Professor Andrew Lees, renowned neurologist and expert on Parkinson’s disease, reflects movingly on his medical education.
Written on the tombstone next to my grandpa’s grave were the words, “In some new brain the sleeping dust will waken,” an epitaph that encouraged me to go on believing that death was a prolonged slumber. Before I went to medical college. I had never had chance to examine a corpse let alone watch its soul on its journey towards the light. Death was hidden and not a fact of life. It was something that happened to birds and old people.
Six to a cadaver we stood motionless in gleaming white coats clutching our dissecting manuals. Mr Wolynski aged 67 looked as if he had been in a fight. His eyes were wide open and his hair was stuck to his scalp with what looked like coagulated blood. When I touched him his arms felt like sculpted damp clay. Lashley mumbled, ‘This is how we will all end up.’ As I cleaned and traced reflecting fascia with my scalpel one of the surgical demonstrators told me to try to visualise the relationships of the exposed tissues and remember their relative depth from the skin surface.
My cell had a single bed, a washbasin, a wardrobe with a glass mirror and an electric fire fastened to the wall. After washing my hands to try to remove the musty sickliness of the dissection room I began my nightly task of learning by rote the shape, the origins and insertions, the nerve supply and the function of each pair of muscles. I then pictured in my mind their surface anatomy with the aid of a poster of Charles Atlas., the Italian-American bodybuilder. New words like distal and proximal, anterior and posterior, ventral and dorsal, medial and lateral, rostral and caudal, superior and inferior were included in the obligatory burden of text used to describe in words the location of arteries and veins I had exposed in Mr Wolynski’s bloodless flesh. Lewd acronyms helped me to memorise lists. The intricacy of his brachial plexus was allowing me to appreciate the exquisite workmanship of life.
By January the 12 dead people had departed and all I saw when I entered the dissection room were stale formaldehyde stiffs with vandalised limbs and eviscerated torsos. The mask guarding the intimate secrets of the body had now been peeled away forcing me to confront my own eventual decomposition. Dismemberment was a hallowed initiation rite essential to the teaching of human anatomy that had changed little since the days of Leonardo and Vesalius. The location of The London Hospital in the poorest part of the capital meant that there had always been a plentiful supply of unclaimed paupers and foreign seamen with gross disease to cut up. The college museum was filled with surgical specimens in pots and jars, The lower level with a central walkway was crowded with pathological exhibits where the skeleton of Joseph Merrick (The Elephant Man) was an atmospheric presence during our seminars.
As I hurried from the medical college to the Tube, I often saw people with physical impairments and disfigurements. There was a small woman in a shawl with no nose, a homeless man with a lump the size of an orange on the top of his head and an elderly man with a bamboo spine that pivoted him forwards in a way that made it appear as if his head was controlled by a marionette string. In the knitwork of terraced streets behind the hospital I encountered a woman who was walking backwards towards me.
The hospital in contrast to the college was a hurly-burly place where groups of people scurried, paused and intermingled, regrouped and moved on, wrapped in thought, nurses with status defined by the colour of their uniforms, midwives in blue, lithe physiotherapists, lab technician carrying wire baskets full of rubber bunged test tubes, smartly dressed porters pushing patients in wheelchairs fastened to drips, doctors in white coats in earnest conversation in the corridors, patients on crutches, patients on stretchers, patients on drips and families clutching bunches of flowers.
My tutors reminded me that medicine was a calling requiring self-sacrifice and courage. A physician’s life’s work was to prevent disease, relieve suffering and heal the sick. Treatment should be evidential but clinical care must always be personal and intimate. When there was no cure a good character and kindliness were powerful healing forces. I was required to learn by heart Hutchinson’s prayer:
From inability to let well alone, from too much zeal for the new and contempt for what is old, from putting knowledge before wisdom, science before art and cleverness before common sense, from treating patients as cases and from making the cure of the disease more grievous than the endurance of the same, good Lord deliver us.
I now saw Mr Wolynski as my first patient. His sacrifice had provided me with restitution and a lasting feeling of gratitude. In compiling a carnal index of vital structures I had learned respect and humility. I regretted I would never know his stories of looking out to sea from the deck of a freighter.
Although medical students were not directly involved in clinical care on the wards, I was encouraged to discuss my findings with the house officer and my case notes were inserted into the patient’s dossier. In comparison with the official records my version of the patient’s story was copious, less structured and replete with red herrings and irrelevancies. Once or twice though I noticed glaringly obvious things that the junior doctor’s dulled perception had overlooked.
On one memorable day on the second medical firm the senior registrar decided to teach us about diabetes mellitus. He began by telling us that Diabetes was Greek for siphon but the Romans had added the Latin word mellitus for sweet because they noticed that bees were attracted to the sufferer’s urine. He then went into the sluice room and came out with a sample. He proceeded to dip his finger into the urine and then sucked it suggesting to us he had tasted sugar. He then asked us all to do the same. He looked us with a triumphant smile on his face and said, “Today you have learned an important clinical lesson relating to the importance of observation. None of you noticed that I dipped my middle finger into the urine but licked my index finger”
A strong Jewish vibe still prevailed on the streets of Whitechapel when I lived there as a student. Men with side curls dressed in wide brimmed black homburgs, below knee black coats and shining white shirts glanced at me shrewdly with eyes steeped in the mystery of the East. There were others in trilbies and well cut shabby suits carrying brief cases under the arms and muttering conspiratorially to one another as they walked purposefully down the High Street. Bangladeshis and Bengalis had just started to move into Brick Lane. One of the old French Huguenot churches had been converted into a mosque and the first halal butcher had arrived to join the kosher meat trade. On a visit to one of the first Indian restaurants that opened close to the hospital I noticed that one of the waiter’s hands and teeth were stained reddish black, which I learned later was caused by chewing the betel nut, an Asian symbol of love that gave a kick six times that of an espresso but was as carcinogenic as the Cape asbestos factory in Barking.
What happened outside the hospital had the potential to affect what occurred within it and I understood early on that my inspiration for study should not be restricted to the lecture theatres or even the hospital wards. I also needed to be out on the streets observing, listening and touching. I was curious about my patients’ lives and if something affected them then it ought to affect me too. I wanted to try to put myself in their shoes and not only make accurate diagnoses.
As I rotated through different hospital departments, I came to realise that although medicine aspired to be a science it was full of hasty generalisations and imperfect observations. I was learning a tried and tested method that involved the painstaking gathering of uncertain and incomplete information through listening, observing and touching. Anecdotes were not scorned as some sort of inferior unreliable evidence but were valued as an efficient way of grasping new knowledge, personal testimony had been the first step in many important medical discoveries and they carried significance way beyond the particulars they recounted. Some of the diva doctors gave out words of advice or consolation as if it were a divine gift from on high while others incapable of admitting failure concealed their inadequacy and ignorance through the use of Greek and Latin euphemisms and pompous meaningless words like idiopathic. But there were others who I warmed to, that emphasised that doctors should always question every action they took on a daily basis and that rules should be broken if in all good conscience it was felt that by doing so a life could be saved. They helped me to make sense of things that seemed unjust and unfair and taught me it was better to believe in therapeutic nonsense than adhere to therapeutic nihilism. They loved their work and made me understand that there was no place in clinical medicine for a pessimist. It was impossible to be a good doctor without acquiring a lot of facts but the best instructors gave the shortest reading lists and warned me that there was a danger of being over-educated and under-cultivated.
My studies led me to the view that the soul did not occupy the mind or the brain and could never know itself. It was responsible for those dreams that had disappeared for good at 14 where I had soared high above the land bouncing on white clouds. It came from somewhere deep inside, was heartfelt and. something I should bring with my validating science to the bedside.
A.J. Lees
The National Hospital, Queen Square, London WC1N3BG
Andrew Lees is a Professor of Neurology at the National Hospital, Queen Square and at University College London. He is one of the three most highly cited researchers in the world in the field of Parkinson’s disease and was awarded the American Academy of Neurology Lifetime Achievement Award in 2006. He is also a writer; his last two books Brazil That Never Was (2020) and Mentored by a Madman: The William Burroughs Experiment (2016) have been published by Notting Hill Editions and the New York Review of Books. He can be found on Twitter @ajlees and at andrew.lees@ucl.ac.uk.
