replaced.  Yet I fancy Mr Telford’s bridge will still arouse admiration a millennium from now. 

At this point the garage phoned me to gloom me up.  The car was up on the ramp.  The under-tray was beyond repair and needed to be replaced.  Moreover, the mechanic had spotted a bust coil spring.  Well, when I stopped to think about it, it all made sense.  I recently hit a pot hole in Glasgow’s Clydeside Express.  It was a real boneshaker.  A warning exclamation mark illuminated on my dashboard.  I suppose that must have accounted for both the tray and the spring.  Actually I confess, I hit that pothole three times.  Now once is unfortunate, twice careless; three times it’s sheer crass stupidity. 

Repair-wise, a substantial three figure sum was mentioned.  Must needs I suppose. 

By now the day was very hot and I hadn’t brought a hat.  I went back through the lovely Balquidderock Wood and into town, popped into Waterstones and, in order to pass the time, bought Andrew Gimson’s book on the US Presidents.  I grabbed a coffee, found a snuggery, and settled down to read.  Often I read history books from back to front, starting with the familiar and receding into the past and to the unfamiliar.  This book I read in contrary motion, darting from front to back to front.  Washington, Trump, Adams, Obama, Jefferson, Dubya… after the fashion of constructing a bridge from each side of a river, hoping to meet up somewhere in the middle.  Grover Cleveland, or thereabouts.    

The garage phoned.  A glitch.  Something unforeseen.  I was dazzled by technicalities.  The graunching stanchion hook failed to meld with the tamping gurney.  Or words to that effect.  Bottom line, work would roll on to the next day.  All well and good, but I had a pressing appointment next morning.  Could I please have a courtesy car?  They were all lent out.  All right, so can I hire a car?  Yes.  I went in.

It occurred to me that, since the defaulting graunching stanchion hook was really their responsibility, the hired car really ought to be afforded courtesy status.  But, having carried out various medico-mechanical procedures myself, which haven’t always gone exactly to plan, I cut them some slack, and hired the car.  Did I have my driver’s licence?  Yes.  Did I have some sort of DVLA attestation of fitness?  No.  That’s okay, we can do it on online.  Did I have corroboration of my address?  No.  But you must surely have something on your phone.  I can assure you, I have nothing on my phone.  At this stage, the assistant looked at me with profound suspicion, and started to speak more slowly, and more loudly, and with a kind of overlay of faux-kindliness, as if I had suddenly been categorised as elderly, infirm, and demented.  She presented the problem to a higher authority.  The higher authority looked at me, and said, “You a Volvo customer?” and gave her the nod.  I said thank you, and drove home in my Renault Clio.  Blue tooth technology.  All sorts of bells and whistles that I couldn’t interpret.  I might have been in the cockpit of an Airbus A380.  Running the gauntlet of the A811, I found the steering to be a little light. 

Anyway… next morning I jumped into the Renault to attend my urgent appointment.  Small problem, I couldn’t find reverse.  All I needed to do was to “push back” (as the aviators say at the terminal gate) to avoid taking out my neighbour’s fence.  I consulted the car manual, to no avail.  Ever since the bells and whistles took over, the paperwork has become less and less helpful.  I actually released the handbrake and attempted to “push back” manually.  But the car was on a slope and I couldn’t do it.  I phoned and cancelled, or at least, ever hopeful, postponed my appointment.  Then I telephoned the garage, hoping not to be answered by the lady who already thought I was an idiot, to explain my problem.  It turned out I needed to elevate an invisible flange lurking under the gearshift’s knob.  Totally counterintuitive, I can assure you, even if, once explained, it was ludicrously simple.  I attended my rescheduled appointment. 

Then, long story short, the garage phoned and my car was ready.  I duly went in.

“How was the Renault?”

“Okay, once I’d figured out how to reverse.”

He laughed.  “Ah, so that was you!”

“Actually I found the steering a bit light.”  I was reminded of Matt Damon’s line in one of these Bourne Identity-Supremacy-Ultimatum-Legacy films, just before he takes, for a hair-raising drive, the Mini of the lovely Franka Potente.  Something like, “I thought the tyres were a bit squelchy.” So I’m glad to have the Volvo back.  At least I know where to find reverse.  Ovlov.

Mr McEnroe, immortalised by a remark accusing a tennis umpire of levity (chalk, after all, flew up), has received some stick for feeling bad for Emma Raducanu, who had to retire from her fourth round match at Wimbledon, with apparent breathing difficulties.  Well, in the days before the conciliation and arbitration of Hawk-Eye, McEnroe probably got most of his line calls right.  He knows a lot about tennis, and no doubt he knows a lot about what is going on in a tennis player’s mind.  But in any case, he’s not a doctor, so he can hardly be held to account for expressing a lay albeit quasi-medical opinion.  He might as easily have expressed sympathy for somebody having an asthma attack as a panic attack.  It is McEnroe’s critics, rather than the man himself, who seem to assume that hyperventilation, rather than bronchoconstriction, betrays a lack of moral fibre.    

But it just shows you; spot diagnosis, even from a ring side seat, is fraught with hazard.  Doctors have got into terrible trouble for making remote spot diagnoses.  They have phoned the police, convinced that the child they saw on telly must have suffered a “non-accidental injury”.  Type 2 Salter-Harris fracture of the distal radius, officer.  Battered child.  Can’t be anything else.  Pathognomonic.  The police, blinded by science, make the arrest.  But it is the doctor who ends up in court. 

“Pathognomonic” is one of these fancy pieces of medical terminology cobbled together from a dead language, in this case, ancient Greek pathognomonikos (from patho(s), condition, affection, + gnomon, gen. gnomonos discerner, indicator, from (gi)gno(skein) to recognise, perceive), thus, specific and characteristic of a particular disease or condition.  If you elicit the clinical sign, the diagnosis is secure.  Full stop.

Personally, I don’t believe in “pathognomonic”.  Life is never that cut and dried. 

Of all clinical presentations, dyspnoea (there we go again: Latin dyspnoea, from Greek dyspnoia – shortness of breath, laboured or difficult breathing) is perhaps the most hazardous, because a misdiagnosis can have dire, even tragic consequences.  Dyspnoea is a symptom rather than a sign.  It is the patient’s subjective sensation of breathlessness.  The clinical signs associated with it might be a rapid rate of breathing, or short, ineffectual respirations from a baseline of hyperinflation, or evidence of hypoxia – the patient is not transferring oxygen from lungs to blood, and turns blue. 

On the other hand, the patient’s dyspnoea might be “functional”.  It has no underlying pathological cause.  The patient is “just hyperventilating”.  Get them to breathe into a brown paper bag.

Next to making remote diagnoses on the television, deployment of the brown paper bag (why does it have to be brown?) is an even more hazardous undertaking.  Before you make a spot diagnosis of anxiety, better exclude life-threatening pathologies.  After all, people experiencing an asthma attack tend to be pretty anxious.  I remember seeing a 12 year old girl in the emergency department who was “just hyperventilating”.  Her irate mother told her to pull herself together.  Then she told me to tell her daughter to pull herself together.  When she realised that I was taking her daughter seriously, she made up her mind to leave the emergency department and take her daughter home.  I had to think of something creative, and quickly.  I negotiated to carry out a single blood test.  I measured the girl’s arterial blood gases.  It turned out she had DKA (diabetic ketoacidosis).  First time presentation.  For the benefit of any docs – bicarbonate of 3, pH of 6.85.  She was desperately trying to blow off carbon dioxide in an effort to make her milieu intérieur less acidic.  She wouldn’t have survived the night.  A little intravenous fluid (well, quite a lot of intravenous fluid) and a little insulin, and she was fine. 

Of course it can work the other way.  One night the ambulance paramedics radioed ahead that they were bringing in a young lady with severe asthma.  A resus team was assembled and as the young lady was wheeled, gasping, into Resus, the team pounced with oxygen, nebulisers, iv drips and steroids.  I happened to be in the room at the time, and I said to the team leader, “She doesn’t have asthma.”  And indeed as it turned out, she was “just hyperventilating”.  So you can’t win.  Moral of the tale: it doesn’t matter how dire your emergency appears to be, there is always time to pause, and take one long, comprehensive look.  The so-called “endofthebedogram”.

The team leader said to me, “How did you know?”  I said, “I don’t know.  But I’ve spent the last decade in this room treating people with asthma.”  It made me reflect.  What are we doctors doing when we say we have “a gut instinct” about something?  I came to the conclusion we are actually practising triage.  We look at the patient and we say, “Airway… breathing… circulation… neurological disability… exposure and environment…” over and over again.  It’s the long, comprehensive look.

On rereading the above, it sounds to me to be nauseatingly self-serving, and I certainly don’t mean it to be.  I always thought of myself as an average doc, a plodder, who tried to make up for a modest endowment of skill by sheer hard work, close attention to detail, and conscientiousness.  But the episode of the hyperventilating girl who did not have asthma was important to me, because it brought home to me the enormous diagnostic power in acute medicine, of sheer experience.

Mr Hancock, before he retired hurt as Health Secretary, wanted all the GPs to do all their work online, like John McEnroe diagnosing Emma Raducanu from the commentary box.  Perhaps if I had seen my two patients on Zoom I’d have given the first a brown paper bag and the second a ton of oxygen, salbutamol and hydrocortisone.   But why would you want to distance yourself from your patient?  As Ian Fleming once remarked, Nothing propinks like propinquity.  But let’s see now whether Mr Javid is minded to follow in Mr Hancock’s footsteps.