Tuesday, August 25, 2020

Corona Diary Part 12. Monday August 3rd to Tuesday August 25th

 

Monday August 3rd

 

Davina Thompson was the first person in the world to receive a triple transplant – heart, lungs, liver, in late 1986.  Her face, lovely smile, and extraordinary character came back to me in an instant when I read of the death of Professor Roger Williams, the liver specialist, who established the world famous liver unit at King’s College Hospital, where I worked for many years in the 1970s and 1980s.  I don’t know what it is about extraordinary pioneers, but there are some readily recognisable characteristics, and Roger Williams had these in spades.  Firstly, he was clearly very intelligent and gifted.  Secondly, he had enormous drive.  A twelve-hour day was the norm.  Thirdly, though there are obviously some fourthly and fifthlies, he did not care much about setbacks or criticism, and almost always overcame them.  There are some who would say that this characteristic is an ability to ride roughshod over authority, and Roger was certainly able to do this, and indeed seemed to derive some pleasure in doing this on occasion.  For example, the Professor of Medicine during Roger’s early years at King’s was a much less gifted individual who nonetheless had some reputation in bone metabolism.  He had ordered a device for cutting thin sections of bone for microscopic study, a large and expensive piece of equipment destined for an underutilised area in the medical school, but he did not follow through on his plan to supervise this himself.  As a result, some six months after the supposed installation of the bone-cutter, the Prof was showing some visiting overseas specialists around King’s.  ‘And this’, he said, as he swung the door of the lab open, ‘Is the bone-cutter room…’  The bone-cutter, unused, had been parked in a corner, and everywhere he looked, white-coated research scientists were at work, pipetting reagents into test tubes, looking down microscopes, setting up chromatographic columns.  Needless to say, this was Roger Williams’ nascent research laboratory under way.  Exit speechless Professor.

 

Another typical Williams strategy which did not endear him to other consultants on the staff at King’s was the way in which he always commandeered a car parking space in pole position at the front of the hospital.  If he had been called away to see a patient at the Cromwell Hospital, for example, when about to return, he would send his secretary down to stand outside the building in the car park and bodily block a space until Roger’s own car steamed in.  On one occasion this almost led to injury when another (nameless) consultant physically pushed the poor secretary out of the way with his own car.

 

Mrs Thompson had been admitted to the liver unit for further investigation in 1986, and a cardiac opinion was requested.  She was suffering from an advanced liver condition, primary biliary cirrhosis, and a liver transplant was being considered.  As the ‘new boy’ in the cardiac department (only two years into my consultancy) I was deputed to ‘pop up to Roger’s ward and take a look at this lady.’  Mrs Thompson was breathless as well as jaundiced and I brought her back to our department for an echocardiogram.  I went to report on the findings to Professor Williams and he asked me for a full workup of her heart which included a right and left heart catheterisation procedure.  The preliminary findings suggested that she had fibrosing alveolitis, an associated lung condition that sometimes occurs in PBC.  When we undertake catheterisation procedures the patient is conscious, but we use local anaesthetic so that the study should be pain free.  Patients are understandably always scared however, and one very underrated skill of a cardiac operator is to chat to the patient during the procedure, explain what is going on, and put them at their ease.  I always like to take the opportunity to ask the patients about themselves and give them to chance to talk freely.  In Mrs Thompson’s case, I was aghast.  She came from a mining area in South Yorkshire, had had to leave her daughter at home when she came down to London, and her husband, a miner, was effectively out of work due to the miners’ strikes.  I felt desperately sorry for her.  Not only the domestic issues, but a real life limiting major disease to cope with seemed just so unfair.

 

Roger’s clinical presentation rounds were always held in his liver unit seminar room on a Saturday morning.  Attendance from everyone who worked for or with him was mandatory.  In addition, one of the registrars would have to examine the case blind, formulate a diagnosis, and give a treatment plan.  It was like going into the courtroom to argue with Judge Jeffreys.  Roger’s style of teaching would not be condoned today, but it was certainly effective.  You never forgot an experience in that cauldron.  In view of the fact that I was both a consultant, albeit a junior one, and also from a different unit, Roger always treated me courteously and kindly.  The same politeness did not extend to his juniors.  Fortunately, the registrar that day was a very switched on individual, and he was able to detect the signs of pulmonary hypertension, the prominent right ventricular ‘heave’ as it is called, though Roger called him to task for failing to hear the loud pulmonary second sound in the pulmonary area just to the upper left of the sternum.  ‘So what are we going to do about it?’  Queried the Prof.  ‘Well, sir, we could transplant lungs as well’, came the reply.  ‘What does Dr McLeod think?’, enquired Williams.  ‘Well, sir, as I’m sure you know, in pulmonary hypertension, you have to transplant both heart and lungs.  If you just transplant a heart, it cannot cope with the high pressure in the lungs.  If you just transplant the lungs, the damaged heart will fail anyway.’  ‘So’, came the reply, ‘We would have to think about a triple transplant.  Lungs, heart, liver.’  ‘Yes, Professor.’  ‘Hmm’, was the response.  I’ll talk to Professor Calne and see what he thinks.’

 

And that was it.  Sadly, I never met up with Mrs Thompson again, but she survived her pioneering operation with a good quality of life for a further twelve years.  In my brief meetings with her I found her to be a truly lovely person.  Everything I have written above is true, and because of the wide publicity it is all in the public domain, so I do not believe I have transgressed any confidentiality.

 

 

Tuesday August 4th

 

Awake from about 0430.  Tried listening to some relaxing music, placed the eye cover on to block the rather too bright light from my Sony radio alarm clock, which has worked so well for about 20 years, so I have been loth to replace it.  No success.  Remember that I was woken in the middle of explaining what was going on at a cardiac catheterisation to a junior doctor who could not understand what he was seeing.  The catheter was in the left coronary artery.  A tiny amount of contrast medium flowed in to a vessel which terminated within half a centimetre of its origin.  A nub of contrast.  ‘What’s going on?  I don’t understand.’  ‘It’s all right.  The left main coronary is blocked.  All the supply is from the right side.’  ‘How do you know?’  ‘Simple, the patient is alive, isn’t he?  The blood must be getting to his heart from somewhere.’  Wakefulness put an end to the clinical scenario, and eventually I got up and started in on the next few weeks of diary entry.

 

Saturday August 8th

 

The weather has been good and getting hotter.  Temperatures in the high 30s.  Apart from some pleasant golf in midweek I was privileged to go fishing yesterday, and out on the water it was at least a little cooler than indoors.  We motored down to Christchurch Ledge and drifted with the tide.  On the way, we passed the Aurora and the Arcadia, the unused P&O cruise liners.  Both of them looked a little tired, with rusty paintwork, and the Aurora had a substantial dent in the port stern quarter.  This was followed by a lovely evening yesterday in a friend’s garden with champagne, two different Malbecs, one French, one Argentinian, and the remains of the Hauner Sicilian Malvasia.

 

The weather remains unpleasantly hot; just okay sitting outside in the shade, but in our rental house the converted roof space means our bedroom is at 31deg C.  Not good for sleeping.  Almost like North Carolina.  I remember when living there and the Fall arrived, people used to talk about ‘Good Sleepin’ Weather’, and here in Poole at the moment, it is not good sleepin’ weather.

 

Sunday August 9th

 

A five mile walk in the New Forest.  Lovely, especially in the shady inclosures.  Some thatched cottages at Hale, and the beautiful Thomas Archer designed Palladian Hale House.  A memorial to him (architect of Chatsworth, Chettle House, and St John’s, Smith Square) stands in the little church nearby.  A reminder of bygone plagues – his first wife died within a year of their marriage from smallpox.

 

Hale House (1715), New Forest

Memorial (in Latin) to Thomas Archer.  Note 'Variolarum Lue', another plague (Smallpox)



Monday August 10th

 

It is just too hot to sit up here in our little office and type a diary.  So this will be resumed another day.  Some may have noted however that I have lost interest in the coronavirus, having devoted so much space to it early on.  There is a clear cut upsurge in cases over the last four weeks, but interestingly no uptick (as it’s now known) in deaths.  Perhaps the congregating young are the cases and their mortality is low?  Don’t know.  Our heatwave is echoed on the continent (vague du chaleur, or canicule, in France), but it is worse.

 

Friday August 14th

 

We have now come out of the one-week heatwave.  The last three days have been punishingly hot.  At times I have thought I was back in North Carolina.  The Seniors golf tour to Devon went ahead this week – with numbers reduced from 32 to the ‘Valiant 9’, but social distancing seemed fairly well observed.  We stayed in the Best Western Dartmouth Golf Hotel and Spa, which I would describe as cheap and cheerful, but was good value for money.  The staff were unfailingly helpful and friendly and one felt sorry for them working and serving behind visors, especially in the heat.  The River Exe mussels on the menu were excellent, though the plaice came with cockles (to which I’m possibly allergic) and was only slightly larger than the plaice we threw back when fishing the other day.  But a good time was had by all.  Golf at Churston, which is near Paignton was excellent, but the Dartmouth course was spectacular, with a lot of climbing and descending those steep little Devon valleys.  Nice to renew acquaintance with that distinctive red Devon soil again, which now ingrains the sole and grooves of my clubs.  Our last day was at Thurlestone, which was besieged by har on arrival, but which later cleared to give those views which are so spectacular, particularly on the further parts of the course which overlook Bantham, the Aune estuary, and the famous Burgh Island with its Art Deco hotel.  The hotel, as is widely known was the location for the famous Agatha Christie book, ‘And then there were none’, which is an unusual book in that it has been through three metamorphoses of name.

A challenging par 3 at Dartmouth Golf and Country Club


The weather broke in dramatic fashion in the evening with monsoon-like thundery rain, and this morning is overcast, humid, and a touch gloomy.

 

Watching the news again this morning, there is a plethora of what I previously called ‘talking heads’, but which a friend reminded me the other day are called in the media ‘Vox Pops’.  Vox Populi, Vox Dei is surely a contradiction in terms.  Today the vox pops are related to the predicted grades for A level students which came out yesterday, and have caused many to be disgruntled.  The BBC is quick to focus on the suggestion that predicted grades for posh private schools are thought to be higher than ordinary schools.

 

Cricket has resumed in the second test match against Pakistan, in Southampton.  There were rain interruptions yesterday, and a delayed start this morning.

 

During the last week I received a moving message from a close friend and former nursing colleague, who has endured multiple surgical procedures for primary and metastatic bowel cancer (chiefly liver), and for whom no more can be done.  She has always been something of a ‘wild child’, though I hasten to add, in her career, absolutely committed and professional.  She told me some time back she was looking forward to some druggy bliss, and floating away.  Subsequently, with Krukenberg tumours and drains for peritoneal ascites, she has gone through so much uncomplainingly.  Offering to visit, and/or to supply home-made marmalade which I know she loves, she writes in reply (direct quote): ‘Very weak at the moment with my two syringe drivers.  Just about able to converse for 20 mins so don’t really see anyone in real-time.  Getting weaker every day.  Just wish I could hurry up and die.  It’s very boring waiting to go!!!!!  Love to you both…’  What a person.

 

In complete contrast to the previous paragraph, and to lighten the mood, another story surfaced early this week.  An approach was made by a White House official to the governor of South Dakota, with the possible suggestion that the famous Mount Rushmore carvings of Presidents Washington, Jefferson, Theodore Roosevelt, and Lincoln be extended to include President Trump.  The governor thought this was hilarious, until she realised that the White House emissary was not joking.

 

Finally, the other day, I saw that BBC4 were to screen a recording of Mahler 8 (the Symphony of a Thousand) in a performance from the Royal Albert Hall, conducted by Simon Rattle.  It featured the National Youth Orchestra, and combined total of soloists and choirs of around 800 people.  I watched with love and awe – the scale of the orchestra was fantastic.  The young man with his mandolin, a total of four harpists, and at the end, a kiss on both cheeks from Rattle for the young leader of the orchestra – will we ever see scenes like this again?  It took me back to the only time I’ve seen it live, in 1973, at the same venue… wonderful.

 

Wednesday August 19th

 

Torrential rain today allows time to catch up on a number of things, particularly the diary.  Following many months of aches and pains (I won’t bore with detail) I have an appointment with a rheumatologist later this week.  It is the lot of ageing folk to look with envy on the exploits of the younger.  Last night we were talking about friends who have moved to Lymington and how their bike excursions take them up and around the Beaulieu river, and I was reminded of the John Betjeman poem ‘Youth and Age on Beaulieu River, Hants’ (I think that’s the title), which I first came across, not in my collected edition of his poems, but on an LP (for younger readers that stands for Long Player, a vinyl disc 12 inches in diameter which rotates at 33⅓ rpm, the transducer being a diamond mounted on a piezo electric crystal [stylus]), entitled ‘Betjeman’s Banana Blush’, a collaboration between Betjeman and the remarkable musician and arranger, Jim Parker.  Parker’s music perfectly complements the beauty of the spoken word.  You could try this link: https://m.youtube.com/watch?v=UsNliZAN_7y

And for the record, I am ‘Mrs Fairclough, sipping tea…’

 

About three years ago, my daughter and her partner completed the ‘French Divide’ (qv), a bicycle endurance event, not a race, from Bray-Dunes, near Dunkirk, to Mendionde in the Pyrenees, mostly off road.  And this year’s iteration has been happening, with the leader completing the course of 2400 Km in 9 days.  I would love to do this event – but sadly there is a time limit of 15 days.  I think I could manage it in a month or two.  It was during the briefing for this event that I learnt that if you need fresh drinking water in France, the best place to head for is a cemetery.  Apparently there is some sort of national edict requiring local authorities to provide fresh water in cemeteries– the intent being to maintain flowers on graves.

 

This week has been notable for the fallout of the catastrophic attempts to give A level results when there have been no A level exams (for US friends they are the high school graduation tests which essentially determine whether you get to University or not).  It seems the government have been desperate to avoid ‘grade inflation’ so some sort of algorithm has been used to give results, rather than the pupils’ own teachers’ predictions.  Much distress all round.  This Thursday the lower level GCSE exam results will appear, based on teacher assessments, and a week later the algorithmic results, and pupils will be allowed to choose the higher grade from the two methods.  GCSE results are of no real use to man nor beast, unless you leave school at 16, but no doubt there will be a lot of anger and aggro.  The vox pops this week have been many – angry students not getting to University etcetera.  When I was their age I used to think that Universities were only there for really bright people, but now I realise that the higher education sector is yet another Leviathan, dependent on getting ‘bums on seats’ to secure its funding, and to a large extent merely self-perpetuating degree courses to sustain so-called academics who are not particularly academic at all.  I heard an interview with a teacher who clearly did not know the difference between ‘less’ and ‘fewer’ – she referred to ‘less places at University’ for example.  I despair.

 

Language should always adapt and change, but precision is also important.  Another irritant these days is the PC attempt to desexualise words – the word ‘actor’ is now used to describe actor and actress, for example.  Hero is another word and case in point.  Nobody seems to like to use the word ‘heroine’ nowadays, no doubt for PC reasons too.  Should we be describing the unfortunate South African runner, Caster Semenya, as a ‘heroine’?  Interested parties might enjoy ‘The Conversation’, https://theconversation.com/ten-ethical-flaws-in-the-caster-semenya-decision-on-intersex-in-sport-116448

 

As I write, it is pouring with rain, so golf today is off.

 

The US election campaign is hotting up with much malevolence on the Trump side following the launch of the Democrats’ initial session.  A post on Facebook by a friend speaking of the mess with A level results refers to the malevolence of the present government, thus revealing herself as a probable Guardian reader, but speaking as a hawkish Right Wing Socialist (which is probably how I portray myself) I think the correct word should be ‘incompetence’ rather than malevolence.

 

So now to something really important, and sad to report, the death of Julian Bream, one of my heroes (that word again).  Not only was he a wonderful guitarist who pioneered the classical guitar in Britain, before John Williams came along, but he also did a huge amount of good work rekindling interest in the lute and Elizabethan consort music.  Much of his consort work was in the 1960s, so I was very lucky to hear a late-night Prom sometime in the late 1970s where he reconvened many of his friends to play in a London church.  I also heard him a number of times in recital and was privileged to be introduced to him during a recital by Martin Best in the church of St James in Kingston, Dorset.  The other day I heard the new kid on the block, Sean Shibe, playing Bach’s first lute suite.  The technique was breathtaking.  But my old recording of Bream playing the work, at a much slower tempo, is much nicer.

 

Musically speaking, I am on guitar what in golf we would term a ‘handicap player’, so it was always a pleasure to me to see how hard Bream had to concentrate and to work to produce the music that he did.  I remember him playing a transcription of the 6th Bach cello suite.  He said that the cello suites got harder as they went from 1 to 6 (I don’t know if that is true), and the effort needed to play it was transfixing.  I also saw John Williams a number of times and the feeling with him was one of coldness and detachment, not that he wasn’t a magnificent player.  I mentioned this one day to a musical friend who observed in a down-to-earth nonsequitur, ‘Yes, but he bonked Anna Ford, didn’t he?’  There is no answer to that.

 

My original recording of the Rodrigo guitar concerto was the 10-inch LP by Narciso Yepes, for some years the only one available.  When Bream’s recording came out in about 1967 I bought it, but was also entranced by the section on the album where Bream’s consort played his own arrangements of the ‘Courtly Dances from Gloriana’ by Benjamin Britten.  They are fantastic.  If you don’t believe me, here is a fascinating piece of trivia: they were selected by Paul McCartney as one of his Desert Island Discs.  It’s true.  The sense of astonishment is similar to that which visited me when I heard that one of David Beckham’s choices was ‘Si Tu Vois Ma Mère’ by the jazz soprano saxophonist Sidney Bechet.  Bechet was originally a clarinettist but discovered the straight soprano saxophone during a visit to London.  The piece can be played on either instrument.  I accompanied the late John Oliver in a school concert while he played it on the clarinet and I strummed the guitar chords that he had written out for me.  A far cry from King Edward’s school concerts is perhaps the most beautiful modern version - by the French group ‘Avalon Jazz Band’ – check them out on Youtube.  Their version of Charles Trenet’s ‘Ménilmontant’ is also breathtaking.  Django Reinhart-style guitar playing.  Super.

 

My diary has wandered far from the Corona days.  Nobody seems to know where we are going with it.  There has been a significant upturn in cases without a commensurate increase in mortality.  Wider testing of milder symptoms, some asymptomatic individuals from track and trace, and the increased spread among young and therefore healthier subjects is thought to be the cause.

 

I am due to join a walking group in North Dorset.  For most of this summer we have walked in approach shoes, but following the rain I feel I should wear boots.  To be on the safe and secure side I get out my Leki walking poles – they have cobwebs on them.

 

A final shoutout for Trump.  Following the recent story of the Mount Rushmore enquiry, some wag has doctored a photo of the mountain showing the four presidents with stone hands over their faces.

 

Sunday August 23rd

 

My father would have been 102 today.  Exactly two years ago I climbed Schiehallion with a friend.  It was a favourite mountain of my father’s.  I had never climbed it.  For at least half the ascent there are boulders strewn in random fashion and there is no real path.  Although the vertical climbed is minimal – one starts at several hundred metres of elevation, the ground underfoot is better suited to mountain goats.  On the way down, we stop, and in an unguarded moment, I turn to my friend, miss my footing, and bang, fall.  The rocks are hard.  So concerned about the bash on my leg which hurts a lot and makes me wonder if it’s broken (it isn’t), I don’t notice the complete subluxation of my right little finger until I try to grip my pole.  My friend puts it back.  There is so much pain from my leg and hip I don’t notice the pain from the reduction.  So now I am left with a crooked little finger, a memento to remember my Dad by.

 

It was with a sense of ennui d’automne that I drove northwest from Poole, skirting Wimborne, and started out on the road that leads past Kingston Lacy, with its magnificent avenue of beech trees, and turned north up the Tarrant valley to join friends for a walk.  The wheat fields had been cut and neatly rolled cylinders of straw dotted the landscape.  No sheaves or stooks as I remember from my childhood but efficiently machine rolled butts of pale yellow.  The sun shone after rain and fleecy clouds drifted overhead.  In the church yard at Tarrant Monkton, beside which I parked, the beautiful small building of All Saints, built of stone and flint, stood in silent modesty.  Parts of this date back to 1400 (the chancel), but my eyes were caught by other memento mori, the weathered and lichen-clad headstones.  On the stone commemorating a woman who died in 1880, there is the following:

 

            This languishing head is at rest

            Its thinking and aching are o’er

            This quiet immovable breast

            Is heaved by affliction no more.

 

Amen to that.  Our walk takes us East out of the valley up an old drove track, and looking northwest over towards Cranborne Chase.  Through fields and woodland, purpled with elderberries, where pheasants cluck and whirr, and martins flutter, to the hamlet of Manston before winding back by a more southerly route.  It’s a time to chat with walking colleagues not seen since before lockdown, and the heat of the sun is such to allow me to put the car roof down to meander back past Badbury Rings and Wimborne.




All Tarrant Monkton and above the Tarrant Valley


 

In such an elegiac mood of Weltschmerz, it would be easy to dwell on impermanence, put on Strauss’s Four Last songs, and drift away, but eventually the real world returns (‘Life is real, life is earnest’) and it is back to the here and now.

 

A front page headline caught my eye the other day.  Some academic doctor in Bristol has stated that we must not use the term ‘turning blue’ because it is racist.  To elaborate, he seems to think that because Black people cannot turn blue, we should not be using the term.  Since he is presumably a modern creature and may not have done Latin at school I suggest we substitute the term ‘cyanosis’.  Anyway, he is wrong.  If a black person is cyanotic one can see it in the mucosae and fingernail beds, the areas where we always teach medical students to look because ‘central’ cyanosis is usually more important than ‘peripheral’ cyanosis.  This political correctness is really getting me down at times.

 

Nice ‘phone call from my younger daughter who is off to Tuscany.  Great.  Sensible small Air B&B type accommodation.

 

Spend ages trying to draw to scale how I would like my walk-in wardrobe to be constructed.  With a minimalist house and no attic, there is a small room for clothes storage for each of us, and everything is to be tidied away, a bit like a well-organized yacht.  I might have to change the habits of a lifetime.

 

And a visit to a rheumatologist to discover that my hip pain is not arthritis or myeloma from my IgM paraprotein, that axillary skin tags are not mycosis fungoides (I had worked that one out), and that my backache is spinal stenosis which is not severe enough to require operation.  Anno domini seems to be the watchword for this week.

 

The end of the week has been cheered by England’s performance in the Test match against Pakistan, where after crumbling to around 100 for 4, a stand of over 300 runs by Crawley and Buttler has allowed England to declare on 583 for 8, and Pakistan are currently 77 for 5.  What is it about sport at the national level that lifts us, encourages us, and warms the heart?

                                                                                    

I must now get back to ‘To Kill A Mockingbird’, the current choice for the book club.  Re-reading and musing over it, the power of the narrative and the setting of 1935 Alabama, with the terrible miscarriage of justice, it remains such a powerful book.  But there seem to me to be huge problems with it as a text for schools.  The vocabulary of the Southern USA is completely alien to most UK readers.  Who has heard of scuppernongs, kudzu, Hoover carts, and chinaberry trees, for example?  It is also hard to get the image of Atticus played by Gregory Peck in the film out of one’s mind.  Peck justifiably won the Oscar in 1963 for best actor.  Apparently he was so entranced by the book he read it in a single night.  ‘In the Heat of the Night’ you might say.

 

Monday August 23rd

 

Ennui extends to coronavirus now.  After the initial excitement, alarm, anxiety, and significant lockdown, most people are obviously returning to normal or near normal activity.  Crowds of people flock to pubs, restaurants, and any other venue they are allowed to.  What is different still is the huge reduction in people going to a place of work rather than ‘working from home’.  WFH is a new acronym which everybody understands.  Sports venues, cinemas, and theatres are also empty.  Young people have moved on, and it is only the older generation like me which is still more or less housebound.  Two corona developments to report.  First is definite evidence of reinfection in some cases.  The second infection, recorded in Hong Kong, is a clearly genetically different strain of virus.  Then there is a suggestion that ACE or ARB blood pressure lowering drugs may reduce mortality in Covid-19 infection.  You will remember that the virus competes for the ACE-2 receptor for its ingress to the cell.  Perhaps the drugs block ingress?

 

My daughter seems to have lucked out somewhere in the middle of Tuscany.  Shots of lovely looking infinity pool…  And she’s supposed to be WFH!  Meanwhile my other daughter has just learned that the planned mountain bike event/race in northern Norway will not work out for her because all UK visitors to Norway have to quarantine for 14 days after landing.  £800 down the drain apparently.  A pity because she has been training intensively for this including an 80-mile off-road route last weekend.

 

But here in the modest surroundings of BH12 one still finds interest and amusement in the daily news.  I have written before of the remarkable ability to find humour in the most awful situations, viz. the Nazi concentration camps as exemplified by collations in the Holocaust Museum in Washington, D.C., and although one can in no way compare our current situation with that, it is pleasing to find that we can still make jokes.  My favourite today is related by the Telegraph correspondent who has been to the (socially distanced) revival of the musical Camelot.  Now, following the dictum of my closest school friend, MJW, ‘Mac, never go to a musical’, I have no intention of going to this, but the review is amusing.  King Arthur’s appearance in a shiny grey business suit is mentioned as perhaps not in keeping with the general theme, but the reviewer records the famous words of Noel Coward on attending the premiere which was supposed to last for two hours and forty minutes, but ended up in excess of four and a half hours.  Coward remarked that it was ‘Longer than Götterdämmerung and not nearly as funny.’  In view of the fact that John F Kennedy loved it however it has come to define his presidency.

 

A definite irritant, however, in the news, is a linguist who has stated that older people should not put punctuation in texts, particularly full stops (or ‘periods’ to Americans) because young people find them intimidating.  Oh dear.  Sorry Dr Lauren Fonteyn, whoever you are.  But I don’t expect you will read this.

 

Tuesday August 25th

 

Torrential rain and heavy winds hit from Storm Francis.  Major flooding in Wales.  Seems doubtful that we will get any cricket today in Southampton, and another limping draw is the likely upshot.

 

Duke University messages me to let me know that students are going back this month, with novel approaches to teaching, including spreading seminars out into the evenings to achieve smaller class sizes.  These will be so-called ‘Pyjaminars’.  At Cambridge in the 1960s, evening teaching in seminars was the rule, sometimes accompanied by a civilized sherry from the tutor, though always finishing in time to allow the dons to get to ‘Hall’ for their chance to sup at High Table.  We were required to attend these in jackets, ties, and gowns, and the question of pyjamas never came up.  In view of the modern concerns about university and school lecturers having sexual relations with their students, nobody seems to have thought about the female undergraduates appearing before their tutors in skimpy nightwear and the possible results therefrom.  Maybe it will all be by Zoom meetings?

Monday, August 3, 2020

Corona Diary Part 11. Friday July 17th to Monday August 3rd.

Friday July 17th

 

A beautiful day.  Today our aim is to walk in the Test valley again, then visit Mottisfont Abbey, which is open, but only to timed tickets.  A first this week was sitting on the terrace at the golf club, being served from the bar (no wandering around), after a moderately successful round of golf (at least after a par on 18 and winning 1 up) and in front of me a pint of Sixpenny Handley best bitter.  Apparently now brewed in Cranborne and not in the eponymous village.  The week was notable too for the failure of the England cricket team in the first test match against the West Indies.  I realise that this is rarely an unusual news story.  But with the crammed nature of the fixtures, at least we started again yesterday at Old Trafford and have topped 200 runs for the loss of three wickets only.

A fine trout at Mottisfont


 

Mottisfont Abbey

Returning to the topic of free speech however, and one’s right to an opinion, there was an excellent article in Tuesday’s Telegraph by Benedict Cooper.  This is in response to a Guardian (inevitably) article by the musician and left wing activist Billy Bragg.  Bragg takes issue with the quotation from George Orwell, carved in stone outside the BBC headquarters (I did not know this): ‘If liberty means anything at all it means the right to tell people what they do not want to hear.’  It would take too long to embellish this, but Bragg rails against the reactionary right for a tendency to quote George Orwell out of context and says this is an argument for licence and not free speech.  Cooper points out that there is a tendency for writers and academics and for social media to extrapolate from Orwell, and produce opinions about how he would have reacted today.  In a neatly constructed piece, Cooper clearly shows what Bragg believes is wrong, and ends by amplifying the original quotation in Orwell’s words: ‘I am well acquainted with all the arguments against freedom of thought and speech – the arguments which claim that it cannot exist, and the arguments which claim that it ought not to.  I answer simply that they don’t convince me and that our civilisation over a period of four hundred years has been founded on the opposite notice.’

 

We live in dangerous times – dangerous because of social media.  To give an example; a picture posted on Twitter or some similar platform shows a young white woman, masked, in company with others, in bright sunshine, holding aloft a placard which says ‘Black Lives Matter!’.  The person who posted this points out that behind the young woman, there is a clear cut shadow of her hands in the air – but no shadow of the placard.  In other words, the Photoshop user who doctored the original photograph forgot about the shadow.

 

A despairing letter in the newspaper tells how the writer was in Boots the chemists.  There was a woman there wearing a face mask.  She kept her face covered almost all the time, only removing the mask when she needed to cough and sneeze before replacing it.  ‘God help us’ he pleaded.  While not being aware of God keeping an eye out for problems in Boots I would probably still endorse his final plea.

 

Sunday July 19th

 

After another beautiful day yesterday, it is cloudy and drizzly, but the weather at Old Trafford should be good today.  England, for once, made a huge total on Thursday and Friday, thanks to big century innings by Stokes and Sibley.  Saturday saw continuous bad weather and not a ball bowled.  I well remember trying to explain English cricket to my American friends in North Carolina.  The incredulity that one stopped for lunch and tea, and that play could go on for five days, even then without reaching a result.  We are engrossed in series 2 of the West Wing, a TV series made nearly 20 years ago, but which is relevant today, most of the world’s problems recurring with a depressing inevitability (African coups d’état; India-Pakistan conflict; problems in the Persian Gulf).  This sentence is not entirely a non-sequitur.  We have just made the acquaintance of the feisty and attractive political analyst, Ainsley Hayes, played by Emily Procter.  Her accent took me straight back to North Carolina.  True North Carolinians have a very distinctive vowel sound, which I have great difficulty in imitating, but which once assimilated is unmistakable.  Many of my colleagues at Duke had other accents – a widely varying mixture – but Lewis, a student from rural NC doing pre-graduate experience in our lab had the characteristic accent.  So it was a pleasure to look up Emily’s bio and to find that she was raised in Raleigh, NC, and is an alumnus of East Carolina University.

 

There is no clearer indication of how age saps one than to look at our own cycling last weekend (32 miles up and down in Hampshire on Sunday; exhausting) and to compare it with my daughter’s Strava of her weekend break in the Cotswolds (32, 93, and 70 miles).  Ichabod.

 

Just finished a book called ‘The Porpoise’, by Mark Haddon, author celebrated for ‘The curious story of the dog in the night time’.  Don’t think he quite pulled off the magical realism, but a remarkably inventive book.  It helps to have read Shakespeare’s ‘Pericles’ beforehand.

 

We finished our little walk in King’s Somborne and Horsebridge on Friday with a drink outside at the John of Gaunt pub.  Dutifully handed over our names and phone numbers for subsequent identification should any customer prove to have coronavirus and be interrogated for their movements (track and trace).  I then realised what a hostage to fortune we were.  Should we be contacted, could we claim that we were outside and socially distanced?  Would we be forced to self-isolate?  Would our builders have to stop work?  Given that we always meet the building team outside, would this provide sufficient protection for the health hounds to not disbar them from work?

 

Main scientific news this week has been that vaccine preliminary trials have been going well with minimal side effects and definite antibody and T-cell response.  Also that both China and Russia are trying to hack into Oxford University’s research (denied on TV this morning by the Chinese and Russian ambassadors.  MRDA.  Mandy Rice-Davies Applies).  The virus has now been found to vary substantially in various locations.  A single aminoacid mutation in the spike protein gives it greater affinity for its ACE-2 receptor and greater infectivity.  In other research, it would appear that a particular variant is mostly responsible for the severe pneumonitis clinical pattern.  Whether this is of practical use is unclear.  It has also emerged this week that death figures from PHE (Public Health England) may be overstated.  Apparently any death recorded in a person who at some time has tested positive for coronavirus is attributed to the virus, irrespective of whether that death is due to the virus or not.  For example, if somebody had Covid in April and died in a road accident in June, that death is automatically slated to be due to coronavirus.  Some work required here, and evidence that PHE is ripe for reorganisation and probably some funding too.

 

It is now possible to see where our new house is heading, what the architectural concept is, and we hope it will prove a suitable memorial to our late friend and the originator of the project, Richard Horden (qv).  It is not quite as Richard originally conceived it.  We felt that we could not afford the ‘Belvedere’ on the third floor.  Richard wanted this to echo the ‘conning tower’ design on the top of the famous 1938 Oliver Hill (qv) house, ‘Landfall’, which stands close by, and which Richard greatly admired.  His colleague in the architectural firm replaced this with a clerestory, which will create a virtual third storey, and also bring light into the upper hall.  During construction and visits to the roof, it has become clear that the original Belvedere would not have gained the most spectacular view, which is from the Eastern end of the roof and which takes in Old Harry rocks, but Richard could not have known this.  A recent review of the new edition of Pevsner’s buildings of Dorset complained of the expansion in size of the book, due largely to inclusion of many examples on Sandbanks, examples which the reviewer termed the ‘Lombard’ school of architecture.  We hope that Crichel Point will not be of this school.  (Lombard stands for ‘Loads Of Money But A Real Dickhead’).

 

Friday July 24th

 

It’s hard to know where to begin when so many events have caught the eye and the ear in the last five days, but this is the hazard of not making a daily entry.  So I will start with a confession.  I have been a long standing fan of Boris Johnson, but I am not any more.  Why a fan?  Enthusiasm; wit; a refusal to be boring; allied with a very real sense of history and classical scholarship.  In addition (and both Remainers and Brexiteers do not know whether this will be a good thing), I was in favour of leaving the EU.  I voted (yes, I was old enough to vote) in the original referendum that took us into Europe.  It was a vote for free trade within our European partners.  We were told that stupid taxation differences between countries would be eliminated, that there would be better standardisation – I remember thinking that all electric plug sockets would eventually be the same in whichever country we visited (faint hope), and that there would be widespread reform of policies and rules with regard to agriculture and fisheries (faint hope).  Naively I thought that French wine might be cheaper.  But Christmas booze cruises, evidence of cheaper continental prices, continued until quite recently.  In about 2000, I even bought a car in Holland because it was much cheaper than in Britain.  When we joined, you may remember, it was called the EEC, the European Economic Community.  Now it is a ruling federation, which seems primarily to exist to improve the lot of poorer countries at the expense of others, and I can’t remember how many countries, many with lower standards of accountability, are now members.  Scientists and liberals whinge that the future of research will be destroyed if we leave the EU.  But what they fail to realise is that the main driver of the sharing of scientific knowledge and cooperation in the last 20 years has not been the EU, it has been the internet.  The jury is out, and I suspect it will be out for at least 20 years before we know whether it was a good or bad thing to leave.  So, some future writer will have to assess whether Boris has done good or ill by spearheading our leaving.

 

But in domestic policy, Boris has shown himself to be pathetic.  A friend has loaned me a copy of the London Review of Books, LRB, mainly to read an article about Shakespeare, but the leading article, a clear and cool eyed view of the Johnson era, was eye-catching reading.  Entitled ‘Superman Falls to Earth.  Ferdinand Mount on Boris Johnson’s first year’; it is hard to disagree with this intricate dissection of the current government.  The beginning is superb: ‘Precaution and continence, as we know, are not qualities that characterise Boris Johnson in any sphere of his life’.  The article is too long to paraphrase, and hindsight is certainly a wonderful thing, but we do know that Johnson failed to attend five COBRA meetings, and that his initial approach to the pandemic was casual to say the least.  Mount, who interestingly was head of the Number 10 Policy Unit in 1982-3 under Margaret Thatcher, goes on to say that ‘it is jarring to hear Ministers claim that they are proud of our achievements in the middle of a pandemic which has cost, so far, more than 50,000 lives.  The world’s second highest death rate per capita – wow, that’s really something.  Bolsonaro, Trump and Johnson: these are men you wouldn’t put in charge of containing an outbreak of acne’.  There is more, but I did not mark it, as I seem to remember Casca saying in Julius Caesar.

 

Which leads me on to Shakespeare, the main reason for the LRB donation.  Michael Dobson, director of the Shakespeare Institute in Stratford-upon-Avon, reviews a substantial book about the language of Shakespeare, by of all people, a Swiss scholar called Margaret Tudeau-Clayton.  Musing about the influence of Shakespeare, who is unchallenged in the role of ‘National Poet’, he points out that many of the Bard’s references to England are slighting and not at all celebratory.  Even the dying John of Gaunt’s This England speech, ‘…this royal throne of kings, this sceptered isle, the envy of less happier lands…’ reveals that when the main verb arrives after 19 lines, it laments that (England) is now leased out…like to a tenement or pelting farm’.  Hardly a recommendation for those forced to live in it.  There are amusing diversions.  Richard III, just before Bosworth, condemns the invaders from France as an effeminate gang of sexual predators:

‘If we be conquered, let men conquer us, and not these bastard Bretons…  Shall these enjoy our lands?  Lie with our wives?  Ravish our daughters?’

 

Curiously, Shakespeare is almost more famous in Europe than he is in England, or should I still say ‘Great Britain’?  The first national society for the study and appreciation of Shakespeare was founded in 1864 – in……  Germany!  The city of Gdánsk in Poland boasts the stunning Teatr Szekspirowski, three quarters funded by the EU (Ha!), and opened by Donald Tusk in 2014.  Despite the very learned discourse and fascinating facts, I find Dobson’s critique hard to follow, probably because he comes to no very clear conclusion about what it is that Margaret Tudeau-Clayton is saying in her book, which is entitled ‘Shakespeare’s Englishes: Against Englishness’.  But perhaps neither does she.

 

All of this does not give the reader who has persisted any very real feel for how the latter part of July has gone on in Poole and Dorset.  The weather has mostly been kind.  Reported Covid-19 deaths in the last 24 hours are still over a hundred – 123 – and there is the hint of an upturn in the number of daily cases reported with a very persistent tail in the death rate.  Today a new rule of wearing masks in shops was introduced, with a £100 fine for non-adherence.  The young woman in front of me when I collected my newspaper this morning was blatantly not wearing a mask; the woman who entered the store as I came out was wearing a mask which only covered her mouth…  I continue to have a very variable and unpredictable sleep pattern, and some others I’ve spoken to experience the same.  A hot chocolate and some guitar practice in the middle of the night can be enjoyable.  A BBC Sounds download called ‘The Sleeping Forecast’ consisting of chanting of the mantra of the forecast from the various shipping areas against a background of calm music can help to get one back to sleep.

 

The most extraordinary piece I have noted in the last few days was posted by a Twitterer who said she thought it was a joke, but apparently, unless I can contradict this from later experience, it is not.  AP (Associated Press), major news gathering agency, have issued in a new ‘Style Matters’ advice, the instruction that whenever the word black is used to describe someone it should be capitalised; as in ‘Black’.  But not white!  White is not to be capitalised.  Did you notice that I was only able to do that because it started a sentence?!  What a crazy world we’re living in, as Joe Brown sang in 1962.

 

‘Dad’s gone down the dog-track; Mother’s playing Bingo;

Grandma’s boozin’ in the parlour, you ought to see the gin go.

No-one seems to notice me, isn’t it a sin?

What a crazy world we’re livin’ in…’

 

The only note I had made to help me write my diary was that I was going to fill you in on Thin Film Amorphous Boron Nitride, but perhaps that had better wait for another day.

 

Parenthesis.  A lovely large and vigorous grass snake observed on Wednesday on the Ladies’ 3rd tee at the golf club.  It was keen to get away.

Grass snake rapidly vacating the 3rd tee


 

Monday July 27th

 

To begin with a gripe against gripers.  Quite suddenly, the government has announced that all incoming people from Spain must quarantine for 14 days.  There has been an upsurge of coronavirus cases in Spain, and particularly in Catalonia.  Following this the BBC’s coverage in its morning news (the talking heads programme, you will remember) has been of grumpy individuals complaining that this is ridiculous and wondering whether their employers will pay them if they cannot go back to work after their week or two of lazing in the sun.  If the current Welfare State, or social support systems that we regard as comprising Britain (I hesitate to use Great) do not provide everything for you on a plate, it seems that Britons will gripe.  Where is one’s sense of personal responsibility in this?  We are not in a normal year where for the price of a few hours discomfort and overpriced snacks Ryanair will fly you to and fro for your mandatory Spanish suntan.  Granted there are some anomalies.  The rate in the Balearic Islands and the Canaries does not show this surge, and perhaps there could have been a bit more logic applied.  But the BBC does little to counteract the mindless anti-Government griping.  At least this morning, it had the rather clever Jason Leitch, clinical director for Scotland on the programme, who not only tells it like it is, but phrases his dialectic in language most can understand.  I am not holding a candle for the Government here; but am just fed up with the BBC.  As someone else said; ‘Why do you have to go to Spain?  Why not support the British holiday industry?’

 

This last weekend saw the end of the Premier League football season, with the sadness of our local team, Bournemouth, being relegated after five years in the top flight.  But our cricketers have been doing well again in the final match of the series vs the West Indies, somewhat curtailed today by rain in Manchester.

 

Moore’s Law, originally posited in the 1960s, states that the number of transistors on a chip or integrated circuit doubles every two years.  A recent article in the Economist questioned whether we have reached saturation point.  As the electrical links between transistors have become finer and closer together there is a problem of charge leakage due to the tiny gaps that now exist between connections.  But a new material shows promise in insulation.  Thin film amorphous boron nitride can be pasted by vaporisation to create a sub-microscopic insulating layer.  So Moore’s Law seems to be safe for a little while yet.  This discovery seems to have been the result of research primarily in South Korea.  South Korea is in the news again today – blamed by North Korea (of course) for its first reported case of Covid-19!

 

Moore's Law


After some lovely weather we have had a fair amount of rain; torrential on Saturday, and on and off today.  It promises to warm up and become drier from tomorrow.  No cricket in Manchester today though.

 

Saturday August 1st

The weather cleared in time for England to pull off a substantial victory in the Test Match.  Otherwise there has been improvement through to more record high temperatures on Friday, resulting in the now expected influx of people to Bournemouth and Poole beaches, with more cars parked in roads leading to the sea than ever seen before.  Most of the day trippers would presumably have been in French campsites, Spanish hotels, and Greek beach resorts, so now they have invaded us.  We decided beforehand to cycle today and to risk the Sandbanks ferry over to Studland.

 

The traffic had become gridlocked through Lilliput and all approaches to the beach.  Weaving our way through stationary vehicles we reached the ferry and were allocated our ‘box’ to stand in with our bicycles.  On the other side cars were parked on both sides of the verge in the Ferry Road for nearly two miles up towards the Knoll House Hotel, and then also on the verges to access the beaches beyond.  On returning later in the afternoon we noted that almost all of these vehicles had been ticketed, presumably for encroaching on the roadway.  As I get older the routes which I used in the early 1990s seem steeper and harder, and on reaching the Swanage turn I push my bike up the slope to the obelisk on the ridge, where formerly I would pedal up.  A short ride further up from the obelisk (built to celebrate the bringing of fresh water to Swanage) and it is two miles of glorious downhill on grassy track towards Old Harry, with the view ahead of the Isle of Wight and the bay filled with mothballed cruise ships, including the gigantic ‘Empress of the Seas’.  Picnic near Old Harry, and then cycle to visit friends in Studland, and relax in their garden.  Coming back to the ferry, there is a commotion as three ambulances roar past on their way up the hill (apparently a woman has fallen off the cliff), followed by a complete jam as a fire engine tries to get through.  Traffic approaching the ferry is stationary from the village downwards.  There is the biggest queue I have ever seen of pedestrians and cyclists waiting for the ferry, but only a few cars are allowed on because of gridlock on the Poole side as well, and the rest of the car deck space is eventually filled by walkers and cyclists.  A remarkable sight and experience.  One can only assume that many of these people visiting Poole would be elsewhere at this time of year as mentioned above.

Sandbanks Ferry, Friday 31st July
The new normal


It wasn't this one who fell off the cliff
 


Monday August 3rd

 

A lovely walk yesterday from Rockford in the New Forest.  Although the car parks are crowded there is space enough and once on the tracks away to the East over Rockford common there are only a few walkers to be seen.  Picnic by the Dockens stream, a rather poor little brook at this time of year.  England won again on Saturday in the match against Ireland, and Arsenal beat Chelsea 2-1 for a deserved victory in the belated FA Cup final.

 

At our house this last two weeks, the windows have arrived and are being fitted by a charming team of Albanian window fitters, most of whom speak pretty good English, but all of whom smoke.  Enthusiastic conversations about Norman Wisdom ensue.  He’s still a legend in Albania, with statues of him all over the place.

Windows


 

Our mountain bike 24 miles pales into insignificance by comparison with my daughter’s 75 miles in the Haute Chaine du Jura.  Although based in France, their route took them over into Switzerland on Saturday (passports required) where they were surprised to discover that it was Swiss National Day.  Anna obviously had forgotten our experience in Lenzerheide in her earlier years, though apparently vague memories of the street fair, incessant Swiss music, and evening fireworks came back eventually.  Anna and Graham have all the kit and the posh bikes, though I remain proud of my (very old) cycling jersey with the Mapei and Latexco logos emblazoned on them.  Two years ago, while cycling in Brittany, I was approached by a man with a Belgian car registration plate, who asked me if I was Johan Museeuw (no I can’t pronounce it either).  He was disappointed, but also astonished that I hadn’t heard of this famous Belgian who had been the star of the renowned one-day cycle races some years ago.  Races with odd names like E3 Harelbeke.  Having looked up Johan I would be surprised if he now looked as old as me, but maybe cycling over that pavé day in, day out, ages one severely.  I now have a lot of empathy with Mapei because I understand we will be using their products to make our shower watertight.  My cycling daughter works for Rapha, and has sometimes been approached for articles emphasizing cycling for women.  When she was a baby I would not have envisaged her one day going public on the virtues of cycling without knickers.

 

I am not a particular fan of motor racing.  Formula 1 consists of cars whining their way around the track using vast amounts of fossil fuel with often very little happening, until eventually someone waves a chequered flag.  But seeing that it was being transmitted from Silverstone yesterday, I tuned in for the last few laps.  What a race!  Perhaps the most dramatic finish ever seen (now that’s a ridiculous hyperbole), but almost as soon as I switched on, Bottas almost came off the track as his tyres started to delaminate, and Lewis Hamilton, who had built up an enormous lead over Verstappen began to experience the same thing on his penultimate lap.  With the cars sliding all over the place, sparks flying from the ground contact, and Verstappen rapidly overhauling him, Hamilton crossed the line with not a moment to spare as bits of rubber flapped wildly in the breeze.  Apparently it was unusually hot for Britain, which led the tyres to deteriorate more quickly.  Friday was again a very hot day, up to 38 deg C at Heathrow.

 

To more serious matters.  It has worried me for some time that the Twittersphere is filled with grudge holding junior doctors, seemingly with the world, or at least a chip, on their shoulders.  Everyone on Twitter is always right, and it is not a place for reasoned debate.  But it distressed me when I read a Tweet from a junior doctor saying ‘Finished my last ever A&E shift, thank heavens, 1/10’.  Are things really as bad as that?  Are they in the wrong job?  The expectations of young doctors are ridiculously high it seems to me.  If life isn’t perfect all the time they take their moans to the world in 140 characters.  I thought that the days of the great autocratic consultants had gone, but I am not entirely sure about that.  Our own experiences of 50 years ago at UCH filled us with a burning ambition to be better, kinder, more tolerant, and I’m upset if things have not improved.  For the whole of my medical career I tried to remain connected to my juniors, to help and to instruct, to support and take an interest in them.  It pleases me that so many of them now fill excellent posts in Medicine and Cardiology.  In Nottingham for instance, as a junior, one could rarely have wished for more supportive consultants than I worked for there.  Nottingham was an interesting place to work.  Many of the older consultants (before my arrival) were smokers, and had hit the buffers in the late 1960s, so the people I worked for, with the exception of one lovely older and avuncular consultant, were young, dynamic, and enthusiastic.

 

I was reminded of Nottingham particularly because one of our teachers there, who had also trained and worked for the same boss as I at UCH, has written a letter to the Telegraph about stethoscopes.  This was occasioned by a feature in the Telegraph on 27th July by Dr Michael Fitzpatrick, about ‘point-of-care-ultrasound’ which suggests that the stethoscope is now obsolete.  Fitzpatrick states that stethoscopes are rarely cleaned, potential vectors of infection, and that they are of little use in assessing heart and lung disease.  Peter Toghill disagrees.  ‘For diseases such as lobar pneumonia, heart failure, pericarditis and pneumothorax, using one can provide a working diagnosis with seconds’.  It would be sad to see the stethoscope disappear.  Most of the personnel one sees in hospital wearing one are no longer doctors – nurses, physios, care assistants.  Indeed I have observed several of my younger cardiology colleagues doing ward rounds without a stethoscope.  Armed with the latest ultrasound, CT, and MRI imaging reports about their patients, they do not need a stethoscope.  The problem is – about 99% of those who carry a stethoscope do not know how to use one properly.  And some of the cheaper clinic stethoscopes are almost useless.  An experienced cardiologist can diagnose, for example, mitral valve prolapse, in a few seconds.  I recall once watching a very famous cardiologist place his stethoscope on the chest of a patient for about a second.  When challenged about whether he could reach a diagnosis so quickly, he merely replied; ‘I knew already what I was going to hear.’  As Toghill says, the cost per diagnosis made is a fraction of the cost of an ultrasound machine.  But the limitations of the stethoscope are well known.  When I was a medical student, I was asked to present a case blind to the senior students’ round at UCH by Peter Heaf, the famous chest physician.  One had to go to talk to the patient and examine them, but not look at the notes or investigations, and then reach a diagnosis.  I saw the lady, a very pleasant person in her 50s, who was obviously distressed and short of breath.  I did the examination assiduously and carefully.  The venous pressure seemed normal, she did not look anaemic.  I listened to her heart and chest, felt for lymph nodes, checked the abdomen.  Nothing.  Terrified I walked into the lecture theatre.  Heaf asked me to present the case.  I did so.  ‘And what were your findings?’ he enquired.  Shamefacedly I had to admit that I had found nothing wrong except that she was clearly very breathless.  ‘Yes, that’s the whole point’, said Heaf.  He then posted up the chest X-ray.  A myriad of abnormal white shadows, all over the lung fields, was evident even to the first year’s in the back row.  The unfortunate lady had metastatic thyroid cancer.  I had missed the faintest of scars on her neck which might have given a clue, but the point about the limitations of the stethoscope was well made.

 

In Britain we seem to be a long way behind other countries as regards point-of-care ultrasound.  Twenty years ago I had a junior working for me who was from East Germany.  She explained to me that they had all been taught to use ultrasound in the Emergency Room when medical students.

 

But perhaps the last word on the stethoscope should go to that wonderful doctor, gentle humourist, and subtle educator, the late Michael O’Donnell.  O’Donnell founded and edited a journal called ‘World Medicine’, which functioned as a sort of Private Eye for doctors, though that is probably to belittle it.  Amongst other iconoclastic articles, well-known doctors were also asked to contribute a ‘Mea Culpa’ column, where they talked about their own mistakes for the interest and benefit of others.  I doubt that the lawyers would permit it nowadays.  I particularly remember an article by an anaesthetist who worked for a surgeon who was never sober after about 8pm, though apparently during daytime hours he operated well.  He knew that the surgeon refused to operate on a patient unless blood was available in theatre for transfusion if necessary.  Knowing this, and called to an emergency operation late at night, he pretended to trip on entering the operating theatre with two (glass) bottles of blood, which of course smashed and spilt on the floor, thus preventing the operation from taking place.  Cursing the anaesthetist, the surgeon left for home, returning sober to complete the operation in the morning.  As you will realise, the fact that the blood was contained in glass bottles means that this happened a long time ago.  O’Donnell first wrote about the stethoscope in this magazine.  His article was hilarious, and he had toned down some of the anecdotes by the time he came to write the British Medical Journal article in 2008 cited below.  On one occasion, he was asked to visit and examine an attractive lady who was known for her dalliances.  At this point, I should mention that when a heart murmur heard through a stethoscope is very loud, the vibrations travel to the surface of the chest, and are palpable.  This is called a ‘thrill’ and often implies serious disease.  O’Donnell, prior to placing his stethoscope on this lady’s ample charms, as she rapidly peeled off the flimsies she was wearing, placed the flat of his hand over the heart.  ‘What are you doing?’ enquired the lady, fluttering her eyelashes provocatively.  ‘Madam, I am feeling for a thrill’, said O’Donnell.  She removed his hand and placed it firmly at a much lower spot of her anatomy.  ‘If you try there’, she said, ‘we could both feel a thrill’.  O’Donnell, we are informed, remained professional.  Otherwise it is clear that the story could not have been recounted.  Here is his marvellous reply to Des Spence, a Glasgow GP, who asserted in the BMJ that the clinical examination was outdated.  Sadly, in the Coronaculture of telephone consulting nowadays, what Spence requested might come to pass, but here is O’Donnell at his best:

 

‘Salute to the Stethoscope’  BMJ 2008; 336:1326.

 

‘Is Spence really unaware of the pioneering work of the postwar generation of general practitioners who established the stethoscope as a valuable aid not to auscultation but to meditation?  I can still recall the thrill of discovering that if I placed the business end of my stethoscope over an inert portion of a patient and used the other ends to plug my ears, I could create the perfect ambience for contemplating not just trivial problems such as “What is the matter with this patient?” but more serious ones such as “What is his or her name?”, or “What crisp, reassuring, non-discussion provoking phrase will get me out of here in time to watch the football on television?”

 

The beauty of this clinical manoeuvre is that the very act that enables you to struggle with your own problems gives your patients the impression that you are thinking deeply about them.  As a result, you can make decisions free from the pressure of time.  The longer you take, the more your patient is impressed by your thoroughness.

 

Sophisticates improve this empowering quality by bunging the earpieces with cotton wool to eliminate distracting sounds that may intrude if they inadvertently place the instrument over the heart or other noisy organ.  Sound proofed stethoscopes are particularly useful for dealing with talkative patients whom a doctor can halt in full flow by applying the instrument to their chests and telling them to breathe deeply.

 

Over the years, doctors have found many uses for the stethoscope – as a tourniquet, a paperweight, a hook for retrieving hats that have fallen behind chests of drawers, and an effective binder for boxes with loose lids.  I knew a senior doctor who used an old stethoscope to keep his trousers up, and a junior one, who, when faced with a personal credit crunch, would use his stethoscope to siphon petrol from cars left overnight in the hospital car park.’

 

They don’t write them like that anymore, and especially not on Twitter.

 

Oh, and by the way, it is a beautiful day.

Borage flowers awaiting a date with a summertime glass of Pimms