Cutting for Stone (again)

It isn't often that a book and its characters continue to haunt my consciousness after I've finished reading the book. Of course it's the reason some books become classics, the people who inhabit the book really seem to exist. They are three-dimensional or multidimensional people. Think of Leopold Bloom, Anna and Vronsky, Elizabeth Bennet, Billy Prior, Shakespeare's vividly realized Rosiland, Lear, and a host of others; Charles Dickens's crowded city of all kinds of folk with oddly apt names like Scrooge and Pickwick, Mark Twain's Huckleberry Finn, and so many others who come to life on the page. It's one reason these works are classics. Now I have another book to add to the list. Long after I finished reading it, Sister Mary Joseph Praise, Marion Stone, his twin brother Shiva, Ghosh the dedicated internal medicine specialist turned surgeon, Hema, Genet, and others who inhabit Cutting for Stone, live on still with me. The book ends in high drama close to melodrama and a surgical feat that strains credibility but is nonetheless possible, maybe has even been performed by now; by the time you get to the end you can believe it really happened, feel for the twin who lived and the enigmatic one who did not. That's why I think this book will become a classic; and I hope Abraham Verghese will write more I can read while I am still able to read.

Ottawa Race Weekend

The weather gods smile upon us. With 5 K, 10 K, half marathon and marathon races this weekend, over 60,000 runners altogether, there would likely have been many people collapse in the unseasonal heat and high humidity of last weekend and the midweek heat wave, 35 C at its peak and humidity making it feel like upwards of 40 C. But a cold front came through yesterday bringing gentle breezes from the Arctic. At 8 am when the marathon began, our balcony thermometer was reading 13-14 C and the air felt dry, quite perfect conditions. I snatched glimpes of the leading runners as I watered our balcony plants, as usual from Kenya, Somalia, Ethiopia, also a champion from Morocco or Tunisia I believe; they went past our condo well ahead of the pack I saw later going by, a river of people in shorts and tee shirts of every colour, making me think of the 'super-organism' E O Wilson and others speak of, reminding me a little of the river of people I watched emerging from the railway station in Bombay in the morning rush hour -- although that was a far larger crowd, over a million I was told, every day. Belatedly I thought of the camera and took a few photos, showing the laggards going south on the other side of the Canal, and average runners on our side, still mostly making a good pace after about 38 K. David, who has run a few marathons, and others, friends who have talked about long-distance running, speak of the feeling of group solidarity that emanates from these long distance runners and I've seen glimpses of it in the groups running by in former years, wasn't close enough to the action this year to detect it, but no doubt it was there, enough to give me a good feeling about a few of the best human qualities as I watched briefly between the hectic sequence of Sunday morning chores. It's one of the annual events in Ottawa that I always enjoy and look forward to from one year to the next, even though I take part only vicariously and this year only fleetingly.

The Master Chef

...and to complement the previous post, here is Richard at work, preparing some of the delectable dishes for our Victoria Day al fresco banquet

Victoria Day and since

Hot off the press, here is Jonathan's photo of a few of us gathered beside Rebecca and Richard's pond for a delicious lunch last Monday, the Victoria Day holiday. It was fairly hot that day, got hotter as the week progressed, as I've already reported in my last post. Here, from Left to Right, are Janet Wendy, me, Richard, Jonathan, Dorothyanne, Rebecca, all of us looking well-fed as indeed we were after another of Richard's delicious meals.

There's not much more to report: we've had various contacts with ALS helpers this week, and more suggestions about ways to make life easier for Wendy. The outcome of this will be more bits and pieces of equipment delivered early next week. We have also had some more useful suggestions about ways to take in fluid and food without risk of choking. It's all a matter of adjusting and readjusting so life can be made as comfortable and easy as possible. For example it's easier to swallow jelly without choking than to swallow a glass of orange juice.

Signs of the times

Today is another day of unprecedented heat, 33 C with very high humidity. I think I heard the CBC radio weather forecaster say there's never before been a day in May when the temperature exceeded 30 C. Now we are having several in succession, yet another series of weather records in this year of one weather record after another. Weather records are being broken all around the world -- hotter in some regions, colder in others, wetter, or drier, or more stormy, than since the beginning of record-keeping. It all fits the climate change models, in which weather everywhere is becoming more extreme. Seasonal crop yields reflect these weather extremes too; in general, yields are down, food reserves are falling, have fallen below critical levels in many places. Here in north-eastern North America it's not only hotter than ever before, it's also drier, the rivers are low, lake water levels are down. This year's crop yields will be affected. My comments a few days ago about increasing populations and increasing violence struck chords with several readers of my rambling remarks; all chose to comment directly to me, rather than using the little box for 'public' comments (I suppose it's legitimate to refer to the 'public' because there do seem to be a surprisingly large number; I don't know whether I should feel pleased, flattered, or alarmed). So now I'll add another thought that might attract a few comments. I find myself agreeing with James Lovelock that by the end of this century, the human population of planet earth - Gaia, as he calls our home in the universe - may have collapsed to around a billion or fewer, rather than continuing to expand to 11 or 12 billion by 2050 and to 17-20 billion by 2100 as some demographic forecasts predict. It's certainly clear to any responsible, informed observer that present population levels are unsustainable, especially in huge mega-cities, many with unserviced peri-urban slums lacking credible infrastructure. Even without pestilence and war, the limiting factors of food and fresh water shortages in a hotter world than the world we live in now may be enough to generate a population crash on this scale. Mass starvation, in other words, is a distinct possibility. I wonder how many nations, if any, have national food policies of the kind that kept the British alive, and overall better fed than they had ever been before, despite the food losses due to submarines during the 1939-1945 world war. The British nation as a whole, and especially the children, emerged nutritionally better off than they had ever been, thanks to a food rationing policy that ensured sufficient for all, and a well balanced diet especially for infants and growing children. I believe James Lovelock is right and a population crash is certain within the next few decades. He and E O Wilson also lament the loss of biodiversity, the extinction of species. The greatest danger I think may come from the loss of species at the base of food chains, marine food chains in particular as well as those on land. That seemingly unstoppable oil spill off the coast of Louisiana, Alabama and now Florida about which I also commented a few weeks ago soon after it began, is beginning to damage and destroy sensitive ecological zones in wetlands along the coast and in the Mississippi delta. That's bad enough, but the real and more deadly damage may be occurring at the level of single-cell organisms and phytoplankton species, whose metabolism is disrupted not only by toxic substances in the oil, but also by chemicals used in attempts to disperse it. I don't know what proportion of the American people's protein requirements come directly or indirectly from the sea; in South and South-east Asia it's about 25-30%. It's probably quite a lot less in the USA, but it's an appreciable proportion for sure; and now that proportion is at risk. Where will the replacement protein come from?

Two other readers had a different comment on my post about violence, anarchy etc, more or less to the effect that people of European stock (and the Japanese, according to one reader) are in danger of declining in numbers while other 'races' (ethnic groups) are becoming more numerous. If this happens I don't see it as a 'danger' and I don't think this is relevant in our world of increasing demographic turbulence. I'm all in favour of miscegenation, the more the merrier. I think, without exception, the offspring of every 'mixed race' couple I know display the best attributes of each part of their genetic heritage. Our world will be the better for more miscegenation, not less. The most enlightened among my friends and acquaintances seem to share this view whenever the topic comes up in conversation, and I find this most encouraging.

Oddities of English

What a quirky language we speak! This morning I did our weekly 'smalls' wash -- clothes that we consider too delicate to put in the industrial-strength washing machines in our basement laundry, used mid-week by our cleaning lady, Sue Ng for our sheets and towels. Among these 'smalls' was a colourful skirt that Wendy actually bought, as opposed to making it herself as she mostly does, or rather did until she fell ill; it cost all of $4.00 in a sidewalk sale. I asked her as I put it in our dinky little apartment-size washing machine, "Are these colours fast, or will they run?" She understood exactly what the question meant. I inserted an entry on"sanction" in the Dictionary of Public Health specifically to make another point about the English language, that this word can mean either of two diametrically opposite things, and the meaning becomes clear only from the context.(That was self-indulgence, pure and simple: the word has no particular relevance to public health). When I was learning to speak Italian many years ago, my teacher, who came from Torino (Turin) and loved his lovely language, drew our attention to an Italian phrase that has this quality. Unfortunately I've forgotten what the phrase was. Perhaps one of my readers can remind me. There are a few like this in French too, that crop up from time to time in the CBC Radio program, C'est la Vie. A young Japanese doctor, son of my host when I'd been a guest of the Japanese Public Health Association, found these peculiarities of English altogether too perplexing and just about switched off, thereby destroying his reason for coming to Canada and the USA in the first place. No doubt when we learn how to communicate with whales and dolphins, we will find oddities like these in their languages too.

Cutting for Stone

In my rather long life I have read scores of "medical" novels and stories -- creative fiction by doctors, about doctors. One or two helped to reinforce my schoolboy decision to study medicine myself. Several deserve to be called Literature. Now I'm reading Cutting for Stone, by Abraham Verghese which unquestionably is literature. Even before I finished reading it, I elevated it confidently to the topmost pinnacle among literary works by and about doctors and matters medical. It's an astonishing book, an intricately plotted work set mainly in Addis Ababa then in New York about complex, believable characters, doctors who were well trained in Madras or Edinburgh, and found their way to Abyssinia when it had that name, left then returned after it had become Ethiopia when the next generation of doctors -- offspring of two characters who appear early then disappear from the scene, one of them dead, but leave indelible imprints on the narrator and his twin brother. There are graphic but not stomach-churning accounts of surgical and obstetric procedures, and vivid descriptions of everyday life in the exotic setting of Addis Ababa. It's colourful, gripping - unputdownable in places - tinged with magic realism, wise, and really beautifully written, Verghese has written short stories and articles for New Yorker, Atlantic Monthly, etc, and two previous books, one of which I read, about his experience with HIV/AIDS in a small Tennesee city when he was young doctor, and saw how this disease exposed the local people's weaknesses and strengths. That book was fact, Cutting for Stone is fiction. He writes equally well in both modes, and his fiction is truly outstanding. He is now a professor of medicine and medical humanities at Stanford University school of medicine where he teaches students (I really envy those students!) and is able to pursue his career as a writer. This is definitely a book to read, to own and reread. I think it will become a classic.

Blenders

Between them, our two blenders can reduce just about any food from steak and veggies to soup with suszpended lumps of meat, vegetables and swollen lumps of barley to a fairly homogenous mush that usually slips down easily. Although its appearance sometimes conjures up images of something quite unpalatable, it smells like the food of which the mush is made and Wendy assures me that it tastes anywhere from good to delicious, depending in the foods I've blended. But despite her increasing disability, her discriminating tongue can identify and reject lumps that have evaded the blender's sharp blades, and 'stringy bits' that might stick in her gullet. Also, she complains that some blended dishes are 'too dry' -- a problem I can solve by adding soup to the main course I'm blending. We had a small crisis as a result of the combination of dryness, lumps and stringy bits a couple of days ago. A small, trivial event to be sure but our lives are dominated these days by small trivial things. Yesterday afternoon our friends Pat and Don Muldrew called on us, bringing among other things, milk shakes. We had these in the late afternoon, and when it was time an hour or so after their delightful visit for me to get our evening meal ready, neither of us felt like eating. Well, a milk shake is blended milk and icecream, so I suppose we'd had a very successful blended meal. Even now next morning before breakfast, I still feel comfortably satisfied. So more milk shakes will be on our menu in future!

More advice on living with ALS

Yesterday we had a session with Susan Geis, the senior physiotherapist in the ALS Clinic. As usual she offered several very sensible and useful suggestions about ways to cope with Wendy's increasing disability. All the paperwork and other preliminaries are already in place to get a battery-powered electric wheelchair, which should be delivered in about a month. Susan pointed out that an ordinary wheelchair - she called it a 'transfer chair' - would be very useful too on many occasions. We had a long discussion also about the logistics of showering when her muscle strength declines beyond a level when she can get in and out of our shower unaided: the shower and the step up into it are about 15 cm above the bathroom floor and because of the confined space it's going to be a challenge to figure out a way to overcome that hurdle. Susan suggested that the two experts on ways to deal with such problems, the one based at the ALS Clinic and our community-based expert, Courtney Henderson, should confer together and figure out the best way to deal with this. As on many occasions since we were hit withWendy's diagnosis, I am very favourably impressed by the cheerful willing and aways positive approach that is shared by every one of the experts in the team that looks after Wendy.

I may need to do more about blenders. We have two, but neither coped very well with the delicious spiced salmon dish that I got for our supper last night. The aim is to render all Wendy's meals into what often looks like a very unappetizing mush, but actually tastes and smells pretty good.

Anarchy abroad and at home

We don't have to go to Bangkok to find visible evidence of tension, confrontation, even conflict, between factions in society. There's visible evidence a few hundred meters from our home, at the branch of the Royal Bank of Canada on the corner of First Avenue and Bank Street -- Wendy's bank. Several days ago this bank was fire-bombed. About 3 am, two men were seen in the entrance where automated banking machines are accessible 24/7. They evidently tossed a Molotov cocktail or two through the glass partition into the bank itself, started a fire that did about $500,000 damage before it was extinguished by the firemen from the local fire brigade station less than half a kilometer away. Today a shadowy anarchist group posted their own video of the event, and claimed responsibility for it, apparently the same anarchist group that attempts violently to disrupt meetings of the G8 and G20 when these are held in Canada. I'm neither shocked nor surprised by this action or this claim. We live in a world that is increasingly overcrowded beyond sustainable levels, in which there are widening gaps between the haves and the have-nots. I've been watching this world and as much as I can of what goes on in it for more than 70 years; I began a life-long habit of reading newspapers and listening to radio news broadcasts in the 1930s, when the Spanish civil war was raging, the Nazis were expanding their regime from Germany into Austria and Czechoslovakia, and on the other side of the world, the Japanese had invaded Manchuria and were committing rapine and slaughter in Nanking and attacking Shanghai. The domestic front was uneasy too, with massive unemployment lingering as the great depression of the early 1930s slowly faded, and labour disputes on the waterfront and in coal mines often got violent and bloody. It seems to me that throughout my entire lifetime there has been a rising tide of social unrest that often ends in violence, punctuated of course by the world war of 1939-45, and innumerable smaller, more or less localized and increasingly barbaric wars since then. When there is no actual violent armed conflict, tiny explosions of violence like the fire-bombing of our neighbourhood bank, are less dramatic signs of the same underlying causes for unrest and discontent. Whatever the economic or political 'cause' of the conflicts and lesser forms of violence, I believe the real underlying cause is that too many people have been competing for a share of the world's shrinking supply of essential resources; and inevitably there are some who have plenty, including a few who have an obscenely large share, and others who do not have enough. I'm quite sure there are too many people to allow an equitable share for everybody. I was worried about population pressure long ago, when I was a medical student: in 1949, a few months before I graduated from medical school, our student magazine published my first-ever 'professional' paper. Among other things I thought the world's population was increasing too rapidly to be sustainable; it was increasing then by about 20 million a year and the world was carrying less than 2 billion people. At its peak in the early 1990s, the population was increasing by about 85 million a year; now, as the total approaches 7 billion, it's slackened off a bit, to about 60 million a year. In my lifetime, the world's population has increased more than threefold. As I've traveled about the world I've seen with my own eyes enough convincing evidence of population pressure to trouble me. I have no idea how or when all this will end. I hope for all our sakes that it all ends happily, but I'm not very hopeful about this.

Wendy's story of the two baby pigs

Today's post on the blog is an excerpt of Wendy's memoir of her childhood. Her father had been gassed during one of the battles in France in the 1914-1918 world war, and his permanently damaged lungs made it difficult for him to work year round. In warm weather he worked outdoors, overseeing telephone linesmen setting up new phone lines across the South Island of New Zealand. Her memoirs contain several memorable anecdotes about her experience as the youngest of three children during the great depression of the early 1930s, with her brother John and her sister Rae. This is the story of the two pigs, Adolphus and Jemima.

Among the stray animals that Pop found while out in the country were two white piglets. He had sat in the truck eating his lunch when he heard a baby crying, a strange sound when he was miles from any house. He got up to look around but could see nothing, so he followed the noise to a dense bush and peering underneath it he saw two little white pigs snuffling and mewling in the grass. He reached in and picked one up because it certainly wasn't the wild boar variety and he wasn't afraid of a domestic pig. It didn't resist at all and he was wondering if he should just leave them there for the mother to return, but no domestic pig would be out in the country so far from any farm. The little fellow was obviously thirsty because it latched onto Pop's sleeve and started to suck it. The other one heard its brother and missing its warmth beside it came out to investigate. Pop had an old tin in his tool kit so he brushed it out and poured some of his tea into it, blew it cool and pushed the pig's nose into it. They were too small to be weaned, but with the help of Pop's finger it got some fluid and seemed satisfied. He repeated the process with the second one, then returned them to the hiding place and left them for the return of the mother.

He carried on across the country, unreeling telephone wires, climbing the poles he and his gang had put up previously, and connecting the wires to them. At knock off time he retraced his route, and looked under the bush to see if the Mum had collected her babies. The two were still there, very vocal and hungry, so he reasoned that a hard hearted farmer had just thrown these surplus piglets out to fend for themselves, because no mother animal would leave her babies for so long. He still had some tea in his thermos, and this time they didn't get so much up their noses. They were two smart little animals. He made room in his tool kit and wrapped them up in a bag and put them in the box, and drove home. We had finished tea when he returned, and were intrigued when he walked in with this bundle under his arm. We were thrilled when he put the two little pink pigs down on the floor and they skittled around squealing. Mum was not quite so enthralled, but she put some warm milk into a bottle and with a wick of towelling they could suck it and had a good feed. We found a big cardboard box and they soon were snugly snoring, cosy in some old rags.

The next day Pop unearthed the half tank from the orchard, and with all of us heave- ho-ing, we moved it near the house, put a box sideways in one corner, with hay and the rags in it, and straw in another corner for their toilet. They always used this and never soiled any where else. A bowl for water and their new home was ready. We bought 2 lambs teats, so we could bottle feed them simultaneously. We called them Adolphus and Jemima, and after a week they came to their names. They loved to be picked up and I had a great time dressing them in dolls clothes, putting them in an old doll's pram and pushing them around the garden. They would lie there happily and quite often doze off. In a short time they were eating solids, but they still liked a bottle of milk.

The two pigs grew rapidly and soon could stand on their hind legs to peer over the top of the tank. Jemima could get out but we couldn't imagine how she did it. She would appear at the back door and squeal until Mum gave her a tidbit and returned her to the tank with an extra snack for Adolphus too. After a few days she was long enough in the leg to go up the back stairs and she would follow Mum around the house until she got attention and a snack. Needless to say Mum wasn't all that thrilled with her company.

Whenever there was a Nor'Wester I would have a "bilious attack" and stay home from school until the nausea subsided. I was sitting in the garden by the tank when I heard a commotion, with grunts and squeals and chasing around. Getting up to see what was happening, I saw Jemima rear up on her hind legs and put one foot on the bolt that held the tap in place, and then Adolphus gave her a push with his nose under her tail and she tipped overboard, landing with a grunt on the other side. After a shake, she purposefully trotted off to the back door, while Adolphus sat back and waited for the extra rations. It was time for larger accommodation.

Pop made a superb pigsty down by the creek a good distance from the house, where there was a convenient slope so that the manure from their deck could be hosed down through the slats, run down away from the sty into a holding tank for manure for the garden. They had a good sized living room with an adjoining bedroom full of dry straw and a roof over both. Their deck was large enough for them to chase each other around for exercise and bask in the sun when it was warm. The feed troughs were out there so that anything that was spilt could be hosed down and not encourage flies. There was a gate between the living section and the outdoor deck, so the pigs could be shut in one half or the other to facilitate cleaning. By now they were two gross pigs full of push and playfulness that was enough to knock even Rae, my 14 year old sister, over.

One Saturday when the posh people over the creek were having a garden party with tables set out on the lawn sloping down to the creek, we decided to clean the pig sty, and as the guests were assembled up near the house some distance from the creek we didn't anticipate that our activities would disturb them.

With a family effort and much enthusiasm, the inside gate was not fastened securely, and as we were hauling the straw through the outside gate from the deck, Adolphus pushed out onto the deck, sent my brother John flying, and leapt from the deck, making a mad dash for the creek, and the garden party opposite.

Rae who was tall for her age dashed after the pig, grappled him in the creek, but with the wet skin lost her grip and both of them charged up the slope towards the astonished guests. Rae was gaining slightly, but the gap between the pig and the guests was getting alarmingly small when with a gigantic effort, Rae threw herself forward and grabbed Adolphus's tail. She hung on like crazy as he changed direction and headed back to the creek.

By this time all the family had got into the act. Pop, my brother John, the dog and even the ducks on the creek all set up a great hullabaloo, and as Adolphus and poor Rae being dragged along behind still grimly hanging on, rushed towards them they formed a corral and caught the culprit. Ever after Adolphus had a straight tail, while Jemima's was pert and curly. Rae was the heroine and the neighbours never had another garden party in our time.

There's no mention in the memoirs of what ultimately became of those two pigs, but I have my own theory about this. When I was assembling her memoirs, stories, poems and paintings into the book of her selected works, I thought it best not to go into this theory.

Today's rant

Am I just an old crochet, an elderly curmudgeon who can't stand new ways of doing things? I don't think so. Generally, I'm pretty tolerant and sometimes I've even been at the cutting edge of what's new and exciting. But one thing that really upsets me, that makes me grind what's left of my teeth in rage, is to listen to a lovely ballad being mutilated by some trendy, wailing contemporary -- and here I'm stuck for a word, something that doesn't often happen to me -- singer? No! Those who perpetrate these atrocities can't sing, can't usually span more than a couple of octaves, obviously can't read music or sing in tune by ear, and worst of all, seem to believe they can improve on a time-honoured ballad by an anonymous mediaeval composer, or on the pitch-perfect music and words of Cole Porter and others of his kind. Some of those early to mid-20th century tunes are quite lovely; a few have words to match that are genuinely poetic. A week after hearing it I'm still simmering with rage at the desecration of the hauntingly lovely tune, Smoke Gets in Your Eyes, by somebody who, charitable chap though I am, I think it would have been a kindness to strangle at birth. So that's my rant for the day.

How and why we came to Ottawa

This has ben a busy week with visits by us to the ALS Clinic, and several very pleasant visits by others to us here in our 11th floor pad. The last of the week's visitors were especially welcome: Mariella Peca, Monica Prince, and Pauline, who used to be Pauline Carr but has been married for about 25 years now and to my shame I've forgotten her married name. If she reads this, she can let me know. In the 1970s all three worked in our office; Mariella still does, and they've been good friends with each other and with us ever since. It felt just like old times to see all three of them sitting in our living room, a really delightful reunion. We should have celebrated with some South Australian liquid sunshine, but Wendy doesn't drink nowadays, Mariella was driving, and cups (or rather mugs) of tea seemed more appropriate to the occasion. I think it was Pauline who asked if I am still Australian, so I told the sad story of how I had to sacrifice my birthright and become Canadian in 1976 so that David, then aged 17, could begin his career as an officer cadet at the Royal Military College. He had to be a Canadian citizen, and before he turned 18 and was of legal age to become one on his own, I also had to be Canadian. I sacrificed my boomerang, must get a visa to enter the land of my birth, but I've kept my Australian accent as a permanent reminder that deep inside I'm still an Aussie. How did we end up in Canada, Pauline asked. It's a long story. We left Australia at the end of 1963 for a post at the University of Vermont, in Burlington, an old university founded before the American Revolution, then a little over a year later, left the USA for the University of Edinburgh. We had five very happy and, for me, very productive years in Edinburgh. Then I began to get serious invitations to move onward and upward, to an English medical school, or to one of several in the USA. The most attractive of these was a cross-appointment between the Harvard Medical School and the Harvard School of Public Health. I took that one very seriously, went to Boston, jumped through the necessary hoops, and provisionally accepted the position. Almost as an afterthought I flew on from Boston to Ottawa, arrived here late on a hot June afternoon. I had a room at the lovely old colonial Bytown Inn, since demolished. I had eaten in Boston, or on the plane, or perhaps both, so I went for a walk, over to the Rideau Canal and along the pathway beside it, up to one or two streets beyond where we live now. Kids were playing street hockey while their parents sat on the doorsteps watching them and chatting. I had one of those life-changing flashes of insight: this would be a better place to raise our kids than Boston! To put it in context, the late 1960s were a violent and turbulent time in the USA; we had lived in the USA before, had then and have now many very good American friends. But there are aspects of the American way of life we never embraced. One of the deciding factors in 1965 in choosing Edinburgh over Baltimore (where I'd been offered a position at Johns Hopkins School of Hygiene and Public Health) was the right to bear arms. It came up one evening at dinner with three other couples, gentle folk from other faculties of the University of Vermont. We were the only ones who didn't keep a loaded handgun in the house - in Burlington, a small, peaceful university city! Wendy and I had been appalled, had decided there and then that we didn't want our kids to grow up with values like those of our American friends. Pierre Trudeau was Prime Minister of Canada then; we'd seen and heard him being interviewed on BBC TV. We liked him, and what he said about Canada. In Edinburgh I'd met enough Canadians to feel comfortable about sharing values in common with them more than with many Americans. So despite the eminence of Harvard and the prestige that might have come from working there, despite the lowly status of the medical school in Ottawa in those days, and even despite the long and bitterly cold winters, we chose to come to Ottawa. We've never regretted it. The medical school has come up in the world since 1970 (I like to think I have contributed a little bit to its ascendency); the city has become a cosmopolitan metropolis, with more gains than losses from the transformation; and thanks to global climate change, even the winters have gotten shorter and milder in recent years. And lately of course, we've been very thankful that Canada is among the civilized nations that has a pretty secure social safety net.

I may be the only person ever to have declined invitations to join the staff of two of the most prestigious schools of public health in the world, Johns Hopkins, and Harvard. But I don't boast about it. I declined both of these attractive invitations (and a few others also) because I didn't feel inclined to gamble yet again with my dependent family's future, as I had when I left the security of general practice and all four of us lived on my savings for a year while I studied public health sciences, and when we left the School of Public Health and Tropical Medicine at the University of Sydney to join Kerr White's group at the University of Vermont, an episode I have yet to describe in this blog. Those gambles had both succeeded. It was best to quit while I was ahead. Neither the Johns Hopkins nor the Harvard position was tenure track or "hard-funded" -- my salary and the family's sole source of support could have been shot out from under me at any time, even without warning. That could have precipitated a nightmare scenario that doesn't bear thinking about. Anyway, it all worked out well, and we lived happily ever after, more or less.

A corner of a foreign field that is forever Holland....

Princess Margriet of the Netherlands, now 67 years old, is visiting Ottawa this week. She was born in a wing of the maternity suite at the Ottawa Civic Hospital that was declared Dutch territory for the purpose, so she could, in theory anyway, be born in her homeland. The story was written up as far away as in the Adelaide Advertiser when I was a school boy and read about it for the first time; for some obscure reason it piqued my interest more than stories about royal families, aristocracy and other kinds of nobility usually do.The Dutch royal family lived in exile in Ottawa during the Nazi occupation of the Netherlands. Princess Margriet is a jolly, cheerful-looking, quite handsome woman now, a frequent visitor to Ottawa. As a gesture of gratitude to Ottawa for its hospitality, the Dutch royal family gives 10,000 tulip bulbs to our city every year. I'm glad she is here this week, this year, because the tulips have never looked better, as demonstrated by the photos I posted on the blog a few days ago.

The Dutch royal family is very down-to-earth, just regular folks as the Americans would say; so is the Swedish royal family. Both ride their bicycles around the streets of their city, without armed guards or escorts. Once when I was in a book shop in Amsterdam, I glanced up from the book I was browsing to see Queen Juliana, with a solitary female attendant, also browsing on the other side of the same table of books. After she left the book shop, the sales clerk confirmed that my recognition of her from photos was correct. Not long after that I was in Stockholm for a conference on the philosophical foundations of medical ethics, convened by the Nobel Foundation and the Karolinska Institutet. It was opened officially by the rather handsome Spanish-born Queen of Sweden, who spoke briefly in Swedish and English, then came and took a seat immediately in front of the seats occupied by my friend Claes-Goran Westrin and me. I could quite literally breathe down the back of her neck had I chosen to do so. I have a photo to prove it. After the opening ceremony and formal speeches, she joined us plebs for coffee. I was not sure what I should do if introduced to her, but fortunately that didn't happen. These two families are an interesting contrast to their British counterparts. I wonder whether this is related to the apparent success of Holland and Sweden as functioning societies, compared to Britain, as revealed by the statistics of the Human Development Index and other objective indicators...

Of course there is something else, a special bond between Holland and Canada: in April 1945, the Canadian contingents of the allied armies liberated Holland from the Nazis who had invaded Holland and Belgium in 1940 as part of the Nazi takeover of almost all of Europe. This special bond between the two nations is another reason for the annual gift of tulip bulbs. The Nazis had been particularly brutal and vicious in Holland. In the final year of their occupation they looted virtually all the food and destroyed much of the country's capacity to produce food, precipitating the famine known as the Dutch Hunger Winter. The Canadian liberators brought not only liberty, but food as well. As an adopted Canadian, I've had the pleasure of basking in the Dutch love of everything and everyone Canadian, and so has David, both when he wore the Canadian forces uniform and subsequently as a civilian.

Breathing machines

Today we had an appointment with the respiratory technician at the ALS Clinic, to test-drive a machine that can do the breathing for Wendy while she is sleeping. For several weeks now as I lie awake listening to her breathing, it's become clear to me that it is an effort for her to breathe. I was sceptical before the machine was demonstrated but the respiratory technician, Joan Nordgren, soon convinced both of us that it would be a good idea. Our late neighbour and friend Ken Scott, who died of ALS a little over a year ago, had one of these for the last few months of his life, and both he and his wife spoke of how beneficial it was. It takes over from the weakening muscles of the diaphragm and rib cage, so they can rest a bit while she sleeps. I was expecting it to be noisy but it's quite silent - a lot less noisy than her laboured breathing has been lately, because her own built-in breathing machine, her respiratory muscles, aren't working well, so every breath she takes is an effort. While she sleeps, this machine will take over so her muscles can get some rest. We both decided early on in the course of this illness (Wendy decided first, and with greater determination than I) that we would not have any life prolonging interventions like a stomach tube to feed her after her ability to swallow has been lost. But this is different: the breathing machine, like the various other devices she uses, simply makes her remaining life easier. So I'm all for it, and so is she.

Wendy's progress

Several correspondents, family members and friends, have sent emails with comments on recent posts on this blog. Those photos of tulips and spring crab apple blossom resonated more than I expected. We had a cold and blustery weekend so when David drove Wendy and me home from Rebecca's Mother's Day lunch the tulips were as ablaze with colour as they had been earlier in the week, but most of the crab apple blossom was gone. Even so and cold as it was, we were snug and warm in the car and very much appreciated this further chance to see the tulips at their best.

Janet Wendy almost fell on Rebecca's front doorstep, and later in the evening, she did fall, on our bathroom floor. "Fall" isn't perhaps quite the most precise word to describe what happened. Her leg simply gave way under her, because the muscles didn't have enough strength to hold her up. So I have to report that her disease is progressing relentlessly. Fortuitously we have a date at the ALS Clinic tomorrow so we can get a thorough assessment. There's no doubt that her muscle strength is ebbing away, but she is in good spirits, she thoroughly enjoyed the Mother's Day festivities yesterday, and so we go on taking life one day at a time and getting as much enjoyment as we can out of each day.

The Pill at 50

More nostalgia today: fifty years ago today, the US FDA approved the oral contraceptive pill for use under medical supervision, specifically to treat "menstrual irregularities" - a convenient euphemism that enabled millions of American women to complain of menstrual irregularities. The Pill was not yet available in Australia; we had been married three years by 1960 and had to rely on the other available and often messy alternatives. I can't remember when we first moved in social circles where use of the Pill was commonplace, heard younger women chatting casually about how the Pill had liberated them; our main emotion was envy. There's no doubt it was a major contributor to the liberation of girls and women from excessive, inappropriate pregnancies and perpetual fear of unwanted pregnancy. It was among the small handful of really important twentieth century innovations in preventive and clinical medicine that had, and will always have, a transformative effect on society. It seems entirely fitting that its fiftieth anniversary should fall on Mother's Day.

VE Day + 65

I remember it as if it were yesterday. The 1939-45 world war began for us on September 3, 1939, and from early 1940 - before the Nazi invasion of the Lowlands of Belgium and Holland, before Dunkirk and the fall of France - things had gone badly for us. Things kept getting worse and worse throughout 1941 and 1942, only slightly less awful in 1943; but by about the middle of 1944 with the D-Day landings in France on June 6, and the Russian steamroller beginning to push the Wehrmacht back towards Germany, it began to look as if we might prevail. By the beginning of 1945 it was fairly certain, unless Hitler's "secret weapon" that he kept boasting about turned out to be something truly terrible - as the atomic bomb proved to be later. By April of 1945 the Germans were fighting on several fronts on their own soil; clearly it was just a matter of time. When the great day, May 8 1945, dawned, we already knew in Australia because the peace treaty had been agreed the previous day and the great victory celebration and parade through the streets of Adelaide was already better than half-planned. We students at the University of Adelaide (who already included a sizeable contingent of ex-servicemen) planned our own celebration and eventually virtually took over the official celebrations, as I've described in my memoirs. The highlight was one of the ex-servicemen, a student in law if I remember well, wearing his uniform, the trademark beret and rows of medals some legitimate, some perhaps not, cleverly made up to produce a startlingly accurate resemblance to the hero of El Alamein, Field Marshall Sir Bernard Montgomery. He sat in an open touring car just like the one we had seen in innumerable newsreel shots, taking the salutes of the adoring crowds, many of whom seemed really to believe that "Monty" had come all the way to Adelaide to share in and preside over our victory celebrations.

The sense of relief we all felt on VE Day is impossible to convey to anyone who didn't experience it. That war was a dark, depressing, dangerous time. It touched us all directly, even remote from battle fields or risks of air raids as my family and I were in Adelaide. Early in the war my cousin "Bucky" Judell, the only son of my favourite uncle, had been killed. Several other cousins a few years older and close to me in interests and values, had horrendous experiences of combat, like my cousin Ross Ragless at the siege of Tobruk and the battle of El Alamein; another cousin was captured in an earlier battle in that same theatre of war, spent several years in a POW camp. I had turned 18 a few months before VE Day so I was eligible for call-up and intended to take leave from the medical course at the end of 1945 by which time I would know enough anatomy and physiology to be useful in uniform as a medical orderly. We all expected the war with Japan in the Pacific - our near north - to drag on for at least several more years. We knew nothing about the Atom Bombs that would bring an abrupt end to it in August of the same year.

It would have been a better world since the middle of the 20th century if that terrible world war had brought about a lasting worldwide peace. But of course it didn't. There were some just wars of liberation from colonial domination, some ideological wars, some proxy wars, some absolutely unnecessary, immoral wars. It almost seems that humans are hard-wired to be aggressive and quarrelsome. Yet we also seem to be hard-wired to come to the aid of those who need help, as pictures and newsreel shots from disaster zones like earthquakes demonstrate. So we aren't all bad, and I'm comforted by the thought that the good far outweighs the bad.

Medicine and literature

Let's go back to books again. In the late 1990s my friend Karen Trollope Kumar invited me to take part in a symposium or colloquium on the role of the humanities in medicine and healing. I accepted with pleasure, gave a talk that was well received, and subsequently got this published. This is not part of my list of essential books, although a few are -- I'll come to those in a later post sometime. To go on with, I will paste here the text of those remarks at McMaster University Medical School in 1999.

Medicine and Literature

Passion, compassion, confusion and other emotions in stories about sickness and healing

A complete physician needs insight transcending the knowledge, skills and attitudes that professional training provides. How can this be achieved? Personal experience of illness and suffering, or that of a close family member or a loved one, can do it. It is painful, but it can be a good way to comprehend the complexities of life, and of human nature.

Another way is through the humanities -- a rich source of insight into the human condition and the role of healers. The ethical, moral, and spiritual dimensions of sickness and healing are eloquently displayed in the creative arts -- in music, painting, sculpture, and most of all, in literature -- drama, poetry, fiction. Here I can only skim over the surface, touching without penetrating into the immense variety and richness to be found in literary works. (I mean real literature, not what authors of journal articles commonly call “the medical literature” -- a phrase that is almost always an oxymoron).

Our understanding of the complexities of society and human nature, and our values, come from good literature as well as from our medical experience. Fiction can portray social conditions brilliantly, as Charles Dickens did, for instance in Oliver Twist (1837) Dombey and Son (1848) and Little Dorritt (1855). Good writers often reflect life and the values of their time. HG Wells, in Kipps (1905) and Anne Veronica (1909); JB Priestley, in The Good Companions (1929); Sinclair Lewis, in Babbitt(1922); John Steinbeck, in The Grapes of Wrath (1939); George Orwell, in Down and Out in Paris and London (1933), and The Road to Wigan Pier (1937); and legions of others in many countries have upheld this tradition through all the wars and turbulent events of the 20^th century. John Updike’s four books about Harry (“Rabbit”) Angstrom, which dissect the life and values of an “average” American man and his family over the four decades from the 1960s to the 1990s are a good contemporary example.

The workings of the mind, and the whole range of emotions are another fruitful field for novelists -- and for poets. James Joyce's Ulysses (1922) perhaps the greatest novel in the English (or any other) language may be the best textbook ever written about how the mind works. Sylvia Plath and Anne Sexton revealed their tormented souls in their poems. Moran Campbell, a former chairman of the department of medicine at McMaster University, movingly described his bouts with the peaks and troughs of manic-depressive disorder in his autobiography, Not Always on the Level. The 19^th Century Scottish poet James Hogg captured the personality of a paranoid psychopath in The Private Memoirs and Confessions of a Justified Sinner (1824), a work of fiction that reads chillingly like fact.

And the works of Shakespeare, of course, are the human mind laid bare, displayed in all its glory, misery, squalor, high spirits, splendour, imaginative sweep. Shakespeare's plays are at the highest pinnacle of a tradition that began with Homer and the Greek tragedians and continues through Samuel Beckett and Arthur Miller. Shakespeare is the undisputed master. If you would understand humanity, heed Hamlet, know Lear, love Rosalind, roister and frolic with Falstaff.

You can learn about the human dimensions of many aspects of disease and medical care from literary accounts:

· How tuberculosis affects people, from Thomas Mann's Magic Mountain (1946) and in a more emotionally wrenching way, from The Rack (1958) by the pseudonymous AE Ellis.

· About the sorrows and pleasures of growing old, from Love in a Time of Cholera (1989) by Gabriel Garcia Marquez.

· About transsexuality, from Melisio, who becomes Mimi, in Isabel Allende's magic realist novel Eva Luna (1988)

· About the impact of mental illness, and the deplorable way it has been treated by sadistic mental hospital staff, from Ken Kesey’s One Flew Over the Cuckoo’s Nest (1962) which was made into an excellent movie.

· About the descent into the self-destructive vortex of alcoholism, from Under the Volcano (1947) by Malcolm Lowry, also made into a good movie.

· What the long, slow death from multiple sclerosis is like from the inside, in Journal of a disappointed man (1964) by W N P Barbellion (which is fact, not fiction).

· And about terminal illness and the inevitability of death, from many accounts, best of all perhaps in Leo Tolstoy's masterly short story The Death of Ivan Ilyich (1884).

Passion, compassion, confusion, and other emotions encountered in medical practice have been described by many creative writers, including some doctors.

In “The Use of Force,” William Carlos Williams, a family doctor, and a lyrical poet and short story writer in depression-era Paterson, New Jersey, described the passion of anger. He absolutely had to look at a little girl's throat because he suspected she had diphtheria. She fought him every step of the way. Her throat was hers! No busybody doctor was going to see it. She knocked his glasses off, kicked, scratched, and bit him. He got really angry. Here, abridged a little, is William Carlos Williams in New Jersey in the 1930s:

... now I had grown furious -- at a child. ...the worst of it was that I too had got beyond reason ... I could have torn the child apart. It was a pleasure to attack her... The damned little brat must be protected against her own idiocy ... in a final unreasoning assault I overpowered the child's neck and jaws... I forced the heavy silver spoon back of her teeth and down her throat till she gagged. And there it was -- both tonsils covered with membrane. She had fought valiantly to keep me from knowing her secret. She had been hiding that sore throat for three days at least and lying to her parents to escape just such an outcome as this. Now truly she was furious. She had been on the defensive before, but now she attacked. Tried to get off her father's lap and fly at me while tears of defeat blinded her eyes.

I’m sure this is a true story. Not long before I first read it, I had slapped a girl about that age, in front of her mother too, because I was fed up with her tantrums. (It was the act in my professional life that I am most deeply ashamed of, but at the time, more than 40 years ago, it felt satisfying and amply justified -- and it worked. Now it would be a criminal offence).

William Carlos Williams's gritty, real-life Doctor Stories are beautifully written accounts of real events and real people, but they are not comfortable reading. They explore the most powerful emotions a doctor can experience in dealing with sickness and suffering, birth and death.

Samuel Shem had just finished his internship year when he wrote The House of God about 20 years ago. Its black humour has been compared to Catch 22 and Mash but it is more obscene, scatological, cruelly callous -- yet also it is compassionate, sometimes very funny, and it can be deeply moving. A few scenes are unforgettable. One is the suicide of an intern who can't take it any more. Well, that's the facile, superficial explanation. The reality is that premonitory signs notwithstanding, no one, including the narrator, Samuel Shem’s alter ego, attempted to intervene as the unfortunate Potts slid into irretrievably profound depression. Another is a brief scene, sketched in just a few lines, of a young married woman who is brought in by the police for a medical examination after being raped. Her husband joins her. In a few lines about their body language, Shem describes how their lives and their loving relationship have changed forever:

“Have you called your husband yet?”

“No... I’m too ashamed,” she said, and she lifted her head up for the first time and looked me in the eyes, and first her eyes were dry cold walls and then, to my relief, they broke apart into wet pieces, and she screamed and screamed out, sob after sob ... after I did the workup for rape I called [her husband]. He’d been worried stiff and was glad she wasn’t dead. He could not know, yet, that part of her had died. [Her husband comes to collect her]... I watched them walk down the long tiled passage. He went to put his arm around her, but with a gesture I knew was disgust at the ruination of her body by a man, she pushed it aside. Separate, they walked out into the savageness...

They never will touch one another again as they did before that night's evil was done. Vignettes like this elevate Shem above the brutal obscenity and ribaldry in the rest of this excellent book.

Doctors are often confused. The Yale surgeon Richard Selzer, a superb writer who ultimately quit surgery to write full-time, described how he once was transported back to the Middle Ages, confused, fearful, possessed by a devil, when on opening an abscess he was confronted by something alive, a hideous face with antennae and eyes staring at him. Reading this makes the hair on the back of my neck bristle. He managed to snare this unearthly beast with a pair of forceps, got it into a bottle of formalin. It was the maggot of a bot-fly, the abscess a common one in cattle, rarely seen in people. It was a deeply disturbing, confusing experience.

Confusion? Pity Emma Bovary’s cuckolded husband, poor Charles Bovary! In medical school he didn't even begin to understand what he was being taught, and when he became a country doctor he could not apply any of it. He lurched and staggered from crisis to crisis, reaching the depths with a major medical disaster, a badly botched diagnosis, at the same time as his marital disaster. He was dazed and constantly bewildered as a medical student:

The curriculum that he read on the bulletin board staggered him. Courses in anatomy, pathology, pharmacy, chemistry, botany, clinical practice, therapeutics, to say nothing of hygiene and materia medica -- names of unfamiliar etymology that were like so many doors leading to solemn shadowy sanctuaries. He understood absolutely nothing of any of it. He listened in vain; he could not grasp it. Even so, he worked. He filled his notebooks, attended every lecture, never missed hospital rounds. In the performance of his daily tasks he was like a mill-horse that treads blindfold in a circle, utterly ignorant of what he is grinding.

I can recall feeling a little like that once or twice when I was a medical student, but not all the time, thank goodness. I can also think of one or two students like Charles Bovary whom I’ve tried in vain to teach...

Confusion and disaster go together in Isabel Allende's account of the tragic death of her daughter, Paula -- brain dead in an episode of acute porphyria, and a long, slow death in deep coma. No one should read Paula as an account of a personal family tragedy due to a medical misadventure, though it is that too. Paula is about much else -- the Allende family, the culture and politics of Chile, lovemaking and childbirth as well as death, the evil of the Pinochet era and the good that overcomes that evil (themes that recur in Isabel Allende's other books) and her own passionate nature and the magic reality of her own life. And the long-term home care of a comatose patient with a tracheostomy... Paula is a celebration of life, and I think it will become a classic.

I am an epidemiologist, so I like books about epidemics. Berton Roueche’s “Annals of Medical Detection” in the New Yorker aroused my interest when I was a medical student, long before I thought of becoming an epidemiologist myself. Two and half thousand years later we puzzle, over Thucydides’ meticulous account of the epidemic that struck the Athenians at the end of the first year of the Peloponnesian War. Now we debate its possible cause, because we can't identify it despite the details Thucydides gives us. Daniel Defoe described in fiction 60 years after the fact the outbreak in 17th century London in Journal of the Plague Year (1722). Samuel Pepys who was in London in the plague year described it too, made it come to life so you can feel the fear and fatalism that infected Londoners even when the plague bacillus did not. Albert Camus's La Peste (1948) is ostensibly about the outbreak of bubonic plague in Oran, Algeria, in 1946; but it is really an allegory of how people become infected with evil ideas and beliefs like fascism. Camus fought in the French Resistance, and knew what he was talking about. Alexander Solzhenitsyn's Cancer Ward is another allegorical novel, a treatise on the cancerous onslaught of Soviet communism on the body and soul of Russia.

There is plenty of humour in fictional works about the doctor's trade. Much of it is satirical, deflating the egos, pricking the pomposity that prevails among too many of us. Shakespeare and Dickens let doctors off lightly considering the professional shortcomings of their times. Not Moliere or Laurence Sterne though: Dr Slop in Tristram Shandy (1759-64) is contemptible as well as a figure of fun. Proust’s description of one of his many doctors, who could discretely palm his fee like a magician, makes me smile ruefully. I had a partner like that when I was in practice... Sir Roderick Glossop, the brain surgeon in P G Wodehouse's novels, is a ludicrous caricature with no medical credibility. George Bernard Shaw was merciless, sceptical about the irrational behaviour of doctors in the first half of the 20^th century. In Doctors’ Dilemma, which Shaw called a tragedy, he reserved his most savage criticism of medical customs and mores for the Preface which is salutary reading for everyone in the medical profession who is beginning to suffer from hubris. If Shaw were writing now, would he think we have improved? Have we improved?

It takes a real doctor to display our profession in ways that make me laugh out loud. Has there ever been an account of how to treat a belly-ache that can top A Cure of Serpents? Alberto di Pirajno’s treatment regimen was not only unorthodox, it was highly unethical. But it was very effective! (You must read his book to find out what it was; I won’t reveal it here). Richard Gordon and Colin Douglas, two pseudonymous modern British light novelists can make us laugh out loud too. Gordon's Doctor in the House (1952) and Doctor at Sea (1953) ring hilariously true. I find Doctor at Sea especially satisfying, having been a ship's doctor myself a few times, and had experiences like some of those that Gordon describes.

We have fictional portrayals of noble and good doctors too, like Tertius Lydgate in George Eliot’s Middlemarch. (1871). One “fictional” character from the early 20^th century was a real person, the anthropologist and psychiatrist W H R Rivers, who treated shell-shocked soldiers in the Great War. He is brilliantly and sympathetically brought back to life in Pat Barker’s superb Regeneration trilogy.

The honour roll of doctors who deserted their calling to become writers is long and impressive. But some marvellous writers stayed on. It is a deeply satisfying aesthetic pleasure to read them. William Farr's success as a social reformer owes as much to the power of his language as to the facts he displayed in his Annual Reports (in Vital Statistics, part of his job as Compiler of Abstracts to the newly created Office of the Registrar of Births and Deaths in England and Wales). He held that office for over 40 years, from 1839 until near his death in 1883. Not a year went by without his beautifully crafted, rich and rolling phrases tugging at the emotions and the sensibility of his political masters. In his Report in 1874, he addressed the dramatic differences in health levels among English towns:

Take for example the group of 51 districts called healthy… turn to the district of Liverpool. Here it is evident that some exceptional causes of death are in operation in this second city of England. What are these causes? Do they admit of removal? Is this destruction of life to go on indefinitely? Of 10,000 children born alive in Liverpool, 5396 live 5 years, a number that in the healthy districts could be provided by 6554 annual births. This procreation of children to perish so soon, the sufferings of the little victims, the sorrows and expenses of their parents, are as deplorable as they are wasteful. In Liverpool the death of children is so frequent and dreadful that a special system of insurance has been devised to provide them with coffins and burial ceremonies. The mother when she looks at her baby is asked to think of its death, and to provide by insurance not for its clothes but for its shroud and other cerements.

Farr’s contemporaries wrote well too. Read Florence Nightingale's Notes on Hospitals (1863) or her better-known but slight and slim volume of Notes on Nursing (1859). Read John Simon on Filth Diseases (1876) or on English Sanitary Institutions (1890) or go back to 1798 and read Edward Jenner’s Inquiry into the causes and effects of the variolae vaccinae, which describes his experiments with cowpox vaccine -- probably the most important advance in public health sciences of the past thousand years.

William Osler's Principles and Practice of Medicine, published in 1892 was a tour de force the like of which we will never see again, because it is no longer possible for the mind of one person to encompass and write about the entire body of medical knowledge. Osler's textbook is worth reading today, not only for the timeless clinical wisdom (clinical signs haven't changed) but also for Osler’s graceful, elegant prose style.

Alas, as every medical editor knows, such gifts that once were common among learned people are rare nowadays. Far too many authors of papers in contemporary medical journals are like cuttlefish, hiding in their own ink. Pitifully few can communicate an important medical or scientific message in good prose -- the verbal equivalent of a musician with perfect pitch.

Lewis Thomas did it, in sparkling essays, many of them published as “Notes of a Biology Watcher” in the New England Journal of Medicine. Collected in book form they won two Pulitzer Prizes. Peter Medawar did it, and Oliver Sacks can do it too. But the little company of medical writers whose prose is like music or poetry is shrinking. I can count on my fingers the ones who give me pleasure as I read, and whose thoughts I admire.

You too can make life more pleasant for medical editors and for those who read what you write: learn to write well by following these examples! Even the good writers among you can become better. But of course this is not the real reason to read books like those I have mentioned here. The real reason is to enrich the mind and spirit and experience the pleasures of reading.

Books on the sciences

There's a corridor between the tower block we live in and the car garage, and in this corridor there's a set of shelves in which people place books they have read and no longer want to keep. I'm often intrigued at the diversity of our neighbours' reading habits. Predictably there is a preponderance of thrillers and mysteries, a steady trickle of books on economics, politics etc, a few travel books, and occasionally some rather heavyweight philosophical literature. Of course some of the books are in French, because that's the first language of ten or a dozen of our neighbours. Today somebody left there a copy of Thomas Kuhn's ground-breaking book, The Structure of Scientific Revolutions, which looks as if it's been read by the former owner and by nobody else. I snapped it up instantly. It's mine now, perhaps the fourth or fifth copy of this book that I have owned -- somehow, copies of this book, which I used to keep on the shelves of my office at the University of Ottawa, went walkabout more often than almost any other book.It's hardly surprising. It's one of the absolute essentials for all serious scholars of science, whatever branch of science one engages in. Kuhn's concept of paradigm shifts has been almost of biblical significance ever since it first came out, in 1962 according to the copyright page of this copy, which is the umpteenth printing of the second, enlarged edition, first published in 1970. I think I would rate this book among the absolutely essential works that all serious students of any of the sciences must read (the others include Claude Bernard on experimental medicine, preferably in a better translation than the one I struggled through, Peter Medawar's Induction and Intuition in Scientific Thought, and going back a while, Charles Darwin's Origin of Species. Having said this, I've just looked at Kuhn's footnotes and realized something I only half-remembered from the last time I read his book, that his citations are almost entirely confined to the physical sciences, astronomy and chemistry. I don't think there is a single reference to biological or medical sciences. Perhaps he didn't consider these to be sciences at all. I shall have to settle down and read the book again nearly 40 years after I first read it, to see whether I still consider it to be an essential part of the scientific literary canon.

Crab apple wants in

I can't resist adding one more from yesterday, a large crab apple tree in full bloom beside the Dow's Lake pavilion. This was a "point and click" photo out the driver's side car window when I took my foot off the accelerator pedal, let the car creep very slowly forward. I daren't stop. Not only threatening signs but a traffic police lady just behind me might have got very cross if I'd stopped. A flower I forgot to mention yesterday is the native trillium, a delicate three-petal flower that grows in the shade under trees. Not many around the Canal, but lots further afield, and like everything else, better this year than any time in the past 40 years.

Spring time in Ottawa

Our seemingly never-ending spring continues after a momentary interruption, a steamy, oppressive day yesterday. But today was another lovely day of clear warm sunshine with occasional clouds. The profusion of blossom and spring flowers was the best I've ever seen in Ottawa, too lovely to enjoy on my own, so I bundled Wendy into the car and took her for a short spin along Queen Elizabeth Drive around the Rideau Canal to Dow's Lake to enjoy the display of tulips that are at their best now. As well as tulips, there are large beds of daffodils, crab apple blossom, lilac in full bloom, magnolias, apple blossom and others I don't recognize. Even the thousands of yellow dandelions in the grass that most people think are weeds looked splendid I thought, better than lawns that are nothing else but manicured grass treated with pesticides. Our enlightened local government has banned pesticide treatment of lawns. The two photos above are among the selection I took today. I'm tempted to add others but these are enough to show what the city looks like today. Wendy thoroughly enjoyed her day out, so it was well worth it. Incidentally, the office tower visible above the tree tops and the bed of orange-colored tulips is where Rebecca works. I suppose she was hard at work in there while Wendy and I were admiring all the flowers and blossoms.

Smoking kills

One of the ineffable pleasures of life is reviewing proposals that publishers receive from aspiring authors. Publishers reward reviewers handsomely in cash or kind for this service: they invest a lot of money in making, marketing, promoting the books they publish; if the book is rubbish that nobody buys, the loss is substantial. In the case of scholarly books, scientific books, textbooks, reference books and the like, reviewers provide a vital additional service, a detailed critical review, analyzing the science, the logic, the new discovery, whatever, that the book is about. Sometimes my reviews of books in that category were many pages of single-spaced typescript in length. One long review of that sort (a negative review, advising the publisher not to invest in publishing the book in question despite an eloquent proposal, detailed outline, and sample chapter) earned me a fee of $500. The book was eventually published of course, by another publisher; and reviewers for specialized journals cut it to pieces; it sold very few copies, and later I saw whole rows of remaindered copies in a New York book shop. I reviewed many proposals for Oxford University Press and almost always asked for books to the value of the money I would otherwise have earned. My book shelves, and our grandchildren's, are the richer for this. About five years ago I reviewed for the Wellcome Foundation for the History of Medicine, a proposal by Conrad Keating for a biography of Richard Doll. The book has been published, and I've been reading it with the same kind of ineffable pleasure that I got from reading the original proposal and many others like it.

I knew Richard Doll for about 50 years, at first as a highly respected colleague in my field, then as a friend. I met his wife, Dr Joan Faulkner, who was the executive secretary of the Medical Research Council, early in 1961 when I was a visiting fellow in the MRC Social Medicine Research Unit, then met, or rather heard Richard speak, on several occasions later during the same year. I first got to know him and his wife Joan as friends when they stayed with us at our home on Island Park Drive in the early 1970s. Our rather snobbish neighbour was horrified that Sir Richard and Lady Doll were shucking strawberries in our kitchen, helping Wendy and me to prepare for the guests -- my colleagues and assorted dignitaries -- whom we had invited to meet the Dolls that evening. I didn't bother to mention to that neighbour that Richard Doll, like several other distinguished British doctors who grew up in the 1930s, was for many years an active member of the Communist Party; perhaps I should have. During the last 10-15 years or so of his life, I became, as he was, one of the elder statesmen of the International Epidemiological Association, although of course I merit that term "elder statesman" many orders of magnitude less than he! And during those years we became good friends who shared many values beyond our commitment to epidemiology. The book that Conrad Keating has written, Smoking Kills: the revolutionary life of Richard Doll, is excellent. Keating writes well, explains and interprets for lay readers the results of Richard Doll's research with accuracy, clarity and eloquence that rarely grace the prose of non-scientists who write about science. For me there is the added pleasure of knowing as colleagues and often as friends a high proportion of the people mentioned by name in the book. I've seldom enjoyed a biography more than this one, indeed on reflection, I don't think I ever have. I'm sorry to say that the book is not very well made -- like a few others sponsored by the Wellcome Foundation, I am left with the impression that they went to tender to get it published, and selected the lowest bidder. The end result is acceptable, just, but could have been so much better if the book had been published by one of the university presses for instance. It's a small blemish though. The contents count for more that the slightly shoddy book-making. And I give the contents three thumbs up.

A Wedding is Coming in July

Last night Desre and David Skype-phoned us from Toronto with the happy news that they are to be married in July, in a small private ceremony at the home of Desre's sister in Irvine, California (a little way south of Los Angeles). We are delighted for them. They are clearly a well-matched couple. Desre is a widow; her first husband died of cancer of the pancreas. David's marriage to Dorothyanne ended in an amicable divorce after 23 years and three grown up children. They face some logistic problems. David has just been appointed head of the department of politics and economics at the Royal Military College in Kingston; Desre is on the research staff of Waterloo University in the faculty of health studies; she is a PhD sociologist, and she lives in Toronto, commutes westward to Waterloo but works also from her Toronto home. David commutes to Toronto at weekends, and sometimes Desre commutes to Kingston when there is a function she wants to take part in, like some of the formal ceremonies and balls at RMC. It's an easy 2-hour commute by train, and they don't seem to mind or find it tedious. They will sort out their living arrangements in a few years when David's term as department head comes to an end. The photos above are of the happy couple at Christmas time and at a ball at RMC in September 2009. May they have long and happy lives together.