Author: jamescalumcampbell

I’ve been reading Freud all week.  The Interpretation of Dreams.  Occasionally, by way of antidote, I pause and read a few pages of James Thurber’s Let Your Mind Alone!  Then I return to the Herr Doktor Professor with renewed scepticism and say in a Columbus Ohio drawl, “Well, I’m not so sure about that!”

Freud’s thesis is that all dreams are meaningful.  He opposed the view that dreams are the mind’s way of sifting memories and discarding rubbish much as you would put waste paper through a shredder.  The discarded memories are all incoherent and disjointed like ticker tape.  But he went much further.  He said that all dreams without exception are wish fulfilments.

I can see why this idea met a lot of resistance.  I only have to look at my own dreams.  I have three recurring dreams.  (Freud called such dreams “perennial” and said he didn’t experience them.)  I will describe them in reverse chronological order.

After I stopped practising medicine I dreamt about medicine every night, without fail, night after night, for months.  For a long time I was on permanent night shift, with no nights off.  In my dream I am working in a hospital emergency department, at night.  I am trying to deal with some ghastly complicated clinical problem, I’m not making headway, and meanwhile the patient backlog is piling up.  And the dream seems to go on all night.  When I finally wake, there is a tremendous sense of relief that I no longer have to grapple with the complicated problem.  But there’s also a nagging sense that I am walking out on my colleagues at the end of my shift, leaving them to sort out all my unfinished business.

My second recurring dream relates to music.  Just before I went to Medical School I was playing viola in a number of ensembles.  My teacher was the principal viola of the Scottish National Orchestra (SNO, now RSNO), and occasionally he would smuggle me into the SNO and I would rehearse with them throughout the week and then play concerts in Edinburgh and Glasgow.

Now from time to time I still dream I am playing in the SNO – but in the present and with lapsed facility.  I’m sitting in the orchestra waiting to be identified as the person making the dreadful noise.  The conductor will dismiss me.  It will be a very public humiliation.  This dream even spills over into my waking life.  I recently ran into a retired RSNO member who invited me to play some chamber music.  I felt an intense sense of unease and, in explaining why I really wasn’t up to it, I said, “You’ve got to remember that when I played viola professionally it was so long ago that viola jokes hadn’t even been invented.”   He laughed and said, “That in itself is a viola joke.”  I did recently play in an amateur gig with an RSNO viola player and I told her of my dream.  She said she wasn’t in the least surprised.  She had a recurring dream in which she mistakes the orchestra dress code and turns up for a concert in the wrong attire.

But my third and oldest recurring dream has become the most bizarre and surreal.  In this dream I am a pupil back at school.  I started having this dream not long after I left, when I was 17, so at first my dream was not anomalous.  I remember a couple of guys who were 19 before they left.  One had had a protracted illness and the other a background of exotic foreign travel.

The school itself, in Glasgow’s west end, is accurately represented in the dream, (it looks like an open plan penitentiary) and I usually find myself in the first floor corridor of the north wing, just west of Room 11, where I studied mathematics for five years.  I have lost my class.  I am struggling with my timetable, trying to interpret where I ought to be.  I am dreading entering the classroom because, as with the SNO dream, I am dreaming this in real time and I know the idea of a middle-aged man still at school, and in school uniform, is utterly ridiculous.

If these dreams are wish fulfilments then the wishes are surely deeply concealed.  When Freud’s patients pointed out to him that many of their dreams were unpleasant, he explained that the wish-fulfilling aspect of the dream had merely been distorted and the distortion could often be explained in terms of events in the patient’s waking life, often on the day before the dream.  If Freud could not interpret the dream, he even had a fall-back position that seems to me a kind of reductio ad absurdum:  the patient had dreamed the dream to have the satisfaction of proving Freud wrong.

It is clear that my three recurring dreams are all anxiety dreams.  Further, they concern the relationship of an individual (me), to a large society or organisation.  They have the Kafkaesque quality of a vulnerable individual up against an impersonal and inimical authority.  And there is the dread of the vulnerable individual being exposed as an impostor.  I relate most of this to my school life.

When I was about thirteen, I and my class mates were given, as a home reader, The History of Henry Esmond by Thackeray.  The assignment was quite simply to read Henry Esmond with a view to answering a question on it in an examination.  No help was offered.  You may say that quarter was neither asked nor given.

There was never any possibility that I would read Henry Esmond.  I can’t remember how I got round that, but I do remember doing rather well with a character sketch of Mr Micawber, not having read David Copperfield.  I think I stole it out of a crib.  School taught me how to cheat.  I came away under the impression that the way to get on in life was to fake it.

Not that our teachers were unkind.  I think many of them felt as incarcerated as we did.  I remember towards the end of my final year, I wandered into the school one morning at quarter to ten, smack into the headmaster at the front gate.  He gave me a look of pained indulgence and wished me good morning.  We both knew the game was up.  I’d overstayed my welcome.  Time to move on.  At the end, after the prize-giving and all that, Miss Watson (principal maths) offered me a cigarette.  Maybe that has a Freudian interpretation.  But shouldn’t I have been offering the cigarette to Miss Watson?  Perhaps not.  As Freud himself said, sometimes a cigar is just a cigar.

I’m not sure if I’m fulfilling a wish in returning to school.  But I have a notion why I sometimes go and walk around its shadowy and insubstantial domain.  (Or is it I who am the ghost?)  I’ve got some piece of unfinished business there, and I can’t for the life of me think what it is.  There’s something I didn’t do, which I ought to have done, while I was there.  So I go back, from time to time, and wander the corridors, and struggle with my timetable, and think, what is it that I should have done, while I was here, that I failed to do?  What did I omit?  What have I forgotten?  What is that one thing that I failed to do?

Orthopaedic surgeons are not renowned for their social skills.  Sometimes I think that as part of their training they are given a special course on how to be abrasive.  A long time ago in a far off land in a distant galaxy I once referred to orthopaedics a man who’d had the misfortune to fall from a height and land on his feet, fracturing both heel bones.  The orthopod took one look at the x-rays, walked over to the patient, and said, “Basically mate, your feet are stuffed.”  Hold this thought.

On Friday I visited the “acute campus” that is the site of the newly opened South Glasgow University Hospital complex.  I wanted, albeit reluctantly, to confirm something with my own eyes.  It is this fundamental fact about that most sacred of British cows, the NHS: that while there are some wonderful doctors and nurses who occasionally get together to run some wonderful units, by and large the great clanking juggernaut that is the NHS continues to have no respect for the patients it purports to serve.

I know this because, tucked away round the back of the hospital, 250 metres from the grand entrance into the enormous airport terminal atrium with its M & S, and W H Smith, its restaurant and coffee bars and cash machines and self-check-in consoles, there is a small sliding door leading into a low-ceilinged waiting room, about the size of half a badminton court.  This is a thing called “A & E”.  Next to “A & E”, but distinct from it, is another unit, the Acute Assessment Unit.   That is really all you need to know.  But I can tell you on the basis of this brief description that if you have the misfortune to enter a system like this as a patient, basically mate, you’re stuffed.

Let me explain.  Let’s go back round to the front of the hospital.  What is its purpose?  Since we now know that acute care is being delivered round the back, the front must cater for “elective” or “scheduled” work.  This is confirmed by the fact that patients can check themselves in, much as they would if they were getting a boarding pass for a flight in an airport.  The patients are “ambulant”.  They may be attending an out-patient clinic, a diagnostic facility, or presenting for admission for an elective procedure or for planned surgery.  Given the grandeur of the surroundings (in stark contrast to the modest facilities round the back) we may suppose that elective health care delivery outranks acute health care delivery both in importance and in bulk.  This is confirmed by acute care signage and terminology.  “Accident & Emergency”, “A & E”, “Casualty” – these are now all exclusively British terms.  “Casualty” is the title of the flagship BBC emergency medicine soap.  It is salutary to look up “casual” in the dictionary.  Chambers has:

Casual  adj.  accidental: unforeseen: occasional: off-hand: negligent: unceremonious:  (of a worker) employed only for a short time, without fixed employment. – n. a chance or occasional visitor, labourer, pauper etc: a weed not naturalised… n. casualty that which falls out: an accident: a misfortune… casualty department, ward a hospital department, ward in which accidents are treated; casual ward formerly, a workhouse department for labourers, paupers etc.

That Dickensian paragraph is essentially a description of a British “A & E”.  Unscheduled care is an add-on, a little piece of pro bono beneficence handed down to the poor and needy as a special favour, so long as it doesn’t interfere with the essential work going on at the front of the hospital.  Indeed, “A & E” (it pains me to use that term but I suppose that’s what it’s called around here) is hardly thought of as part of the hospital at all.  That is the origin of the “four hour rule” prevalent in most acute hospitals throughout the UK.  Get 95% of the patients out of here as fast as possible, either home, or into the hospital where they can be properly looked after.  If I were to tell a hospital manager that the Emergency Department (to give it its proper term) is the most important and vital location in the whole hospital, he would look at me as if I were mad.  That is because he does not know about the phenomenal diagnostic and interventionist power of a properly resourced Emergency Department.

But it’s true.  It’s true because all medicine is acute.

There are two groups of people who know that all medicine is acute.  One are the health care providers who work in any form of primary or “undifferentiated” care.  This would include doctors either in General Practice or in Emergency Medicine.  The other group?  The patients themselves.  The primary care doctors and the patients know that all medicine is acute because they are the ones present from the beginning.  Every episode in health care starts with a Presenting Complaint.  “I’ve got a cough” – “I’ve got chest pain” – “My sore hip keeps me awake at night” – “I’m miserable”…   The patient says to the doctor, “I’ve got a problem.”  Occasionally, in the spheres of screening and case finding, it is the doctor who says to the patient, “You’ve got a problem.” All presenting complaints are unscheduled.  Nobody looks at their diary and says, “I’m going to crash my car next Thursday.”  I was very struck by something somebody – not a patient – said to me once at a Christmas Party.  “A minute before I took my stroke I felt very well; I didn’t know I was going to take a stroke.”

Because GPs and emergency physicians are dealing with acute problems all the time, they are very good at gauging levels of acuity; they know who needs to come into hospital.  A GP will happily refer one patient to hospital during a day’s work.  If he refers two, he wonders if he is pushing his luck.  He will bend over backwards not to refer anybody else.  If he refers three, he will be abjectly apologetic.  “Sorry to bother you again…”  But it needn’t be this way.  We need to stop thinking that an admission to hospital represents some kind of societal failure.  Doctors call it “acopia” – failure to cope – the most cynical word in the medical lexicon.   In fact, helping patients who are unable to cope outside of hospital is what a hospital is primarily for.  That is why the preposterous opulence of the front door of the new hospital is such a travesty.  It’s a huge confidence trick.  All these people checking themselves in at the state-of-the-art consoles, they are on a waiting list.  The front of the hospital is designed to impress; it’s all about prestige.  Yet at the end of the day this is a cathedral dedicated to the art of waiting.  There’s an irony inherent in the very vastness of this atrium; it’s a monument to vacuity.  But Medicine is not remotely like an airport check-in counter, much as the managers would like it to be so.  Medicine is messy and complicated and unpredictable.  Hospitals that dedicate their grand entrances to the art of waiting are trying to remove themselves from the hurly-burly of life.  But they need to do precisely the opposite.  They need to roll up their sleeves and engage with the real world.  They need to move their focus of attention closer to the point at which pathological processes become evident.  So let’s go round to the back of the hospital again.

Something needs to be said about that other unit – the acute assessment unit.  In most acute British hospitals, there are two modes of entry into hospital for patients who are acutely unwell.  If a patient’s GP has made contact with an in-patient specialty to arrange an admission, then the patient is likely to go through the acute assessment unit, unless the patient is deemed to be unstable, in which case the transfer to hospital will be by ambulance and into the Emergency Department where there are resuscitation facilities.  If the patient self-presents, he will be “triaged” into the Emergency Department.  The GP-bespoke acute assessment patient has a higher status than the self-presenting “A & E” patient.  An in-patient service has already assumed ownership of the former, while the latter is not really in the hospital at all.  In other words, there is an apartheid system working at the front (ie the back) of most British hospitals.  If patients are unaware of this, it is because they have no idea of the tribalism, the ancient and acrimonious turf wars that exist among the medical specialties and Royal Colleges.  In particular, there is a schism between the specialties of Emergency Medicine and what used to be called “General Medicine” or “Internal Medicine”.  Many of the consultants in these areas don’t particularly mind.  The Emergency medicine consultants are happy to concentrate on unstable patients, and the physicians are happy not to have the acute responsibility of resuscitating them.   But neither side are prepared to give up their perception of their own sphere of interest.

I see an opportunity here which, if embraced, really could make British hospitals “world leaders” in acute care.  Emergency Departments and Acute Assessment Units should amalgamate.  Neither side would be giving up anything, but both sides would be taking on considerably more, while sharing the burden.  The greater change of mind set would be in that of the acute care physician working in the acute assessment unit.  I’m basically suggesting that, if a general physician wants to work at the coal face of acute care, he should broaden his diagnostic repertoire and become an emergency physician.

Then the amalgamated units should move out of the back of the hospital and occupy that absurd mausoleum at the front of the building, get rid of all the retail and the money changers, and turn the front door into a state-of-the-art Department of Emergency Medicine, designed, funded, and staffed to cope with everything that is thrown at it in an expert and expeditious fashion.  Put all the acute services together, right at the front of the hospital – the emergency department, radiology, diagnostic suites, catheter labs, intensive care, and theatre – all next to one another.  These are the locations where medical interventions happen.  The crucial role of the general ward is in observation and nursing care.  Here, patients get better.  It is a mistake to imagine that doctors cure people.  They merely try to engineer the optimal conditions that will allow nature to heal the patient, with the best possible outcome.  The mysterious thing about pathology is that the disease and the cure are one and the same.  And time really is the great healer.

We need to relocate the Department of Emergency Medicine to the hospital front door.  If we don’t do this, if we don’t practise a form of acute care medicine more appropriate for the twenty-first century, then basically, mate, you’re stuffed.

It was the best of times, it was the worst of times…

I was in Edinburgh on the day of the general election, and took a walk up the Royal Mile all the way from the Scottish Parliament to Edinburgh Castle.  The usual street theatre was in evidence.  I stopped – I am the eternal average man – and joined a crowd of tourists to watch a man juggle three flaming torches while simultaneously bouncing a ball on his head.  This is Edinburgh on show, depicted on a shortbread tin, Edinburgh in inverted commas.  It’s a permanent Edinburgh Festival Fringe.

Next morning, according to the First Minister, “The political firmament, the tectonic plates in Scottish politics, have shifted.  What we are seeing is a historic watershed.”  I am inclined to forgive her for mixing her metaphors; she had after all been up all night.  Post-seism, not only the watercourses, even the stars above have altered their trajectory.  That is one Big Shoogle.  The newspapers said, “The SNP tsunami has caused a seismic shift…”  These tectonic plates again. Doesn’t the earthquake cause the tsunami?  But I quibble.

That day, I happened to be in Glasgow.  Glasgow is 44 miles from Edinburgh, but culturally it might as well be 44 light years.  Perhaps if I took a stroll down Buchanan Street from the Royal Concert Hall to the Clyde I might figure out why.  I stopped for a coffee in the concert hall.  In the loo, a guy started talking at me in that abrupt way Glaswegians start up a conversation.

“Aye she wanted the Tories back all along!”

“I might not agree with you.”

“Believe me – it was all planned!”

I was non-committal.  “We live in interesting times.”   He gave me a withering look.  Meanwhile I was trying to turn the tap off – difficult as the faucet handle had come off.

“It’s been like that for weeks now!”

The Concert Hall is the home of the Royal Scottish National Orchestra.  Around the time when the Glasgow tram lines were being ripped up, the St Andrew’s Hall was burned down and the RSNO (then SNO) moved into temporary accommodation.  The city fathers turned Glasgow into an asphalt jungle of super highways on concrete stilts but took thirty years to finance a decent concert hall. (I remember as a child attending an SNO concert for school children held in a disused cinema in the middle of a building site.  The orchestra played Webern’s Six Pieces – an astonishing thing to do at a children’s concert.  The fourth movement is a funeral march culminating in a huge percussive crescendo towards a silence Sir Simon Rattle has described as “deafening”.  It was hard to distinguish the bass drum from the pile driver operating just outside and, in the event, the silence did indeed turn out to be deafening.  Apologetically, the conductor folded before the competition and cut the concert short.)

Back outside, I negotiate the picnic lunches on the concert hall steps.  There’s a move afoot to take the steps away but the lunchers are not happy.  Squatters’ rights.

Looking south down the slope of Buchanan Street towards the Clyde, the perspective is foreshortened and it’s like staring at a Brueghel painting full of jugglers and tumblers.  But it doesn’t look like a shortbread tin.  Somehow it’s the real deal.  Beside Donald Dewar’s statue a guy has put up a tightrope between two lampposts and is cavorting around on it with extraordinary facility, to the deafening clatter of a bunch of drummers and a bagpiper, all dressed in faded dun plaid.  Terrifying.  Was it Wellington who said of his troops on the eve of Waterloo, “I don’t know if they frighten the enemy, but they certainly scare the s*** out of me.”  If there are any tourists, they are invisible.

Down by the river, things get quieter.  I like to walk west along the river bank occasionally swapping sides over the bridges – the suspension bridge, Jamaica Bridge, Bells Bridge, the Millennium Bridge.  This is a part of Glasgow that has become familiar to many because, on the south bank of the Clyde, political pundits emerge from BBC Scotland and talk to Huw Edwards in London against the back drop of a defunct crane, the Squinty Bridge, the SECC, and the Hydro.  It’s all rather chic.  When I was growing up in Glasgow nobody in their right mind would have ventured down here.  Dereliction.

But on this occasion I turn east.  Glasgow is a very territorial city.  I know people from the west end of Glasgow who have never ventured even as far east as Glasgow Green.  It’s as if there is a Berlin Wall at the Salt Market.

And here, just to the east of the city centre, lies the great mystery about Glasgow and Edinburgh. If you are male, resident in the leafy suburb of Barnton in West Edinburgh, you can expect to live until you are 85.  If you are male, resident here where I walk now, you can expect to live until you are 55.

And nobody knows why.

Let’s talk about the elephant in the room.

I once attended a lecture given by the charismatic John Guillebaud, Emeritus Professor of family planning and reproductive health at UCL.  He put up a slide of the elephant in the room.  It depicted a board room, with a group of people gathered round a mahogany table and, beside it, dwarfing everything, a large elephant.  It’s a farcical image.  You could imagine yourself seated at the table, thinking, why is everybody pretending the elephant isn’t there?  Am I imagining it?  Should I mention it?

Prof Guillebaud is very interested in the potential effect of effective contraception on world population. I nearly juxtaposed the words “population” and “control” there but that is a great taboo for those in the west seriously interested in addressing the elephant in the room.  It’s political dynamite.  When war, famine, and rising sea levels cause people to drift across the Mediterranean it is much easier for the PM to emerge from a meeting in Brussels and say, “We’re going to put a stop to this by blowing up the traffickers’ boats.”

But I digress.  The elephant in the room this week is of course the General Election.  There are three topics to be avoided in polite middle class discourse – sex, religion, and politics.  Have you experienced that rueful feeling when you come away from a social gathering where you have indulged in some robust conversation, grown a little impassioned, perhaps even intemperate, and departed with a vague sense of free floating anxiety?  “Maybe I shouldn’t have said that.” Last September before the Scottish Referendum I would go to dinner parties, talk about the weather, and ignore the elephant in the room.

Joe Epstein, one of the founding fathers of emergency medicine in Australasia, another charismatic speaker, used to give the following advice to those of us involved in the furthering of emergency medicine amid the tribal collegiate turf wars of the medical colleges:  don’t be seduced into a fruitless argument with somebody whose entrenched views you will never change.  That is pretty much a description of a political leaders’ debate.  Have you ever seen a politician on Question Time listen to an opponent and say, “That’s a good point; I never thought of it that way; you’ve changed my mind”?  Last night on the news I caught a snatch of conversation from a bitter and acrimonious encounter in Edinburgh.  One of the party leaders said to another, “Are you calling me a liar?”   It’s excruciating.  I switched off.  I’m rationing myself.  Only three days of campaigning left to endure.

But let’s talk about the elephant in the room.  I’m going to stick my neck out and make a prediction.  I think Mr Cameron is going to get a second term.  He’s the incumbent; and he’s stuck with it.

This opinion is entirely non-partisan.  It’s based on the “Red Lines” everybody has started drawing.  Mr Cameron won’t lead a government that is not offering an in-out EU referendum; and Mr Miliband won’t have any truck with the SNP.   Politicians aren’t usually that specific.  They usually leave themselves some wriggle room.  This is all very mysterious.  And now Mr Miliband has come out with his six policy statements, “A better plan, a better future”.  And he has, literally, set them in stone, with a pledge to implant them, like a Henge, in the back garden of No 10.  I list them here in full, and ask you to examine them, not so much as a student of politics, but as a literary critic.  Examine them the way F R Leavis, at his most ferocious, might have done so.

1. A strong economic foundation.
2. Higher living standards for working families.
3. An NHS with time to care.
4. Controls on immigration.
5. A country where the next generation can do better than the last.
6. Houses to buy and action on rents.

Who would not buy into all that?  But then again, it’s so abstract as to be completely meaningless.  If Mr Miliband were running for the Presidency of the USA he might as well have run on a “mom and apple pie” ticket.  We might invoke Leavis’ accusation against Shelley and his “weak grasp upon the actual”.  Isn’t it ironic that something as non-concrete as “A better plan, a better future” should be set in stone? There isn’t a policy or a pledge in there.  Scrap Trident, or even Keep Trident – these are pledges.  Mr Miliband’s limestone menhir is completely vapid. He must know it.  We all know it.  So here’s the question.  In this day and age when the voting public have become profoundly suspicious of gimmickry, and when they have grown to admire certain women politicians who “talk normal” and espouse clearly defined policies, why on earth would Mr Miliband choose to insult everybody’s intelligence?

The only rational explanation I can find is that he has decided the top job is such a poisoned chalice that he doesn’t want it.  Maybe he knows the “recovery” is a figment, and that, if Mr Balls were to walk into No 11, he might find a note: “There is no money.”

Mr Cameron doesn’t want to lead a coalition again.  “Been there, done that, got the T shirt.”  But he may have no choice.

There is one alternative scenario:  On Friday morning Mr Miliband has a slight attack of post traumatic amnesia – I’m leaving myself some wriggle room.  After all it’s not going to contradict anything carved on his Henge.  So he talks to the other progressive parties.   Including the elephant in the room:

The SNP.

A hundred years ago when I was about eleven, my parents took me and my brother out one night to see Bruce Forsyth play the Alhambra in Glasgow.  But first we dined in the Berkeley in North Street.  Asparagus was on the menu.  I had never tasted asparagus, but I was very keen to order it as I had just read Ian Fleming’s Diamonds are Forever.  On board the Queen Elizabeth, en route to Southampton from New York, Tiffany Case prepares for Bond a dish of asparagus and sauce béarnaise.  It seems an unlikely aphrodisiac, and indeed I have a notion Fleming in subsequent editions took out the asparagus and substituted steak on toast canapés.

I didn’t much like the asparagus.  Each spear was an effigy of the Chrysler Building and I fancied tasted like a triffid, bitter to the youthful palate.  But I wolfed them down.  Then we went off to the Alhambra.

Even so long ago, Brucie was a very famous entertainer and had been around for ever.  It was a one man show.  We were seated quite near the front.  Half way through, I developed the most appalling indigestion and became an irritable and fractious child.  I don’t think the family was very sympathetic.  “Well, if you will insist in ordering exotic vegetables…”

But I knew better.  It wasn’t the asparagus.  Halfway through the show, it became apparent that Brucie wanted some audience participation and was looking for a child to join him on stage.  I had a panic attack, sank low in my seat and thought, “Avoid eye contact!”  I couldn’t bear it.  In the end, he chose a girl from Rutherglen.

Fast track forward a century.  Yesterday I was in Dunblane Cathedral for morning service, seated, as is my wont, in the back pew, about a football pitch from the clergy.  The associate minister is from South Carolina and has a great way with kids.  Audience participation again.  She had ten of them up.  She said to the first five, “Now I want each of you to find somebody in the congregation you know, and bring them up.”  And to the second five, “Find somebody in the congregation you don’t know, and bring them up.”

Another panic attack.  I hid under the pew.  Nothing ever changes.  At least I didn’t get the indigestion.  And the kids had more sense than to drag me up.  We moved on to the lesson – Mark 12; the widow with two mites who put it all in the collection.

I was brought up to go to church.  While at Edinburgh Medical School, I intermittently sang in the choir in St Giles.  Then for a long time I never went.  But more recently I have become a more regular, if invisible attender.  Like Nicodemus, visiting Our Lord by night.  There is the magnificent architecture, the fine Flentrop organ (the postlude yesterday was J S Bach’s Piece d’Orgue BWV 572 – nothing could be more majestic), the beautiful flowers that Mr and Mrs Murray kindly left behind after their nuptials.  What’s not to like?

But of course it’s more than that.  I come here to get some relief from life’s bunkum.  Before I went to Dunblane I’d caught the Andrew Marr show on BBC 1 and the paper reviewers were musing on the Times rich list.  Apparently since the crash they’ve all doubled their wealth.  The UK has the biggest number of billionaires per capita of any country in the world.  The rich get richer and the poor get poorer.  I have a notion that human affairs operate by and large as part of a Huge Scam.  Economics, the Dismal Science, tries to get to the bottom of it but never will.  Everyone’s a dodger, says the Aaron Copland song.  Even the preacher!  That would be insupportable.

Yet I flatter myself when I pretend I am Nicodemus.  Nicodemus has two cameo appearances in the gospels.  He returns to help Joseph of Arimathea dress Jesus’ body after the crucifixion.  He became one of the committed.  I sit invisibly in my rear pew and feel like a fake.  That is why I panicked when the children started looking for me.

At least I was right that it wasn’t the exotic vegetables that unsettled me, all these years ago.  Yet those dear to me still warn the hostess at dinner parties: “For God’s sake don’t let him anywhere near that asparagus.”  I happened to say to one of them the other day, when we were talking about the worldliness of the world, that if Jesus returned in 2015 and walked the streets of Glasgow, telling people to sell all they had and give to the poor, he would pretty soon be in deep trouble.

“Trouble?  He’d be crucified!”

Amongst the bereft and marginalised in our society, a group I feel particularly sorry for are those who have had an incomplete education.  I think particularly of those who have had the misfortune to attend a private school.  (In England, for reasons that escape me, a private school is called a “public” school.)  You might call such an institution an “exclusive” school.  Membership of an exclusive club of any sort is generally much sought after, but is there not something distasteful about wishing to be exclusive?  The first duty of any exclusive club is to retain its exclusivity; this is achieved by the act of excluding people who are undesirable.

The trouble with attending a private and exclusive school is that you are liable to acquire a skewed notion of life, and of how life is, for most people.  This is particularly harmful to those who have been groomed (and I use “groomed” advisedly – it is after all a kind of abuse) for positions of political leadership.  Reared in a world of exclusivity, you are liable to come out with that political sound bite that I have come to distrust most of all – “We have had to make some tough decisions.”

Nothing could cast a more lurid and macabre light on the election immigration debate than the news that 700 souls have been lost in the Mediterranean this weekend.  Can you conceive of any utterance more crass than that voiced by many European nations, including the United Kingdom, that Mediterranean search and rescue should be abandoned because it only encourages others to attempt the journey?  Perhaps we said to the people in the water, not waving but drowning, “We have had to make some tough decisions.”

When I heard about all this I reread Edgar Allan Poe’s The Masque of the Red Death.  Have you read it?  Do.  I should think it’s less than 2,500 words long – a fifteen minute read.  It is one of these pieces of literature that will change you, irreversibly.  But it is not a comfortable experience.  It’s like one of these news items that comes with a health warning: some viewers might find these images disturbing.  It is very hard to believe that it was written in the first half of the nineteenth century, because it is of our time.  If I were to choose a piece of literature that reflects our zeitgeist, redolent of the predicament of our time, it would be The Masque of the Red Death.

When his dominions become devastated and depopulated by a virulent infection characterised by a haemorrhagic eruption and rapid decompensation, Prince Prospero retires, with a thousand of his knights and dames, into the deep security and seclusion of his castellated abbey, where he gives himself over to pleasure.  There are seven chambers in the abbey, irregularly placed but running more or less east to west, each more grotesque than the last.  On the west wall, there is an ebony clock with a pendulum, and, on the hour, a doom-fraught chime.   “There were buffoons, there were improvisatori.”  (How could Poe have known about television, and how it was going to evolve?)  I won’t describe much more, but it will hardly surprise you that the plague gets in, and everybody has a bad end.  It’s an archetypal story.  It has the same horrific quality as the story of Belshazzar’s feast, so vividly re-enacted in William Walton’s oratorio.  The great panegyric to all the false gods of precious metals, suddenly cut short by the writing on the wall.  Mene mene tekel upharzin.  Thou art weighed in the balance, and found wanting.

I wonder if Fortress Europe, or more generally, “The West”, is Prospero’s Castle.  Read The Masque and see what you think.   Imagine you stand on the shore of a country that has become so hellish that it seems a good option to get into a rickety boat, with hundreds of others, and risk drowning.  This is like being trapped on the 80^th floor of a towering inferno; you elect to jump – it’s the better option.  Almost none of the Great Issues of our time – War, Famine, Pestilence, Injustice, climate change, and – the elephant in the room – overpopulation, figure in the current election debate.  How are we all going to get on together, without destroying one another, and the planet?  There isn’t even an academic discipline devoted to this question.  Our best young minds are encouraged to do something else.

Meantime, should we pull up the drawbridge and deploy the portcullis?  And renew Trident?  When we finally get round to deploying Trident I know exactly what will be said at the ensuing press conference.

“We have had to make some tough decisions.”

Dined in an Indian restaurant in west Edinburgh last week with two friends from Medical School.  They were kind enough to compliment me on this blog, and said I was a “debunker”.  I am certainly happy to aspire to debunk.  There is a lot of bunkum, or buncombe, around; humbug, humbuggery, hokum, or, to use a more technical term, “bullshit”.  Why is there so much?  The definitive answer to this is the tract “On Bullshit” by Harry G. Frankfurt, Professor of Philosophy Emeritus at Princeton University (Princeton University Press, 2005).  A compelling read.  I can’t quite decide whether it’s an essay in profound thought, or in farce – or both of these at once; I suspect the latter.

There’s an occupational hazard to being a debunking aspirant.  You are always in danger of turning into a Victor Meldrew figure, or a Scrooge.  Bah, humbug!  I always remember a piece of advice my father gave me, not to hang around with people who are always moaning.

So this morning let me write in praise of something.  I’ve become rather fond of a word that can increasingly be heard used, especially on the radio, in a special sense.  I’m not generally impressed by words that trend (and “trending” itself is increasingly trendy) – “It’s not about this, it’s not about this, it’s about that, d’you know, going forward, like.”

The word I like is “so”.  Have you noticed this?  It’s best heard in a radio interview, usually with a boffin.  A scientific expert is hauled in to cast light on some technical aspect of an issue that the popular press has picked up on from the academic journals.  “Professor, what exactly is the Higgs Boson?”

“So…”

And a short lecture follows.

I get a warm feeling when I hear “So”.  It’s an invitation to prepare to receive a little piece of encapsulated knowledge, lucidly and coherently presented.  To be lucid and coherent on air is not easy at the best of times, and particularly when dealing with a conceptual difficulty.  You never know whether you really understand something until you have successfully explained it to somebody else.  I remember training to sit the Australasian Emergency Medicine exams in Sydney.  I and my colleagues would rehearse, swapping roles as examiners and examinees, endlessly grilling one another.  We would increase the level of tension by choosing an intimidating setting, wearing suits, conducting the oral before an audience and in front of a video camera.

“Now doctor, tell me about the metabolism of paracetamol.”  And you would pause to gather your thoughts.

“So…”

One of the examiners once said to me (not referring to me – I was a plodder), “The good candidate makes it look so simple.”  Science strives after simplicity; there’s an article of faith in science that the laws of physics are fundamentally simple.  Lord Rutherford said that if you couldn’t explain your research to the Cavendish Laboratory’s cleaners you didn’t really understand it.  But simplicity is deceptively complex.  The opposite of simplicity is not complexity; it is obfuscation.  There is a lovely story about the physicist and virtuoso bongo drummer Richard Feynman.  Towards the end of a lecture he described two ways of dealing with a physical problem as “complicated and messy” and “simple and very elegant”.  “We don’t have much time left, so I’ll show you the complicated and messy way.”

So… here is the meaning of “So”.  It means, “In the following statement I am going to do my best to explain something as clearly as I can, without recourse to smoke and mirrors, obfuscation, and the other paraphernalia of bunkum.”

I’ve been listening out for “So” this week from political campaigners.  I have heard lots of “Let’s be clear” but I haven’t heard a “So”.  Maybe “So” is strictly for scientists.  Does it occur in literature?  Henry IV part 1?

So shaken as we are, so wan with care…

Not really in our special sense.  How about Beowulf:  Hwaet we Gardena…  Not the Glasgow “stairheid” patois translation (“What wee gardens!”), but Seamus Heaney:

So.

Philip Hobsbaum, who taught English at Glasgow University, once said to me, “The only difference I can see between Mr Heath and Mr Wilson is that they are both exactly the same.”  Having puzzled over that remark for a few decades now, I finally got it, during the political leaders’ debate last Thursday.  The smaller parties are refreshing because they each espouse an individual cause.  But the traditional parties, the anonymous men in suits fighting for the centre ground, are hardly separated by a cigarette paper.  You might say their positions on “austerity” differ, but only by degree.  One party wants to pay off the debt quicker than another.  It’s not quite the same as wanting to dismember the United Kingdom.  I confess I fell asleep during the commercial break.

The panel of seven were asked four questions.  Briefly, how are you going to eliminate the deficit, fund the NHS, control immigration, and give hope to the young?  The best question was the last one, because it was the most open-ended, encompassing the challenges of getting an education, getting a job, getting a house, getting a pension.  In other respects, this was not so much a political debate, as a work-shop for middle management.  To spark a debate, you need to ask the right question.

I remember another debate.  Ten years ago, in Baruch College in New York, two combative orators debated the motion “that the 2003 invasion of Iraq was necessary and just”.  The debaters were George Galloway and the late Christopher Hitchens.  Both speakers were compelling.  They both had a remarkable gift, but their styles were different: Galloway, oratorical, rhetorical, intense; Hitchens, lower pitched, conversational, but no less mesmerising.  Both had coherence, fluidity, and mastery of the brief.  Their points of view were diametrically opposed, Hitchens for the war, Galloway against it.  There was no love lost between the contestants.  The encounter was bitter, bruising, and acrimonious.  You can see the US audience, so used to politeness in public discourse, wondering if they can believe their ears.  Mr Hitchens called Mr Galloway “a disgrace”, and Mr Galloway called Mr Hitchens “a slug”.  Then it got personal.

Yet, for all the vituperation, the chairperson, Amy Goodman, never had any difficulty maintaining order.  Mr Galloway and Mr Hitchens for the most part listened to one another in silence.  Thus they were both able skilfully to debate what they were respectively hearing.  I’m still not sure who, in terms of performance, won that debate; but at least there was a clear choice to be made.

So what question would I have put to the seven party leaders last Thursday?  This:

How can we all get on together, without destroying one another, and the planet?

This is the seminal question for our time.  You might argue that it has been a question for all time, but the reason why it is specifically our question is that it is only in our time that we have had the capacity to destroy both ourselves and the planet.  Therefore we have ownership of, and responsibility for, this question.  And yet we continually duck it.  Something else happened on Thursday that made the leaders’ debate seem utterly parochial.  Driving home in the early evening I heard on Radio 4 about the attack on Garissa University in Kenya.  It was still breaking news but it was already clear that the number of fatalities was going to be very large.  Back home, I switched on BBC 1 to catch the 6 o’clock news and was amazed that the news of the attack had been pushed down the schedule by a prolonged trailer for a televised event in Salford that was yet to take place.

Something comes to mind… something about rearranging the deckchairs on board the Titanic.

I saw a clip on TV this week of the grand culmination of Richard III’s trip from an anonymous urban car park to Leicester Cathedral, and was struck by the way a sizeable crowd of people lining the streets, perhaps six deep, were casting white roses on to the royal coffin.  It reminded me of similar scenes during the funeral of the Princess of Wales in 1997.  The death of the Princess of Wales was an event that, according to her brother, left the world, “in shock”.  I know this because I was in Queenstown, New Zealand, when her car crashed in Paris, and the following day I flew to Little Rock, Arkansas, where I also found a lot of Americans to be “in shock”, glued to the TV, looking for “closure”. The inference to be made is that, in both life and death, many members of the public feel a strong connection with royal personages, and interpret the narrative of their own lives through the prism of those who are perceived to be making, or to have made, history.

So I got out a history book and read about Richard III and the Wars of the Roses.  I’m woefully ignorant about the Plantagenet dynasty, or, closer to home for that matter, the Stuarts.  Perhaps Mr Gove was right, before he left the Education Ministry to become Chief Whip.  Maybe I need to learn all these dates to get a sense of chronology.  1066 and all that.

And yet the same thing always happens to me when I delve back into history in this way.  First I get confused by the complexities of the intrigues of the nobility; who plotted against whom, who changed sides, who scrambled up the greasy pole to the “slipper toppe”, only to be knocked off and replaced.  Then I get sickened.  All that gore; all these beheadings.  It’s profoundly distasteful, like watching two grown men brawling in the street.   And it’s just as bad north of the border, maybe even worse.  Up here, I get “scunnered”.  Sometimes I think history is just a memoir of the filthy rich vying with one another to get their snouts deeper into the trough.  But I wonder if this is really history at all, in any useful or meaningful sense.  I have this notion that all these battles, murders, and executions are a kind of “antihistory” and that, alongside this bloody chronology, quietly occupying an almost invisible parallel universe, history is taking place.

This week I’ve been reading a very interesting book about the development of the contraceptive pill.  The Birth of the Pill, by Jonathan Eig (MacMillan, 2015).  Have you heard of Margaret Sanger, and Gregory Pincus?   Many of the people who truly make history seem to pass by unnoticed.  If history is anything, it should be a kind of Grand Integral, the sum-total of all the little bits of history that make up the lives of individuals.  Inevitably, most of it gets lost.  How much of the remainder is misinterpreted and distorted?  It’s the caprice of memory.  As soon as something happens it becomes murky.  It’s as if we lead our lives by walking along the road in a thick mist, with visibility down to a few metres.  We can’t see ahead; we look back and everything is receding into the fog.

History has a special meaning in Medicine.  The single most important skill of a doctor is the ability to take a history.  You say, “What happened?” and then you go into a trance and try to relive it.  Of course you are aware that what is offered you is only an approximation of the truth.  I once observed the late Henry Walton, Professor of Psychiatry at Edinburgh, take from his patient a history that was a self-serving, sanitised, cosmetic version of reality.  Then the Professor undercut it with a single, cripplingly hurtful comment that, for the first time, permitted the patient to confront the truth, and to be free.

It’s very hard to get at the truth.  We’re always trying to interpret Chinese whispers.  Yet we should try.  There is Santayana’s famous remark that those who cannot remember the past are condemned to repeat it.  Then there’s Henry Ford: “History is bunk!”

They can’t both be right.

Ever since the banks crashed in 2008, austerity has had a bad press.  The politicians hijacked the word and used it as a shorthand for a particular economic policy characterised by public spending cuts.  “Austerity” has become a euphemism for “poverty”.  This seems to me to be a misuse of language.  I don’t care for poverty, but I’m a fan of austerity.

For instance I like austere music.  Do you know the music of Edmund Rubbra?  English composer, 1901-86.  Nobody does austere like Rubbra.  I’ve just looked him up in my Britannica (1991 edition) and he’s not there. He has no entry, and he’s not even in the index.  I find that quite astonishing.  He composed eleven symphonies.  My favourites are Nos 7 and 8, but with the approach of Easter I particularly mention here No 9, the Symphonia Sacra, opus 140, completed in 1972.  It is subtitled “The Resurrection”, and tells the story of Jesus from the crucifixion to the ascension.  It is very beautiful.  You never hear it.

As you get older, austerity becomes more and more attractive.  You lose the urge to material acquisition.  Towards the end of her life, whenever my mother was presented with a gift, a look of horror would come over her face and I knew exactly what she was thinking:  oh no, not another mantelpiece trinket, another item of apparel, more plate, more bric-a-brac.

I passed a jewellery shop yesterday and paused to look at the wrist watches in the shop window.  Some had a price tag of £6,000.  Clearly some people aren’t suffering from austerity.  Why on earth would you spend £6,000 on a wrist watch?  Maybe such a timepiece is fantastically accurate, like an atomic clock.  But no, it’s really a piece of bling.  You wear it like a badge.  It’s a statement; it says something about you.  You probably also drive an expensive car.

Other commodities can have fantastically inflated prices.  Dinner at a posh restaurant, real estate, wine, Art.  You can generally tell you are about to be ripped off if the language of the sales pitch becomes absurd.  When the menu describes your fish and chips as “Fillet of halibut enjambments in a cataclysmic farce of coulis-drenched pommes frites compotes (£32.50) – mind your wallet.  Occasionally you hear in the news of a disgraceful junket when a dozen public officials go out to dinner and you and I pick up the tab at £50,000.  What could possibly taste that good?

Well, it’s conspicuous consumption.  There is that marvellous line in Jonson’s Volpone:

“Could we get the phoenix, though nature lost her kind, she were our dish.”

Acquisitiveness is surely a form of addiction.  The appetite can never be satisfied, you can never get enough.  I feel sorry for politicians who get stung by undercover media people posing as Chinese businessmen buying lobbying favours.  Anyone who feels they need (or are “entitled to”) £5,000 for half a day’s work is surely in thrall to something from which they can’t escape.  How can the rich be helped to break free?  They need the help and guidance of the poor,  After all, we’re all in this together.  It’s such a liberation to come to the realisation that you have enough; you don’t need any more stuff.  Let it go.  Pare down.  Embrace austerity.  Listen to Rubbra 9.  Take the walk from Jerusalem to Emmaus.