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Showing posts with label medicine. Show all posts
Showing posts with label medicine. Show all posts
Monday, August 7, 2017
Monday, August 7, 2017
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Usually when I say a show has got its head shoved up its arse that's a bad thing. Not so with the excellent one woman show Gutted, which chronicles performer Liz Richardson's battle with ulcerative colitis - a condition that seems to involve randomly shitting blood all over the place. I say it's a battle, but it sounds like more of a drawn out war - Liz having spent her life bouncing in and out of hospital wards as her condition flares up, gets better, flares up again and so on.
Eventually she's exhausted all her options for treatment and things are only getting worse. Her doctor proposes radical surgery - removing her bowel and forming a 'pouch' from her small intestine. While this heals she'll have a stoma: her small intestine poking out of her belly and leaking her waste into an ileostomy bag. Theoretically, it's a temporary measure, but a proportion of these 'pouches' fail and there's a chance she could be ileostomy'd for life.
This condition, which apparently affects one in 420 people in the UK, isn't really in the public eye. This primarily because a) it's considered embarrassing and b) it involves a lot of poop. It also tends to affect young people, who are understandably a little squeamish about standing up and being the public face for an undignified bowel condition.
But, quite rightly, Liz Richardson wants to create a forum to publically discuss conditions like this. And so, Gutted presents her story in the most matter-of-fact way possible - explaining candidly what it's like to suffer from this disease, the hurdles she's cleared during treatment and the way people around her have reacted to it. Her delivery is cool, crisp and concise, taking on various personae who've assisted her along the way: leaky pensioners, paranoid teenage girls, bossy nurses and the impeccably named gastroenterologist Doctor Goodhands (and you'd hope so too, given where they're going).
You realise early on that Liz is incredibly difficult to embarrass. After all, she's spent countless hours with doctors probing around in her anus, her family and friends helping with her ileostomy bag, dealing with the anal seepage, and having to be catherised and cleaned by nurses. I imagine that after you've been through all that, standing in front of strangers and giving them a guided tour of your colonoscopy is easy street.
This all makes Gutted is a fantastically educational show. The explanation of how a colectomy and ileal pouch work was particularly fascinating. Liz using herself as anatomical mode, to demonstrate, drawing her colon and small intestine onto her belly and then erasing and redrawing it to show the results of the operation.
Her crystal clear explanation of the stoma and ileostomy bag was similarly neat, conveying the weird body horror of suddenly having a pulsing, oozing extra orifice on your body that kind of looks like a biological USB port. One of my favourite incidental details of the show was that the NHS literature strongly recommending that patients with stomas do not use them for sexual escapades - I would love to know the story behind that.
But behind all this is a genuinely heartwarming tale of how Liz' family and partner came together to support her through all this. Throughout the show audience members read dialogue from her partner Luke and her mother, each of them proving how important it is to have people you can rely on no matter what, and how love can shine through even in the most unpleasant or embarrassing of moments.
The cherry on top is Liz saying "I will never hear a bad word said about the NHS". It left me wondering what it might have cost her if she'd been born in the US, so I googled a bit and learned that she'd be on the hook for $40,000 just for the pouch surgery. Once you add in drug treatments, incidental incurred in hospital visits someone like Liz would be looking at a bill the hundreds of thousands of dollars - and as a further kick in the teeth "people living with inflammatory bowel diseases (IBD) commonly have problems obtaining affordable insurance". The NHS really is something to treasure and fight for.
Liz Richardson has metaphorically and literally seen a lot of shit in her life, but in a Jodorowskyian twist, she's turned that shit into gold. Gutted is a fantastic and important Fringe experience: bold, confident and entirely genuine.
Gutted is at the Pleasance Dome, Edinburgh Aug 8-13. Tickets here.
Friday, November 4, 2016
Friday, November 4, 2016
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In Still Ill, Morrissey asks one of the classical biggies of philosophy "Does the body rule the mind or does the mind rule the body?" Are we creatures of intellect or instinct? Are we beholden to our flesh? Do we fool ourselves when we imagine transcending these prisons of bone, sinew and blood?
It's weighty dramatic territory, but there's few more appropriate prisms to examine it through than psychogenic disease, specifically functional neurological syndrome disorder (FNsD).
FNsD is a condition in which you begin suffering neurological symptoms like unexplained weakness, seizures or loss of muscular control (to name but a few). If you research these symptoms online, the first thing that's going to leap out at you are two terrifying words: brain tumour. So you make the trip to the hospital and end up nervously lying inside an MRI. When the results come back, the doctor happily explains that there's no physical abnormalities in the brain.
Awesome! There's nothing wrong with you! But even after the all-clear the symptoms persist, maybe even get worse. There's something wrong with you, but the doctors say you're completely fine. Suspicions start to build that you're malingering: making the whole thing up for attention. After all, there's nothing wrong with you, and 'nothing' can't be treated. And yet you're in constant agonising pain.
Up and coming young actor Sophie (Sophie Steer) finds herself trapped in this cruel medical oubliette. The condition first rears its head as she's playing a doctor in a cheesy medical drama. During a stressful day on set her left hand contorts into a paralysed claw. Terrified, she consults a doctor who injects it with botox; it's miraculously and instantly cured. Problem is, botox only starts working after two days.
As the months progress things only get worse. Sophie begins suffering frequent seizures, chronic pain and even loses muscle control in her leg, confining her to home. The once ambitious young actor is reduced to listlessly watching TV and researching her condition online, each possibly diagnosis inevitably leading down a medical dead end. She grows depressed. Her brother Mark, initially sympathetic, grows suspicious and resentful. All too soon, life has turned to shit.
Still Ill is a marvellous bit of drama: stuffed fulla dramatic creativity, top notch performances and lots and lots of interesting medical information. It's an hour and forty minutes straight through, yet manages to avoid being dull by deploying a tonne of contrasting tones - running the gamut from broad comedy right through to bone-chilling medico-horror.
Sophie Steer is the star attraction: pouring every last drop of her soul into an incredibly physically and mentally demanding role. It's pretty breathtaking stuff, the character going on an odyssey to the depths of frustration, pain and misery. Sounds pretty heavy right? Fortunately it's a journey leavened with humour, and saved from sentimentality by some pretty severe probing of the fourth wall.
Mind you, Hamish McDougall and Harriet Webb are no slouches, believably inhabiting a variety of supporting characters. They fill in the dramatic blanks, constructing a world of helpful yet emotionally distant doctors, snippily caricatured TV production crews and support ground attendees.
On top of all that, the show is liberally studded with countless imaginative bits of staging, set design and lighting. Characters reach 'through' television sets, conduct brain surgery on a cauliflower, cover the stage in discarded medical supplies, insert a catheter up a cucumber cock or conduct mock Skype sessions through on-stage cameras. In addition, there's some seriously smart blocking - at one point confining Steers to the far corner of the stage, isolating her even within the set.
But the performances and theatrics are all in service to director James Yeatman's masterful control of tone and pace and on-stage live musician Zac Gvirtzman. Still Ill is a show of lulls and swells, snowballing from calm to complete sensory overload. These moments press you back into your seat, the drama almost symphonic as it reaches a series of crescendos that perfectly simulate the stress, frustration and misery experienced by the lead character.
Since watching Todd Haynes' excellent 1995 film Safe, I've been fascinated by psychogenic and psychosomatic illnesses; having spent time reading about medically strange conditions, like electromagnetic hypersensitivity, Morgellons and multiple chemical sensitivity. They present a curious paradox: when external or physical causes have been empirically ruled out, how do you explain a a patient that their life is ruined purely because of their malfunctioning psyche? How can you deliver that information without passing the blame onto them. It's easy to discount these conditions as 'all in the mind': these people are experiencing pain, and medicine is largely failing its obligation to sooth and treat it.
This is the second great play I've seen this week named after a Smiths song, the other being the excellent Rubber Ring (the obvious lesson is to only go see plays full of Moz references). Still Ill deals with this tricky (and unfortunately still fringe) medical subject with style, grace and empathy, making for an enormously affecting bit of theatre. You leave with Morrissey still jangling around in your head, still asking "Does the body rule the mind or does the mind rule the body?"
I dunno.
★★★★★
Still Ill is at the New Diorama Theatre until 19th November. Tickets here.
Thursday, March 26, 2015
Thursday, March 26, 2015
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A successful historian must play psychoanalyst to their period. Entire societies are gently laid on the couch, their ambitions, paranoias, pride and history intelligently probed in an effort to get at what made them tick. You could look at what they say about themselves, but this strays into the realm of propaganda, neither individual nor civilisation wants to look like a chump.
You can approach this understanding of the past through many prisms, each refracting the past in their own way. Professor Andrew Scull has chosen the processes and understandings of mental illness: the understanding of cause, processes of diagnosis and treatment shedding light into the minds of our ancestors.
This interrogation is the subject of the 2015 Roy Porter lecture, hosted by the wonderful people at the Wellcome Collection. Prof. Scull, a former colleague of Porter, is Distinguished Professor if Sociology and Science Studies at the University of California, San Diego. His new book, Madness in Civilisation: The Cultural History of Insanity has just been released and provides the raw material for this lecture, which zeroes in on the nascent science of mental illness in the 1800s.
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| George Cheyne |
Our introduction to this world is the pioneering work of physician George Cheyne. His publication, The English Malady; or, A Treatise of Nervous Diseases of All Kinds, as Spleen, Vapours, Lowness of Spirits, Hypochondriacal and Hysterical Distempers (1733) was a huge influence on popular conceptions of mental illness and depression. That title, with the English laying proud claim to mental disorders, initially feels a touch odd. Why would an proud, patriotic nation hurry to 'own' these conditions?
As a point of comparison, Prof Scull explains the shifting colloquial names for syphilis, which in England, was called 'The French Disease', in France 'The Italian disease', in Italy 'The Neapolitan disease' and so on, with the Turks throwing their hands up and simply calling it 'The Christian disease'. These pejorative names are reflections of nationalistic spite: after all, nobody really wants to be 'the syphilis country'.
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| George Durer's Syphilitic Man |
What this reveals is that far from being a negative, 'nervous disorders' were proudly incorporated into the English psyche as a point of patriotic pride. The explanation for why is based around comparing 'primitive' and 'modern' man. The primitive has their mind occupied with acts of survival, a daily life and death struggle for food and shelter. Whereas the modern man, with his refined sensibilities, sharpened mind and rarefied talents, is akin to a precision-tooled piece of machinery - with many more components able to fail. Or, as Cheyne put it:
"those of the liveliest and quickest natural Parts...whose Genius is most keen and penetrating were most prone to such disorders. Fools, weak or stupid Persons, heavy and dull Souls, are seldom troubled with Vapours or Lowness of Spirits." CHEYNE (GEORGE) The Natural Method of cureing the Diseases of the Body, and the Disorders of the Mind depending on the Body.
So, the more Britain succeeded economically, scientifically and culturally, the more 'nervous disorders' we should expect to see - with mental illness an unexpected herald of social success.
This period of history, with luminaries like Isaac Newton, Robert Hooke, Edmund Halley and Christopher Wren et al defining the boundaries of the universe and identifying hitherto unknown invisible forces like electricity, gravity and magnetism must have been an astonishing time to live through. Finally the nuts and bolts of the universe were being revealed, the role of God gradually moving towards to absent caretaker rather than a being that intervenes in the lives of men.
Anything must have seemed possible, an outlook that gave rise to the success of one Franz Mesmer. He invented the concept of 'animal magnetism'; that energetic transference takes place between all objects, animate and inanimate. By manipulating this process he claimed to be able to cure nervous illnesses. Word soon got around, and before long crowds rich and poor were clamouring for a taste of mesmeric therapy.
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| A mesmerist using his 'magic finger' to cure a comely woman. |
It was all bunkum of course, Prof Scull inferring that a decent portion of his success came from providing erotic experiences for buttoned down society women. With scandal constantly nipping at his heels, Mesmer hopped between European cities, eventually coming a cropper at the hands of a scientific dream team that included Antoine Lavoisier, Joseph-Ignace Guillotin, Jean Sylvain Bailly, and Benjamin Franklin. They conducted tests, concluding 'biomagnetic fluids' to be a load of cobblers. Mesmer soon vanished into obscurity, the last 15 years of his life large unknown.
Though firmly discredited, his therapies acted as a seed in treated conditions of the mind. Mesmer's animal magnetism therapies evolved into hypnosis therapy (from which we get the word 'mesmerism'). We later learn that Sigmund Freud began his therapeutic career as a hypnotist, the interaction of patient and clinician eventually formalising into psychoanalysis.
It's here that Prof Scull links the behaviour of the past to the present. His examples outline the broad strokes of the 18th century 'personality': nationalism, scientific progress and a belief in progress. Mesmer's popularity inevitably leads the mind toward modern pseudo-scientific therapies, arguably more popular now than they've ever been. Similarly, the ownership of mental disorders feeds into identity politics: in an increasingly homogenous world everyone wants to stand out, with internet self-diagnosis leading to the rise of 'disease/allergy/mental illness as fad'.
What will future historians think of us when they examine these trends? What rationale can be given for masses of people running to alternative therapies when faced with the myriad miracles of modern medicine? Why are increasingly large amounts of people desperate to find 'their' disorder?
Perhaps it's only with the hindsight of history that the answers can really be theorised. Nonetheless, Prof Scull's lecture leads us down fascinating intellectual paths, subtly nudging us towards applying historical analysis to modern trends. It was a real treat watching him speak, I'll have to get hold of his book.
Prof Scull's book, Madness in Civilisation: The Cultural History of Insanity is available here.
Thursday, February 21, 2013
Thursday, February 21, 2013
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Fire in the Blood exposes some unsettling truths about the consequences of Western economic dominance. It’s a catalogue of injustice and cruelty perpetuated without hate or malice, but, with a beady, utilitarian eye on maximisation of profits. What we see in this film are the blunt and bloody consequences of capitalism: desperate people gasping their last breaths in a hospital bed, bodies thrown onto an enormous pile millions of corpses high: a sacrifice to the almighty free market.
This documentary is about the supply of antiretroviral drugs (ARVs) to HIV/AIDS sufferers, with a focus on sub-Saharan Africa. In 1995, millions of people across Africa had no future to look forward to a slow and painful death. Suddenly through this gloom shot a ray of hope - a new course of treatment with results that seemed nothing short of miraculous. Skeletal, bedridden patients when administered ARVs began rapidly improving in health, a condition the doctors began to call “The Lazarus Effect”. In Fire in the Blood we see South African High Court Judge Edwin Cameron's life transformed from utter misery to competing in a long-distance cycle race entirely through the effects of ARVs. It’s not a cure, but ARVs make living with HIV/AIDS possible, to allow them to be able to work, exercise and appreciate life again. In these sub-Saharan countries, with vast swathes of populace stricken with HIV/AIDS this was a light at the end of a very long, very dark tunnel.
But there's a problem. Though the drugs cost peanuts to produce, the price was strictly controlled by enormous, avaricious drug companies. Treatment cost $15,000 dollars per year, a sum impossibly out of reach for the poor with HIV/AIDS. The message from the developed West from companies like Pfizer and GlaxoSmithKline is clear - if you haven’t got the money then get ready to embrace death, sucker. The resulting genocide of 10 million Africans is almost incomprehensibly horrific - men, women and children who died as a result of not having access to medicine that costs a few cents to make.
Much of Fire in the Blood is an impeccably and methodically researched argument explaining precisely why the price is so high and the moral contortions big pharma twists itself into to justify having the blood of millions on their hands. We come to learn that the reason these drug companies behave like this isn’t because the individuals running them are monstrously evil, it’s because they are entirely beholden to a system of maximising profit. Their reasoning was that if they lowered the price of ARVs in Africa, then they risk their US customers - their most profitable market - turning against them. If they allow generic ARVs (chemically identical to the patent version at a fraction of the price) to be imported, they run the risk of setting a legal precedent against their patents, potentially lowering the worth of their intellecual property. If profits dip from the stratospheric to the slightly less stratospheric, shareholders will get antsy and the board will be held accountable. The upshot is that on an accounting spreadsheet in an air-conditioned New York skyscraper, numbers are moved from one column to another. As a result in Uganda, hundreds of thousands of people die needlessly.
It’s easy to see how people buy into the drug company’s rhetoric - at first they seem to have some good points, but Fire in the Blood systematically demolishes them. These arguments range from the practical and vaguely plausible: "the reason these companies need to charge so much is to recoup what they spend in research and development". The implication being that if they sell these particular ARVs at a low price, then future R&D will be affected adversely. Gray shows us that far from these companies leading the way in development, they tend to gobble up smaller companies that have developed drugs using public funds. According to the film, they’re responsible for only 12% of R&d research worldwide.
The other end of the scale in the argument that poor Africans should be denied these life-saving drugs is far more insidious, dipping into outright racism. Spurious arguments are made that Africans can’t be trusted to follow a course of drugs (it eventually turns out they can - better than Western patients) with reasons ranging from some kind of innate laziness, to not being able to comprehend the idea of a clock - “they tell time by looking at the sun!” bleats one particularly gormless looking US senator. Even among HIV sufferers in developed countries there’s a fear that providing ARVs to poor Africans might lead to a drug-resistant strain of HIV/AIDS evolving, so, really it’s in everyone’s best interests if these Africans would just crawl off and die as quietly as possible, preferably without making too much fuss. As they say: “fuck you, got mine”.
So we’re presented with a situation where, as Professor Peter Mugyenyi, specialist in the field of HIV/AIDS simply puts it, “‘the disease is where the drugs are not”. To illustrate this we see cartoons of a skeletal man in a hospital bed reaching vainly towards a giant, locked pill bottle. Fortunately there are those who stood up against the drug industry, working both within and outside the law to get the ARVs where they’re needed most. The highlights are the Indian manufacturers of generic ARVs who devise a way to provide the medication for less than a dollar a day to HIV/AIDS sufferers - a yearly course costing just $350 rather than $15,000. We meet committed political activists who risk their own lives and liberty, like Zackie Ahmet, co-founder of the Treatment Action Campaign (TAC) in South Africa who personally sacrificed his health in a boycott of ARVs until they could be provided for everyone. The above mentioned Professor Peter Mugyenyi ordered low-cost generic ARVs from India, defying Uganda’s patent laws and challenging authorities to arrest him until the drugs were allowed into the country - an action which opened the floodgates of low-cost generic ARVS into Africa. Some of the ‘good guys’ end up being quite surprising - for example it’s a pretty unique experience to think for a second “hey, maybe George Bush Jr wasn’t all bad...”.
Fire in the Blood is one of the clearest political arguments I've seen in a long time, but thankfully it works as a piece of cinema too. It’s frequently quite beautiful, the African scenery popping with colour and framed with an expertly artistic eye. There are some very clever cuts subtly linking ideas, like cutting from the grave of an AIDS victim in Uganda to the US Capitol Building in Washington DC. We never dip too much into the abstract, and Gray's confidence in the importance of his material shines through - he always lets his interviewees speak rather than bombarding us with a blizzard of quick cut visuals. Perhaps the only slightly disappointing aspect are some aspects of the score, which is a bit heavy-handed: long ominous bass tones when they’re telling us about terrible things, light orchestral triumphant pieces when something good has happened. Perhaps this is simply the nature of the beast in documentaries, but it’s a tiny bit frustrating to be emotionally prodded rather than trusted to react to the material in a humanistic way.
Fire in the Blood is a sober and eye-opening look at a topic so terrible, wide-ranging and complicated that many prefer to regard HIV/AIDS in Africa as “just one of those things”. Gray has created a film that breaks the situation down into easily digestible chunks, building his case against the drug companies piece by piece into an incredibly compelling whole. Apart from the central narrative, it becomes a searing indictment of free market capitalism. The frantic race towards maximising profits literally leads to mountains of corpses, the deaths of millions justified as a necessary evil in protecting someone's bottom line. A person that profits from restricting the supply of generic life-saving drugs to the world's poor should be on trial for crimes against humanity - they have consciously and coldly committed genocide for financial gain. Before watching the film I assumed the title Fire in the Blood referred to HIV/AIDS. It is, but it's also appropriate for the anger you'll feel when you learn about this senseless waste of life.
*****/*****
'Fire in the Blood' is playing at the Prince Charles Cinema on 22 February and across the country on the 25th of February.
Thursday, January 17, 2013
Thursday, January 17, 2013
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Agonising, torturous, tender, stinging, stiff, thumping, raw, itchy, stabbing, dull, crippling. We have many words for pain, many ways of trying to put into words a sensation that seems to defy communication. Asking someone “how much does it hurt?” seems a simple question, but as I learned at the Dana Centre last night, there are innumerable physiological, psychological and even cultural factors to consider when you’re trying to work out just how much pain someone is in. Being able to accurately quantify pain is hugely important to medicine, allowing the correct prescription of analgesics and courses of treatment for chronic conditions.
The speakers last night at the Dana Centre came from a variety of medical backgrounds, and all are trying to understand different aspects of pain. Our facilitator was the charmingly pleasant Tim Crocker-Buque, a junior doctor working in Accident and Emergency at the Royal London Hospital, and the rest of the panel was composed of Matthew Howard, a research scientist from the Department of Neuroimaging at Kings College London; Archie Naughton, a patient liaison representative speaking about his personal experience with pain; Melvin Muzue an Oxford DPhil student researching advanced magnetic resonance imaging of the brain; and Becky Saul, a lecturer-practitioner in paediatric pain at Great Ormond Street Hospital.
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| The Pain! |
It’s useful before we begin to pin down exactly what pain is. Tim Crocker-Buque quotes from the International Association for the Study of Pain Subcommittee on Taxonomy, 1986, telling us:
“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”
It’s an elegant, precise definition, consciously clinical and antiseptic in its language. Accurate it may be, it begins to seem a little cold when Tim begins to tell us about some of the patients he’s seen in Accident and Emergency over the last week. People in excruciating pain from kidney stones, back pains rendering people unable to move, rugby players with dislocated joints and most memorably someone who had drunkenly fallen out of a window and impaled their thigh on a fence. I suspect if you asked any of these people if they were having an ‘unpleasant sensory experience’ you’d get the dirtiest of dirty looks from them.
Trying to get accurate information out of people that are in pain is tricky at the best of times, if they’ve just suffered a serious accident then they’re likely be in a heightened emotional state. Even if you are totally calm, it can still be frustratingly difficult to translate the exact kind of pain you’re in to a medical professional. Later in the evening an audience member makes a good point that even if you do explain yourself well, how you know whether the doctor or nurse has really understood what you’re talking about?
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| A classical 1-10 scale |
Traditionally, a 1-10 scale as shown above is used to allow patients communicate their pain. It’s easy to administer and understand, but also a rather fuzzy and subjectivel. The problems with it range from assuming numeracy in patients, the ability of the patient to communicate, the emotional state of the patient, and even, fascinatingly, their cultural background. We’re told how patients from Mediterranean backgrounds will happily and extensively describe exactly how and where their pain hurts, while those from Eastern European backgrounds tend to be taciturn and stoic, declining analgesics or even refusing to admit that they are in pain.
We’re told repeatedly that one of the primary roles of medical professionals is to relieve pain as soon as possible. When someone comes into A&E in crippling pain, very quickly they’ll be administered analgesics. I was surprised how readily doctors were willing to administer drugs like morphine to A&E patients, but on reflection they may well have to wait for a period before their injury can be treated. Personally I’d much rather be in a waiting room full of doped up and dozy injured people rather than on where the air is filled with agonised shrieks.
Quickly knowing what kinds of analgesics to administer becomes very important, and underlines the importance of accurate diagnostic tools. We’re talked through the ‘Wong-Baker faces’ pain rating scale. These cartoon faces are an excellent way for children to convey the amount of pain they’re experiencing in a way that eschews language or numeracy. The scale is flexible enough to allow for children to communicate the levels of emotional pain they feel too, Becky Saul shows us a pretty heartbreaking example of the Wong-Baker scale coloured in by a child at Great Ormond Street, where the most extreme pain is described as equivalent to when his father goes away on an extended business trip. While these faces are an excellent tool, and are elastic enough to be useful in understanding pain at the opposite end of the age scale in the elderly, it is still subjective, relying on the patients ability to communicate.
The pipe dream of many of the medics here is having an objective way of measuring pain. There are extremely accurate ways of measuring lots of physiological functions, we’re told how someone can have a sensor placed on their finger that shows precise blood oxygen levels. The patient can be administered an oxygen feed, and you can view in real time the numbers moving towards a safe level. The fantasy equivalent for this with pain, as Tim put it, would be a sensor you could slap onto someone’s head that would authoritatively tell them that the person is experiencing a pain level of, say, 7.8. Treatment could then be administered, and the doctors could watch the numbers fall.
This is currently science fiction, the closest realistic version being found in neuroimaging research using MRI machines that let us see how the human brain functions when the patient is experiencing pain. Blood has the useful property of being magnetic due to the presence of iron in haemoglobin. This allows us to see which areas of the brain ‘light up’ with increased blood flow during a painful experience. Much research into this in the 20th century was focussed on trying to identify a ‘pain centre’ in the brain. The existence of a single part of the brain that governs pain is a sensible prediction to make; senses like vision and hearing only stimulate certain areas. But as the MRI researchers on the panel tonight explained, physical suffering activates many different areas of the brain – what is referred to as a ‘pain matrix’.
That we are on the cusp of being able to objectively say whether a patient is in pain or not raises some tricky ethical issues. What do you do if the situation arises where a patient insists they’re in agony and yet an MRI shows no signs of it? Is it right to ever assume they’re lying? Similarly, what do you do if someone claims to be perfectly fine, and yet their brain scan shows the ‘pain matrix’ lighting up? At the moment these are hypothetical problems, but soon enough they won’t be, and the medical profession will have to wrestle with some pretty tricky dilemmas.
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| The 'Pain Matrix' |
Even if you could objectively detect pain within a patient, you still have to treat it. It's underlined that there's many factors that affect pain. These range from the context the pain is felt in to the emotional state of the patient and their cognitive abilities. Apparently, if a patient is depressed, they will tend to experience higher levels of pain than if they were happy. Excitement or danger can also influence the sensation of pain, if someone is pumped full of adrenaline then even the pain from a sudden massively traumatic injury like a lost limb can be temporarily suppressed.
This exploitation of the patient’s state of mind, getting them to focus on something other than the pain seems to be very useful. In Great Ormond Street, when an injured child is brought in by helicopter they’re quite rightly often terrified of what’s going on around them. The best tactic to calm them down is, apparently to give them an iPad to use, presumably a few sessions of ‘Angry Birds’ doing an awful lot to provide a familiar distraction for a traumatised child.
Conscious and unconscious mental exercises designed to relieve or suppress pain aren’t fully understood, but they seem an excellent unobtrusive way to work with chronic pain. Our speaker from the patient’s perspective, Archie Naughton, lost his lower leg in a car accident in 1976. He’s suffered phantom pain, sensations that the body perceives as coming from the missing limb. He describes these as being equivalent to someone cutting through his flesh with a rusty knife. This is a classic example of pain being experienced with no obvious physiological cause. So if there is nothing ‘wrong’ with Archie, how can this pain be relieved?
He tells us about his mental exercises to diminish the pain, ‘forcing’ it into another part of his body and telling himself not to worry about it. It’s an admirable example of the brain’s ability to consciously repress neurological signals. Exercises like this are fantastically useful, especially as Naughton has had bad experiences with painkillers in the past. He tells us of his unpleasant experiences with Tramadol, which he was prescribed after suffering from kidney stones. The notion of having to weigh up which is more important, pain relief or undergoing unpredictable and unpleasant mood and personality changes is a difficult one, to say nothing of the prospect of quickly developing a physical dependency on painkillers.
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| A cartoon illustrating common sensations of phantom pain. From 'A Gimp's Guide to the 801' |
Pain is the root cause of some of the most insidious misery a human being can go through. If depression is linked to pain then it seems to me to inevitably lead to a pretty horrible spiral. You feel depressed, so you feel pain, which makes you more depressed and so on. If you see nothing in the future but chronic pain, with no relief in sight then it’s not surprising that many sufferers commit suicide.
Conversely, pain is a sensation that keeps you alive. It’s a warning signal that something is wrong with you, an affirmation of life. There’s a genetic condition called congenital analgesia where the sufferer does not feel physical pain. These people do not tend to live very long, commonly biting off their tongues, breaking bones and not being able to detect pain from severe diseases, delaying treatment. So next time you stub your toe and dance around angrily berating the sky, take a moment afterwards to appreciate the fact that you can feel it.
When it comes to really understanding the ethics of treating pain, I like this 1968 quote from Margo McCaffery, pioneer in pain management:
“Pain is whatever the experiencing person says it is, existing whenever and wherever the person says it does.”
Even though we may not understand the causes, mechanisms or psychology of why someone is feeling pain, it doesn’t make that person’s individual pain any less valid. With this in mind, the intelligence, good humour and strong sense of empathy with their patients that I saw from the speakers tonight is immensely heartening.
Thanks to everyone who organised this at the Dana Centre, and please let me know if I’ve made any factual errors in the comments.
Friday, July 6, 2012
Friday, July 6, 2012
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Talking about Leonardo da Vinci is a big undertaking. He was involved in almost every field of science and art during the Renaissance, making huge strides in disciplines as disparate as art, architecture, music,engineering, geology, cartography, writing and warfare. From the perspective of someone in the 21st century he seems almost superhuman. We struggle to imagine how someone could fit so much learning and expertise into one lifetime, how you can be not only ‘good’ but a groundbreaking genius at pretty much everything he set his hand to. Last night’s talk zeroed in on one of his disciplines, his work as an anatomist, and the anatomical illustrations from his notebooks.
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| Professor Martin Clayton and Dr Alice Roberts |
Professor Martin Clayton is the curator of the ‘Leonardo da Vinci: Anatomist’ exhibition at the Royal Collection. This is the largest ever exhibition of Leonardo’s anatomical notebooks, images from which have become iconic in their own right, and one which I’m visiting tonight (so expect a full writeup of it tomorrow). I’ve seen samples from his notebooks before at the V&A and at Birmingham Museum & Art Gallery, the amazingly precise drawings and indecipherable scrawl generate a kind of ‘wonder in discovery’ to someone reading it. In conversation with Martin Clayton was Dr Alice Roberts, anatomist, writer and broadcaster. I’ve seen her on television in numerous programs, she’s got a rare talent for making complex science seem accessible and ‘friendly’.
The discussion began with Prof Clayton giving us a quick overview of the life of Leonardo, coupled with a slide show showing us some notable works by him, explaining exactly why he is revered among the anatomical community. I was a little concerned that these slides were moving too quickly, the pictures are so intricate and detailed that even after long minutes staring at one, new details are still becoming apparent, but I needn’t have worried as during the more conversational part of the evening they went back and discussed drawings in details.
As I’m off to see the actual drawings tonight, I don’t want to pre-empt tomorrow’s article by talking about them directly too much, but the explanation of how they were produced gave me a new understanding of just how groundbreaking they were. One slide of a drawing of a bear’s foot struck me as a particularly striking graphic representation. It seems almost alive as a picture, with the tendons delicately folded around the muscles, and the palpable tautness around the heel. My appreciation was heightened when Clayton explained the medium on which this produced. The paper is chemically treated and dyed, giving it its distinctive blue colour, leaving it with a rough surface like sandpaper, but finer. When a silver nib is scratched over it, it leaves a line. But once it’s on the paper you can’t erase it or make alterations to it. As someone who lives in the age of Photoshop I’m amazed by the confidence of the lines here. It gives you an insight into his effortless skill and his ability to produce works of such beauty.
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| 'The anatomy of a bear's foot' c.1485-90 Leonardo da Vinci |
One aspect that was repeatedly touched upon was Leonardo’s spatial awareness, his ability to not only perceive things in three dimensions but to translate that into an ‘exploded’ illustration of part of the body. Modern medical students are partially taught using 3D computer displays of models of the body that can be viewed from whatever angle the student wishes. In many instances Leonardo works to the same principle. His practical, mechanical mind is visible in pictures that show how the muscles and bones of the shoulder fit together in a way that is at once both clear and also beautiful.
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| Modern medical CGI model of a shoulder. |
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| 'Anatomy of a shoulder' c.1485-90 Leonardo da Vinci |
My favourite Leonardo anecdote from the evening was the tale of how he sat at a dying man’s bedside in a Florence charity hospital, and stayed there until he had breathed his last. His notebooks tell of the conversation. The man told Leonardo that he was over 100, that he had no specific pains in his body but just felt weak. As Leonardo delicately put it:-
“While sitting on a bed… without any movement or other sign of any mishap, he passed from this life. And I dissected him to see the cause of so sweet a death.”
Very sensitive and poetic words from Leonardo who we shouldn’t forget was perched, vulturelike over this dying man, waiting to slice him up. But anyway, the dissection and analysis that followed features the first accounts in medical history of coronary occlusion, arteriosclerosis and cirrhosis of the liver, which Leonardo notes as having the consistency of “congealed brain”. The care and precision of the descriptions and the exactitude of the diagnosis were 300 years ahead of their time. Anecdotes like these, and the examples of the poetic and descriptive language that Leonardo uses give us the view of the the man as opposed to the intangible genius separated from us by hundreds of years.
The way in which Prof Clayton and Dr Roberts talk about Leonardo is refreshingly free of awe. They treat him with the appropriate gravitas that a figure like him commands, but also as a fellow scientist. One of the highlights of the evening was a discussion about what Leonardo was intending to show in a picture of the act of copulation. Prof Clayton argues that the correct interpretation is that Leonardo is depicting the moment of conception as a combination of the three parts of the divine anatomy; the soul (represented by the brain), the spirit, (represented by the heart) and the body (represented by the testes). Therefore, all three of these need to be connected to the penis, and he argues that this picture is a representation of this. Dr Roberts offers a different interpretation of the image, that what these connections might actually be is a literal representation of the pelvic splanchnic nerves, and that rather than seeking to wedge the spiritual into an anatomical drawing, he is simply reporting what he sees from animal or human dissection.
It’s an interesting discussion, one which I suppose is in effect trying to read the mind of someone who has long passed from this world. The discussion moves through a number of interesting notions at breakneck speed, with fascinating historical and scientific tidbits thrown at us. For example I had no idea that medieval medicine held that breast milk was composed of menses that moved from the uterus up the breasts during pregnancy. It was with scarcely less surprise that I learned that breast milk is in fact a form of modified sweat.
Going to a lecture like this and being surrounded by highly intelligent people can sometimes feel a bit humbling, but this is one instance where we are all humbled by Leonardo, the ghost in the room. I’m very much looking forward to the viewing tonight, and getting a chance to view his notebooks at my own pace in relaxed surroundings.
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