Author: jamescalumcampbell

On Saturday I thought to ignore my birthday, this recurrence having lost its novelty value, but I was saved by the kind cards and solicitations of friends, and ended up in the Whiski Rooms on Edinburgh’s mound with an old buddy from New Zealand, a nurse and midwife on a pilgrimage and on her way to Iona.  This assignation had the ghostly, hallucinatory quality of Kurt Weill’s Alabama Song:

For if we don’t find the next whiskey bar

I tell you we must die, I tell you we must die…

It was an opportunity to grow maudlin and re-evaluate the past.  Thus we compared and contrasted our varied and respective lives.  Spontaneous or ramshackle?  Would we have done it any differently?  My friend spends a lot of her time working with the indigenous peoples of Australia’s Northern Territory.  In stark contrast, she has spent the last six weeks mixing with people in grand villas on the outskirts of Edinburgh, wondering if, in not pursuing the archetypal middle-class nice husband nice job nice home nice family nice schools she has missed out on something.

It is a forlorn pursuit, Robert Frost’s contemplation of the road not taken.  In The Unbearable Lightness of Being, Milan Kundera muses that you can never know if the decisions you take in life are the right ones because there is no opportunity to make the other choice; you only get one shot at it.  It occurred to me that many people experience a kind of Grand Fulcrum of Middle Life, un point d’appui.  You spend, indeed you are encouraged to spend, a large part of your early life planning for the future.  You conjure in your head an ideal of life – ideal vocation, ideal location (location location), spouse, lifestyle, social milieu…  You strive to make it happen.  Maybe you fall short.  It doesn’t all work out the way you’d planned.  Events, dear boy…  Yet you do your best; you do what you can.  You compromise.  You come up with a result, whatever it might be.  You evaluate it.  This is the Grand Fulcrum.  A swing of the pendulum.  Now the future, whatever it may be, appears to have narrowed down.  You cease to conjure the future because the future has become immutable.  Rather, you conjure the past.  What if?  Your memory of all that teenage angst is gone, and all you can remember is the sense of possibility.  You would trade the certainty of what you have achieved, for the mere possibility of youth.  Thus you abandon the quest for a fanciful future and gain consolation from the recollection of a past that has been expunged of its agony.  Or, as Shakespeare put it in Measure for Measure,

Thou hast not youth, nor age,

But as it were an after dinner’s sleep

Dreaming on both.

Sometimes I play a mind-game; scientists call it a “thought experiment”.  I’m given a one-way ticket on the Tardis and William Hartnell (long before he developed gender dysphoria) says testily, “All right, where do you want to be dropped off?”  Do you ever play this game?  You say to yourself, if I had it all to do again, would I do it differently?  Knowing what I know now…  So you ask to be dropped off, on a particular path, a road, a corridor, moments before you reach a bifurcation of ways, so that you may make another choice.

No thanks!  I have a sense that my first shot was my best shot, that it wouldn’t be wisdom that I took back with me, but rather a tempered appreciation of my own limitations.  Who knows, I might even whinge in a pathetic way, “How can I play for a Grand Slam when I’ve been dealt a chicane?”

Anyway, even from a practical point of view, it would be a nightmare, to be an aged man trapped in a pubescent body.  You’d be arrested before midnight.  No.  It’s not an option.  Think of yourself as a snooker player in one of these frames in which the cue ball has become constipated within a cluster of reds, and, amid the stalemate of endless safety play, the players ask the referee to rerack the balls.  But the ref says no!  You got yourself into this mess.  Play yourself out of it.  That actually is a much better mind-game to play – the here-and-now game.  You want to go back?  Okay.  Abracadabra, you’re back.  If you still have passion, if you still have hopes and dreams, consider yourself to be back.  Take yourself along that self-same corridor, if you will.  Make that change, if you dare.  Effect that volte-face.

 

To the Far East on Friday, Edinburgh to be precise, to the Festival to hear the Cincinnati Symphony Orchestra in the Usher Hall.  In the first half of their concert they played American music – Bernstein and Copland.  One felt the music was in the orchestra’s blood. They were magnificent.

The Symphonic Suite from On the Waterfront derives from music Leonard Bernstein composed for Elia Kazan’s 1954 depiction of corruption and exploitation on the wharfs of New Jersey.  The cast was stellar – Marlon Brando, Lee J. Cobb, Karl Malden, Rod Steiger, and Eva Marie Saint.  The film was nominated for twelve academy awards, and won eight.  Bernstein’s symphonic suite remains as powerful as the film, perhaps even more so.

Aaron Copland’s Lincoln Portrait followed, a thirteen minute depiction of the character and words of the sixteenth President, for narrator and orchestra.  The narrator on Friday was Charles Dance.  He had Lincoln’s tall, slim, Presidential bearing.  His mid-west accent was, at least to my ears, faultless.  The timing and balance between speaker and musicians was perfect. Charles Dance avoided histrionics and allowed the language to speak for itself.

The dogmas of the quiet past are inadequate to the stormy present.  The occasion is piled high with difficulty, and we must rise with the occasion.  As our case is new, so we must think anew and act anew. We must disenthrall ourselves, and then we shall save our country. 

When was the last time you heard a president, or any politician for that matter, speak like this?

It struck me that On the Waterfront and Lincoln Portrait share a common theme, of the battle of an individual against a remorselessly corrupt and malevolent system.  Actually, both works are about slavery.  Given the recent events in Charlottesville Virginia, it could hardly have escaped the notice of the capacity audience in the Usher Hall that the topic could not be more relevant to the current “State of the Union”.  This might account for the electric atmosphere in the hall.  In the second half, Brahms’ First Symphony was played with equal passion and commitment.  What an orchestra.

At concerts, it’s usually rewarding to engage your neighbour in conversation.  A glamorous German lady sat on my left.  She took a picture of the orchestra on her mobile, and sent it off somewhere.  At least it was before the music started.  I said, “Are you emailing a friend?”

“My boyfriend.  He will wish to know I am not flirting.”

“Is he very jealous?”

“Yes.  He is French.  He is very much in love with me.”

“And is this sentiment reciprocated?”

She rapidly rotated a wrist, an equivocal Gallic gesture she might have learned from the jealous monsieur.  “Too early to say.”

She sounded just like Marlene Dietrich.  She even looked like her.

Phaw-lling… in loaf again, nevah vaunted too…

Vot am I taw doo…

Kant ‘elp eet.

She was deeply impressed by the Cincinnati Symphony.  “One criticism.  The women.  Ugh!  They are not elegant.”  I had noticed that the gentlemen were in white tie and tails, and that many of the ladies wore black trousers and plain black tops – almost jeans and T-shirts.  It wasn’t the last time I saw ladies in black this weekend.  The Black Ferns beat the Red Roses in the rugby world cup final in Belfast.  I’m a New Zealand citizen, therefore may allow myself a brief period of rejoicing.  I didn’t see the match, but I did see a bit of the Haka which was pretty intimidating.

Then Floyd Mayweather beat Conor McGregor in the boxing ring on the Strip in Las Vegas.  I don’t follow the fight game but I was intrigued to hear that, according to the BBC, the contest earned Mr Mayweather an eye-watering £200,000,000.  Let’s see now.  The fight was stopped in the tenth round.  Does a professional boxing round last three minutes?  That’s two hundred million quid for less than half an hour’s work.  Four hundred million pounds is surely a generous hourly rate.  It equates to £111,111 and eleven pence a second.

It was pouring when I came out of the Usher Hall on Friday night.  I passed a beggar on the pavement on my way back to the car.  He was drookit.  I gave him a pound and said, “This is not a night for being out, mate.”  He agreed.  Not that I helped much.  Mr Mayweather earns a pound in nine millionth’s of a second.  Nice work if you can get it.

 

 

“Quotes of the Day” caught my eye in Thursday’s Herald, this one from Tory MP Sir Nicholas Soames, on the decision to silence the chimes of Big Ben for four years in order to protect the hearing of workers during the refurbishment of the Elizabeth Tower:

“Tell these poor little darlings to put headphones on.”

Well!

He might have said, “It’s health and safety gone mad I tell you!”

I developed an interest in health and safety from a very young age – I think I was about three – when I saw my first corpse.  It was on Byres Road in Glasgow’s west end.  A bloodied man lay supine, inert, across the tram lines.  He was a cyclist whose front wheel had got jammed in the line, and he was struck by a vehicle.  A lady, deeply upset, was screaming for somebody to bring a blanket to cover the body.  Precisely this scenario recurred in Edinburgh earlier this year, at the corner of Princes Street and Lothian Road.  The victim was a medical student.

Shortly after the Byres Road incident, Charlie, a pal of mine, abruptly ceased to come out to play with me.  He had died, I was informed, as a result of having stuck a pencil up his nose.  I was strongly advised never to stick a pencil up my nose.  Indeed I never have.  I suppose he must have breached the cribriform plate and introduced a bacterium with subsequent meningitis and perhaps a cerebral abscess.

At school, the russet front cover of the standard F2 jotter was completely dominated by road safety advice.

DANGER!  DANGER!  DANGER!

And then, a list of dos and don’ts.

At the kerb, halt, look right, look left, look right again…

It occurs to me that Nicholas Soames’s grandfather Sir Winston Churchill must not have had the benefit of an F2 at Harrow.  In 1931 he stepped off the kerb and under a car.  In his own words, he nearly died.  Granted he was in New York and forgot the traffic was coming in the wrong direction but even so, if he had looked right, left, and right again, he would have saved himself a lot of trouble and a considerable period in hospital.  Or, as the F2 sums it up:

Better a moment at the kerb, than a month in hospital!

How true.  Winston’s summing up of the entire episode was characteristic.

“Live dangerously.  All will be well!”

Despite, or perhaps because of the F2’s dire warnings, our cohort was given remarkably unsupervised and unrestricted freedom.  We went out to play all day and in all weathers.  In addition to the road safety advice, we were advised never to accept lifts from strangers.  I was playing on a tricycle on the pavement of Glasgow’s Crown Road North – I was about four – when a mad woman came over, hurled abuse at me, and pitched me off my trike.  I played chases with my cousins around the back lanes of the west end of Glasgow.  I fell down a basement in Crown Road North again, cut my head open, and spent a night in Yorkhill Hospital for Sick Children.  The following week I fell in Kinoull Lane and did the same again.  Our games were largely of our own devising.  We fashioned bows and arrows out of string and bits of cane.  It’s a wonder one of us didn’t lose an eye.  We had a crazy phase of firing air pistols at one another.  We used a Gaelic bible for target practice.  It survives, covered in bullet holes.

When I was in Primary VII I was in a team that took part in a road safety quiz competition under the auspices of the City of Glasgow Police.  One of our teachers, Mr Ross, tutored us on the sorts of questions we might expect to be asked.  We would stay behind after school for a practice session.  Mr Ross would light a cigarette – Players or Capstan or Senior Service – and fire questions at us.  He must have done his job well because we won the competition.  We went on TV.  I remember being grilled in a studio in BBC Scotland on Queen Margaret Drive.  The programme went out live in the early evening.  After that, by way of thank you, I and my fellow team members clubbed together and bought Mr Ross a packet of ten Senior Service.  I got them from the Windsor Café just across the road from the school, where I would occasionally pop in to buy a “tipped single” for threepence.  I was 11.  I didn’t particularly realise it at the time, but I think Mr Ross was touched, perhaps even moved.  It was like something out of The Browning Version.

I saw a great deal of road carnage while working in emergency medicine in New Zealand.  The annual road toll at the time was about 500 fatalities.  In a population of – then – just over three million, that is appalling.  Per capita, it would equate to an annual road toll in the UK of 10,000.  People were rather fatalistic about it.  There seemed to be little awareness that road trauma, trauma of any kind, was a pathological entity that had an epidemiology.  Trauma could be studied in terms of its aetiology, pathogenesis, morphology, and clinical features.  William Haddon, the father of injury prevention in the United States, left us a model whose application might sometimes prevent, and would always attenuate trauma.  This model is the Haddon Matrix.  The Haddon Matrix is a square divided equally into nine smaller squares, like a template for a game of noughts and crosses.  The x axis is a time axis labelled pre-event, event, and post-event.  The y axis is a space axis labelled host, vehicle, and environment.  In each of the nine squares are listed the interventions that might cut down morbidity and mortality.  Take a road crash as an example.  Here are some interventions you might consider:

Pre-event: host – go on an advanced driving course; vehicle – design to withstand impact; environment – enforce appropriate speed limits.

Event: host – wear a seatbelt; vehicle – deploy an airbag; environment – site crash barriers at dangerous bends.

Post-event: host – educate in the principles of first aid; vehicle – equip with an emergency locator beacon; environment – provide a sophisticated advanced trauma life support system.

You might say that is all common sense and indeed it is.  But is sense common?  Only a generation ago there was a political struggle to make it illegal not to wear a seatbelt.  Such legislation was deemed by some to be an infringement of personal liberty.  In motor sport, around the same time, three time F1 world champion Jackie Stewart started campaigning to improve survival rates in race car drivers who at the time would kiss their wives goodbye on the morning of a race and not know if they would return at night.  Sir Jackie looked at drivers, cars, and race tracks.  I don’t know if he was aware that he was utilising the Haddon Matrix.  He was ridiculed and vilified by a substantial constituency of the old guard who thought that if drivers were not prepared to dice with death they should be sent a white feather.  Some people entertain an absurd nostalgia for the good old days, of boys in grey flannel shorts and girls in gingham playing bows and arrows and hop-scotch in the street, of grinning miners with dirty faces and pneumoconiosis lighting up, and of the brylcreem generation driving death traps without seat belts up trunk roads without speed limits.  Next to that, and to return to the Palace of Westminster, I suppose hearing loss due to noise exposure constitutes a less severe insult.  Yet it is an occupational injury.  I find myself deeply suspicious of somebody who cares to make a crass remark about “little darlings”.  Why not shut the bongs down for four years?  Radio Four could have a different outside broadcast every day at 6pm.  I would recommend Glasgow University Tower.

I suspect the reluctance to silence Big Ben runs parallel with the reluctance of the establishment to vacate the Palace of Westminster for its much needed refurbishment.  They can’t bear the idea of moving into a modest municipal building in Cardiff or Liverpool or Belfast or Dundee.  I wonder if they fear, deep down, that without the pageantry, the trappings, and all the pomp and circumstance, they will be left with nothing but a void of vacuous emptiness.

 

I was toying with the idea of upgrading my kitchen and bathroom to bring my bijou cottage into the twenty first century.  But I’m bemused to find I’m reluctant to make any long-term or even medium-term plans.  Best wait to see what happens in south-east Asia later this month.

At time of writing, North Korea’s generals are drawing up plans to test medium range ballistic missiles by sending them across Japanese airspace – directly over Hiroshima apparently – to ditch in the Pacific just a few miles off Guam, the US strategic military base in the Pacific.  If the supreme leader approves the plans, these tests will take place during August.

Conflicting messages are emanating from the White House.  While the US Secretary of Defence is looking for a diplomatic solution to these escalating tensions, the President has promised that any North Korean act of aggression will be met with fire and fury “the likes of which the world has never seen.”  Whether this “good cop, bad cop” double act is accidental or deliberate, the undeniable impression is that the US is running on a very short fuse.  Mr Trump says the US military machine is “locked and loaded”.

“Locked and loaded” is a succinct expression, pregnant with meaning.  It sums up the ethos of nuclear deterrence and the way it works, or is supposed to work.  That the system is “locked” implies that it cannot be subject to further interference.  Thus any potential aggressor must realise that an act of aggression will inevitably unleash fatal consequences as sure as night, in this case, a long wintry nuclear night, follows day.  The scene is set; there is nothing anybody can do about it.  Only two possibilities remain; either the aggressor continues on a suicidal path, or he backs down.  It is salutary to reflect that, over the course of the next two weeks, the doctrine of deterrence is being put to the test.

What can you do?  Keep calm and carry on.  I went to see Dunkirk with a New Zealand pal.  She loved it.  I didn’t.  I emerged, shell-shocked, as if from under a bombardment at Passchendaele.  I think that was the general idea.  Call me a stuffed shirt, but I’m becoming disaffected with cinema.  Don’t get me wrong; I thought Dunkirk was beautifully shot.  That Spitfire gliding over the beaches with its engine shut down was a sight to behold.  And Mark Rylance can do no wrong.  But what a racket.  I was already in a surly mood after the coming attractions’ thirty minutes of high decibel bludgeoning, only to find I was to remain under fire for another couple of hours.  You can frighten the life out of anybody by creeping up behind them and discharging a pistol next to their ear.  Yet even a deafening heartbeat – tinnitus begets tinnitus – was preferable to the bastardization of Nimrod from Elgar’s Enigma Variations that was meant to evoke some ancient mystic Britannic myth.  I don’t like to be manipulated.

I went back to Volume Two of Churchill’s The Second World War, Their Finest Hour, and reread The Deliverance of Dunkirk.  This in turn sent me back to Volume One, The Gathering Storm, which I’m currently rereading.  This volume covers the period November 1918 to May 1940, and is in two parts.  Part 1 deals with the years between the two world wars.  Part 2 covers the period of the phoney war, between its outbreak on September 3^rd 1939, and Hitler’s invasion of the Low Countries in May 1940 leading to the fall of the government and Churchill’s acquisition of the premiership. Theme of the volume – How the English-speaking peoples through their unwisdom carelessness and good nature allowed the wicked to rearm.  Churchill called the Second World War “the unnecessary war” because he thought that at various times throughout the thirties Germany’s expansionist ambitions could have been thwarted by peace loving nations working in concert within the ambit of the League of Nations.  He abhorred Stanley Baldwin’s indifference to foreign affairs, his insouciance, and subsequently Neville Chamberlain’s policy of appeasement.  He thought Hitler could have been stopped, if people had been prepared to stand up to him.

Mr Trump brought Churchill’s bust back into the Oval Office when he attained the office of President.  I have a notion that, in putting down a red line for Kim Jong-un, he considers he is being Churchillian.  There’s that famous Santayana quote, that those who do not study history are condemned to repeat it.  The trouble is that history never really repeats itself.  And North Korea isn’t Nazi Germany.  Whatever Mr Trump does, he had surely better act in concert with Japan, Russia, China, and the European Union.

But what do I know?  I have a horrible feeling if I’d been around in the thirties I would have been an appeaser.  “Is this really necessary, Adolf – may I call you Adolf?  Couldn’t we find some way of avoiding this unpleasantness?  Couldn’t we reach some sort of accommodation?  What exactly is it you want?”

At Berchtesgaden, the Fuhrer would have walked all over me.

 

I was chatting this week to a nurse who works in the Catheter Laboratory at the Royal Infirmary of Edinburgh.  She painted a vivid picture of a 24-7 full-on, highly pressured, highly stressed and overpopulated environment.  When I was a medical student, and indeed a junior doctor, in that august institution, there was no such thing as a Cath Lab.  Now it is the sine qua non of acute cardiology.  In fact, cardiology exemplifies perhaps more than any other specialty the way that medicine has changed out of all recognition over the past 40 years.  In these far off days, there was no interventional medical treatment for patients suffering a heart attack.  Patients were given oxygen and morphine and the pathological process would run its course.  (Interestingly, patients in this situation are no longer given oxygen, unless they are blue, because the evidence suggests it results in further occlusion of narrowed coronary arteries.  In my day, failure to give oxygen would have been regarded as a “fatal error” – potentially fatal to the patient and therefore fatal to the medical student under examination.  Similarly, giving beta blockers to patients in heart failure was another fatal error; now it’s often fatal if you don’t!)

The purpose of the Coronary Care Unit (CCU) was to watch for complications such as a cardiac arrhythmia which might be corrected by a drug chosen from a modest pharmacopoeia.  I used to “cover” CCU on call at night, from an on-call room situated four storeys above the unit.  There was a bed, a phone, an ECG visual display unit by which you could observe the patients’ heart traces, a telly and, bizarrely, a drawer full of porno magazines.  There were large numbers of patients many of who smoked, were overweight, had bad diets and got little exercise.  Consequently many suffered major heart attacks and were left in heart failure, for which the stock drug was the loop diuretic frusemide.

Nowadays, the optimal treatment for acute coronary syndrome (see how the terminology changes) is restoration of the patency of the coronary arteries in a Cath Lab, where the vasculature is imaged and the occlusive lesion identified; a catheter is introduced either via the femoral or radial artery, guided into the coronary vasculature and the site of the lesion, and the vessel is reopened with implantation of a stent.  If this is done quickly, heart muscle does not die.  Time is muscle.  This reversal of a potentially fatal pathological process is little short of miraculous.

It wasn’t all doom and gloom in the 70s and early 80s.  The cardiothoracic surgeons were performing coronary artery bypass grafts (CABGs) – sometimes acutely – and valve replacements.  These procedures were highly invasive and in some patients extremely hazardous.  As medical students we had an option to select a subspecialty of our choice and join a unit for two weeks.  I chose cardiothoracic surgery.  My colleagues thought I was mad because the cardiothoracic surgeons had a reputation for being irascible psychopathic bullies.  In fact they themselves were so gobsmacked that a student should choose to spend time with them that they treated me with great kindness.  The morning ward round, in a remote and seldom visited location in the infirmary, began at 7 am.  I would assist in CABGs or valve ops that would take all morning or all afternoon.  After the split sternum had been wired back together the surgeon would depart and leave me laboriously to close up a ten inch skin incision with multiple interrupted sutures, to the great amusement of the anaesthetists.  “This operation is now in the hands of a medical student.”  The craziest of the cardiac surgeons gave me a lift home one night.  We paused at an Off Licence so he could buy a bottle of gin.  “Hold that.”  When I got dropped off I left the car still holding the gin, with the intention of getting out and then placing it on the seat.  He made a panicked dive to retrieve it.

Nowadays, it is getting more difficult to die of heart disease.  In addition to the stents, you will be offered an array of “secondary prevention” medicines.  If your conduction pathways are damaged you will have a permanent pacemaker implanted.  If you are liable to suffer fatal ventricular fibrillation, you can have an implanted automatic internal defibrillator.  This is why patients who have been through this route often end up dying of an entirely different disease, or of “pump failure”; eventually the heart just gets tired and gives up.

Practising medicine is a little like waging war.  You are liable to find yourself employing the tactics and strategies of the last war.  But you mustn’t do that.  The French Maginot Line was useless against Hitler’s blitzkrieg.  One of the reasons why the NHS is creaking and thus is never out of the news is that all these therapeutic options have become available during a time when so much has remained unchanged.  The model of delivery of care, the human resources, the budget, and the ethos are essentially as they were circa 1977.  That doctors and nurses should in any instance now offer a state-of-the-art service is, to say the least, valiant.  And it’s not just cardiology.  The same level of accelerated scientific progress could be demonstrated in respiratory, gastrointestinal, renal, endocrine, musculoskeletal, reproductive…  And the acceleration is accelerating.

We need to find a way of delivering health care such that doctors and nurses don’t go to work every day feeling as if they are organising an evacuation from Dunkirk.

I was driving home from Edinburgh between 5 and 6 pm one day last week, with one ear on Radio 4’s PM programme. Eddie Mair was interviewing one of the BBC political correspondents, as far as I remember, about Brexit.  The correspondent described the current political situation as “a plunging chasm of uncertainty.”

“Plunging chasm of uncertainty?” queried Eddie, in an amused tone.  At the end of the interview he said, “In your honour, I’ll try to use ‘plunging chasm of uncertainty’ before the end of the programme.”

True to his word, he moved on to an interview with a BBC Washington correspondent, about the bizarre reports currently emanating from the West Wing.  “Would you describe the situation as a plunging chasm of uncertainty?”  The correspondent was probably used to fielding the unexpected from Eddie, and he deftly compared the internal conflicts in the White House to the Montagu-Capulet stand-off in West Side Story between the Jets and the Sharks.

The PM programme doesn’t formally end; it just elides seamlessly into the chimes of Big Ben and the six o’clock news via the weather forecast.  I had to laugh when the weather man described the situation as a plunging chasm of uncertainty.

Come to think of it, it’s rather an extreme simile.  You could certainly plunge into a chasm, but if the chasm itself is plunging, well, that would certainly imply a seismic shift of the tectonic plates.  (It’s as well Eddie Mair isn’t interviewing me.  I can just hear him: “Seismic shift of the tectonic plates?”)  There is no finer interviewer on the BBC.  Look what he did to Boris after the general election and the Queen’s Speech.  Not that he interrupted, badgered, or was argumentative or aggressive in any way.  He merely asked succinct, direct, and well-briefed questions.  I don’t know how far behind Chris Evans he is on the BBC pay scale but I reckon he’s worth every penny.

But to return to these chasms, what are we to make of Mr Trump’s appointment of Anthony Scaramucci, replacing Sean Spicer as White House Communications Director?  Mr Scaramucci seems to share a lexicon with Peter Capaldi’s character Malcom Tucker in The Thick Of It.  Of erstwhile White House Chief of Staff Reince Priebus he is quoted as having said, “Reince is a f****** paranoid schizophrenic, a paranoiac.”  Mr Priebus struck me as rather a mild-mannered man.  I confess I got distracted by his unusual name.  I have a bad habit of seeking anagrams hidden in unusual names.  I actually sent a crossword clue to The Herald:

Pi, uber-sincere mixed-up politician (6,7)

The Herald didn’t use it.  Funny, that.  Anyway, Mr Priebus is gone, to be replaced by a four star general (maybe **** has another connotation in the Rose Garden).  General John Kelly has no political experience.  But then again, maybe the military is what is needed, to bring some discipline to the West Wing.

From this side of the Pond (I think we should re-name the Atlantic Ocean “The Chasm”), American politics look more and more like a reality TV show.  The predominant themes of shows such as Big Brother, The Apprentice, Strictly, I’m a celebrity get me out of here, Dragon’s Den and many more, are Survival & Expulsion.  Expulsion of an individual becomes a weekly ritual announcement following a protracted and excruciating pause, itself perhaps following weeks of incessant bullying and persecution from which the mass audience derives a sadistic pleasure.  In the same way, US politicians are being serially expelled from the West Wing amid the same apparent atmosphere of bullying and persecution.  It would all be very amusing but for the plunging chasm of uncertainty we all inhabit with respect to global warming, international terrorism, the gap between the rich and the poor, and the ever present threat of nuclear war.  Who on the other wide of The Chasm is addressing any of these issues with wisdom and humanity?

Senator John McCain, who, despite the inconvenient encumbrance of a brain tumour, turned out to cast the deciding vote in support of Obamacare.  Hats off to Mr McCain.

Brian Quail is back in jail.  The redoubtable 79 year old CND pensionista and former Glasgow Schools Latin teacher was arrested for his part in a peaceful demonstration outside the nuclear arsenal at Coulport.  I’m not sure what the charge was.  The last time he was in court it was on a charge, ironically enough, of breach of the peace.  He halted the progress of a nuclear convoy by lying down on the road in front of it.

This time his trial is set for August 3^rd.  He was offered bail, on condition that he agreed not to go within 100 yards of Faslane or Coulport.  He said he was unable to give this guarantee; consequently he is currently languishing in HM Prison Low Moss, from which he sent The Herald a letter, which appeared in the Letters Column on Thursday.  It is, as ever, beautifully written.  Mr Quail belongs to a movement, Trident Ploughshares, which condemns Trident as being manifestly illegal and morally reprehensible.

On July 7^th the United Nations agreed a draft treaty banning nuclear weapons.  122 states signed up to it, but this did not include any of the nine recognised nuclear powers.  Despite the fact that Winston Churchill advised us that to jaw-jaw is better than to war-war, the UK did not even turn up for the UN treaty negotiations which ran between 27^th  to 31^st  March, and from 15^th June to 7^th July.  (This goes a long way towards explaining why Mr Quail is a supporter of Scottish Independence.  The SNP would remove Trident from Scottish waters and Mr Quail believes there is no viable harbour for it anywhere else in the UK.)  So far as I could see, UK mass media gave the UN negotiations scant coverage.  I didn’t see anything about it on the BBC.  I am fortunate to be kept informed by my sources in CND and, indeed, Low Moss.

Mr Quail is widely respected.  He said himself that the police who arrested him treated him with the utmost courtesy, and I imagine that the judge who sent him down did so with the greatest reluctance.  Yet, with respect to hawks and doves, the hawks are winning the debate.  People who go on CND marches are a bunch of bearded vegans in sandals, admirably idealistic but hopelessly naïve.  Sir Michael Fallon’s arguments carry the day: we effectively use Trident round the clock because every day it functions as a nuclear deterrent.  This is why it is being upgraded, in order to provide us with defence for the next half century.

Well, there has been an impasse between the hawks and the doves for the past 72 years, and I guess this blog isn’t going to make a whit of difference.  Yet can I move the debate forward one Angstrom?  It seems to me there are two preconceptions about the pro-Trident camp that are widely accepted as being true but which are, under scrutiny, fallacious.  The first is that those who are pro-Trident are supporters of multilateral nuclear disarmament.  That this cannot be true is demonstrated by the fact that the UK government did not send representation to the UN conference.  I have the General Assembly’s ten page document in front of me now.  “United Nations conference to negotiate a legally binding instrument to prohibit nuclear weapons, leading towards their total elimination.”  Anybody truly seeking a nuclear-free world would have gone to that, if only to highlight difficulties in the path ahead.  But the current British government has no intention of relinquishing the Bomb.

The second misconception is that in some sense the hawks are really doves; they are only bluffing.  The interviewer says to the Defence Secretary, “Sir Michael, why are you spending vast sums of money on a weapon you can never use?”  And Sir Michael, who is a very plausible man, replies, “On the contrary, we use our deterrent every day.  Every day our submariners are on patrol, our shores are protected.”  Hence the Bomb’s use is not in its deployment, but rather in its state of readiness.  So when Mrs May was asked in the House if she would be prepared to deploy the weapon, she immediately and unequivocally replied, “Yes.”  This was widely understood not necessarily to be a statement of fact, but rather a necessary utterance without which the entire Trident project must collapse.  In order for the deterrent to work, a potential enemy must believe that you are prepared to deploy the weapon.  So it helps to project a swashbuckling persona with more than a hint of instability and unpredictability.  The nuclear power which from our viewpoint carries off such a coup-de-theatre most effectively must be North Korea.  Whether their possession of a long range ballistic missile and their imminent perfection of a deliverable nuclear warhead makes their country safer (as apparently Trident makes us safer) is another matter.

We don’t know whether or not the PM is bluffing because we are not privy to the contents of her directives to the Trident submariners, the “letters of last resort”.  Is it not outrageous that in a parliamentary democracy the future – or otherwise – of the entire planet should be at the whim of a single individual who need not communicate let alone debate her decision with anybody else?

Yet I have a sense that it matters not one whit whether or not the PM is bluffing.  Events develop a momentum of their own.  If the payload, and the means of delivery, are held in readiness, then the deployment becomes merely a matter of time, either by accident or design.  We witnessed the same thing in 1914.  A planned mobilisation was simply put into effect.  The inevitability of war was merely subject to the vagaries of railway timetables.  In our present case, all you need is a rapid deterioration in international relations, and the sense that a nation state is facing a supreme crisis.

But we already knew that the Bomb is not a bluff.  Just ask the hibakusha.

The London Proms have returned.  Over the course of the weekend, the Berlin Staatskapelle played Elgar’s First and Second Symphonies under the baton of Daniel Barenboim.  It is always a pleasure to hear a great non-British orchestra under a great non-British conductor play Elgar.  Somehow all the barnacles of tradition and convention are stripped away and you hear the music first-hand, afresh.

When I was a schoolboy the Scottish National Orchestra under Alexander Gibson undertook an Elgar season.  What a revelation it was.  Yehudi Menuhin, who famously recorded the violin concerto in 1932 with the composer conducting, performed to a packed house.  I was standing at the back.  Nowadays, the only violinist who fills the hall in Glasgow like this is Nicola Benedetti. (She’s playing Shostakovich in the London Prom on Tuesday).  Menuhin, ever a generous man, was actually playing in a slum.  In 1962 somebody threw away a cigarette following a boxing match in St Andrews Hall and the magnificent edifice, all but the façade, went up in a puff of smoke.  That it took the City Chambers twenty eight years to replace the hall is a dark stain on the record of the city fathers who for decades told the populace what was good for them and in the latter half of the twentieth century created an asphalt jungle of concrete flyovers and underpasses heading nowhere.  The trams and trolley buses had already vanished.  Sauchiehall Street conveyed nothing but tumbleweed.  Of a Saturday evening I would take the electric train from the west end along a deserted Clydeside dominated by a huge empty and derelict granary.  At Charing Cross I would alight and head for the river across a mud bath where the pile drivers were gouging out the future M8.  Stranded in this blighted landscape stood the Gaiety Cinema where the SNO had become refugees.  I imagine Menuhin must have been reminded of Paris in 1944 when he returned to the newly liberated city to resurrect culture.

In that same season, Jacqueline du Pre was to play the Elgar Cello Concerto but she was indisposed.  (Might this have been the start of her tragic and debilitating illness?)  Andre Navarra stood in at short notice.  I remember the spike of his cello kept slipping!

The First Symphony made a huge impression on me with its opening A Flat theme, nobilmente.  I was sitting next to a pal of mine who ostentatiously opened his copy of The Daily Record I think in some vague protest against the British Empire but even he let the paper slip to the floor.  What else did the SNO play?  I remember the Introduction and Allegro for Strings, Falstaff, and the Variations on an Original Theme, Enigma, the enigma being that Elgar never told us what the original theme was.  It’s like Fermat’s last theorem, a tease.  Elgar liked such mysteries.  He inscribed the score of the violin concerto “Aqui esta encarrada el alma de…” (Here is enshrined the soul of…)  Of who?  I remember Sir Michael Tippett conducted Enigma.  I was sitting in the front row, barely six feet from him.  He was very moved.  He actually sang all the variations as he conducted, from Nimrod to the end.

Daniel Barenboim came on the Andrew Marr Show on Sunday morning principally to talk about an up-coming concert in aid of research into Multiple Sclerosis, the condition that thirty years ago took away his wife Jacqueline du Pre so cruelly.  He spoke very warmly of the Proms, of its attentive audience and particularly of its adventurous programming.  This certainly struck a chord with me.  In an age when “bums on seats” are so important, and when many orchestras’ subscription series can be very conservative, and repetitive, the Proms seem to be able to fill the vast capacity of the Royal Albert Hall every night with music that can be extremely audacious.    On Sunday night, for example, Elgar 2 was paired with the UK premiere of Sir Harrison Birtwistle’s Deep Time.

The mood of Elgar 2 is quite unlike any other piece I can think of.  In many ways it harks back to Beethoven’s Eroica Symphony.  Both are on a vast canvas; both in E flat; both have a funeral march in the second movement.  Both have some connection with disillusionment.  Beethoven was disillusioned with Napoleon declaring himself Emperor.  In the Elgar the sense is more abstract.  There is a wistfulness, a profound nostalgia for something that is being lost.  Elgar lingers for a while, in a coda perhaps reminiscent of the close of Brahms 3.  The rendition on Sunday night was beautiful.

Then something extraordinary happened.  The Staatskapelle played Pomp & Circumstance March No 1 as an encore.  It was extraordinary because they had already done the same on Saturday night.  It was as if they were hijacking the bill of fare of the Last Night, and divesting it of its jingoism.  As if to underline a point, Maestro Barenboim made a speech – another Last Night tradition.  To be honest, it’s a bit of a cliché, to say that in a fractured world music has the healing power to bring people together.  But is it true?  Didn’t the Nazis purloin the music of Richard Wagner for their own nefarious purposes?

It would be no exaggeration to say that Daniel Barenboim is the preeminent musician in the world today.  I think of him as having assumed the mantle following the untimely death of Lord Menuhin in 1999.  His work with the West East Divan Orchestra has put him in a position, like it or not, of moral leadership.  He has taken the orchestra to Israel, and to Palestine.  He wants to take them to Tehran.  Now, it seemed to me, he was wading into the Brexit debate.  He is worried about the parlous state of the world, about religious fanaticism, and, in a European context, about isolationism.

But what exactly was he saying?  He said he wasn’t being political, a remark that elicited some ironic laughter.  His solution to the problems of the world?  Education.  (Tony Blair would have said education education education.)  He might have said coffee bars in book shops.  His remarks ended up as runic and enigmatic as any quotation Elgar might have inscribed above his score.  I think I prefer the Shelley quote Elgar put at the head of his Second Symphony.

Rarely, rarely comest thou, spirit of delight.     

Saturday.

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?

One thing.

But of this I cannot speak.  I’m not admitting anything!

 

Do you give alms to the poor?

Sometimes I do.  Not always.  If I were to distribute largesse at every opportunity travelling east on Princes Street or Sauchiehall Street, by the time I had reached, respectively, Edinburgh’s Balmoral Hotel, or the Glasgow Royal Concert Hall, I should be bankrupt.  There is an argument that, faced with a huge and intractable problem, there is no point in carrying out an individual act, because its effect on the overall problem will be indiscernible.  The counterargument is that the effect on the individual who is helped is tangible, and therefore worth doing.

Some people think the problem is factitious.  These people sitting on the pavement, perhaps shrouded in a cowl, accompanied by a snoozing dog, with an empty polystyrene cup in front of them, with a message of helpless abandonment scrawled on a piece of cardboard – well, maybe they’re skivers, working under the tutelage of an overseer organising a corporate scam, much as a bevy of prostitutes might be overseen by a pimp.

When I was a medical student in Edinburgh I was once accosted by a tramp (I have a notion that terminology might be politically incorrect but it was the patois of the time) in Nicholson Square.  Nicholson Square was a meeting place for tramps.  It was a stone’s throw from Edinburgh Royal Infirmary. I particularly remember Mr Black, alias Mr Green, a tramp who would occasionally present to the Emergency Department with an acute medical problem.  He would be admitted, sorted out, and discharged to resume his former vagrant life.

Anyway, this particular tramp said to me, as I passed, “Have you got the price of a cup of tea?”  I said to him, “Come with me and I will buy you your dinner.”  We attended a fish and chip shop and I bought him a fish supper.  He stuffed it in a pocket of his overcoat and as I bid him farewell, he said, “Have you got the price of a cup of tea?”

Around the same time I treated a waif, a street urchin, in the Infirmary’s Emergency Department.  He had no shoes.  I nicked up to the hospital residency and grabbed an old pair of slippers and proffered them to him.  He gave me a look of disgust and said, “I wouldn’t be seen dead in these.”

I was reminded of these and similar memories on July 1st when I happened to visit the newly opened Carnegie Library and Museum in Dunfermline.  It is a splendid facility in a spanking new building beside Dunfermline Abbey.  The Abbey and its ancient environs give the town a medieval feel.  The library has an old-fashioned air.  Good heavens, it’s full of books!  Mr Carnegie opened almost 1600 libraries in the US alone during his lifetime.  His generosity continues.  He gave Pittencrieff Park to Dunfermline.  It is situated directly west of the Abbey, with a deep gorge (“The Glen”) its remarkable geological feature.  Directly above it stands the remains of Malcolm Canmore’s tower.  The king sits in Dumferling toune, drinking the blude-ried wine!  The park is very well maintained.  I imagine that is due to Carnegie‘s legacy again.  In the new museum’s café I sat and read his remarkable essay The Gospel of Wealth.  Agree with it or not, it is a beautifully written piece.  It is a robust defence of Capitalism and an abrupt dismissal of Communism.  It’s basically a piece of advice directed towards rich men.  By rich men he meant people like himself, people of fabulous wealth.  He said, don’t pass your wealth on to your descendants.  That’s just vanity and it won’t do your offspring any good.  He even said don’t give your money to the poor and needy, or at least, not without provisos.  It will merely be diluted and likely as not squandered.  Rather you must do good works.  Give a helping hand not to the indolent but to those who would help themselves.   And don’t merely leave the money in your will for this purpose.  You will have no say in what becomes of it.  Rather, you must spend the bulk of your wealth on public works, while you are alive, so that you bring to the project the same talent that allowed you to accrue all that wealth.  It is disgraceful to die rich.  You can’t take it with you.

In his argument, Carnegie chided a friend of his who gave a quarter of a dollar to a beggar.  Another act of vanity.  He does not advocate “such imitation of the life of Christ as Count Tolstoi gives us.”  The Gospel of Wealth is indeed a new gospel.  I am reminded of Mrs Thatcher’s take on the Parable of the Good Samaritan.  The Good Samaritan was able to help the injured man at the roadside precisely because he was a man of wealth.  I’m always a little wary of invocations of the Parable of the Good Samaritan.  They often shed more heat than light.  On Radio 4’s The Moral Maze about a year ago the issue of how to deal with the influx of refugees crossing the Mediterranean was discussed.  Don’t patrol the waves, ran one argument; it only encourages them!  This inevitably led to an invocation of the Good Samaritan.  You can always tell when The Moral Maze is about to degenerate into a shouting match.  Did the Good Samaritan merely encourage lots of other people to make that dangerous trip from Jerusalem to Jericho?  So who are you in this story, passing by on the other side?  The priest?  The Levite?

I think I’m the man lying injured in the gutter.  I confess Andrew Carnegie paid me through Medical School, courtesy of a Carnegie Trust Grant.  It was my second degree.  I might still have been paying off the fees.  38 years later I was sitting at the back of Dunblane Cathedral and I had an odd moment of epiphany.  The Reverend Macintosh asked the question from the pulpit, “What is that one thing that you need to do, that you have been putting off?”  It was as if the entire cathedral emptied itself so that the minister and I were the sole occupants.  He addressed me across the vast space of the nave.  What is that one thing?  I realised I needed to hang up my stethoscope.  So I visited my accountant – his office happens to be in Dunfermline – and asked if I could afford to quit.  Well, I could.  I danced out of the office and popped into the modest cottage beside the Abbey that is Andrew Carnegie’s birthplace, to pay my respects.  Then I returned to my car in the carpark next to the Abbey and, in a trance, promptly reversed into the BMW parked behind me.