I went to see the quack this morning.  The snow had all but thawed, but the wet ice outside the surgery was treacherous.   Was this an opportunist way of creating new business by a new entrepreneurial NHS?   Anyway, Dr Watson agreed enthusiastically with my deductions and I now have a bottle or crimson and custard minibombs to assist my waving immune system, a caution against unwise excursions into the mountains and more concern that the stress may have aroused dormant histiocytes.  I get the blood tests back tonight.   

It’s amazing in a way how a non specific infection like flu can bring on the gamut of unexplained symptoms; the exhaustion, fatigue, depressing muscle ache, the anorexia and early satiety, the bowel aches and pains, shortness of breath, the lot.   It’s like the virus switches on a non specific pattern of illness not unlike that induced by trauma, grief or disappointment, the chronic loss of hope that erodes life force.  I didn’t hear from my daughters this Christmas.  Maybe that’s what’s got to me

I came across a lovely few lines by Emily Dickinson on hope

Hope is that thing with feathers,

that perches in the soul,

and sings a song with no words

and doesn’t stop at all.

Only that particular yellow bird had gone off to feed in another garden. 

Time to re-stock the feeders.

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What bowels would not be angered

by what cannot be explained.

There may be no red flags, but you’re

drowning In unpredictable pain. 

.  

Just remember, life is a terminal illness 

and Medicine an inexact  science;

 an exercise in probability. 

In shadow and with occult blood,

the assassin flatters to deceive

.

So what’s the worst?  The surgeon,

Green in mask and gown,  

punctuates your abdomen,    

creates a semicolon, but don’t fret,

it’s not yet a full stop.

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Maybe it was the tiredness.  Maybe my body was physiologically in a state of conservation and repair.  I’d stopped fighting or thinking.  I was just existing.   With the first few bouts of fever, the sensitivity of my scalp, the persistent headache, the shivering, induced a state of despair.  I was  delirious and repeating, ‘ Oh my God, Oh my God, Oh my God’, worryingly reminiscent of my mother’s  anxiety dementia.  But then I seemed to give up and accept whatever would happen. 

 Such states of body and mind correspond to Hans Selye’s  General Adaptation Syndrome (1936),  in which he documented a stereotypical responses to stressors of all kinds, physiological, medical and psychological.   They all, he concluded, tap into the same mechanism. 

The first response to a stressor is to fight it with the sympathetic nervous system; hence the anxiety, the pain, the shivering  but this gives way to a state of sweating and sleep; a state of conservation  dominated by the parasympathetic nervous system.  You see the same response in animals, whose ultimate response to overwhelming stress is to curl up in the corner of their cage and ‘play possum’.   But both people and animals vary according to whether or how quickly they exhibit which response.     

Post Traumatic Amnesia is a kind of dissociation.  It is a response to overwhelming trauma and could be thought of as a mechanism that protects the individual from the knowledge that would destroy their sense of self, like risk of death, abuse, or the collapse of a key relationship.   It is often associated with other aspects of the post-traumatic stress reaction, such as nightmares, bodily weakness, and a variety of somatic symptoms.   If you cannot remember or deal with what has happened, then nightmares and somatic symptoms often remain to express the trauma in coded form. 

So what is the mechanism?  But what is the mechanism?   The stress response not only involves the autonomic nervous system (sympathetic and parasympathetic), it also includes the hypothalamo-pituitary adrenal (HPA) system, which releases a cascade of transmitters and hormones (CRF, ACTH, cortisol, aldosterone) as a compensatory mechanism to offset the damaging effects of excessive and sustained  sympathetic arousal on the body.  The HPA system maintains the function of the organism in the face of overwhelming stress, maintaining energy supplies, damping down the immune system, suppressing inflammation and pain and blocking memory.  

So can it all be explained by activation of the HPA axis.   If so, why are Chronic Fatigue Syndrome and Alexithymia (the disconnection of the emotional and rational expression), which may both coexist as part of the post traumatic reaction, associated with diminished cortisol responses.   Does this represent a state of exhaustion or switching off.  There is never an easy response to anything. 

With a days of the Malaria being treated, the tiredness disappeared is.    I became frustrated with  being in hospital and although still weak began, to devise strategies for discharge.  The will to live had reasserted itself; what would have been the point of remembering what it was like?

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Cut into its surface.   A red black pulp like raspberry jelly oozes out and between the pulp are islands of white tissue, called Malpighian tubercles. 

The red pulp is composed of large blood spaces or sinuses lined with columns of cells.  The blood passes slowly though the sinuses and the cells filter it, destroying  bacteria, viruses, protozoa .  Similar arrangements of fixed macrophages exist in the sinuses of the liver (Kupffer Cells) and in the lymph nodes.  Together they comprise what is known as the body’s ‘reticulo-endothelial system’.  But the spleen also destroys tired red blood cells, worn out and dysfunctional after their 120 day journey round the vascular system,  recycling the haemoglobin to bile pigments and iron stores.   

The white nodules contain lymphoid follicles rich in B lymphocytes, which produce antibodies and sheaths of T lymphocytes, responsible for ‘hand to hand’ cellular conflict.  They are also major producers of monocytes, which are despatched to sites of injury where they transform into dendritic cells and macrophages and assist wound healing.  So both white and red components of the spleen are important parts of the immune system.  The same functions can be carried out in other parts of the body, but without a spleen, immunity is seriously compromised.      

In other mammals, the spleen is also an important reservoir of blood.  In the horse, 30% of the blood is stored in the spleen; in the dog 15%. Operate on a dog and you can see the spleen shrink before your eyes.  The spleen used to produce new red blood cells but loses that ability just before birth when that function is taken over by the bone marrow.   

Doctors have known about the spleen since ancient times.   It was, they thought, the origin of black humours, the source of melancholy (literally black bile) and hypochondria (below the ribs).   In the eighteenth century, women were often diagnosed as suffering from The Spleen when they were sad, bad tempered and out of sorts in mind, body and spirit.  Alternatively they might be said to be suffering from the Vapours (of the Spleen).   The term splenetic indicated that somebody was in a foul mood, though the same term in French meant sad and melancholic. 

So don’t ignore the spleen or provoke it, for if it ever gets ‘vented’, take cover immediately!

The little bastards that that bloody insect injected into me have swollen my spleen from 11cm to 15cm.  The insurance company seem to think it will explode in the low pressure environment of the aircraft cabin. It’s a solid organ, I insist!  Physics doesn’t work like that!  It’s enough to give anybody The Spleen!   

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The opening sequences set the mood, time passing in the ticks and strikes of the clocks, the unrelenting passion of the crimson carpets, walls and drapes.  We see a woman or is it a man; the angular face and lank hair obviate sexuality.  She is lying in bed.  Another woman, plump and beautiful with ringlets of honey blonde hair lies asleep in a chair.  The invalid gets up stiffly and walks painfully across to her bureau and writes in her diary, ‘It is Monday and I am in pain.’ 

Agnes is dying of cancer.  Her sisters, Karin and Maria, have returned to look after her, but it is the peasant Anna with her plump expressionless face and simple faith who loves and cares for her.  ‘In elliptical flashbacks, intended to give us emotional information, not tell a story, we learn that the three sisters have made little of their lives.’ Karin is icily detached, married to an older husband, a calculating, sneering diplomat, whom she loathes. She cannot bear to be touched and in one awful scene lacerates her cunt with a broken glass and smears the blood over her lips to avoid her husband’s attentions.  Maria is beautiful, but corrupt and heartless.  She is married to a weak man, whom she despises and so she consoles herself with other liaisons.  When her husband stabs himself and pleads for help, she turns away.  Maria and Karin were close as children, but are now too damaged to allow any real intimacy.  Agnes always felt isolated, especially from their tragic though beautiful mother.      

Theirs is not a happy house, it’s a place of guilt and repression, cries and whispers.  Nobody can get close enough to draw comfort from anybody else.  Agnes is in agony, her back arched as she struggles to breathe, desperate for human warmth, but her sisters turn away.  Only Anna can console her, pillowing her head in the living flesh of her breasts to ease her terrible transition.   

Cries and Whispers is a disturbing film, a film about life and death.  It’s not only Agnes who is dying.  Karin and Maria are too, and in a way, we all are.  Their lives have no hope, no meaning.  Karin works while Maria plays, but these are evasions.  Theirs is a simalcrum.   Without human warmth, without love, there can be no life.   Paradoxically, it is Agnes,  who finds life  in simple pleasures, the garden, a drink of water and the comfort of  being held.   So Bergman presents us with a contrast, a counterpoint between the hopelessness, defensiveness and meaninglessness of  Karin and Maria’s lives with their compromises, pretences and terror of real contact and the dreadful void of death that confronts Agnes.  

Bergman does not spare us the shock and horror.  Harriet Andersson is not beautiful in death; sweat glistens on her angular face, her hair is lank, her skin pale and grey, her eyes terrified;  she arches her back, she drags air into her damaged lungs with long, tortured stridor, she retches, she beats her fists on her barren, wasted chest. 

The cinematography is superb.  As the critic, Roger Ebert, wrote, ‘The camera is as uneasy as we are. It stays at rest mostly, but when it moves it doesn’t always follow smooth, symmetrical progressions. It darts, it falls back, is stunned. It lingers on close-ups of faces with the impassivity of God. It continues to look when we want to turn away; it is not moved.  Agnes lies thrown on her death bed, her body shuddered by horrible, deep, gasping breaths, as she fights for air. The sisters turn away, and we want to, too.’  We know things are this bad, but we don’t want to have to feel it.  The scene of  Anna embracing the decomposing Agnes has all the soul searching depth of a Rembrandt,  the horror of embracing death but at the same time a moving and familiar reminder of the pieta.   So the death of Agnes  represents the corruption of humanity.  And here again we have the dialectic;  life in death and death in life.   This film gets as close as any film can get to the crimson membrane of passion and sexual disquiet that for Bergman is the soul.  

Cries and Whispers has little narrative.  We don’t know how the major characters arrived there; we are left to fill in the gaps from the darkness of our own experience.  This is the power of Bergman.  He does not attempt to explain; he just shows us what its like.  He communicates on a level of human feeling so deep that defies description – but how well he communicates.

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If thou hast a heart

famed for tenderness and pity,

contemplate this spot.

In which are deposited

the remains of a young lady,

whose artless beauty, innocence

of mind and gentle manner

obtained her the esteem

of all who knew her.

But when nerves were

too delicately spun

to bear the rude shakes

and jostlings, which we meet

in this transitory world,

nature gave way.  She sank and died

a martyr to excessive sensibility.

Mrs Sarah Fletcher,

wife of Captain Fletcher,

who departed this life

at the village of Clifton

on the 7^th June, 1799

in the 29^th year of her age.

May her soul meet that peace

which this earth denied her.

Sarah committed suicide.  Her ghost was said to haunt the house where she lived. Her tomb is in Dorchester Abbey, Oxfordshire.

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The day started well.  I sat out in the chair for breakfast, but when Beckie, the staff nurse, she of the sidelong glance and provocative eyes, asked if I wanted to have a shower,  I could have kissed her.  Getting to the shower was painful but not impossible, but the luxury of hot water was nothing short of bliss.  I ripped all the ECG tabs off and soaped myself all over.  I even managed a bit of a bowel action and I collected the urine sample, Beckie, wanted – though it more resembled a glass of pink grapefruit.   

It was the sample that did it.  Haematuria ++++!  Bugger!  Beckie was back in a few minutes, eyes raised, smiling.  ’The doctors want you to have a scan of your abdomen’ and she added with a note of triumph,  ‘It’s strict bed rest for you!’ 

The scan showed I had fractures of 3 lower right ribs, fractures of the transverse processes of some of the vertebrae and collections of blood above the liver and around the kidney.  I must have had quite a biff.  It’s probably a mercy I have no recollection of the event.

The edict was reinforced.  I felt like a man who had been let out of prison only to be recaptured a few hours later.  I had already been walking about.  I was moving, feeling better with each step, my urine was as clear as a mountain spring. This restriction seemed very negative. 

I rebelled.  I sneaked to the loo when Becky wasn’t looking, but she always caught me.  But in the end, I submitted.  I was a doctor.  If I couldn’t obey the rules in hospital, then who could?  And I didn’t want to get Beckie into trouble.     

Bed is the most dangerous place if you don’t need to be there, particularly a hospital bed.  The body needs to be active to recover.  Lying in bed does not encourage you to breathe deeply.  Secretions can collect and stagnate at the bases of the lungs.  Stagnation encourages infection and hospitals are breeding grounds for the strangest and most resistant of infections.  Coughing is often painful and non-productive.  The worse complication of being in hospital is a chest infection. 

The second is probably a urine infection. It is difficult to pass urine while lying in bed. People don’t drink enough and hold on.  Stagnation of urine can allow it to become infected, especially in women who are especially to infection rising from the perineum through a short urethra.

Another torment of bed rest is constipation.  Using a bed pan to pass faeces is an acrobatic feat.  Sore muscles and ribs make it impossible to strain.  The result; your waste just sits there, producing noxious gases, irritating the rectum with its presence, infecting your mind.  There are few ailments as depressing and frustrating as constipation. 

If bed rest is prolonged for more than a few days, it is accompanied by other perils, such as muscle wasting, loss of bone, impairment of appetite and depression.

Broken arms and legs can be protected in plaster or pinned or plated, but fractured ribs and vertebral processes must be allowed to heal up by themselves, surrounded by their splint of inflammation and muscle spasm. Muscles that are not used, waste with great rapidity and no longer protect damaged bones. 

Bones lose calcium if not used,  becoming weak and brittle, and leaching calcium which can deposit in the kidneys as stones. 

The appetite suffers when we are not active.  Hospital food often doesn’t help.  And with loss of appetite and mobility as well as the companionship of friends and family, we get depressed, losing energy and drive and the essential will to get well.    

Bed rest is essential if you have an infection or a heart attack or a flare up of colitis or rheumatoid arthritis, you just don’t feel like doing anything else.  You have no energy and no choice.  It is the effect of infection and tissue damage.  But if you have had none of these things, then enforced bed rest is one of the greatest perils of being in hospital.  So if your body tells you it’s ok and there is no obvious risk of movement, get up as soon as you can, keep moving, exercise, stretch.  Listen to your body.  Believe me; it will save your life.

I am slightly, but only slightly, ashamed to admit that I ignored the edict and as soon as seemed polite and feasible (that same evening!) took my own discharge.  They do say that doctors make the worst patients in that they won’t always do as they’re told, but I sometimes think that their insight gives them the opportunity to get better more quickly.  

It is just six days after the accident and I have completed an inspirational run – well an old man’s soft shoe shuffle – down Dove Dale and back.  I feel tired, sore, but I’m healing up.

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