A bed, a bath, and no bugs.

I don't like to do this too much but two different friends have asked me for copies of a blog entry from 3 years ago, before I came to the US. Ostensibly it is about Bloomsbury and medical treatment, but it might have subtexts -- I can't decide. Since recently I have been very busy with no time to write here - I am repeating that old page with the promise to myself I will post some fresh stuff soon. This post is rather timely because another blogger whose page I read, has been working through some difficult problems lately, and her struggles with the palpable pain of time slowly passing -- put me in mind of Virginia Woolf. I sent her a Woolf quote - which is a dangerous thing to do since so many Woolf quotes dally with the notion of suicide.

Ms. Woolf was one of the most famous literary residents of Bloomsbury. She might aptly be called the patron saint of bloggers, with her statement

If you do not tell the truth about yourself you cannot tell it about other people.

Most quotations herein are from T.S Eliot’s, The Love Song of J Alfred Prufrock, except where otherwise noted. Eliot was an American who took up British residence (and citizenship) and also lived in Bloomsbury, as did so many literary figures of the nineteenth and twentieth centuries. He was awarded the Nobel prize for literature.

Streets that follow like a tedious argument
Of insidious intent
To lead you to ask an overwhelming question.
Oh do not ask “what is it”
Let us go and make our visit…

The thing is, you see, I can’t decide if I am a cynic or an incurable romantic. There is no possibility that I am anything in between… except possibly a nihilist. I could happily inhabit the Left Bank or the Montmartre district of Paris. I could smoke Gitanes and argue the Myth of Sisyphus over café au lait… If only it weren’t for all those infernal French people ;-) But I’m doing the next best thing… I’ve spent the last week in Bloomsbury, mostly in the care of the National Hospital for Neurology in Queen Square. Queen Square is like Evelyn Waugh’s secret garden, “not overlooked by any window.” No one knows it is there. Cab drivers drop you off a block away because they can’t find it or can’t get in. It is approachable from the south only by a pair of tiny narrow streets, one of which is one-way in the wrong direction. From the West only a pedestrian alley gets you in, as is also the case from the North. From the East is the most feasible approach Start from High Holborn, walk down Lambs Conduit Street and turn left on Great Ormond Street. To come in that way unveils a pageant of grand old Victorian red-brick hospitals with intriguing names like The Hospital For Sick Children, and the Royal Homeopathic Hospital (presumably a little of what you don’t fancy does you good). What do you suppose the emergency ward is like in the Royal Homeopathic Hospital? If a man is brought in with multiple gunshot wounds what do you suppose they do? Put very very dilute lead-extract drops under his tongue?

Anyway, Great Ormond street terminates in Queen Square, and suddenly there you are in this perfect little hidden Victorian enclave, about three hundred meters square, with a lovely little manicured park and gardens in the center, surrounded by very Londonish black iron railings. All around the square facing inward are high echoing, six storey cool stone and redbrick buildings, with a multitude of terraces, cornices, reliefs, stained glass, ledges, steps, brass signs, black railings and plaques commemorating where Duke this or Princess that or Lady so-and-so dedicated a new something, always in the name of her majesty goodness-gracious Queen Victoria herself. The little street that runs around it is just wide enough for two hansom-cabs to pass. Unfortunately cars are parked on both sides, leaving a strip of road just wide enough for a slender cyclist to navigate. This does not deter the delivery trucks (sorry – “lorries”) that pick their painful way between the parked cars around the right-angles of the square with only millimeters of clearance on either side, often getting stuck until the owners of the offending vehicles return hours later to move them.

The reigning monarch of the square is the National Hospital for Neurology and Neurosurgery, which occupies buildings on both sides of the quadrangle and generates a steady stream of pedestrian traffic from one side to the other, cutting through the peaceful little park with its mysterious statue of “Humphrey” the cat, and its numerous daffodil flowerbeds and bench seats. The whole scene is a delightful enclave of pregnant peace, humming and echoing with the hushed sounds of the city, nearby but unseen… a world of its own.

In the light airs of summer you might think you have stumbled on the lost valley of Shangrila. Time has no meaning here. The mighty rumblings of London do not enter. This is a little wormhole in the fabric of the British universe, immune from the present day. In the dark dreary winter the London fogs descend under their own density into the square and sit there, transforming the geometry into the limitless. You can almost feel the languid tedious gazes of scores of patients from the hospital windows as time hangs heavy like the yellow-gray curtain of mist outside.

And indeed there will be time
For the yellow smoke that slides along the street
Rubbing its back upon the window panes…

If you have to have a neurological disorder and if you have to get treatment or diagnosis somewhere in the world, this is probably the place to come. I have not been to all the famous venues, such as Johns Hopkins or Mayo, nonetheless intuition tells me they would lack the grand style of this institution. My cumulative man-years of experience in American hospitals have taught me to expect extreme efficiency, modernity, processity, systemity, automity, dispassionity, and the kind of mediocrity which comes from being subjected to all the aboveity. The National Hospital for Neurology (NHN) has the incomparable advantage of being British, which means it avoids being efficient at all costs. This results in a delightful staff-to-patient ratio about three times higher than in the US. It also means that rather than shuttle you in and out of an outpatient facility in a single day, to save money, or several days in a row, to save money, with all the associated travel and trauma, they are inclined to provide the patient with a nice little bed to sleep in, a nice little bathroom to shower in, a TV to watch, and three free meals a day. Oh yes – did I mention the numerous free cups of tea and coffee from the trolley which comes around? Cookies too! With so much idle time on one’s hands, the clatter of the tea-trolley becomes a welcome Pavlovian signal of distraction to the resident patients.

For I have known them all already, known them all;
Have known the evenings, mornings, afternoons,
I have measured out my life with coffee spoons…

All this while reclining in splendor in the bosom of Bloomsbury, drinking in the curving colonnades of Georgian townhouses, with the grand old British Museum, and the University of London for neighbors, not to mention the ghosts of the English literati reposing all around: E.M. Forster, Virginia Woolf, T.S.Eliot, Dylan Thomas, Oscar Wilde, Aldous Huxley, John Maynard Keynes, Bertrand Russell, G. E. Moore, A. N Whitehead… Oy Vey! All those agnostics! This is a high rent district sure enough. It exudes antique grace and charm from every pore of every brick of every townhouse. There is more charm and history in a single beech tree on Great Russell street than in most North American cities.

Come, we shall find a room with a bed, a bath, and no bugs, in Bloomsbury.
Poet: Dylan Thomas, resident of Bloomsbury, spoken to his wife.

London has a reputation as a stimulating city, but those who judge it so, and who care about such things are usually travelers – or those trying to entice travelers. Areas steeped in history like Bloomsbury are part of the city’s international charm. If I were wealthy and I chose to live in London I would take up residence here myself. At night I would haunt the streets of Soho and Covent Garden – a stones throw away. By day I would stroll the dappled tree-lined squares of Bloomsbury.

Thank God most visitors and travelers never get to see the rest of London. I know it well because I was born there, and I can tell you, once you get beyond a fairly small area, most of it is an immensely depressing and dingy place. North London, which I know best, is fine as far as Hampstead. But North of the Heath is like a different planet. Once you get up into the desolate tracts of Golders Green, Finchley, Hendon, Cricklewood or Kilburn, it is one vast drab wasteland of endless streets with endless rows of maisonettes, and tawdry little high streets packed with curry joints, fish and chip shops, betting shops, Tesco supermarkets, dirty little pubs, and dark apartment buildings. There are enclaves of quaintness to be sure but on the whole the national character of the architecture and the mindset is soggily stuck in what Sir Terence Conran calls the “Georgabethan” style. The charm, history and character of the city is unknown and irrelevant in these minions. Here it is just double-decker buses, death and taxes. The hopelessness is written on the faces of the inhabitants. In the animated film of “Yellow Submarine,” Eleanor Rigby is set in a bleak brown forbidding world of British pre-war terraced houses and crumbling businesses. That just about sums it up. In that context, the well-known lyric: “Look at all the lonely people” seems to be a comment on the alienating nature of that urban landscape. I would rather live in Bakersfield, and that’s saying something.

So we recline in splendor here in Bloomsbury, this little community of diverse humans from diverse walks of life, thrown together by little twists of neurological fate – a little myelin missing here, a little substantia nigra eroded there, all people with obscure and difficult disorders, some life-threatening, some not, some more debilitating, some less, but all with two things in common: First, we all need periodic treatment and evaluation to keep us functional, second – we are all to some extent guinea-pigs. In the world of neurology there are very few cures. It’s a good gig being a neurologist: there are few happy endings -- your patients don’t really expect one, but they keep coming back anyway. You keep measuring, testing, trying new dosages and discussing the latest miracle drugs which, it turns out, aren’t. A neurologist is not so much a doctor in the sense that he solves medical problems, but more of a highly professional mechanic, fiddling with a machine he does not understand and cannot fix, but he knows more about it than you do, and he can keep tweaking it for optimum performance, given the circumstances. Neurology is a highly intellectual pursuit, with little hardcore empirical evidence of anything. Often the only valid confirmation of a diagnosis is an autopsy: a procedure which most patients would wish to forego. Good neurologists are highly intuitive puzzle solvers, wielding a battery of tests which only vaguely indicate the problem, and only slightly narrow the possibilities. Conclusions from tests are usually an intersection of matrices rather than smoking guns. Ultimately their best diagnostic tool is their own intellect and insight, combined with a certain amount of trial and error.

Here in Bloomsbury is accumulated an enviable clique of these intellectual giants. The hospital has a distinguished reputation as a center of excellence for teaching and study, as well as being a headquarters for neurological clinical studies. If you are a patient with condition “X” and you want to participate in a clinical study you read about in the papers, you can certainly apply, but you will quickly find there are five thousand applicants for ten positions, and your odds are slim. But if you are a patient of one of the intellectual giants at NHN, guess what…? It is they who conduct many of the studies, and they frequently select participants from among their own patients. The reason is simple … publish or perish! There is enormous competition among the “consultants” as they are called, to attain celebrity status. Preferably international celebrity status. The more studies they can run, the more they can publish the results in Lancet, or Journal of Neurology, or New England Journal of Medicine. The more they can intellectually dissect the complex field of neurological disorders into categories and subcategories, the more papers and monographs they can publish, claiming ownership of some allegedly new variant of a condition, to be quoted in future by other consultants. I think I am unlikely to enjoy that honor. If you see any publications citing Best, et al, please let me know. You will make my day.

You can see how these consultants view themselves by watching them do their rounds. Once a week they swoop through the wards to inspect their charges, like princes obliged to hobnob with villagers. While everyone else wears white or standard medical garb, the consultants swagger around in tailored suits, accompanied by a fawning bevy of wannabe students, younger doctors, distinguished international visitors, and miscellaneous scribblers who write down everything frantically. The nurses naturally buy into the whole “prince” mentality and dart around like worker ants, fetching and carrying at the prince’s beck and call, preparing patients for inspection with all the dehumanizing haste and flurry of runway models behind the scenes at a fashion show. God forbid that some record or chart should be unavailable or lost at the precise moment a great prince requests it. The poor nurse responsible for it gets a slightly disdainful “never mind,” which is probably the career equivalent of a kiss on the cheek from Al Capone. As far as the patients are concerned, the princes speak about them in a very loud British accent, charged with supreme confidence, as if they were not even there, unless of course it is necessary to ask them a question. Once the answer is obtained however, the patient is immediately excluded from the process again.

You have to remember every patient is a puzzle to be solved. He or she is a piece of meat to be prodded, poked, tested and adjusted, this way and that, until some acceptable result is obtained. What tends to happen is that the patient is completely excluded from the diagnostic process until it is complete. It is much like the way Holmes always treated Watson, keeping him in the dark until the very end, when all was revealed. So the NHN will send you upstairs and down for test after test, without sharing the results at all. You sit on your little bed, eat the three meals a day and chat with your shipmates. Every so often the porter arrives to wheel someone off to the dank catacombs of the castle for some other hideous unimaginable procedure. When he returns he is none the wiser. He knows what was done to him but he knows not why. He sits in ignorance contemplating his fate. He reads the British papers. He watches the “telly.” He drinks more tea. Perhaps like me, he writes a journal…

And when I am formulated, sprawling on a pin,
When I am pinned and wriggling on the wall,
Then how should I begin
To spit out all the butt-ends of my days and ways?

Sooner or later though, the consultants come up with an answer, or a best guess. Then the patient gets a slightly different kind of visit, in which he is told what is wrong with him, and what kind of treatment he is going to get. At that point he may be released to the care of his family doctor (or “GP” in England) or he may be set up with visits to a hospital in his hometown, or – he may win the lottery – like me – and be placed on the list of “regular” patients at party central – the NHN itself! That is precisely my situation… every so often I need an intravenous infusion of rather rare and expensive drugs. There’s a faint – very faint – possibility of an adverse reaction, so they prefer to administer the drugs themselves. Thus I get to enjoy the Bloomsbury hospitality for a few days. However the main reason they want to keep me coming back is because the condition needs constant monitoring and evaluation. As a result, I get to enjoy five precious golden minutes with the prince, my consultant, one afternoon during my treatment.

You have to know how to manage this royalty. I have found the best method is to do all my own medical research on the internet, where all the latest advances can quickly be found, then to print out the papers on the topics which concern me, and which may be of benefit to me. Then when the consultant breezes through with his entourage of drones, and draws the curtains around my little bed in a single authoritative swoosh, I hit him with requests for state-of-the-art progress in all the areas I have researched. If there is some new technique or drug he has not heard of he is likely to say – “There is no applicable research on that yet.” At that moment I present him with the printout and say “Actually, there is… Let me give you this information for your review and …” (here you look directly at the poor worker drone who is scribbling notes) … “we can make a note to review it at our next meeting, yes?” The drone looks at the prince, who says “Yes,” (what else can he say without losing face?”) and the drone licks his pencil and writes this down. Then I cement this by saying “Let’s see … what date will that be…?” The consultant is then obliged to figure out the next time we will meet and say the date, and so the poor drone is obliged to write it in the notes, because the prince hath spake it.

It’s good to have things in the notes because then if they don’t get done I can refer the consultant to his own notes, which is embarrassing, and usually results in them getting done the next time. It’s all silly games and politics I know, and I don’t really want to belittle the skills or abilities of these neurologists: they are among the best in the world. Unfortunately in the world of medicine, the relationship between doctor and patient has become far from simple and direct, particularly in the specialty fields. The only way to break through the iron rule of isolationism, protectionism, and bureaucracy among specialists is to apply a little left-handed politics… all the while shrugging affably and trying hard to act like you are just a dumb layman…

Advise the prince, no doubt an easy tool,
Deferential, glad to be of use,
Politic, cautious, and meticulous...

At least the British system makes this possible. Now that I am living in the US again, I see what tends to happen is – after the initial diagnosis all treatment is administered by nurses only, and on an outpatient basis. They just follow a written regimen. The specialist rarely if ever visits the outpatient clinics, and the infernal American medical insurance companies make it as difficult as humanly possible for you to get to see your specialist again. You must first see a primary care physician, who if you’re lucky will then write you another referral, so you can book another appointment with the specialist – probably months later. There is simply no opportunity for regular exchange of information with the princes, and regular review and evaluation. The American scourge of cost-saving efficiency renders the prince remote and unapproachable, leaving the poor patient to fend for himself, with his future dictated by royal covenants from a distant palace, rendered by faceless nurses... who, unlike their British counterparts, do not serve me tea, and think my fears are cause for silent snickering behind the curve of the great desk at the end of the room that marks the intractable boundary between their world and mine.

Should I, after tea and cakes and ices,
Have the strength to force the moment to its crisis?
But though I wept and fasted, wept and prayed,
Though I have seen my head (grown slightly bald) brought in upon a platter,
I am no prophet – and here’s no great matter,
I have seen the moment of my greatness flicker,
And I have seen the eternal Footman hold my coat and snicker,
And in short, I was afraid…

London, 2004.

Footnote: In July 2005, in Russell Square in the heart of Bloomsbury, a terrorist bomb blasted a London bus into twisted metal, killing and wounding many people. Buses still ply the square, and daffodils still grow -- but quo vadis Virginia? I fear we both are lost forever.