A King’s Speech

Last weekend everything was different! More pure, more clean, more innocent! All dressed in white. While spring is round the corner, we had the first snow of the year. It lasted only a night. But it was stunning (photo). The sharp cold suddenly disappeared, people went out for an evening walk, everything was quiet, illuminated, calm. Of course you’ll bump into these people who ‘ll start complaining “but when the snow melts down…” Smile to them and keep walking! It was an opportunity to go for another walk on Sunday morning while snow was still covering pavements and parks, to get ink for my pen.

A stunning white evening, yellow street lights, quite, soft path perfect for a night walk

Yes, I write with a fountain pen! You think I’m old-fashioned? There is something magical when you write with a pen. The way that the heavy, shiny object balances evenly on your fingers, the way that, against all laws of physics, the nib smoothly glides on the rough paper, the small elegant glass ink bottles, the act itself of filling up and cleaning your pen every few days. Still old-fashioned? :-) I got news for you! I’m writing this blog, using voice-recognition software! I do most of my computer writing using voice-recognition software. Do you know what is old-fashioned? Using a keyboard! I find the idea of striking random keys on a plastic pad to create individual letters completely ridiculous! In 5 or 10 years people will be laughing at the idea of having to use a keyboard to communicate with their computers! So don’t call me (!) old-fashioned! :-)

We went to a little shop in Turl street, official suppliers of Mr Samandouras’ ink :-) The shop is not bigger than ten square metres. Once you push the heavy, wooden door you feel like you enter into a secret world, like a magical movie plot: every bit of the wall is covered with old books, historical photos with expensive frames, miniatures of boats, aeroplanes and hot air balloons. The shelves are filled with hundreds of antique objects: magnifying glasses with curved handles, leather-bound journals that you feel when you open them you will see an old treasure map, Venetian masks worn at a Renaissance masked ball (photo). To top it up, everything is immersed in melodious classical music.

Here everything is magic. There is a story behind every object!

Take the narrow wooden staircase to explore old books and antique maps of the world.

I got the Mediterranean blue ink, I am biased :-) eighty millilitres of blue ink, a touch lighter than the boring blue, from people who been manufacturing ink for a century and a half.

Monday morning I saw my new admissions at the hospital: a woman in her 40s, lets call her Mrs Smith, who could not speak and express herself clearly during the last month or so. She wanted to say that her head was hurting and she was pointing to her chin. The part of the brain called the parietal lobe just above and behind the ear is responsible for purposeful movements, like doing up buttons and putting an arm through a jacket’s sleeve. Pathologies in the parietal lobe results in abnormalities in purposeful movement, called medically dyspraxias (praxis in Greek means act). The reason for Mrs Smith’s dyspraxias was a large tumour in her dominant, left parietal lobe. And at the bottom part of this lobe and just a bit front is the brain centre that understands what someone is saying to us, something as simple as “what’s your name?”. If that part is damaged, a patient can’t understand what this question means, and his answer is completely irrelevant, such as “yes, I had lunch”. How horrible not to be able to perceive the world around us!

Another man in his 60s, lets call him Mr Jones, was referred from my neurology colleagues because of balance problems. “I am walking like a drunk” Mr Jones told me with his lovely Cockney accent. He had a large mass in his left temporal lobe, the part of the brain between the eye and the ear. 40 years ago Mr Jones had been operated on by a man that you may know, a man you might have seen when he was a kid! No, I’m not suggesting that you are ancient :-) I just believe that you might have seen a movie, “The King’s Speech”. You may remember the quieter of the two speech therapist’s kids, the one portrayed in the movie always reading a book (photo). That was Valentine Logue. You may remember now that the King used to call his therapist “Logue”.

The boy Valentine Logue went on to become a neurosurgeon, one of many famous Queen Square neurosurgeons. His portrait hangs on the “Hall of Fame”, a long corridor on the sixth floor of the Department of Neurosurgery, where photographs of all Queen Square neurosurgeons are hanging, from the first ones in 1860s to the ones currently practising at Queen Square. No, I haven’t put up my photo yet, “I am waiting for my sculpture” :-) that’s what I say when people are asking me when my frame will go up on the wall!

Young Valentine reading a book in Logue's family room. He went on to become a Queen Square Neurosurgeon, a "historical" colleague of mine! (From the movie "The King's Speech").

Mrs Smith speech problems and a tormented prince trying to finish his sentences in the magnificent “King Speech” got me thinking: What is voice and what is speech? Combinations of sounds, packets of air squeezed through the larynx, some dry transmission and exchange of information like the Morse code? Take an example, two different people go and ask for the same thing using the exact the same words, one gets “yes” one gets “no”. Ever thought why that is? Every word we utter has layers of emotions and millions of shades coming from the depths our psyche.

Every little or big unspoken thought about ourselves and the others, about our confidence or lack thereof, about what we believe we deserve on a particular situation or what we deserve in life, colours our voice and shapes our speech. The voice can influence, can persuade, can motivate, can encourage, can charm, can seduce, but also can destroy, can hurt, can belittle. As medics, or surgeons, or scientists we are conditioned to focus  on the content, not the delivery, you either know an answer to a factual question or not, we are used to think that delivery is irrelevant. I know it sounds counterintuitive and even superficial, but in social settings, what you say is of little importance, how you say it matters more.

For those who combine both content and style, miracles happen. Have a listen to a man speaking. The date is 28 August 1963, the place Washington.  The speaker, a 33-year-old clergyman and activist talking to a quarter of a million Americans of all ethnicities. (http://www.youtube.com/watch?v=smEqnnklfYs). It has just over a humble million views on youtube, (lady gaga has well over 400 millions, bless her!) but listen to it, from start to the end! Imagine a man who can hold the power of that moment.  For me, Martin Luther King’s speech in front of Lincoln’s memorial in 1963 is next to Watson and Crick’s double helix of DNA in 1953 or Duke Ellington’s jazz piano at the Hurricane in the 1940s, or the 1977 Voyager space mission to explore what lies beyond our solar system, all fine pieces of the human spirit of the last century.

The power of one man's dream. Martin Luther King at the steps of Lincoln Memorial ending his speech: “Free at last! Free at last! Thank God Almighty, we are free at last"! What a fine moment in human history!

From Martin Luther King’s speech and “The Kings (George VI) Speech” back to Mrs Smith’s speech and her brain tumour. My plan was to remove aggressively her tumour without damaging her or her speech areas. Removing tumours from eloquent brain areas is much like walking into a minefield. Any step can set off an explosive. At Queen Square we routinely discuss all our tumour cases at a neuro-oncology conference every Tuesday morning with doctors and surgeons of all specialties related to brain tumours. “Its too risky, I am not sure surgery is the best option for this patient” said one of my oncology colleagues when I presented Mrs Smith’s case. My belief is that for certain brain tumours, nothing fights cancer more than the surgeon’s knife. Despite that, the day when we will beat cancer and no operations will be necessary, will be one of the happiest days of my life! In the case of Mrs Smith,  I knew that she would not survive more than a couple of months without an operation.

In the operating theatre I exposed a small part of the the left side of her brain in and placed a tiny 10 mm incision into the brain’s surface based on what I felt the least likely area to cause damage to her brain’s highly functional areas.  Mrs Smith had already drunk a fluorescent dye four hours prior to her operation. This substance called 5-aminolevulenic acid and colours the tumour cells leaving normal brain cells undyed. Using a blue filter under the operating microscope the tumour cells appear bright red, like a hot coal. Looking under the high magnification of the operating microscope you see the enemy, necrotic lumps of tumour and unnatural large and thrombosed arteries. What used to be elegant nerve cell architecture is replaced by ugly, chaotic, random layers of monster cells. Looking down the microscope you know that you are looking straight to the eyes of the beast. I removed away all that could possibly be removed, separating the normal from the abnormal, by judging minor changes of the way normal and abnormal looks and feels. Your hands learn, even within gloves and through rigid instruments, to feel minute differences in texture, what’s healthy and what’s diseased, even if they look the same to the untrained eye. Your eyes and hands have to be well-trained to see and feel. Shakespeare said it well: “the innocent eye which sees the world afresh does not see at all”!

Between surgery cases I went to recovery to see how Mrs Smith was doing, did she wake up? could she move her right arm? could she understand and could she speak? the surgeon’s moment of truth! She greeted me with a smile, she was looking good: “I feel like I did not have an operation”. No, not only she wasn’t any worse but her preoperative deficits had already resolved! No time to congratulate myself, time to go back to theatre to operate on another patient, another human story, someone else’s life that changed suddenly from one day to the other.

Yes, I know Mrs Smith will never give a speech in front of Lincoln’s memorial like Martin Luther King (to the best of my knowledge!), she will never address the nation at a wartime like King George VI, but I have peace of mind that she will speak to her children and she will understand her husband, her parents and friends. These patients are Kings and Queens for their loved ones, and this is how they are treated on the operating table. When I was at school I read a story about a French Prime Minister about half a century ago, who was due to have an abdominal operation. Before entering the operating theatre he said to his distinguished surgeon “I hope that you won’t treat me like one of your peasant patients, don’t forget I am the Prime Minister” The famous surgeon replied “For me, any of these peasant patients is a Prime Minister”.

That’s what I was reading at school :-) (along with Batman, Spiderman, X-Men, and Avengers and along football and basketball magazines-God knows when I was doing my homework!) Which reminds me, five months left (20 July) for Batman’s last movie “The Dark Knight Rises”. At least last for genius Christopher Nolan who closes his trilogy that transformed Batman from a mediocre uniformed gadget-guy to a dark and deep super hero. Watch the trailer at the IMDb playing the “Short change hero” from “The Heavy” (mute the trailer’s voice). Doesn’t get any better than that.

A glorious end for the dark hero?

And while waiting for the movie of the year you can kill some time with the Avengers (opening 27 April) or if you are super cultured with “Museums at Night” with a party atmosphere in after-hours London Museums (18 May) or the Greenwich International Festival with outdoors theatre, dance and arts (21-30 June).

As for neurosurgical events something big will be happening in May. If you are a neurosurgeon at a flying distance to London clear your schedule (now!) for the weekend 18-19 May. For more info watch this space and wait for my next blog!

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