All babies are blue at birth, then they bawl as loudly as I did. It’s cold outside and they no longer hear that soothing maternal heartbeat. Freed from their claustrophobic cocoon, they thrash their little arms and legs around and suck in air for the first time. At that point they should turn pink. This little mite stayed blue and silent. Listless, with eyes wide open but seeing nothing.
The midwife recognised that things were not right. She vigorously rubbed the baby’s greasy back and swept her finger around its throat. Rough stimulation suddenly caused its breathing efforts to begin, but with a whimper not a roar. And the baby remained blue, a darker blue despite the rapid breathing, and still cool and limp. Now beginning to panic, the midwife called for an oxygen cylinder and some help. At first, the tiny oxygen mask helped. Baby’s muscle tone improved but her grim slate blue colour persisted. The doctor arrived and listened to the tiny heaving chest with his stethoscope. There was a heart murmur, not loud but clearly audible when searching for something specific. It transpired that the artery to the lungs hadn’t developed properly – pulmonary atresia, we call it. Dark blue blood returning from the tiny body streamed through a hole in the ventricular septum and back around the body. The chaotic circulation was progressively depleted of oxygen, accumulating more and more acid. The baby was doomed. A ‘blue baby’. The doctor shook his head and walked away. Nothing could be done to help.
All this passed the mother by as she sweated in pain and perineal Armageddon. She was impatient to hold her new daughter. As they handed over the dying infant, the midwife’s grave expression told the story, as did the child’s pathetic face, lifeless and grey, eyes rolling aimlessly. Our factory girl pleaded for an explanation. Why so still and silent? Why not pink and warm like me in the cot next door? Milk started to flow, but there was no suckling. In 1948 blue babies died.
They returned to the maternity bed next to my mother. There was a stark contrast in mood after nine months of excitement and anticipation – one woman radiant, proud and optimistic with her robust, pink son, the other desolate with a grey, motionless little girl left to die in her arms. The curtains were pulled around. Her expectant husband was stuck at work, rolling steel, never to see his daughter alive. The hospital chaplain arrived as a matter of urgency to christen the child as life ebbed away. It was probably too late, but they went through the motions.
This emotional meltdown already greatly saddened my mother, then the contrasts deepened at visiting time when the families arrived. There were repeated emotional breakdowns as the young woman’s parents, then the bereaved husband, arrived too late to see the dead baby before it was spirited away in a shoe box. Feelings of guilt quickly followed. What did she do wrong? Was it the cigarettes? Or was it the sickness pills? Should she have gone to church? My own family’s joy was tinged with compassion for the poor girl. My mother stayed in the maternity bed beside her for five days while she was taken for pelvic surgery, with nothing to bring home but sadness and stitches.
The day was particularly sad because mother had read in her newspaper about a new blue baby operation in America, a miraculous procedure that could turn blue babies pink. Why had no one mentioned that? Surely the shiny new NHS, already three weeks old, could have managed to do the same. These grim memories never did fade. So it was that every birthday she took flowers in memory of the blue baby in the cot next to mine, a thoroughly decent thing to do on what should have been a happy day.
The story my mother recalled in The Times went something like this. At the Johns Hopkins Hospital in 1944, the children’s heart doctor Helen Taussig challenged the chief of surgery Alfred Blalock to come up with a surgical solution for these doomed infants. Blalock’s concept was that the subclavian artery that supplied blood to the baby’s arm could be diverted into the chest and joined to the obstructed artery to the lungs. He anticipated that smaller collateral vessels around the shoulder blade would grow and keep the baby’s arm supplied, as they did in animal experiments. The professor first attempted what became known as the Blalock–Taussig shunt in November that year. He was not a technically adept surgeon and had difficulty in joining the tiny blood vessels, yet to everyone’s relief the operation immediately changed the child’s colour from blue to pink, with an immediate resolution of breathlessness. What’s more, the deprived arm continued to grow normally.
News spread fast about this transformational procedure. The pioneering British chest surgeon Sir Russell Brock – whose operating boots I inherited at the Brompton Hospital – invited Blalock and Taussig to demonstrate their operation in London. With no shortage of sickly blue babies, Blalock performed the shunt in ten consecutive infants without a single death, all the babies miraculously turning pink and beginning to grow. To conclude the visit, Blalock was invited to present his triumph in the Great Hall of the British Medical Association.
His lecture concluded with the room still darkened and silent following the projection of lantern slides. Suddenly a wartime searchlight traversed the length of the hall, its beam falling upon a Guy’s nursing sister wearing her dark blue uniform with white linen cap and holding a blonde two-year-old girl. Days before, the little girl had been dying from cyanotic congenital heart disease. She was now pink following the new shunt procedure, and this theatrical effect prompted tumultuous applause from the audience. My mother’s account of this story from The Times always resonated with me – quite simply, one of my earliest childhood recollections was of blue babies.
In the pioneering days after the blue baby operations, those who persisted then ultimately succeeded in operating on the heart undoubtedly had psychopathic tendencies. Could cardiac surgery in Europe really be possible? Probably, but there was still a long road ahead, one along which I was incongruously destined to travel from a very early age and was uniquely equipped to follow.
Most people have a dominant left cerebral hemisphere, which results in right-handedness and governs their language skills. In turn, the right cerebral hemisphere regulates spatial awareness, creativity and emotional responses. But I inherited a curious brain. I side-stepped lateralisation – an evolving process whereby different areas of grey matter adopt control of the various aspects of behaviour and skills – and developed co-dominant cerebral hemispheres, rendering me ambidextrous. Although I was predominantly right-handed through indoctrination at school, I could manipulate a pen, paint brush and eventually surgical instruments with both hands, and throw knots equally well with my left or right hand. I kicked a rugby ball with my left foot and batted left-handed at cricket.
Despite being totally useless at foreign languages, I possessed the innate ability to visualise the world in three dimensions. Manual dexterity paired with very precise spatial awareness made me a competent child artist and ultimately a natural surgeon. I painted landscapes of the steelworks of my native Scunthorpe lighting up the night sky, vivid red sunsets as the blast furnaces opened, courting couples kissing under the gas lamps and the steelworkers’ grimy faces after a long day in the rolling mills. Unusual for a teenage boy, but crossed wiring makes people different.
Later in life, these innate skills enabled me to dissect the human body, then place every stitch in the right place first time, no faffing about. Precision of movement translates into economy of time. I became an effortlessly fast operator, although my hands never moved quickly. Of course, I had no understanding of this gift until I became a surgeon. Eventually I discovered that speedy operations were critically important in cardiac surgery – the shorter the procedure, the faster the patient’s recovery.
At school I was known as the introverted artistic lad who wanted to be a doctor. But I wasn’t particularly bright and would never secure a place at medical school these days. Bright pupils mastered maths and physics – I struggled, although I was good at biology and got by in chemistry. Ultimately it was my sheer determination to escape the dilapidated streets and terraced council houses that found me reading medicine in London, the fish out
of water who wanted to be a heart surgeon when he grew up.
It was my attempt to fit in with the public school crowd that compelled me to play rugby and drink beer. I had all the requisite skills to kick and throw the stupidly shaped ball. In fact, I was rather good at it, rapidly ascending from a clueless beginner in the 4th XV to a regular spot in the 1st. For a so-called caring profession, London hospitals rugby was outrageously physical and violent. At its peak in the late 1960s, a Guy’s player captained England and the legendary fullback J. P. R. Williams played for St Mary’s and won his first Welsh cap in 1969. General George S. Patton once remarked, ‘I don’t measure a man’s success by how high he climbs but how high he bounces when he hits bottom.’ As a wing forward I tried to tackle Williams during a Hospitals’ Cup game at Richmond and took a battering for my efforts. Yet with bruised ribs and a bloody nose I finally succeeded.
My most serious injury was yet to come. It happened on a rugby club tour to Cornwall at the end of my second term. I have absolutely no recollection of the incident myself, so the explanations came later. We were confronted by a team of hefty Cornish farmers on a muddy, windswept pitch in Penryn. I had just prevented an opposition try with an outrageously high tackle that inevitably provoked retaliation. The loose scrum broke up and the players ran to scramble after the ball. I was left prostrate and senseless face down in a puddle following a targeted boot to the head. It was some time before these caring medical students came back for me, and by then I was blue.
When I came round again I was staring at a dim lightbulb that seemed brighter than the sun. All around were my equally dim medical school teammates, ready to cart me off to the bar instead of a hospital. As in boxing, a knockout wasn’t uncommon in student rugby, and we still had some serious drinking and singing to do. The touring tradition was that we entertained the local yokels with merriment and senseless dirty lyrics as only the London medical students could. Our lodgings were miles away in St Ives, so despite the headache from hell and a light show that resembled New Year’s Eve over the Thames, I had little alternative but to join in.
Next morning I was difficult to rouse. Steve Norton, a well-meaning friend, gave me a gentle shake, and I responded by projectile vomiting over his legs. My head hurt and the winter sunlight burned my eyes – photophobia of the worst kind – so I dived back under the blanket. Half an hour later the local doctor arrived. He was a good old-fashioned GP who took my pulse and blood pressure, then attempted to inspect the back of my eyes with an ophthalmoscope. These three observations were sufficient. I was in deep trouble. Slow pulse rate, high blood pressure and swollen optic discs. In addition, there were tell-tale comma-shaped bruises beneath both eyes. Everything pointed to a battered, swollen brain that last night’s beer didn’t help. The doctor berated my clueless teammates, sent for an ambulance and dispatched me to the neurological unit at Truro Hospital. This spelled the end of my jolly tour and, as I subsequently learned in London, it could have heralded the end of my medical career. Bizarrely, it had quite the opposite effect.
The skull X-rays revealed a hairline crack in the frontal bone, so, as thick as my skull appeared to be, the kicking had fractured it. The obvious signs of raised intracranial pressure went along with that. A gruff brain surgeon from Plymouth was in the hospital for an outpatient clinic and came to check me out. Treatment meant an intravenous drip with mannitol solution to draw water from my swollen brain, along with a urinary catheter and bag to cope with the diuresis. He wanted to take me back to Derriford Hospital for an intracranial pressure monitor, but I abjectly refused to go. The pipe in my penis was bad enough. I didn’t want a hole drilled in my skull and a bolt in my brain too. This stroppy lack of cooperation was a sign of things to come. I was agitated and overtly aggressive, no longer the mild-mannered, sensitive lad who had travelled down to Cornwall. There were no CT scans back in 1967, so there could be no direct images of my traumatised cerebral cortex. But something had definitely changed. Everyone expected me to revert to normal when the swelling abated. Fortunately for me, I didn’t.
Truro shipped me back to Charing Cross Hospital, where they admitted me to a quiet single room on a surgical ward overlooking the Strand. That same night I tried to seduce a pretty staff nurse, who responded by giving a sharp tug on my urinary catheter. The rapid displacement of the restraining balloon from bladder to prostate gland was enough to quell my ardour for one night, although the memory didn’t last. I was soon at it again.
The following day I was surrounded by student nurses who knew me from the Friday-night dances. Then my teammates brought in Playboy magazines and bottles of beer that they hid in the commode. It felt as if I were being treated like royalty. A bespectacled Harley Street neurologist in customary morning suit came to assess the injured medical student. I remember thinking that he looked like a penguin. When asked what I remembered about the whole episode I impolitely answered, ‘Bugger all, I’m afraid!’, backstreet language that I would never normally use in the company of a senior consultant. This clearly amused him and helped confirm his impressions about the severity of the injury. He tested every reflex and movement and, while noting my crossed wiring, declared my motor skills to be intact. He then sent along a psychologist. She did more tests, then decided to give me a tutorial about the consequences of frontal brain injury.
She explained that the right cerebral hemisphere is the home of critical reasoning and those thought processes involved in the avoidance of risk-taking. The crack in my skull was directly over the right frontal cortex, so the brain swelling probably explained the lack of inhibition, irritability and occasional aggression reported by the staff looking after me. I thought I had been polite and nice to the Charing Cross nurses, but maybe not. Some of her tests suggested that I scored highly on something called the ‘psychopathic personality inventory’.
‘But don’t worry,’ she said, ‘most high achievers are psychopaths, particularly surgeons.’ She then went on to explain my temporary change in personality using a classical case study that they use to teach psychology students.
In 1848 Phineas Gage was the foreman of a crew of construction workers in the American Midwest who were excavating rocks to make way for a railroad track. This involved drilling holes deep into boulders, then filling them with dynamite. A fuse was inserted and the hole plugged with compacted sand using a tamping iron. During the process a spark between metal and rock ignited the explosive, causing the four-foot iron rod to be propelled at high speed through Gage’s skull. Having entered beneath the left cheek bone, it exited the scalp and was recovered thirty yards from the accident. Gage didn’t even lose consciousness. He simply climbed into an ox cart and headed off to seek medical assistance. The local physician, Dr Harlow, removed shards of bone and replaced larger skull fragments, then covered the wounds with adhesive tape.
Gage’s brain unfortunately became infected with fungus and he lapsed into a coma. The family prepared a coffin for him, but Harlow operated, releasing eight fluid ounces of pus from under the scalp wound. Miraculously he recovered and within weeks had regained ‘full possession of his reason’. But his wife and those close to him recognised sinister changes in his disposition, which Harlow described in the Bulletin of the Massachusetts Medical Society.
He is fitful, irreverent, indulging at times in the grossest profanity which was not previously his custom, manifesting but little deference for his fellows, impatient of advice when it conflicts with his desires, at times pertinaciously obstinate yet capricious and vacillating …
In this regard, his mind was changed so decidedly that his acquaintances said he was ‘no longer Gage’.
Clearly that story resonated with me. I had sustained damage to the prefrontal cortex, which could cause personality changes while leaving other higher neurological functions intact. Yet I denied the fact that I was in any way different. Poor Gage lost his job and ended up displaying himself along with the tamping iron in Barnum’s Circus in New Yor
k. After dying during a seizure at the age of thirty-five, he was buried in San Francisco. Soon after, his unscrupulous brother-in-law exhumed the body, and Gage’s skull and the tamping iron are still on display at Harvard Medical School.
At that point I felt that the nice psychologist was gently trying to tell me something like ‘Go back to Scunthorpe and join the circus.’ When my brain swelling abated, I did head home for the Easter holidays, leaving my poor parents baffled as to the unexpected effects of a medical school education. Then I returned more determined than ever to resume my medical studies.
While I wouldn’t recommend head trauma as a career-enhancing strategy, what that head injury did for me in the medium term was quite extraordinary. In place of the wilting violet, I became disinhibited, bold and egotistical – no more exam anxiety nor embarrassment when called upon to speak in front of a crowded lecture theatre. Within weeks I had become the wildly extrovert compere for the students’ Christmas show, social secretary for the medical school, then cricket captain … and so it went on. I seemed immune to stress and now became a habitual risk-taker, an adrenaline junkie who constantly craved excitement. Personal problems that I used to dwell upon for days were swept aside. In short, I emerged from the head-injury experience both disinhibited and ruthlessly competitive. Born with both the coordination and manual dexterity to become a surgeon, I had now acquired the necessary personality traits as well. Yet I never lost my empathy, that element of emotional intelligence enabling us to appreciate the feelings of others, the ability to care about people that all doctors and nurses are meant to have, although many don’t.
With the introduction of magnetic resonance imaging it became possible to visualise brain networks within the cerebral cortex. The frontal lobes sense then process danger or fear by relaying scary stuff to the amygdala deep within the brain. Psychopaths lose the connection between the two, and characteristically manifest ruthlessness and disregard for authority. Two psychologists named Blumer and Benson wrote about the personality changes of traumatic prefrontal cortex injury, describing the syndrome as ‘pseudo-psychopathy’. Head-injury patients may show lack of inhibition or restraint, failure to appreciate risk, impatience and diminished guilt, but without the loss of compassion that characterises the inherent psychopath. That was me in a nutshell, although I had no insight into it at the time.
The Knife's Edge Page 7