Between one in ten and one in twenty of the women who attended would turn out to have a cancer; the others’ lumps were all benign. Many had fibroadenomas – milk-producing tissue from the lobules of the breast that had become tangled in a complex web of ligaments and ducts. They are harmless apart from the worry they bring. Most of the others had fibrocystic change – a condition so common as to be considered normal. It’s characterized by noncancerous, fluid-filled cysts within the breast that often wax and wane over the course of a menstrual period, like the phases of the moon.
Those women with fibroadenomas would usually be reassured without arranging further tests – the lumps are characteristically painless, smooth and mobile, and much commoner in the young. Fibrocystic change can be more painful and difficult to diagnose, and so my colleague would perform a “fine needle aspiration,” passing a needle into each lump with the help of an ultrasound scanner, and drawing out amber fluid from each cyst. Occasionally she’d find a harder lump that seemed fixed to the tissues around it – a worrying feature. She’d use a broader needle to take a biopsy or, if it was too deep within the breast, arrange a “lumpectomy” under general anesthetic.
In the clinic we’d also see women who’d returned to have their surgical wounds examined to make sure they were healing properly. There were those who’d had mastectomies for cancer, others who’d had reconstructive surgery, and a few who’d had breast reductions because the weight of their breasts had begun to cause back strain. The patients were seen in rapid succession, having been allocated a cubicle and had their clothing arranged by one of the nurses to facilitate a quick examination. The wound was the focus of the consultation: how well or badly it was healing, and its cosmetic result. I don’t remember the women being asked how they were coming to terms with the transformation of their bodies.
FROM A CLINICAL MANAGER’S perspective, healing may be seen as an impersonal, reproducible process, to be systematized and rolled out as cheaply as possible. One autumn I went to see a unique exhibition about breast cancer recovery that explored an alternative perspective: a collaboration between an artist and poet that examined one individual’s path to healing once she’d got beyond those walls of glass and steel.
When, in her fiftieth year, the poet Kathleen Jamie discovered she had breast cancer, she didn’t have immediate reconstructive surgery; after removal of the tumor she woke up with a long, Y-shaped scar that curled around her chest wall. It was a shock for her to look down and see her chest wall flattened in a way it hadn’t been since childhood, her heartbeat fluttering beneath the skin. As she lay convalescing at home she began to think about her scar and the transformation it represented. A new line wound around her chest, and she observed that “a line, in poetry, opens up possibilities within the language, and brings forth voice out of silence. What is the first thing an artist does, beginning a new work? He or she draws a line. And now I had a line, quite a line!”
She began with that line on the body, but began to see references in it to what’s known, for better or worse, as the “natural world.” It was a map, a river, a rose stem. She had been subject to the gaze of a great many clinicians through her treatment, and began to wonder how it would be to have the scar examined instead by an artist. She asked an artist friend, Brigid Collins, if she would consider making a series of paintings and sculptures relating to the scar. To introduce a measure of reciprocity into the project, Jamie began to write short prose poems. Jamie’s poems and Collins’s artworks evolved in tandem, rather than being created to illustrate or explain one another – each of the women worked together to create separate but connected responses. “The healing that took place therefore became a shared experience,” Collins later wrote, “of both recent and past wounds, that can be seen at once as being both personal and universal, using our experiences of the natural world as a starting point.”
The exhibition the women put together had its origins in two separate traditions of visualizing the body. The first considered anatomy through the lens of the surgeon-artists of old like Charles Bell, and the traditional medical illustrators, who prepared images of disease and mutilation for the purpose of medical education. Though beautifully executed, those images were often amputated from their context – the lives and stories of the women they depicted.
The second tradition they drew on was older, with its origins in classical perspectives on health, and imagined the body as a mirror of the cosmos. If the body is a landscape, and illness a disturbance in the greater harmony of which we are but a small part, then the world around us holds clues as to restoring inner balance.
When Jamie sees the tumor on her mammogram, it doesn’t horrify her or symbolize a threat, but is instead “rather beautiful, a gray-glowing circle, like the full moon seen through binoculars.” As she lies in her garden recuperating, a flock of birds in the rowan trees recalls the image of that coagulated tissue: the birds are “a density in their branches.” “Sometimes I almost hear a sweet wild music,” she writes in one of her poems, “it’s audible in the space between the rowan leaves.” Sounds distant from the garden remind her of “the sound of knots untying themselves, the sound of the benign indifference of the world.”An accompanying painting imagines her scar as a rowan branch, the text overlain by layers of gesso and shellac then sanded back to visibility, as if the text and the rowan leaves are emerging into new life. Another centers on a line from Robert Burns: “You seize the flo’er, the bloom is shed,” and inspired a painting of a dog rose, shaped to the contour of Jamie’s scar and emerging from a stained page like the illumination of a medieval manuscript.
A feature of breast cancer is how often it runs in families, woman to woman through the generations. Jamie remembers sitting on her grandmother’s knee as a girl, cuddling into her breast. “My grandmother called her breast her ‘breist,’ her bosom her ‘kist,’” she says in “Heredity 2.” “‘Come for a wee nurse aff her Nana,’ she’d say. ‘Courie in, hen.’” The accompanying sculpture by Collins is called “Kist.” It was designed as a “place of safe-keeping,” wrote Collins, “a feminine embrace, a container, a sewing box, or skirt, which might keep one safe from the world.”
The last piece that Jamie and Collins created together imagines thousands of house- and sand-martins feeding over a river in preparation for autumn migration – they’re “kissing the river farewell” just as Jamie ends her summer of convalescence, “preparing themselves, sensing in the shortening days a door they must dash through before it shuts.” A period of healing can be seen not just as something to be endured, but something to be thankful for: “recovering from the operation was bliss of a sort,” Jamie explained in her introduction to the work. “No one wanted anything of me … I walked by the river and slept better than I had in years.”
The name “Frissure” was coined by Collins to describe the project. The scar is a fissure on the skin, and as Jamie explained, “the naked, scarred body certainly causes a frisson.” The precise way Jamie has with language, and her lack of sentimentality, allowed her to take the anxiety and pain of breast cancer recovery and make of it a celebration.
When I was taken on a tour of the breast clinic, meeting half-dressed women in a succession of cubicles, it was because my teachers thought that that was the right way to learn about “healing.” Frissure offered a lesson to take back into my medical practice – healing involves restitution not just of our inner worlds, but an engagement with the environment that sustains us.
UPPER LIMB
9
SHOULDER: ARMS & ARMOR
But what are men, but leaves that drop
from their branches to the earth?
Apollo’s speech, The Iliad, Book XXI, v 540
TRAINING IN EMERGENCY MEDICINE often felt like being awash in a sea of humanity, my pocket textbook a pilot-book for mariners. The departments themselves were often windowless as the engine room of a ship, and the staff moved in shifts just like deck officers on watch. Signing up for the training was a
bit like enlisting in the Marines: the strict hierarchy of the medical staff, their bleached uniforms, their codes of behavior, the alcoholic blowouts after hours.
On one afternoon shift it was sunny outside, but deep in the department there was only artificial light. A radio screamed an alert that an injured motorcyclist was on his way in by ambulance. The ambulance paramedic, Harry, let us know that although the biker was breathing and conscious, his shoulder and chest had been badly injured. Harry was someone I’d come to know well in that department: battle-hardened, cynical but tremendously skilled at trauma life support.
A few minutes after the radio call, Harry hurried into the room, pushing the patient ahead of him on a gurney. The biker had a moonish pallor to his face, and crew-cut black hair. I noticed first his rigid plastic collar, then his oxygen mask, then, with relief, that he was breathing for himself. Harry had slashed open the left sleeve of his leather jacket to fit a blood pressure cuff and an IV drip. He’d splinted the right arm because its position looked wrong – the right hand hung limply at an angle, like a snapped lance.
“Chris McTullom,” Harry said, “twenty-five years old. He lost it on a bend, going forty or fifty I’d say. Hit the siding and went over the handlebars. There was a pillar by the side of the road – I reckon he went onto it with his shoulder.”
“How long did he lie?” I asked.
“Just ten or fifteen minutes.”
“Any sign he’s lost blood?”
He shook his head. “None. He’s had a liter of fluid IV, blood pressure is a hundred over sixty, pulse is a hundred and ten – no wounds. He’s a lucky lad.”
“Has he said anything yet?”
“Not much. Coma Scale is 11, pupils fine.”
I looked down at Chris and began to check him over: neck immobilized, breathing well and plenty of oxygen getting into his lungs. His pulse was fast but with good volume and there was no blood leaking onto the sheets.* His fingertips on the left were pink and warm. I yelled in his ear, “CHRIS!,” and his eyes opened, but then closed again. “How is the bike?” he moaned suddenly, “My bike …” He wouldn’t squeeze my fingers when I asked him to, but when I pushed a pen hard down on his nail bed to check his responsiveness he pulled his hand away, swore and tried to punch me with his good arm. From being pale and expressionless his face began to boil with violence.
You can bleed to death internally without a drop spilling onto the floor: pelvic fractures, femoral fractures or bleeding into the chest or abdomen can all cause enough internal blood loss to threaten life.
“GCS is 12 or 13 now – he seems to be coming round.”
McTullom was straining with anger now, trying to get up and off the table, but unable to for the pain in his arm and the restraints on his head and neck. With Harry’s help I held him down and gave him an injection of morphine. He fell back into a doze, and we were able to cut through the protective armor of his jacket’s right sleeve. There was no blood on his T-shirt, but his right shoulder looked distorted – instead of being muscled and square as it was on the left, it was a pulpy, swollen diagonal. Harry was right: he must have hit the pillar with his shoulder, slamming his weight onto the collarbone. Once he had been tranquilized by morphine we rolled him carefully on his left side while maintaining the straightness of his spine, to see if he had any other injuries of his vertebral column. All normal.
“Can you feel me touching your hand?” – I began stroking the fingers of his left hand. His teeth were gritted, but he tried to nod – an impossibility in a hard collar. “Don’t nod, just say uh-huh if you can feel me.”
“Uh-huh.”
“What about here?” I began to touch his fingers on the right. Nothing.
“And here?” I began to touch his arm higher up, toward the elbow, then the swollen shoulder. Nothing – he couldn’t feel me touching the skin. “Can you bend your fingers?” I asked, putting my own fingers into his right palm. There was a slight flicker as he tried to make a fist. “Good. And bend your arm?” Nothing. The rage he’d shown just a few minutes before was starting to give way to a drowsy, drug-addled fear.
“What do you do for a living?” I asked him.
“Soldier,” he said. “A gunner …”
When the X-rays came they showed that his right collarbone was smashed into pieces. There’s a fine network of nerves behind the collarbone, emerging from the neck and controlling movement and giving sensation to the arm. He hadn’t just broken up his shoulder in the crash; he’d paralyzed his right arm.
HUMAN CULTURE EVOLVES with the drama of history, but our anatomy, and the limitations it imposes on us, remains the same. Homer’s Iliad was first written down almost three thousand years ago, describing a Greek siege of the city of Troy that may have taken place several centuries earlier than that. In Book VIII there’s a scene of heavy fighting – Teucer the master-archer is bringing down a slew of Trojans, and being cheered on by his king, Agamemnon. “I’ve shot eight arrows, and killed eight young warriors so far,” says Teucer, “but there is one mad dog I cannot hit.” The “mad dog” is Hector, a prince of the Trojans. The next passage is worth quoting in full:
Hector jumped down from his chariot with a loud cry, picked up a great stone, and ran straight for Teucer in fury. Teucer took an arrow from his quiver and laid it upon his bow, but before he could take aim and fire Hector struck him with the mighty stone; he hit him on the collarbone, where it divides the neck from the chest – a deadly place. His hand and wrist were numbed by the blow, and as he fell forward onto his knees, the bow fell from his hand.
Teucer’s brother Ajax ran forward and stood over the fallen man, shield aloft, to protect him from a rain of arrows. Two more of his comrades ran over and lifted him, “groaning in pain” back to the safety of the Greek ships.
The author of The Iliad was a surprisingly accurate observer of anatomy. The battlefields of antiquity must have been chaotic places, sprawling with bodies and mired in blood. The warriors and camp-following poets were familiar with what is now called “major trauma,” and may have developed their own trauma care. There are some medically qualified Homer enthusiasts who have gone so far as to propose him as an early battlefield medic. Repeated through The Iliad are careful accounts of spear wounds, arrow strikes and sword blows, which take care not just to describe the part of the body that has been wounded, but the physiological effects of those wounds and, on occasion, specific treatments.*
But as the classicist K. B. Saunders noted dryly, “I do not expect every wound described by Homer to be realistically explicable. One should try to come to some physical explanation of events if possible. But miraculous things do happen in The Iliad … miraculous wounds should not be a surprise to us.” Classical Quarterly 49(2) (1999), 345–63.
When Hector paralyzes Teucer’s arm by hitting him “on the collarbone where it divides the neck from the chest” it’s an accurate description of a trick still used by martial arts experts today – “The Brachial Stun.” A blow to this area may not just temporarily paralyze the arm: if it causes pressure on part of the carotid artery, it can trigger a reflex slowing of the heart. In sensitive individuals the heart can slow to such a degree that the victim falls unconscious. There are innumerable “brachial stuns” available to view on the Internet – home videos of US Marines practicing on one another in their barracks, black belts filmed in the ring, even police officers attacking their suspects. Watching them, I thought of Teucer crumpling to the ground with his numb, lifeless arm.
THE NAME GIVEN to the spaghetti junction of nerves behind the collarbone is the “brachial plexus,” and when anatomy took a greater part in medical training every student had to memorize its arrangement:
Five nerve roots from five vertebrae in the neck unite to form three “trunks,” which divide into anterior and posterior divisions. Those divisions perform an elegant interleaving with one another before braiding into three “cords”: “medial,” “lateral” and “posterior.” The posterior cord supplies those
muscles that straighten the arm and wrist, as well as supply sensation to the back of the hand and forearm, while the medial and lateral cords activate those muscles that flex the biceps and wrist, and operate the small muscles of the hand.
The arrangement seems overly complicated, but arises from the way the arm forms in the womb. Brachium in Latin has the same root as our word branch – it starts as a bud, sprouting straight out from the trunk the way a branch grows from a tree. It begins to bud at just four weeks’ gestation, and over three subsequent weeks divides into a rudimentary hand, forearm and upper arm, then rotates through ninety degrees. It’s the movement of those muscles as the arm grows and rotates, and the fixed origin of the nerves in the neck, which provide the warp and weave of the brachial plexus. Homer didn’t know of the origin of the plexus but he was acutely aware of its anatomy, and the martial advantage that knowledge could give.
BETWEEN TRAINING in emergency medicine and as a general practitioner I took a job as a medical officer in Antarctica. The British Antarctic Survey sent me as a ship’s doctor to sail the length of the Atlantic Ocean and finish up at one of the most remote research stations in the world: Halley Base. The station would be isolated for ten months of the year, during which I was to stay as base doctor. The evacuation of medical casualties was almost impossible for those ten months, so before taking up the post I was sent to a mixed military and civilian hospital for extra training.
The military doctors taught me how to give my own anesthetics, drill out rotten teeth, and perform simple, single-handed trauma surgery. I’d always been suspicious of military medicine: to join a troop of soldiers intent on killing and maiming their enemies seemed to contradict every principle of ethical practice. Hippocrates said “first, do no harm,” but a close reading of his works also turns up “he who would become a surgeon must first go to war.” From antiquity until today, war has provided an abundance of casualties to learn from: in medicine, as in other fields of expertise, practice makes perfect.
Adventures in Human Being Page 9
