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And Lord Brain said …
  1. Michael Swash
  1. Professor Emeritus, Queen Mary School of Medicine, University of London, Barts and the London, Department of Neurology, Royal London Hospital, London E1 1BB, UK; mswash{at}

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    Lord Brain, by Karsh of Ottowa (reproduced with permission from the Royal London Hospital, UK).

    First clinical teachers are often formative. Mine was Lord Evans (1903–63), a tall Welshman with a wry but lively sense of humour, Physician to the Queen, and in 1959 immersed in medical affairs of state. In those halcyon days at the London Hospital students spent the first year of their clinical course on just two attachments, one medical and the other surgical. Since there were only about 50 students in each clinical year, of whom a third had come down from Oxbridge to join the London students, each firm consisted of less than half a dozen students; there were just five of us in my group. All clinical teaching took place at the London Hospital itself, apart from some additional midwifery, and an elective period of up to three months in the final year. Students were therefore sought out by any enthusiastic teacher—and there were many of those. We worked on the wards, and in out-patients with our consultants (two to each firm) and with the senior registrar, registrar and house physician. We were on call from our beds in the Students’ Hostel every fifth night. Lord Evans’ teaching was combined with Dr Wallace Brigden, a charismatic young cardiologist.

    The first patient I clerked on my first clinical attachment after the introductory course was a young dock worker, less than 40 years old, who drove a crane. His crane was more than 100 feet high and he climbed the ladder several times each day to get to the cab from where he operated it. This was before the days of container ships. He had developed angina climbing up to the cab, and could document the inexorable progression of the symptom over a period of a few months. The question I was supposed to answer was: why? Well, he was pale, and a bit sallow, and had odd burning and tingling feelings in his feet. His vision had unaccountably deteriorated recently, and he was a bit unsteady on all those steps up the crane’s ladder, especially when it was dark. I found his tongue was smooth and red, and his skin yellowish. He had very poor position sense in his feet, absent vibration up to the sternum, absent ankle jerks and extensor plantars with rather pale optic discs. There was tachycardia with a third heart sound. He was an intelligent and alert man and he sensed my enthusiasm for his case. I went off with a venous blood sample (yes, we had to do that too) to check his haemoglobin, white cell count and ESR in the students’ lab set aside for our use on the ward, and was astonished to find his haemoglobin was only 5 g, and his red blood cell indices were all over the place (we had been taught to do all this in our preclinical studies). So he had B12 deficiency and subacute combined degeneration of the cord, optic neuritis and peripheral neuritis (I use the older terms advisedly).

    The next morning I presented all this to the firm (minus Lord Evans). After a respectful silence it was made clear I would present this case to the Lord himself that afternoon, and then to his weekly Clinical Demonstration, due a few days later. My patient was delighted to discover he had not been found to have leukaemia or some other serious disease and was happy to go along with anything. A jovial man, he thought it his duty to encourage this terrified first year student and was keen to rehearse me in the presentation of his case. So we went over it together. I tested his stomach contents for acid, tried to stimulate his stomach with histamine, checked him for bilirubinaemia and bilirubinuria and so on. The famous Schilling test followed prior to starting treatment, and lots of blood was drawn for reticulocytes. The neurological examination was checked daily, and he was not allowed even to contemplate going home until his haemoglobin had returned to normal. He improved haematologically and neurologically with remarkable speed—he and I were equally impressed and surprised. The medical registrar, Dr Gerald Stern (then about to start his neurological training), found the literature rather contradictory about peripheral neuritis and optic neuritis, so we decided to ask Lord Brain’s opinion. This was to be accomplished by asking Lord Evans to ask Lord Brain to attend the former’s weekly Tuesday afternoon Clinical Demonstration, an event open to all, including local general practitioners, and immensely popular.

    As the most junior clinical student in the hospital, well known to be more involved with rowing than anything else, I was about to be thrust into the limelight. A few days later, I found myself standing in my best (and only) suit before the assembled medical school. Seated above me on the steeply-raked hard wooden benches of the Barstead Lecture Theatre, were the two Lords, the Dean, Professor Dorothy Russell (Morbid Anatomy), Professor Lucien Rubinstein (Neuropathology), plus assorted consultant physicians, haematologists, registrars, house physicians, students, the ward sister and her student nurses (always allowed to attend these occasions). I recited my history and examination to the accompaniment of a typed-up case summary prepared by Gerald Stern. Lord Evans, standing leaning on the bed-head and speaking to us therefore over the supine form of the patient, picked out the salient points, gave a solemn, almost oratorical account of the disease and its history, including a ghastly account of the pleasures of dining on raw liver, rather briefly examined the patient, allowed him to utter a few words, and then formally asked Lord Brain’s opinion. The moment had come. With bated breath the audience, including the registrars, the students on the firm, the exhausted clinical clerk (me) and the patient turned to the august authority who opined with great solemnity (Lord Brain’s sense of humour was never to the forefront in public): “This is a case of subacute combined degeneration”. Although we waited for enlightenment, there was no more to be said. Lord Evans smiled to himself (or so I thought), and we went our various ways to tea. Such was the power of the neurological diagnosis that none felt aggrieved or let down—except my patient who wanted to know wasn’t there something else we should have found out from the great man? Was there?

    And, do you know, I have never seen another case of B12 deficiency quite so classical in its features ever since!

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